Guest guest Report post Posted July 7, 2007 FAQ Biopsies http://www.breastcancerchoices.org/faqbiopsies.html Link to Biopsy Medical Articles http://www.breastcancerchoices.org/medartbiopsy.html After being screened for breast cancer, a suspicious lump has been found. How is the lump biopsied? Primarily, there are three ways to biopsy a suspicious lump: (1) fine needle biopsy (FNA), (2) large gauge needle (core) biopsy, and (3) excisional biopsy during which the whole lump is surgically removed. I have just had a mammogram and my doctor sees a suspicious mass in my breast. My doctor has suggested a needle biopsy. Is there any downside to this procedure? Background: Needle biopsies pierce the suspicious breast mass to draw out tissue for analysis. Some researchers fear these procedures may spread (or seed) the cancer, causing something called " needle track metastasis. " Others feel this possibility is not a significant concern or that the immune system, surgery and/or radiation that follows will clean up the area. Each individual must review the information that is presented in this BIOPSY section with her doctor and decide for herself whether or not to undergo these procedures. Hot News: In June 2004, the results of the bombshell Hansen study, " Manipulation of The Primary Breast Tumor and The Incidence of Sentinel Node Metastases From Invasive Breast Cancer, " were published in the American Medical Association's prestigious journal, Archives of Surgery, revealing that patients undergoing fine needle biopsies were 50% more likely to have micrometastases spread to the sentinel lymph node than those patients having the entire tumor removed for biopsy. The implication of this discovery is that a woman without lymph node involvement, who would have been staged at a low level, now will be staged higher,her disease considered more advanced, and more aggressive treatment might be recommended. Over the years, several researchers have voiced serious reservations about routine needle biopsies, but they were mostly ignored by their colleagues. Hansen's research team cited their predecessors, and the research path leads back several decades. It's hard to understand why The Archives of Surgery study, which embodies all of these reservations about needle biopsies, didn't make the front page of the New York Times. Cancer authority, Ralph Moss, comments in his February 6th, 2005 Moss Reports Newsletter: " Imagine the outrage these patients will feel when they learn that many of these sentinel node metastases were caused not by the natural progression of their disease but directly by the actions of well-intentioned (but ill informed) doctors. Imagine, further, what will happen when patients find out that questions have been raised about the safety and advisability of needle biopsies for a number of years by some of the finest minds in oncology. Imagine the disruption of the smooth functioning of the " cancer industry " when patients start demanding less invasive ways of diagnosing tumors. And imagine the class action lawsuits. " Significant parts of the Hansen study below are highlighted in red. Patients may want to include it in their Patient Portfolio. Manipulation of the Primary Breast Tumor and the Incidence of Sentinel Node Metastases From Invasive Breast Cancer Nora M. Hansen, MD; Xing Ye, MS; Baiba J. Grube, MD; Armando E. Giuliano, MD Arch Surg. 2004;139:634-640. Hypothesis The incidence of sentinel node (SN) metastases from invasive breast cancer might be affected by the technique used to obtain biopsy specimens from the primary tumor before sentinel lymph node dissection. Design Prospective database study. Setting The John Wayne Cancer Institute. Patients and Methods We identified 663 patients with biopsy-proven invasive breast cancer who underwent sentinel lymph node dissection between January 1, 1995, and April 30,1999. Patients were divided into 3 groups based on type of biopsy: fine-needle aspiration (FNA), large-gauge needle core, and excisional. A logistic regression model was used to correlate tumor size, tumor grade, and type of biopsy with the incidence of SN metastases. Results Of the 676 cancers, 126 were biopsied by FNA, 227 by large-gauge needle core biopsy, and 323 by excisional biopsy before sentinel lymph node dissection. Mean patient age was 58 years (range, 28-96 years), and mean tumor size was 1.85 cm (range, 0.1-9.0 cm). In multivariate analysis based on known prognostic factors, the incidence of SN metastases was higher in patients whose cancer was diagnosed by FNA (odds ratio, 1.531; 95% confidence interval, 0.973-2.406; P = .07, Wald test) or large-gauge needle core biopsy (odds ratio, 1.484; 95% confidence interval,1.018-2.164; P = .04, Wald test) than by excision. Tumor size (P<.001) and grade (P = .06) also were significant prognostic factors. <FONT COLOR= " #000000 " BACK= " #ffffff " style= " BACKGROUND-COLOR: #ffffff " SIZE=3 PTSIZE=12 FAMILY= " SANSSERIF " FACE= " V Conclusions Manipulation of an intact tumor by FNA or large-gauge needle core biopsy is associated with an increase in the incidence of SN metastases, perhaps due in part to the mechanical disruption of the tumor by the needle. The clinical significance of this phenomenon is unclear. ---- According to the