-: [Professor Anurag] The evaluation of a patient
presenting with breast symptoms, namely a lump,
pain in the breast, nipple discharge, nipple retraction,
or any change in shape or size of the breast
is carried out by triple assessment.
The triple assessment consists of clinical evaluation
with focused history and clinical breast examination
followed by breast imaging
and finally histological confirmation
of the disease by biopsy of the abnormal lesion.
Triple assessment for symptomatic breast disease,
comprises three arms,
clinical evaluation,
imaging of the breast
and pathological confirmation of the lesion.
Why we insist on triple assessment?
Because the combined diagnostic accuracy
exceeds 95% to 100%
and we can obtain a confident diagnosis
in 95% cases or more.
Let us now learn the method of history taking
and clinical breast examination.
The learning objectives of this module
are to note what to ask from a patient with a breast problem
and record the history,
and then learn the method of physical breast examination,
also called clinical breast examination.
While taking history note down the following points.
If the lady noted the presence of a lump,
it's duration, it's rate of growth,
whether it's growing rapidly or slowly,
whether she noted any pain in the lump, or it is painless.
If she noted presence of any nipple discharge,
please ask her about the colour of the discharge,
the duration of the discharge,
whether it occurs spontaneously,
that is without any pressure,
or occurs only on pressing the breast or the nipple area.
Please also note whether the discharge
emanates from a single milk duct,
or from several ducts on one side,
or from both nipples.
Note down the use of any oral contraceptive pill
or hormone replacement therapy
or other hormones being used.
Associated medical history
in the form of history of blood pressure,
heart disease, diabetes,
and what drugs she's taking for these ailments
should also be recorded.
Especially important is the intake of aspirin
and other antiplatelet drugs,
because they need to be stopped
few days prior to biopsy to reduce the chance of bruising
or undue bleeding at the time of operation.
Note down the history of previous breast disease
and if she has undergone any surgical treatment
for the breast condition,
because this may determine the type of therapy you offer.
Any past history of nipple discharge
should also be recorded.
And in the family,
if some members on mother's side or father's side
have suffered from breast cancer, ovarian cancer,
or any other cancer among the family members
should also be recorded.
Clinical breast examination is carried out in two steps
inspection or seeing the breast
and palpation or feeling the breast.
Usually we do not carry out any percussion and auscultation.
Please note that inspection is best carried out
in sitting position.
You can remember it as S for S, seeing in sitting position
and feeling in flat or supine position,
S for S and F for F.
Inspection is performed in two steps.
Step one involves seeing the lady
in sitting upright position with the arms by the side,
hands kept on the waist.
It is important to appreciate
that the lateral border of the breast
and axilla should be freely visible
so that any abnormality in this area can be noted.
Note down any asymmetry in the breasts on the two sides,
any skin change, presence of any prominent veins
over the breast area should be noted.
Record presence of any dimpling,
or puckering or any bulge in a particular region.
Colour of the nipple and areola should be noted,
size and position of the nipple areola complex
on the two sides should be recorded.
Note the direction that the nipple takes
and if there is any variation on the two sides.
Nipple may be pointing in front, or on sideways.
Any in-drawing of the nipple, that is retraction,
or inversion of the nipple should also be noted.
In step two of inspection
we request the lady to raise her hands above the head.
On arm elevation, note skin of the breast going inside
in the form of dimpling or puckering
and nipple going inside called nipple retraction.
Please also observe the lower half of the breast
and inframammary crease carefully.
Four search patterns are described
for carrying out clinical breast examination or CBE.
These are dial of clock method.
The vertical strips method, concentric ring method,
and quadrant wise method.
Let us now learn each of these in detail.
In the dial of clock method we imagine the breast
as representing dial of a wall clock
with 12 o'clock being located at a point
just below the mid clavicular point
and six o'clock being at the inframammary crease.
Three o'clock for the right breast
is located at the parasternal edge near the midline.
And nine o'clock is located at the mid-axillary line.
For the left breast 12 o'clock and six o'clock
are at the same location.
However, three o'clock would be located at mid-axillary line
while nine o'clock would be located near the midline.
In the vertical strips method
we start the palpation of the breast from one edge
and in a manner shown here,
following these vertical strips or lines,
we carry out the palpation in the vertical strips,
starting from one edge to the other side.
