Breast SUrgery FAQ In Southern New England
There are 4 separate categories: benign, atypical, in situ and invasive cancer.
Benign Breast Biopsy Results
- If the pathology is negative for malignancy that is a reassuring result. However, further information is needed.
- If the abnormal finding on imaging was calcifications then calcifications need to be in the biopsy specimen to make sure the area was adequately sampled.
- If the imaging indicated a solid mass, and the biopsy result was only fatty tissue or no breast tissue was obtained then further evaluation may be needed.
The radiologist will issue a concordance report once the pathology report is available. The radiologist will review the imaging and pathology to determine if concordant, or “what we see is consistent to the tissue removed,” this is an important step to complete evaluation of an imaging abnormality.
Even with benign results further imaging is often recommended to confirm stability of the area of concern, this may include a mammogram, ultrasound and/or MRI in six months.
Common Benign Pathology Results
Fibroadenomas: The most common benign tumors found in a woman’s breast. Fibroadenomas are round, solid, mass like growths. They form from an excess formation of lobules and stroma, can vary with the menstrual cycle. Most often occur between the ages of 20 and 40, and may present in multiple areas. Fibroadenomas do not have to be removed unless the fibroadenoma is very large and distorts the breast, causes pain and discomfort, or if increases in size over a period of time.
Breast Cysts: Breast cysts are benign fluid filled sacs that can change with the menstrual cycle. They can be drained if large and painful, or if non-tender and small can be observed. They can present as a single cyst or multiple cysts, and can vary in size.
Fibrocystic Changes: Fibrocystic changes can appear as thickened or dense breast tissue with cystic changes that varies with the menstrual cycle, especially in the upper outer quadrants of the breast tissue.
Fat Necrosis/Lipoma: Fatty tissue in the breast that can present as a lump. Lipomas do not have to be removed. Fat necrosis can occur after trauma to the breast or following breast surgery.
PASH (Pseudoangiomatous Stromal Hyperplasia): PASH is a benign breast condition that can look on imaging and feel on exam like a breast cancer. PASH is an overgrowth of myofibroblastic cells and stromal cells. The tissue does not have to be surgically removed unless bothersome, and can be followed radiologically for stability.
Intraductal Papilloma: Papilloma is a benign lump that forms within a duct, and can cause nipple discharge. It is usually benign, but must be completely removed since it can be associated with atypia, in situ or early cancerous changes.
Radial Scar: A radial scar is a star-shaped abnormality that can mimic a breast cancer radiographically and histologically, but is considered benign. If a radial scar is found on biopsy, then surgery needs to be done to remove it. Some radial scars may contain atypical cells, in situ or early breast cancers.
If your results were not benign, you should meet with a breast surgeon to discuss what the results mean. Your “case” should be presented to Tumor Board before proceeding to surgery or other treatments. Tumor Board is a weekly meeting held at Rhode Island Hospital and Women & Infants’ Hospital that reviews all new atypical, in situ and cancerous breast cases. At the Tumor Board meeting there are radiologists, pathologists, surgeons, medical oncologists, radiation oncologists, plastic surgeons and genetic specialists. Each case is individually reviewed and a group consensus opinion “recommendation” is given. This process ensures that the patient is given the latest, most comprehensive care possible.
Ask your physician for copies of your imaging and pathology reports for your records. It is common for patients with a new breast cancer to get a second opinion and having the reports will be helpful.
In complicated cancer cases it can be helpful to meet with a medical oncologist, genetics expert, radiation oncologist and even a plastic surgeon before surgery. Further imaging and testing may be necessary before surgery to understand your disease better to provide you with the best treatment possible. There is significant anxiety and emotional distress once a cancer diagnosis has been given and often the patient wants the surgery done immediately. However, surgery may need to be delayed by a few weeks so testing can be completed; the waiting should not affect prognosis or survival, and will allow for the best care for your disease.
It is not clear what causes atypical breast tissue. Atypical hyperplasia forms when breast cells become abnormal in number, size, shape, and appearance and growth pattern. These changes can be observed in both the lobules and the milk ducts which determine if it is atypical ductal or lobular hyperplasia. Common types of atypia: atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), flat epithelial atypia (FEA).
Atypical hyperplasia is thought to be part of a complex, multistep process which may lead to breast cancer development. Atypical hyperplasia occurs when there is an excess development of cells that stack upon one another and take on an abnormal appearance. If these abnormal cells persist they can continue to change and lead to carcinoma in situ or invasive cancer.
If atypia is found on a biopsy, surgery will be recommended to remove the atypical tissue. A MRI may be done before surgery for patients with dense breast tissue and atypia to further evaluate the breasts. Importantly, if atypical ductal hyperplasia (ADH) is found on stereotactic/core biopsy approximately 25 percent of patients will have an early stage cancer found at surgery. Atypia does indicate that you may be at an increased risk for developing breast cancer in the future. Atypical cells found in the breast do not require radiation, but patients can be offered tamoxifen to reduce their risk for breast cancer in the future.
Often referred to as non-invasive or pre-invasive, in situ breast cancer means the cancer cells remain confined to the ducts (ductal carcinoma in situ) or lobules (lobular carcinoma in situ). The cancer cells have not invaded the breast tissue, and typically do not have the ability to spread to lymph nodes or other organs in the body. There are two types of in situ disease, ductal carcinoma in situ (DCIS), and lobular carcinoma in situ (LCIS), although both are in situ disease, they are viewed differently and treated differently.
