Diagnostic Approach
DIAGNOSTIC APPROACH
“Searching for clues, diligently, with an open mind, will in most cases give you a concrete diagnosis and the perfect place to start treatment.”
Triple Assessment
Breast cancer is diagnosed on the basis of Triple assessment. Triple assessment includes Clinical examination, Radiological evaluation and Pathological evaluation of the lump before coming to an established diagnosis. Once the diagnosis of cancer is made, the clinician goes a step further to ascertain the biology of the disease by subjecting the biopsy specimen to further tests, also known as immunohistochemistry for Estrogen receptor (ER), Progesterone receptor( PR), Her-2-neu etc. Alongside, staging investigations to ascertain the extent of disease and possible spread, are carried out on the basis of the assigned clinical stage.
Clinical Examination
The core of Triple Assessment is, without doubt, a good clinical examination. The clinician takes a detailed history and then examines the patient systematically, to make a clinical impression and formulating the next steps. There is no substitute for a well-conducted clinical examination.
Radiological Evaluation
Once a clinical diagnosis is made, the next step would be to perform appropriate imaging. Imaging is non-invasive and should always precede a pathological evaluation. Imaging with the help of mammogram and complemented with an ultrasound of the breast will allow for optimal characterisation of the abnormality in the breast, thereby adding more conviction to the clinical diagnosis.
- Mammogram entails a low dose X-ray of the breast, usually in two views and involves compressing the breast between the X-ray plates. It may be a little uncomfortable but is of immense value in the diagnostic workup of patients with symptomatic, suspicious breast lumps. It gives a global view of the entire breast and with the digitalisation of the process, the quality of information, available on a mammogram has become better. However, mammogram is not infallible and 20% of breast lesions may be missed on mammogram.
- Ultrasound breasts- is a useful adjunct to mammogram and allows for better characterisation of the breast lesion. Ultrasound can distinguish effectively between solid and cystic lesions and also allows for ultrasound-guided biopsy of the lesion under investigation.
- MRI breasts– is used as a problem-solving tool specially in situations where the mammogram and ultrasound breasts are unable to provide the requisite information or in young women where the breasts are dense and the patient is desirous of breast conservation surgery. It is also used in women who are going in for chemotherapy first and desirous of breast conservation post-chemotherapy.
Pathological Evaluation
The final step in triple evaluation, is the pathology, which will be the final word on diagnosis. The current recommendation is to perform image guided core needle biopsy (CNB) or vacuum assisted biopsy (VAB). CNB or VAB give more information than a fine needle aspiration cytology (FNAC). CNB can distinguish between an invasive cancer and a precancerous abnormality. It is also possible to ascertain the biology of the tumour on CNB. This important piece of information not only helps guide treatment but also helps in determining the right sequence of treatment. Ultrasound guided FNAC may be reserved to assess lymph nodes in the armpit and see if the disease has involved the lymph node. This information can impact treatment.