Similarly on the left breast we'll start
either from the medial side or from the lateral side
and complete the palpation of the entire mammary gland
from lateral to the medial edge.
In the concentric method,
we start either from the periphery
and in concentric ring like arrangement.
We complete the palpation going from outside
to the center in a centripetal manner.
One could also start from the center
near the nipple areola,
and then go in concentric rings,
very thoroughly centrifugal method.
And lastly, you can palpate the mammary gland,
imagining the breast as divided into four quadrants,
the upper outer quadrant,
upper inner quadrant,
lower inner quadrant and lower outer quadrant.
Please note that the area of the nipple and areola
is called the central region or retro areola region.
Please do not call it central quadrant,
because quadrant essentially means one fourth.
It's important to appreciate
that the lateral part of the breast
should be palpated in semi lateral position
with the lady requested to roll onto the opposite side
so that the breast tissue by gravity
falls towards the midline
and the lateral half of the breast becomes flat.
One could use our fingers with different manner,
either rubbing action of the fingers,
using pad of three fingers could be carried out,
or you can have vertical movement of the fingers
or piano like movement of the fingers
as if you are playing a piano.
The commonest method adopted by most clinicians
is using pad of three fingers
by the rubbing or circular motion.
Now we shall demonstrate
the actual examination of the breast
showing you a series of video animation
and actual patient's films.
The breast is like a conical mound
with an antero-posterior projection.
On lying supine
the breast tissue is stretched
or the chest wall with decrease
in antero-posterior projection,
thus a rounded mound like structure
becomes a flat disc on lying supine.
Let us visualize the change in alignment,
or orientation of ductal lobular tissue
with change in posture.
In sitting upright, the lobes of breast parenchyma
are oriented in predominantly an antero-posterior direction.
In the supine position however,
the lobes are stretched apart
and are oriented in horizontal plane,
parallel to the chest wall.
In this flattened state,
the skin of the breast comes closer to the rib cage
and enables your palpating fingers
to detect even a small lump,
or change in consistency of the breast tissue.
Most effective method of breast palpation
involves pad of three fingers.
Note that maximum concentration of touch
and pressure receptors is found in our pad of fingers.
A circular motion of pad of three fingers
with gentle pressure enables detection
of a superficial abnormality in a skin or subcutaneous fat.
Palpation with an intermediate pressure
allows you to find a lump or abnormality
in the breast parenchyma,
while palpation with deep pressure
detects an abnormality of chest wall
or deeper part of the breast.
Let us now recap the pathogenesis of various physical signs,
such as dimpling, skin edema,
and retraction of the nipple.
Tumour in the breast arising in vicinity of Coopers ligament
releases various growth factors,
including fibroblasts growth factor or FGF,
which stimulates the neighbouring fibroblasts
to lay down collagen bundles
depicted here by bundles of three tropocollagen molecules.
These bundles finally join together
to form mature collagen scar.
Collagen has a unique property to shrink.
Shrinkage of the Coopers ligament results in pulling
or in-drawing of the skin near the tumour
resulting in dimpling.
If the same process of collagen deposition
occurs in the neighbourhood of mammary ducts
lead to the areola, it leads to pulling inside
or in-drawing of the nipple
resulting in retraction of the nipple.
Let's see what causes a skin edema or peau d'orange.
Peau d'orange is a French word.
Peau means the skin d' means of and orange means orange,
orange peel appearance.
Tumor cells dislodge from the primary site,
travel through the regional lymphatics,
reach the axillary lymph nodes,
block the normal lymphatic pathway
resulting in lymphatic reverse flow.
The lymph shown here as yellowish brown
dilated ducts, then collects in a retrograde manner
in the dermis.
This lymphedema of the dermis
results in elevation of the skin between the hair follicles
resulting in classical picture of orange peel appearance,
or peau d'orange.
We are demonstrating clinical breast examination
on a lady age at 40 years,
presenting with a painless breast lump.
For last three months, there was no nipple discharge.
We request her to disrobe up to the waist
in a warm and comfortable room with full privacy
and a lady chaperone.
We begin the clinical breast examination by inspection
with the lady being seated upright
with arms by the side on her waist.
