Diagnosis and Staging
The main goal at the Siteman Cancer Center is to get a correct diagnosis of your breast condition and decide if treatment is needed. Some breast diseases are benign or non-cancerous and may or may not need treatment. If the condition is a form of cancer, our specialists excel in using the technology and experience to make an accurate diagnosis, often down to the genetic level so the best treatment options may be identified.
Our radiologists, all of whom are affiliated with the internationally recognized Mallinckrodt Institute of Radiology, subspecialize in comprehensive breast imaging. That means 100 percent of the time, these specialists are solely dedicated to interpreting breast imaging studies at the main hospital campus and Barnes-Jewish West County Hospital.
Determining the exact condition, and if cancer, what specific type, often takes more than one approach:
Imaging and biopsies:
The Joanne Knight Breast Health Center offers a full array of all-digital breast imaging services, including screening and diagnostic mammography, breast ultrasound, and breast MRI.
The Breast Health Center is now an all-tomosynthesis (3D mammography) site, enabling radiology technologists to obtain breast images from multiple angles, reducing the potential for patient call-backs to obtain additional imaging scans.
Breast ultrasound is a non-invasive way to help physicians detect more cancers in women who have dense breasts and are at a higher risk of breast cancer. However, ultrasound may produce more false positive results and unnecessary biopsies, so, the Breast Health Center favors MRI for women with dense breasts. According to the American Cancer Society, women with a 20 percent to 25 percent or higher lifetime risk for breast cancer should obtain annual breast MRI screening in addition to annual mammography.
Specialized breast procedures that involve imaging include:
Fine needle aspiration: This is the least invasive method of biopsy. The surgeon or radiologist uses a thin needle with a hollow center to remove a sample of cells from the suspicious area. In cases where the lump cannot be felt, imaging studies guide the needle to the right location, such as with an ultrasound-guided biopsy. Stereotactic needle biopsies use mammography to guide the needle.
Image-guided core needle biopsy: Core needle biopsy uses a larger hollow needle than fine needle aspiration does. The surgeon or radiologist uses the hollow needle to remove several cylinder-shaped samples of tissue from the suspicious area, usually under image guidance. In most cases, the needle is inserted about 3 to 6 times so that the doctor can get enough samples.
Cyst aspiration: Breast cysts, fluid-filled sacs within your breast, are usually not cancer. You can have one or many, with firmness ranging from a water balloon to mimicking a solid structure. If they are painful, your surgeon or radiologist can insert a needle and drain them. The fluid can be sent for analysis in cases of suspected cancer.
Ductoscopy to evaluate nipple discharge: This test, available in few other hospitals in the St. Louis area, is a technique that enables doctors to directly examine the lining of milk ducts in the breast for early signs of cancer and other abnormalities. In women whose breast symptoms include a watery blood-tinged discharge from the nipple, a condition called pathologic nipple discharge (PND), ductoscopy helps the surgeon find the lesion, take it out and save normal breast tissue. More than 80 percent of cancer arises in milk ducts.
Surgical biopsy: Even if less invasive biopsy techniques don’t show cancer, some may indicate certain rare but benign conditions that should be further evaluated. When core biopsies showing these rare conditions were followed by a surgical biopsy, cancers were found in several cases.
Additional tests on the biopsied tissue help determine the type of cancer and the best treatment. These tests give information about:
- How quickly the cancer may grow
- How likely it is that the cancer will spread through the body
- How well certain treatments might work
- How likely the cancer is to recur
Tests include the following:
Estrogen and progesterone receptor test: This test measures the amount of estrogen and progesterone (hormones) receptors are in cancer tissue. If there are more estrogen and progesterone receptors than normal, the cancer may grow more quickly. The test results show whether treatment to block estrogen and progesterone may stop the cancer from growing.
Human epidermal growth factor type 2 (HER2/neu) receptor test: This laboratory test measures how many HER2/neu genes there are and how much HER2/neu protein is made in a sample of tissue. If there are more HER2/neu genes or higher levels of HER2/neu protein than normal, the cancer may grow more quickly and is more likely to spread to other parts of the body. There are specific drugs that target the HER2/neu protein.
Multigene tests: These tests study samples of tissue to look at the activity of many genes at the same time, and may help predict whether cancer will spread to other parts of the body or recur.
Oncotype DX and MammaPrint: These tests help predict whether stage I or stage II breast cancer that is estrogen receptor positive and negative for lymph node involvement will spread to other parts of the body. If the risk of the cancer spreading is high, chemotherapy may be given to lower the risk.
Staging of breast cancer
After breast cancer has been diagnosed, tests are done to find out if cancer cells have spread within the breast or to other parts of the body, a process called staging.
There are three ways that cancer spreads in the body:
- Through tissue: the cancer spreads from where it began by growing into nearby areas.
- Via the lymph system: the cancer spreads from where it began by getting into the lymph system, traveling to other parts of the body.
- In the bloodstream: the cancer spreads from where it began by getting into the blood and going to other parts of the body.