Hansen study, whether the increased incidence of sentinel node metastases will promote a regional recurrence or affect overall survival is unknown. Will a core biopsy increase the chance of a local recurrence? Another research team, led by A. Chen, published " Local Recurrence of Breast Cancer After Breast Cancer Therapy in Patients Examined by Means of Stereotactic Core-Needle Biopsy, " in the journal Radiology in 2002 after finding that a core biopsy followd by a lumpectomy and radiation does not increase the risk of a local recurrence. It is worth noting that the authors of this study speculate that there might be an increased risk of a local recurrence unless adjuvant radiation is used. (See Thurfjell, et al., Acta Radiologica, [2000 ] and Chen, et al.,Radiology,[2002] in the MEDICAL ARTICLES BIOPSY section.) What is the impact of the increased incidence of SN metastases on overall survival? The American College of Surgeons' Z0010 study will address the significance of micrometastases in the regional lymph nodes of patients with invasive breast cancer. The Chen (2002) needle biopsy study and other studies suggest needle biopsies may not only raise the risk of spreading cancer cells within the breast tissue itself to such a degree that radiation therapy is recommended, but Hansen (2004) suggests that these biopsies may also spread them farther, beyond the breast, to the sentinel node. The take home question is: Do you really want to undergo a diagnostic procedure, such as a needle biopsy, which may increase your risk of spreading cancer cells when removing the whole tumor with an excisional biopsy is an option? Cited below are relevant excerpts from the much respected Townsend Letter for Doctors and Patients ( 2004). The article elaborates upon the problems with stereotactic (also called " core " biopsies because a bigger needle is used to draw out tissue) biopsies. Stereotactic Breast Biopsy: what you should know but probably weren't told http://findarticles.com/p/articles/mi_m0ISW/is_251/ai_n6112675 Townsend Letter for Doctors and Patients, June, 2004 by Whitney S. Hibbard [excerpted] Question. Are there any risks inherent in the stereotactic needle biopsy procedure? Answer. Yes. A survey of histological studies reveals that there is a clear danger of seeding needle tracks with malignant cells " displaced in breast stroma or in lymphovascular channels, associated with the traumatic effects of a needling procedure, " according to Dr. Rosen, Department of Pathology, Memorial Sloan- Kettering Cancer Center. Consequently, Dr. Rosen warns that " with tissue disruption, lymphatic and vascular channels may also be breached, and it is conceivable that detached epithelial fragments may enter vascular channels and perhaps even be transported to lymph nodes. " (1) Question. What is the frequency of malignant needle track seeding? Answer. The frequency with which this occurs and the degree to which this leads to metastases is uncertain. Studies range from an insignificant .003% frequency of malignant needle track seeding to a horrifying 89%. (2) Clearly, more research is needed to assess accurately the actual incidence. It is extremely important to understand, however, as Dr. Austin clarifies in Breast Cancer: What You Should Know (But May Not Be Told) About Prevention, Diagnosis, and Treatment, that it is not breast cancer per se that kills: " What kills patients is the spread of cancer to distant parts of the body--distal metastasis. " Question. Isn't this really a moot concern because if a biopsy reveals a malignant lesion it will be removed anyway? Answer. Maybe. The question is whether the whole needle track would be removed during surgery, i.e., surgeons unaware of the malignant needle track seeding problem may not do the necessary excision. Furthermore, it must also be asked as to how long it takes for malignant cells leaked into a vascular channel to be distributed to other areas of the body (e.g., neighboring lymph nodes)? In all likelihood this would be fait accompli long before a scheduled surgery. Question. What are a patient's diagnostic procedural options if she chooses not to undergo fine needle biopsy? Answer. Critics of the procedure recommend lumpectomy with subsequent histological examination once the tumor is safely removed, or surgical excision of the needle track after biopsy. (3) Question. Is there a problem of " false negatives " (i.e., even though a malignant tumor is present, it is missed with the needle so the pathology report is negative) with stereotactic needle biopsy? Answer. Allegedly, the X-ray guided needling in the stereotactic procedure will reduce greatly the number of " false negatives " which run as high as 23% in non-stereotactic needle biopsy procedures! (4) Question. Is there a danger inherent in the additional radiation exposure? Answer. Clearly " yes. " According to Dr. Gofman, MD, PhD, in Radiation and Human Health: A Comprehensive Investigation of the Evidence Relating Low Level Radiation to Cancer and Other Diseases, ionizing radiation is a known carcinogen, there is no safe exposure level to ionizing radiation, and the effects of radiation exposure are cumulative throughout one's life. Specific to breast cancer, Dr. Gofman presents compelling evidence in