We evaluate the two mammary glands
for any asymmetry of the size, shape,
and level of nipple and areola,
direction that the nipple takes,
any color change or the breast or in the armpit.
Any prominent vessels, ulcer,
or skin nodules are also noted.
The next step is request her to elevate
both her arms above the head.
In this position again,
note down any in-drawing of the nipple or areola,
or skin or the breast.
In sitting position with the arms raised above the head
the pectoralis major muscle is pulled up
due to its attachment to the humerus.
This in turn pulls the pectoral fascia
and the Coopers ligaments attached to this pectoral fascia.
If these Coopers ligaments are shortened
by desmoplastic reaction,
they pull the attached skin or the nipple areola complex
towards the chest wall leading to nipple retraction,
or dimpling, or puckering of the overlying skin.
The palpation is next carried out in supine position
with the lady lying on a hard bed or a couch,
pillow placed under the shoulder blade.
She's requested to keep her hand above the head
in order to stretch the mammary gland
by stretching the pectoralis major muscle.
There are various methods of breast palpation.
We are demonstrating dial of a clock method.
In this method the mammary gland is divided into 12 sectors
like dial of a clock,
12 o'clock being located at the mid clavicular point
just below the clavicle and six o'clock being located
at the inframammary crease in the lower part of the breast.
On the right side,
three o'clock would correspond to the midline
and nine o'clock would correspond to the mid-axillary line.
On the left side,
three o'clock will be located at the mid-axillary line
and nine o'clock will be located at the midline.
The palpation is carried out using pad of three fingers
as demonstrated on this video.
Gentle pressure is applied
to feel the skin and subcutaneous tissue.
Next by rotating movements of the three fingers
firm pressure is applied to feel any abnormality
of the breast parenchyma.
And next, even firmer pressure is applied
to feel the abnormality of the underlying rib cage.
We begin the palpation
starting at the periphery of the breast
and proceed towards the nipple areola complex,
describing a circle of about three centimeter in diameter.
The next circle should half overlap the previous one.
This is carried out to reduce the chance
of missing any palpatory abnormality.
one, two, three, 12 O'clock,
One, two, three, one, two, three,
one, two, three, one two, three, one, two, three.
Similarly, one, two, three, one, two, three,
one, two, three, one, two, three.
When we are palpating one o'clock
we pull towards seven o'clock, diagonally opposite.
then two o'clock, one, two, three, two, three,
one, two, three, one, two, three, 3 o'clock.
While I'm palpating three o'clock
I pull the breast to the nine o'clock,
one, two, three, one, two, three, one, two, three.
So this is one circle, second circle, third circle,
and go like three o'clock and four o'clock
one, two, three, one, two, three, one, two, three,
5 o'clock one, two, three, one, two, three.
Six o'clock one, two, three, one, two, three.
So for palpating the outer half of the breast
from seven o'clock to 11 o'clock,
we request the lady to gently roll on the opposite side
so that by gravity breast tissue falls towards the midline.
seven o'clock starting from the inframammary crease,
one, two, three, one, two, three, one, two, three,
one, two, three, one, two, three,
one, two, three, one, two, three.
For nine o'clock I pull towards the three o'clock.
Then we can change hands, 10 o'clock,
one, two, three, one, two, three, one, two, three.
11 o'clock, one, two, three, one, two, three,
and back to 12 o'clock.
This completes the palpation of the breast tissue.
The next part of palpation is focused
towards palpating the mammary ducts.
Major mammary ducts measure about three centimeter in length
from the nipple.
And we palpate these major milk ducts
rolling these ducts between thumb and index finger
in two directions, 12 o'clock and six o'clock,
and then three o'clock and nine o'clock.
Two such movements are carried out
to palpate these major ducts.
And one tries to identify any firmness
or hardness of the milk ducts.
Normal milk ducts are said to be soft and supple
with no pain
and palpation does not yield any fluid.
However, if ducts feel core like or tender to touch,
they are usually indicative of some inflammatory pathology
like periductal mastitis.
Any discharge is also noted
while palpating the major milk ducts.
Now we examine the diseased breast.
For the outer half we request the lady
to roll over the opposite side.
start palpating from 12 o'clock
and continue 'til six o'clock.
Palpation from seven o'clock to 11 o'clock
is carried out in supine position.