Metastasis occurs when cancer spreads to another part of the body. The metastatic tumor is the same type of cancer as the primary tumor. For example, if breast cancer spreads to the bone, the cancer cells in the bone are actually breast cancer cells. The disease is metastatic breast cancer, not bone cancer.
It is important to know the stage in order to plan treatment. The following tests and procedures may be used in the staging process:
Sentinel lymph node biopsy: The sentinel lymph node is the first lymph node the cancer is likely to spread to from the tumor. A radioactive substance and/or blue dye are injected near the tumor. The substance or dye flows through the lymph ducts to the lymph nodes. The first lymph node to receive the substance or dye is removed. A pathologist views the tissue under a microscope to look for cancer cells. If cancer cells are not found, it may not be necessary to remove more lymph nodes.
Chest x-ray: An x-ray of the organs and bones inside the chest can reveal other tumor sites.
CT scan (CAT scan): The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
Bone scan: This procedure checks to see if there are rapidly dividing cells, such as cancer cells, in the bone. A very small amount of radioactive material is injected into a vein and travels through the bloodstream. The radioactive material collects in the bones and is detected by a scanner.
PET scan (positron emission tomography scan): In this procedure, a small amount of radioactive glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do.
After the appropriate tests are done, the cancer can be staged. Staging represents the extent of cancer in the body. Staging is usually based on the size of the tumor, whether lymph nodes contain cancer, and whether the cancer has spread from the original site to other parts of the body.
Stage 0 (carcinoma in situ): There are 3 types of breast cancer in situ:
- Ductal carcinoma in situ (DCIS) is a non-invasive condition in which abnormal cells are found in the lining of a breast duct. The abnormal cells have not spread outside the duct to other tissues in the breast.
- Lobular carcinoma in situ (LCIS) is a condition in which abnormal cells are found in the lobules of the breast. This condition seldom becomes invasive cancer.
- Paget disease of the nipple is a condition in which abnormal cells are found in the nipple only.
Stage 1 is divided into 1A and 1B
- Stage IA breast cancer: the tumor is 2 centimeters or smaller and has not spread outside the breast.
- Stage IB breast cancer: small clusters of breast cancer cells are found in the lymph nodes and either no tumor is found in the breast or the tumor is 2 centimeters or smaller.
Stage 2 is divided into stages 2A and 2B.
Stage 2A breast cancer:
- No tumor is found in the breast and cancer is found in 1 to 3 axillary lymph nodes or lymph nodes near the breastbone; or
- The tumor is 2 centimeters or smaller and cancer is found in 1 to 3 axillary lymph nodes or lymph nodes near the breastbone (middle panel); or
- The tumor is larger than 2 centimeters but not larger than 5 centimeters and has not spread to the lymph nodes.
- The tumor is larger than 2 centimeters but not larger than 5 centimeters and small clusters of cancer cells (larger than 0.2 millimeter but not larger than 2 millimeters) are found in the lymph nodes (left panel); or
- The tumor is larger than 2 centimeters but not larger than 5 centimeters and cancer is found in 1 to 3 axillary lymph nodes or lymph nodes near the breastbone; or
- The tumor is larger than 5 centimeters and has not spread to the lymph nodes (right panel).
Stage 3 breast cancer is divided into 3A, 3B and 3C
Stage 3A breast cancer:
- No tumor is found in the breast or the tumor may be any size and cancer is found in 4 to 9 axillary lymph nodes or lymph nodes near the breastbone; or
- The tumor is larger than 5 centimeters and small clusters of cancer cells are found in the lymph nodes; or
- The tumor is larger than 5 centimeters and cancer is found in 1 to 3 axillary lymph nodes or lymph nodes near the breastbone, as found on sentinel lymph node biopsy.
Stage 3B breast cancer:
- The tumor may be any size and cancer has spread to the chest wall and/or to the skin of the breast and caused swelling or an ulcer. Cancer may have spread to up to 9 axillary lymph nodes or the lymph nodes near the breastbone. Cancer that has spread to the skin of the breast may be inflammatory breast cancer.
Stage 3C breast cancer:
- No tumor is found in the breast or the tumor may be any size and may have spread to the chest wall and/or to the skin of the breast and caused swelling or an ulcer. Also, cancer has spread to 10 or more axillary lymph nodes; or to lymph nodes above or below the collarbone; or to axillary lymph nodes and lymph nodes near the breastbone. Cancer that has spread to the skin of the breast may be inflammatory breast cancer. For treatment, stage 3C breast cancer is divided into operable and inoperable stage 3C.
Stage 4 breast cancer:
The cancer has spread to other parts of the body, most often the bones, lungs, liver, or brain.
Inflammatory breast cancer
In inflammatory breast cancer, cancer has spread to the skin of the breast and the breast looks red and swollen and feels warm. The redness and warmth occur because the cancer cells block the lymph vessels in the skin. The skin of the breast may also show a dimpled appearance like the skin of an orange. There may not be any lumps in the breast that can be felt.
Inflammatory breast cancer may be stage IIIB, stage IIIC, or stage IV.