Virginia Commonwealth University

VCU Massey Cancer Center

How is breast cancer diagnosed?

It is important to remember that a lump or other changes in the breast, or an abnormal area on a mammogram, may be caused by cancer or by other, less serious problems.

To determine the cause of any signs or symptoms, your physician will perform a careful physical exam that includes a personal and family medical history as well as determining current overall health status. In addition, an examination may include the following:

  • Palpation – carefully feeling the lump and the tissue around it (its size, its texture and whether it moves easily). Benign lumps often feel different from cancerous ones.
  • Nipple discharge examination – fluid may be collected from spontaneous nipple discharge and then sent to the lab to look for cancer cells. Most nipple secretions are not cancer, as an injury, infection or benign tumor may cause discharge.

    For women who are at high risk for breast cancer, a procedure called ductal levage may be used. Ductal levage is a procedure that collects cells from inside the milk ductal system — the location where most breast cancers begin.

In addition to a physical examination by your physician, an imaging test will be performed. Imaging tests may include one or more of the following:

  • Diagnostic mammography – a diagnostic mammogram is an X-ray of the breast used to diagnose unusual breast changes, such as a lump, pain, nipple thickening or discharge, or a change in breast size or shape.

    A diagnostic mammogram also is used to evaluate abnormalities detected on a screening mammogram. It is a basic medical tool and is appropriate in the workup of breast changes, regardless of a woman’s age.
  • Ultrasonography – high-frequency sound waves, not heard by humans. The sound waves enter the breast and bounce back. The pattern of their echoes produces a picture called a sonogram, which is displayed on a screen. This exam is often used along with mammography.
  • Scintigraphy – a breast scan that is a specialized radiology procedure used to assess the breasts when other examinations have been inconclusive. A breast scan is a type of nuclear radiology procedure. This means that a tiny amount of a radioactive substance is used during the procedure to assist in the examination of the breasts. The radioactive substance, called a radionuclide (radiopharmaceutical or radioactive tracer), is absorbed by certain types of body tissues.

 

Please visit the new Breast Imaging Web site for more on our diagnostic services, high-risk clinic and convenient locations.  

Based on these exams, your physician may decide that no further tests are needed and no treatment is necessary. In such cases, your physician may want to check you regularly to watch for any changes.

Often, however, the physician must remove fluid or tissue from the breast to be sent to the lab to look for cancer cells. The procedure, called biopsy, may be performed using a needle to acquire a tissue sample or a surgical method.

A biopsy is a procedure performed to remove tissue or cells from the body for examination under a microscope. A breast biopsy is a procedure in which samples of breast tissue are removed with a special biopsy needle or during surgery to determine if cancer or other abnormal cells are present.

Biopsies may be performed under local or general anesthesia. There are several types of breast biopsy procedures. The type of biopsy performed will depend upon the location and size of the breast lump or abnormality.

Types of breast biopsy procedures include, but are not limited to, the following:

  • Fine needle aspiration biopsy – a very thin needle is placed into the lump or suspicious area to remove a small sample of fluid and/or tissue. No incision is necessary. A fine needle aspiration biopsy may be performed to help to differentiate a cyst from a lump.
  • Core needle biopsy – a large needle is guided into a lump or suspicious area to remove a small cylinder of tissue (also called a core). No incision is necessary.
  • Surgical biopsy (also called an open biopsy) – a surgeon removes part or all of a lump or suspicious area through an incision into the breast. There are two types of surgical biopsies. During an incisional biopsy, a small part of the lump is removed; whereas during an excisional biopsy, the entire lump is removed.

In some cases, if the breast lump is very small and deep and is difficult to locate, the wire localization technique may be used during surgery. With this technique, a special wire is placed into the lump under X-ray guidance. The surgeon follows this wire to help locate the breast lump.