On finding a discrete lump, measure its dimensions
using our near caliper in two axis,
the maximum diameter and the diameter at 90 degree
to the maximum diameter,
Ascertain its fixity to overlying skin
and underlying muscle.
Note upper two third of the breast
lies on the surface of pectoralis major muscle,
hence ascertain the fixity of the mass to pectoralis major
for lumps located in upper two third.
The lower outer quadrant of the breast
lies on the surface of serratus anterior muscle.
Hence test the fixity of serratus,
requesting the lady to push against your shoulder
or to the wall.
Axillary nodes are best examined in sitting position.
Explain the lady that you are going to feel the armpit
and that it may feel ticklish.
In order to relax the pectoral muscle
support patient's forearm on your forearm
and steady the shoulder by placing your other hand,
over patient's shoulder.
First, pectoral nodes are felt
by placing your fingers behind the pectoralis major
and the thumb placed in front of pectoral muscle
to provide counter pressure.
Pectoral or anterior nodes are first to be involved
in breast cancer or infection of the breast.
So examine this group very carefully.
Next, rotate your hand towards the ribcage.
You are now feeling the medial group of nodes.
Now rotate the hand towards the surgical neck of humerus
to palpate the lateral group of nodes.
Apply your thumb on the greater tuberosity of humerus
to provide counter pressure.
Next, raise the hand above the head
and try palpating the apical group of nodes
high up in the axilla.
The apical nodes are difficult to feel
and are rarely enlarged.
Let us now move to the back of our patient
to palpate the neck and axilla.
This method of feeling both sides of the neck, axilla
and the breast is called the mirror image method,
first described by professor L.E Hughes of Cardiff.
We start feeling the supraclavicular nodes
lying above the clavicle,
and then infraclavicular nodes,
lying in the delto-pectoral triangle below the clavicle.
The delto-pectoral triangle is bounded by the deltoid,
the clavicular head of pectoralis major
and the lower border of the clavicle.
It contains infraclavicular node along the cephalic vein.
Now request the lady to give a gentle cough
and feel the lateral border of latissimus dorsi muscle.
When she coughs the muscle called latissimus dorsi
becomes palpable,
which runs along the posterior axillary crease.
Lady keeps her hands on the knee joint
to keep the muscles relaxed.
Surgeon puts the fingers
just in front of the latissimus dorsi
and thumb behind the posterior axillary fold like this.
By this kind of movement,
we palpate the posterior axillary folds,
two sides simultaneously.
We then turn the hand towards the chest fold.
We are palpating both medial group against the rib cage.
Then turn the hand 90 degree against the neck of humerus,
against the surgical neck, you palpating the lateral node.
So supraclavicular, infraclavicular,
posterior, in front of latissimus,
medial against the ribs and lateral
against the surgical neck of humerus.
So we cover five sets of nodes from the back.
And this method is called mirror image method
of breast axilla palpation,
first described by Professor L.E Hughes of Cardiff.
Having conducted the clinical evaluation
let us talk about details of breast imaging.
Ultrasound is carried out for all women
presenting with symptomatic breast disease,
evaluating the sonographic features of the breast,
the major milk ducts and the regional nodes in the axilla.
Mammogram is carried out for women
presenting with symptomatic disease, aged 35 and above.
MRI is a problem solving tool
and is carried out in selected patients
in whom there is a strong family history
starting at age 20 to 25 years of age.
Women who are undergoing breast conservation
and there is some suspicion of multicentricity,
patients where tissue diagnosis reveals lobular histology,
lobular carcinoma.
Remember the rule of 10 for lobular carcinoma,
10% are bilateral and 10% are multicentric.
And 10% of all cancers happen to be lobular in nature.
And finally, the last limb of the triple assessment
comprises histological evaluation.
Besides mammography, ultrasound and MRI,
in some patients,
we also arrange a whole body PET-CT scan
to detect any metastatic focus
from invasive breast carcinoma.
The mammogram is conventionally carried out in two views,
the medio-lateral oblique view
and a cranio-caudal view.
In the medio-lateral view
The x-rays pass from medial side of the breast
to the lateral side, towards the armpit
and in the cranio-caudal view,
x-ray source is located near the head,
hence the name cranio,
and they pass through the mammary tissue towards the foot
that is caudal, cranio-caudal, in this direction.