DCIS and LCIS are considered Stage 0.
“Stage” describes how far the cancer has spread beyond the site of original tumor. DCIS and LCIS have 100 percent survival.
DCIS is the most common type of non-invasive breast cancer. Ductal means that the abnormal cells began in the ducts and do not involve or “grown into” the normal surrounding breast tissue.
The most common presentation for DCIS is an abnormal mammogram. DCIS can be associated with irregular calcifications in the breast, architectural distortion, asymmetry, or a breast mass on imaging.
There are 3 grades of DCIS
- Grade 1 (low grade) DCIS cells look very similar to normal cells, slow growing.
- Grade 2 (moderate grade) DCIS cells grow faster than normal cells and look less like them.
- Grade 3 (high grade) DCIS cells tend to grow more quickly and abnormal, there can be areas of necrosis (dead cells). When cancer cells grow quickly, some cells don’t get enough nourishment. These starved cells can die off, leaving areas of necrosis.
The DCIS cells will also be tested for estrogen hormone receptors. If the cells are estrogen positive (ER+), it means that estrogen fuels the cancer cells’ growth. If the cells are ER+ then likely treatment (Tamoxifen, Evista) will be recommended to block the effects of estrogen in the breast tissue.
Surgery and often radiation therapy will be required.
If the abnormality dominates the majority of breast tissue, a mastectomy may be necessary. When having surgery for DCIS lymph node testing is usually not needed. Special cases however may require lymph node testing (sentinel node biopsy) with surgery such as; mastectomy for DCIS, a palpable mass with biopsy of DCIS and suspicious for invasive cancer, over 5 cm of grade 3 DCIS on imaging, DCIS on biopsy and pre-op MRI highly suspicious for invasion.
LCIS is very different from DCIS. LCIS is an area of abnormal cell growth that increases a person’s risk of developing bilateral (both breasts) invasive breast cancer over the next 15 years.
LCIS is not a true breast cancer.
LCIS does not typically show up as an abnormality on mammogram, and is not associated with a palpable mass. It tends to be diagnosed as a result of a breast biopsy for an unrelated reason.
LCIS does not require treatment such as negative margins at surgery or radiation therapy. Often LCIS is not graded and is not tested for estrogen receptor status.
LCIS is usually hormone receptor positive and Tamoxifen or Evista may be suggested to reduce the risk of breast cancer development.
Rarely, if there is a personal history of breast cancer, family history and/or BRCA+ and LCIS is found, your surgeon may discuss the option of prophylactic bilateral mastectomy for risk reduction.
Paget Disease is an uncommon type of cancer that forms around the nipple. More than 95 percent of women with Paget Disease have an underlying breast cancer. Symptoms of Paget Disease include nipple redness, mild scaling and flaking of the nipple skin.
Your pathology report is a collection of information that describes the characteristics of your cancer, and determines the stage. The stage cannot be determined until surgery is performed. When staging breast cancer the TNM System is utilized, tumor size (T), lymph node involvement (N) and if there is metastatic disease (M) are the main components. However, a deeper understanding of the details of your disease is needed to better communicate with your physicians.
Tumor size: The microscopic size of the tumor is the actual size of the cancer cells in the specimen. It is also one of the most important prognostic factors.
Tumor margins: The goal in removing a breast cancer is to have negative margins, meaning to have a margin of normal tissue around the cancer cells. In breast cancer, usually the margins should be 1-2 mm around the entire specimen; anterior, posterior, superior, inferior, medial and lateral. The surgeon will paint the tissue specimen at surgery which will allow the pathologist the ability to know the orientation of the tumor in the breast and the margin status.
Tumor histology: The type of cells such as ductal, lobular or other types.
Tumor grade: It is the way the cells look under the microscope. This classifies the cancer cells by their degree of abnormality.
- Grade 1 well differentiated – look close to normal
- Grade 2 moderately differentiated – intermediate
- Grade 3 poorly differentiated – more aggressive
Lymph node involvement: lymph nodes will be examined in most breast cancer surgeries, usually by a sentinel node biopsy. The number of lymph nodes will be counted and given a result as positive (cancer found in the nodes) or negative (no cancer found).
Receptor Status: The cancer cells will be tested to see if estrogen, progesterone and HER 2 Neu biomarkers are expressed. These factors will be very important to determine the best treatment strategies for your disease.
Other important aspects to the pathology report are if there is lymphatic, and microinvasion involvement. Also if there was any in situ disease present.
Survival rates are often used by doctors and patients as a standard way of discussing a person’s prognosis. The 5 year survival rate refers to the percentage of patients who live for at least five years after being diagnosed with cancer. In order to get 5 year survival rates, the information is based on women that were treated for breast cancer at least five years ago (often even longer in the past). Improvements in treatment and better outcomes since then may result in more favorable outcomes for a woman being diagnosed today.
Survival rates are based on previous outcomes for a large number of women with breast cancer and do not take into account individual characteristics which may factor in for your survival. The survival rate is just an estimate; don’t get fixed on the number. Your cancer treatment will be personalized and tailored to your disease.
Information for the mortality data for the current year is not yet available.
The information for the 5 year survival rates by stage at diagnosis is from the National Cancer Institute (NCI) SEER data from 2001-2007: seer.cancer.gov/statfacts/html/breast.html.