There are special instruments and techniques that may be used to guide the needles and to assist with biopsy procedures. These include:

  • Stereotactic biopsy – finds the exact location of a breast lump or suspicious area by using a computer and mammogram results to create a three-dimensional picture of the breast. A sample of tissue is removed with a needle.
  • Mammotome® breast biopsy system (also called vacuum-assisted biopsy) – a type of tube is inserted into the breast lump or mass. The breast tissue is gently suctioned into the tube, and a rotating knife removes the tissue. In 1999, the U.S. Food and Drug Administration approved the use of the hand-held Mammotome device.
  • Ultrasound-guided biopsy – a technique that uses a computer and a transducer that sends out ultrasonic sound waves to create images of the breast lump or mass. This technique helps to guide the needle biopsy.

A procedure called sentinel node biopsy is used to determine if cancer cells have spread to other parts of the body. This surgical procedure may be performed during the intital diagnostic period to aid in staging of the breast cancer. This procedure involves injecting a dye and/or radioactive substance near the tumor. This injection helps to locate the lymph node closest to the tumor (sentinel node) — the one that is most likely to have cancer cells present if the cancer has spread. The surgeon removes the lymph node that absorbs the dye and radioactive substance and sends it to the pathologist to examine it closely for the presence of cancer cells.

Back to top

What is staging of breast cancer?

When breast cancer is diagnosed, tests will be done to find out if the cancer has spread from the breast to other parts of the body. This is called staging, and is an important step toward planning a treatment program.

What are the different stages of breast cancer?

As defined by The 2002 American Joint Committee on Cancer Staging Manual (Sixth Edition) and referenced online at http://www.cancer.org, stages of breast cancer are based on the size of the cancer, the number of lymph nodes with cancer and whether the cancer has spread to other parts of the body beyond the breast.

 

 

Carcinoma in situ or Stage 0

Most oncologists believe Stage 0 is not a true cancer; it is considered a marker of higher risk, indicating a woman may develop breast cancer in the future:

  • Ductal carcinoma in situ (DCIS) is the earliest form of breast cancer. In DCIS, cancer cells are located within a duct and have not invaded the surrounding fatty breast tissue.
  • Lobar carcinoma in situ (LCIS) is sometimes classified as Stage 0; however, most oncologists believe it is not a true cancer. Instead, LCIS is considered a marker of higher risk, indicating a woman may develop breast cancer in the future.

Stage I

The cancer is no larger than 2 centimeters (about 1 inch) and has not spread to lymph nodes or distant sites, such as bone, liver, lung or brain.

Stage II

Stage II is subdivided into stages IIA and IIB:

  • Stage IIA is defined by any of the following:

    • No cancer is found in the breast; however, one to three lymph nodes under the arm have cancer.\
    • The cancer is no larger than 2 centimeters (about one inch) but has spread to one to three lymph nodes under the arm (the axillary lymph nodes).
    • The cancer is between 2 and 5 centimeters (from 1 to 2 inches), but has not spread to the lymph nodes under the arm.
  • Stage IIB is defined by either of the following:

    • The cancer is between 2 and 5 centimeters (1 to 2 inches) and has spread to the lymph nodes under the arm.

      or
    • The cancer is larger than 5 centimeters (larger than 2 inches), but has not spread to the lymph nodes under the arm.

Stage III

Stage III is subdivided into stages IIIA and IIIB:

  • Stage IIIA is defined by either of the following:

    • The cancer is smaller than 5 centimeters and has spread to the lymph nodes under the arm, and the lymph nodes are attached to each other or to other structures.

      or
    • The cancer is larger than 5 centimeters and has spread to the lymph nodes under the arm. 
  • Stage IIIB is defined by either of the following:

    • The cancer has spread to tissues near the breast (skin or chest wall, including the ribs and the muscles in the chest).

      or
    • The cancer has spread to lymph nodes inside the chest wall along the breast bone.

Stage IV

This stage is defined by either of the following:

  • The cancer has spread to other organs of the body, most often the bones, lungs, liver or brain.

    or
  • The tumor has spread to the lymph nodes inside the neck, near the collarbone.

Inflammatory breast cancer

This type of cancer is rare and the breast looks as if it is inflamed because of its red appearance and warmth. Skin may show signs of swelling or it may have a pitted, dimpled appearance. This stage is considered Stage III unless it has spread to organs or lymph nodes far from the breast.

Recurrent

In this stage, the cancer has come back (recurred) after treatment. It may come back in the breast, in the soft tissues of the chest (the chest wall) or in another part of the body.