And note that the mammary gland is compressed gently
between the two plates, the upper plate and the lower plate.
And there is soft sponge like layer
to reduce the discomfort to the lady.
The compression of the mammary gland between the two plates
is essential to obtain the picture of the entire breast.
So this is how the picture will appear
in the upper medio-lateral view
where you have the chest fall
comprising pectoralis major muscle
and a good mammogram should demonstrate
the pectoralis major muscle up to the level of the nipple.
This is the upper part of the breast.
This is the lower part of the breast
on a medio-lateral view,
and even axilla and axillary nodes can be seen in this view.
Whereas in the cranio-caudal view,
we see the features of the mammary gland
without seeing the axilla.
This is the skin, the nipple and areola,
the breast parenchyma proper looking like dense tissue.
And this area is actually the retromammary fat.
The modern digital mammography machines
are fitted with computer edited diagnostic programs,
which yield very high resolution of the lesion,
which can further be magnified or zoomed,
as in this case to reveal the detailed features of a lesion
such as architecture distortion,
microcalcification, and so on.
Let us see how ultrasound helps a patient
with breast problem.
It is a preferred test in all patients below age 35,
because in young ladies,
breast tissue is rather radio dense
and sonography is the ideal method of investigation
of these young ladies.
It also enables performance
of image guided core biopsy of the lesion.
It is very safe as there is no radiation exposure.
Of course it is dependent on the operator
who performs the sonography.
And therefore we need an expert
to perform detailed, thorough sonographic evaluation
of the entire breast,
including the major milk ducts
and the regional nodes in the armpit.
This is the picture of a classical fibroadenoma,
well defined, almost homogenous density of the lesion.
And usually the fibroadenoma are classically described
as wider than taller.
That is, this axis is wider than vertical axis.
Whereas in cancers, the vertical dimension is more,
because cancers tend to grow in antero-posterior dimension
and hence we call a cancerous or suspicious lesion
as taller than wider.
And please note that in a suspicious lesion for carcinoma,
we'll find irregular margins,
some lobulation or microlobulation
and areas of calcification inside
with the considerable architecture distortion
around the lesion.
Ultrasound usually has low sensitivity
for picking up in situ carcinomas, DCIS.
And it has high false positive rates,
because many benign lesions may look suspicious.
Because of the operator dependence of the sonography
we need a dedicated breast imaging expert
who has spent several years
in evaluation of the breast images by sonography,
mammography, and MRI,
who can easily discern the area of suspicion
and carry out biopsy of the most suspicious area
within a lesion.
A simple cyst will look totally anechoic like this
with thin walls all around.
And this is called BIRADS 2 lesion.
And the importance of ultrasound for such lesion
is the fact that such simple cyst
do not require any biopsy or aspiration
and no specific treatment other than reassurance
and follow up is required.
A complicated cyst is defined as a cyst
which has some floating debris such as this area here.
And this is classically seen
in patients with pyogenic abscess,
sometimes tubercular abscess, and in galactocele.
Some modern ultrasound machines
are fitted with the ability
to detect the compressibility of the lesion,
also called elastography.
In this mode,
we are able to detect the rigidity,
or compressibility of the lesion,
and there is a standard scale depicted by a colour code.
The orange area here indicates hardest lesion
and the blue area depicts the softer lesion.
Pure cyst will look as blue lesions.
So we are able to discern the structural compressibility,
or you can say Young's modulus of the lesion
on elastography.
Some carcinomas induce desmoplastic reaction,
which is due to release of fibroblast growth factors
from the tumour cells.
The fibroblast growth factor stimulates
the surrounding fibroblast to produce collagen.
Collagen makes the surrounding tissue firm to hard.
And this can nicely be detected by the elastography machine,
which demonstrates the areas of desmoplastic
dense collagenous tissue or around tumour.
Compare this picture with a simple sonography
where only the lesion is seen
with no dense tissue around it.
Magnetic resonance tomography of the breast
is used primarily as a problem solving tool
in patients where there is a discordance
between the mammographic findings
and the clinical observation.
It is also useful
in identifying multicentricity within the breast
and to differentiate a scar area from a recurrent tumour
in patients who have undergone breast conservation surgery.