his new book, Preventing Breast Cancer: The Story of a Major, Proven, Preventable Cause of This Disease, that about 75% of those cancers are caused by exposure to ionizing radiation, principally from medical X-rays. People should not forget the massive and heavily promoted early detection mammogram program in the 1950s and 1960s of women under 50 which was scrapped by the National Cancer Institute because the incidence of cancers caused by repeated radiation exposure was unacceptable. That program " caused between 55,000 and 65,000 future cancer deaths per year! " according to Dr. Gofman, a radiologist with a doctorate in medical physics, who headed a $24,500,000 seven-year study on the effects of radiation on human health. [end of excerpt] See full article, Hibbard W, " Stereotactic Breast Biopsy " ,2004 article in MEDICAL ARTICLES BIOPSY section.) ---- Since both FNA and core needle biopsies may be associated with a higher incidence of sentinel lymph node metastases than that associated with surgical biopsy, is there any downside to undergoing excisional surgical biopsy, which will remove the whole tumor? In the previously cited article published in The Breast (2000), Dr. Robert Rosser advocates altering the surgical technique to avoid trauma to the breast in order to prevent any possible creation of injury-induced micrometastases, which he calls traumets. Dr. Rosser writes, " The surgical technique should be altered to avoid grasping a tumor at any time. Retraction and control of the tumor would be better accomplished by placing a large retention suture through the tumor, perhaps several times through the tumor and using the suture to control the tumor while cutting around it. " I've decided to take my chances with a needle biopsy. If I am premenopausal, is there any advantage to timing the biopsy procedure with a particular part of my menstrual cycle? For premenopausal women, timing the surgical procedure with the menstrual cycle has now been studied in the context of needle biopsy as well as in that of breast surgery. It appears that timing breast piercing or surgery after ovulation is worth considering. A relevant study follows: J Surg Oncol. 2000 Jul;74(3):232-6. Menses and breast cancer: does timing of mammographically directed core biopsy affect outcome? Macleod J, Fraser R, Horeczko N. Department of Surgery, University of Alberta, Edmonton, Canada. BACKGROUND AND OBJECTIVES: Studies have shown molecular, genetic and cellular changes in breast cancer during the menstrual cycle. Changes in proliferative and metastatic potential of breast cancer cells during menses could explain improved survival when tumors are surgically removed in the luteal [after ovulation] phase. This study examined if timing of mammography/core biopsy (MAM-CB) also affected breast cancer prognosis (histological tumor grade). METHODS: Eighty-five premenopausal women undergoing MAM-CB at one clinic between March 1995 and February 1998 were retrospectively studied. All patients had Stage I or II breast cancer surgically treated. Patients were grouped by phase of menses at MAM-CB:follicular (F, Days 0-14) or luteal (L, Days 15-35). Groups were comparable in age,menarche, family history, nulliparity, breastfeeding, and total percentage of clinically palpable tumors. Pathological characteristics of the tumors (tumor size, tumor type,estrogen and progesterone receptor status, axillary lymph node status, the presence of lymphatic or vascular invasion and extranodal metastasis) was also comparable across the 2 groups. RESULTS: Low-grade tumors were more frequent in the MAM-CB group L, whereas high-grade tumors were more common in the MAM-CB group F (P = 0.002, chi2(4) = 17.06). CONCLUSIONS: Timing of MAM-CB in relation to menses may be a factor influencing breast can cer outcome. Future studies examining the effect of menses on the outcome of breast cancer should consider the potential effect of the timing of MAM-CB. ------ I do not want anyone cutting into my breast. Are there alternatives to surgery? No Amazon member has definitively gotten rid of a tumor without surgery. One member has shrunken hers with hormone modulation, and another used an alternative medicine program to help shrink hers, but neither person shrank her tumor to the point of disappearance. Conventional medicine might suggest using " neo- adjuvant " chemotherapy to shrink the mass, but this methodology is customarily used in conjunction with a later surgery--which is why it's also called pre-operative chemotherapy. What about these cancer salves I read about? Do they remove the tumor without surgery? Cancer salves may work, but no one associated with the Amazon Group has experienced any lasting benefit associated with using them to treat breast tumors. My biopsy came back positive for cancer. I want a second and maybe a third opinion. How long do I have to make a decision about what kind of surgical procedure to have? Any reputable doctor will tell you there is time to schedule second and third opinions after a breast cancer diagnosis, but bear in mind that studies and articles show that expeditious surgery may counteract potentially negative effects of cells displaced by past needle biopsies. Quote Share this post Link to post Share on other sites
