FAQ Biopsies

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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.

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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.