In women who carry a higher than normal genetic
or family risk for developing breast cancer,
magnetic resonance tomography,
or MRI of the breast is very sensitive screening tool.
It is also needed for patients
who demonstrate lobular histology on core breast biopsy.
Please note that MRI scan with gadolinium contrast
has demonstrated an area
which is very suspicious for cancer,
and this area should be biopsied
to identify its histological nature.
Please note that MRI of the breast
should always be carried out
with gadolinium intravenous contrast
and especially designed breast coils,
which encircle the mammary glands
in a lady who is lying prone
in a specially designed MR table.
A large study where 2,600 patients were evaluated
in a meta-analysis revealed that MRI of the breast
can pick up 16% more lesions,
which were missed by conventional mammography
and ultrasound of the breast.
Moreover, in women who were planned
to undergo wide local excision of the breast
based on mammographic or ultrasound finding,
in 8% of these,
because more lesions or wider lesions were found,
mastectomy had to be carried out.
And in 11% patients a smaller wide local excision
became a more extensive wide local excision,
based on the MRI finding.
MRI of the breast is very helpful
in finding the areas of multicentric
and multifocal tumours within the breast,
or in the opposite breast as well.
Otto Heinrich Warburg,
a famous German scientist won Nobel Prize in 1931,
for describing a unique fact about cancer cells,
which depend almost exclusively on glucose
for supply of energy.
Cancer cells ferment glucose to lactic acid,
even in presence of oxygen,
and this is called aerobic glycolysis.
So we can summarize this equation as follows,
glucose converted to lactate,
along with production of four molecules of ATP.
This happens even in presence of oxygen,
hence the name aerobic glycolysis.
It has been found that this uptake of glucose
is seen in any population of rapidly dividing cells,
be it in cancers or a healing wound or fracture
or site of inflammation.
And this is called Warburg effect.
A PET-CT scan is based on this principle,
first initiated by Otto Heinrich Warburg.
We inject an isotope of fluorine called F-18
tagged to a glucose molecule called fluorodeoxyglucose
or in short known by acronym FDG.
And patient is then evaluated
by positron emission tomography,
or known in short by acronym P E T or PET-CT scan.
It's indicated in staging of patients
presenting with locally advanced breast cancer
and sometimes to discern an occult primary in the breast,
especially if it is not visible on mammography.
It has also been found to be helpful
in predicting the response to neoadjuvant chemotherapy.
And in the follow up PET-CT scan can be used
to detect recurrences either in the local regional area,
or in the systemic spread in bones,
liver, lungs, and brain.
On this picture, we have shown you a PET-CT picture.
Please note that this is the site of the hot spot,
because tumour cells have a markedly increased uptake of
F-18
and F-18 being radio isotope is picked up
by the PET-CT machine and shows as a hot spot.
Axillary lymph node metastasis
and tumour in the opposite side can also be picked up.
There is some physiological hard area
in the urinary bladder area.
PET-CT scan has been found to be fairly accurate
in detecting large tumours in the breast
with an accuracy of 88%.
Even for small tumours, less than one centimeter in
diameter
it is able to detect with about 57% of accuracy.
A special type of mammography called
positron emission mammography
has been found to have a high sensitivity
ranging from 50 to 90% in different cities
and a specificity ranging from 33 to 100%.
And it can even pick up small in situ cancers or DCIS.
For evaluation of the auxiliary nodes
it has a sensitivity of 61% and specificity of about 80%.
It is very helpful in metastatic workup
of patients presenting with advanced breast cancer.
Now we come to the histological evaluation.
This is usually carried out
by taking a large needle core biopsy
using a 14 gauge diameter needle,
which is especially fitted with a cutting cup,
which cuts a piece of tissue.
The procedure is performed
under lignocaine local anesthesia.
And the average size of the core
is of the diameter of a pencil lead.
Now we talk of histological evaluation.
It is usually carried out
by performing a large needle core biopsy.
We usually use a 14 gauge diameter needle,
which is especially fitted with a cutting cup near the tip.
It collects a core of tissue
about the size of a pencil lead.
This needle is passed into the tissues
and then using this cup,
we collect a block of tissue into the tip,
which is then sent for histological evaluation.
The procedure is carried out under image guidance,
mostly under ultrasound guidance,
or if the lesion is seen only on mammogram,
under mammographic control.
We obtain five or more cores of the tissue
on the biopsy needle.
It attains very high accuracy
compared to final aspiration cytology of the breast lesions.
It can discern in situ lesion
and distinguish it from invasive breast cancer.
It'll also allow you to assess the grade of the tumour,
the histological specific type of the lesion,
the presence of estrogen, progesterone,
and HER 2/neu receptors and the mitotic index
assessed by Ki67.
Please note that core biopsy is mandatory
prior to commencing neoadjuvant chemotherapy,
because if the whole lesion disappears on chemotherapy,
you'll not have any tissue available to you
to assess these receptors
after the course of chemotherapy is over,
hence always collect the information on these parameters
prior to commencing any chemotherapy,
or neoadjuvant hormone therapy.
One of the earliest randomized trial
to evaluate the benefit of image guidance
versus blind or palpation guided biopsy
was carried out in All Indian Institute of Medical Sciences
by Dr. Smriti Hari and her group.
And this is the publication.
You can read the details in this study.
36 patients underwent sonographic core needle biopsy,
and the other 36 patients were evaluated
by blind palpation guided core biopsy.
We found that the sensitivity, the specificity,
the positive and negative predictive values
reached 100% in the group evaluated by image guided biopsy
as compared to only 61% sensitivity
and a false negative rate of 38% in women
who had a palpation guided blind biopsy.
So as far as possible,
always arrange image guided biopsy
to attain high accuracy
and minimize the false negative rate.
So, you know what is the harm
of having high false negative like this?
If you perform the biopsy in hundred women,
38 women will return back to the clinic
four to five days later with this report,
which does not confirm the true nature of the disease.
So you have to repeat the biopsy.
The poor lady has to undergo another painful procedure,
more bruising, more discomfort.
And of course, delay in the actual commencement of treatment
by about a fortnight.
What should we do if the lesion is not palpable
and is only seen on mammogram?
We arrange a stereotactic biopsy by a special instrument
called vacuum assisted biopsy system.
It enables you to obtain very wide,
eight to nine millimeter wide cores of tissue.
And usually radiologist will obtain 20 cores,
or even more in large lesions.
And they often place a steel clip
at the site of the biopsy site,
because if these cores demonstrate any cancer,
or suspicious atypia,
we have the ability to pick up that area
via metallic steel clip,
and then excise that suspicious area
with a wire guided procedure.
How do we perform this vacuum assisted biopsy?
We use a special tool called vacuum assisted biopsy gun,
or Mammotome.
This is the trade name by a company Johnson and Johnson.
And there are other makes available in the market as well.
Here, as compared to ordinary core biopsy,
where the radiologist makes several
separate needle insertions to obtain multiple samples,
here the needle enters the tissue only once
through a small incision,
and then keeps collecting the tissue
by repeated movement of the gun
under strong vacuum created by the machine.
If a suspicious lesion is seen
and the biopsy by vacuum assisted device
has demonstrated either carcinoma or atypia
we excise that area by wire guided excision procedure.
Here under image guidance on a mammogram,
we locate the lesion after injecting
some lignocaine local anesthetic, and a wire is passed.
So through a specially designed grid,
the radiologist would calculate the three coordinates,
the X, Y, and Z in relation to the surface of the breast,
and then pass the wire
exactly at the site of suspicious lesion.
This is a specially designed hook wire,
which is passed under image guidance
on a high resolution mammographic machine.
You can see the insertion probe
through which a wire will be inserted.
Patient is then shifted with the wire in situ
to the operation theater
and radiologist helps the surgeon
by making a mark with permanent skin pen
near the tip of the lesion
so that we can carry out excision
without much tissue damage.
This is the suspicious area where a wire has been passed
and the lesion has been excised with the wire intact.
The specimen is then taken back to the mammography machine
where specimen mammography,
or sonography as the case may be,
is carried out to ensure that the tip of the wire
is actually in the center of the excised specimen
and the entire specimen has been removed.
And if there were microcalcifications,
one counts all the microcalcifications
to ensure that the entire suspicious area has been excised.
The skin wound is closed once the entire excision
has been confirmed on a specimen mammography
and patient is then seen in the clinic
with the histology report.
In this teaching video, we'll be demonstrating you
a stereotactic vacuum assisted core biopsy.
There's a special table where there's a hole
through which the breast will hang
between the mammographic plates.
Lady is lying in prone position under full explanation
and local anesthetic injection.
Here the breast tissue is hanging
through this hole in the table
and is now gently compressed
between the mammographic plates.
The lesion is identified on the mammogram,
and then this is the vacuum assisted biopsy gun
with a 8 gauge biopsy needle.
There's a suction tubing attached to the suction machine
it's electrodes, and the tubings are being attached.
There's the suction device.
The machine is set to take the biopsy.
Here the radiologist is locating the site of the biopsy
after local anesthetic infiltration in their skin.
The biopsy gun is localized
using a stereotactic localization
on the mammographic screen.
And then this is the site through which,
after infiltration of the local anesthetic,
a small incision with a 11 number blade
facilitates the entry of the biopsy gun into the lesion.
And then rest of the procedure is guided
by the computer device, locating the X, Y, Z axis
of the localization,
hence the name stereotactic biopsy.
And you can see the amount of tissue
you can sample using this device.
Very large cores with this 8 gauge biopsy needle.
And it is important to,
so the specimen is spread onto a sterile paper,
and then it is put on the mammographic machine
to make sure that all the microcalcifications
have been sampled.
And then the tissue is put in a biopsy specimen bottle
containing 10% formal saline solution
and is sent for histological confirmation of the diagnosis.
Make sure that all the specimen cores
sink at the bottom of the bottle,
because fat, it will usually float
and solid biopsy tissue
will sink at the bottom of the bottle.
Let us now see an ultrasound guided vacuum assisted biopsy.
The same biopsy gun is used here
and under a sterile technique
and localization is now carried out
using a high resolution ultrasound probe.
Here the radiologist has located the lesion
on the ultrasound screen,
and then after local infiltration of the overlying skin,
The same vacuum biopsy gun is introduced
under ultrasound guidance.
You can see the biopsy needle entering the lesion
and taking large cores.
And once again,
please note the amount of tissue sampled by this device
compared to ordinary core needle biopsy.
The area is pressed for five minutes
to prevent any hematoma formation.
And once again,
radiologist make sure that all the samples
sink at the bottom of the bottle.
The lesion is localized under ultrasound guidance
and a solid part of the lesion is chosen
for obtaining biopsy.
The skin is cleansed with antiseptic
povidone-iodine solution
and area is draped with sterile towels.
Skin is anesthetized
with lignocaine 2% local anesthetic solution.
Biopsy gun with 14 gauge needle is utilized
for obtaining tissue biopsy.
A small stab incision is made at the biopsy site,
followed by insertion of the biopsy gun
guided by the ultrasound.
The needle track can be seen on the ultrasound.
Tissue has been placed in a specimen bottle.
The specimen bottle is sent to the department of pathology
for histological evaluation.
The suspicious area on mammogram has been identified
to place a wire under mammographic image guidance.
The skin is cleansed
with antiseptic povidone-iodine solution.
The area is draped with a sterile towel.
The probe is also covered in a sterile dressing,
and next using the ultrasound scan
one localizes the area.
Skin is anesthetized with 2% lignocaine local anesthetic
and wire insertion needle is then introduced
under sonographic guidance.
We can see the track the wire is taking
and its tip is localized just past the lesion.
Wire is firmly fixed to the skin
so that it does not dislodge.
Final position of the wire is confirmed on sonography.
And this is the final wire
inserted under ultrasound guidance.
The suspicious area is marked with a skin marking pen
and patient is shifted to operation theater
for excision of the suspicious area using wire guidance.
In conclusion, we should be cognizant of the fact
that triple assessment is essential for all women
presenting with either discrete breast lumps,
breast pain, nipple discharge, or nipple retraction,
or any other symptomatic breast disease.
A thorough clinical history and examination
should be followed by appropriate breast imaging
and axillary evaluation with ultrasound
followed by confirmation of the exact nature of the disease
by appropriate histology
or cytology of the nipple discharge.
It has been found that a combined approach
called triple assessment
can attain a diagnostic accuracy as near as 100%.