Thursday, November 8, 2007

Breast Cancer: Ductal Lavage

Ductal lavage is a procedure for collecting cells from the milk ducts of the breast for analysis. The procedure is used to identify precancerous cells, called atypical cells. Ductal lavage currently is performed only on women who have multiple breast cancer risk factors to try to detect breast cancer before it starts.

Ductal lavage works on the premise that most breast cancers (about 95%) develop in cells that line the milk ducts of the breast. Cancer usually begins in one duct and may be contained to that duct if caught early, making treatment more effective and increasing survival.

By the time cancer is detected, however, it often has progressed beyond a single duct. (Experts estimate that it takes 8 to 10 years for cancer to grow from 1 cell to a mass large enough to be detected on a mammogram -- about 1 billion cells.)

Doctors hope that performing ductal lavage as a screening tool in women at high risk for breast cancer may catch the disease early when it is most treatable.

How Does Ductal Lavage Work?
Ductal lavage is a minimally invasive procedure that may be performed in a doctor's office or outpatient center. It is performed in three steps:

An anesthetic cream is applied to numb the nipple area. Gentle suction is used to withdraw a small amount of fluid from the milk ducts. This is done to locate the opening of the ducts on the nipple's surface and to identify ducts to be tested. Ducts that do not produce fluid generally are not tested with the lavage procedure, since atypical cells are more commonly found in ducts that produce fluid. Not all women are able to produce fluid with this test. If fluid is not made, the test is not continued any further.
A hair-thin catheter (small tube) is inserted into the natural opening of the duct. Additional anesthetic is delivered into the duct. A saline (salt and water) solution is then infused through the catheter to rinse the duct, which loosens cells from the duct lining. The solution containing the loosened cells is withdrawn through the catheter. (The word "lavage" is French for "wash" or "rinse.")
The sample is sent to the laboratory for analysis to determine if the cells are normal or abnormal (atypical cells). Women with atypical cells have an increased risk of developing breast cancer.

Who Is a Candidate for Ductal Lavage?
Ductal lavage is recommended only for women who are at high risk for breast cancer. There are several factors that put a woman at high risk for developing breast cancer, including:

A personal history of breast cancer.
A family history of breast cancer, particularly in a mother, daughter or sister.
Evidence of a specific gene (BRCA1/BRCA2 mutation).
A Gail Index score of at least 1.7 percent (The Gail Index uses risk factors such as age, family history of breast cancer, age of first menstrual period and first pregnancy, and number of breast biopsies to calculate a woman's risk of developing breast cancer within the next five years.).
What Happens If Atypical Cells Are Found?
Not all abnormal cells are destined to become cancer. Atypical cells are those that have begun to change and are at risk of becoming cancerous. Knowing that you have atypical cells can help you and your doctor plan a strategy to reduce your risk of developing breast cancer. A strategy may include

Increased breast health monitoring, such as more frequent clinical breast exams.
Medication, such as tamoxifen that lowers breast cancer risk.
Surgery such as prophylactic mastectomy (surgery to remove a breast before cancer develops).
What Will I Feel During the Procedure?
Most women do not find the procedure to be painful, saying it is no more uncomfortable than a mammogram. You may feel temporary sensations such as fullness, pinching and tingling in the breast. However, numbing medications (anesthetics) are used to help reduce discomfort during the procedure.

Is Ductal Lavage Used Instead of a Mammogram to Screen for Breast Cancer?
No. Ductal lavage is used as an adjunct, or addition, to regular breast health practices -- such as breast self-exams, annual clinical exams and mammography -- not in place of these screening tools. In addition, ductal lavage is not recommended for women with a low risk for breast cancer.

What Risks Are Associated With This Procedure?
There are few risks associated with ductal lavage. Rarely, an infection may develop at the site of the catheter insertion. It is possible to perforate, or puncture, the milk duct, although perforation is rare and generally causes no permanent damage to the breast.

Breast Cancer: Sentinel Node Biopsy

Sentinel node biopsy is a relatively new way of pinpointing the first few lymph nodes into which a tumor drains (called the "sentinel" node). This helps doctors remove only those nodes of the lymphatic system most likely to contain cancer cells. The sentinel nodes are the first place that cancer is likely to spread.

In breast cancer, the sentinel node is usually located in the axillary nodes, under the arm. In a small percentage of cases, the sentinel node is found somewhere else in the lymphatic system of the breast. If the sentinel node is positive there may be other positive lymph nodes upstream. If it is negative, it is highly likely that all of the upstream nodes are negative.

How is the Procedure Performed?
To locate the sentinel nodes, a labeling substance, either radioactive tracer, blue dye or both is injected into the area around the tumor before a mastectomy or lumpectomy is performed. The tracer travels the same path to the lymph nodes that the cancer cells would take, making it possible for the surgeon to determine the one or two nodes most likely to test positive for cancer by either visualizing the color or using a hand held Geiger counter.

This method varies in how it is performed among hospitals and is still being tested to determine the best way to identify the positive nodes.

What are the Advantages of This Method?
Research suggests that the sentinel node biopsy procedure can be useful in determining which lymph nodes to remove, without the risk of complications associated with surgically removing all potentially cancerous nodes.

When a lumpectomy or mastectomy is performed, only a few lymph nodes are removed for laboratory analysis using the sentinel node biopsy technique. In traditional lumpectomy or mastectomy procedures, a greater number of the axillary nodes are removed, which can lead to complications after surgery such lymphedema.

Breast Cancer: Minimally Invasive Breast Biopsy

When a breast biopsy is recommended for an abnormal mammogram finding, patients may be able to choose a minimally invasive alternative to surgery known as image-guided needle biopsy. This is a technique that does not require surgery. Most of the time, the radiologist performs this type of biopsy.

How Is This Type Of Biopsy Performed?
The needle biopsy can be performed using ultrasound or stereotactic guidance. Stereotactic refers to the use of stereo images -- pictures of the breast taken from different angles -- to determine the precise location of the abnormal tissue.

When stereotactic guidance is used, the patient lies on her abdomen on a specially designed exam table. An opening in the table allows access to the breast. The table is raised and the biopsy is done from below the table. This procedure may also be done with the patient sitting upright in a chair - particularly for those who are unable to lie on their abdomen for any reason. When ultrasound guidance is used, the patient lies on her back on the exam table.

The area that needs to be tested is centered in the window of a specially designed compression paddle. Mammogram films are taken so the radiologist can examine the breast tissue to be biopsied. These films are called SCOUT films.

After giving a local anesthetic, the radiologist makes a small opening in the skin. A sterile biopsy needle is placed into the abnormal breast tissue. Computerized pictures help confirm the exact needle placement using digital imaging.

Tissue samples are taken through the needle. It is common to take multiple tissue samples (about three to five). There are a number of biopsy instruments that can be utilized to obtain the tissue sample. They include core biopsy which uses a needle to obtain a piece of tissue about 1/16 inch across and ½ inch long, and a vacuum assisted needle biopsy device (VAD), which uses vacuum suction to obtain a tissue sample. This tissue is then examined under the microscope to look for cancer cells. This part of the biopsy takes approximately 15 minutes. Upon completion, sterile strips and a small adhesive bandage are applied to the skin. The entire procedure takes approximately 30 minutes to an hour. Results are usually available in three to five working days.

What Are The Benefits Of Minimally Invasive Biopsy?
Minimal scarring instead of a large incision.
Reduced post-procedural pain and risk of infection.
Potentially lower hospital costs.
Immediate return to work.
Shorter recovery time and immediate resumption of daily activities.
How Safe Is Minimally Invasive Biopsy?
This procedure is as safe as "open" surgery when performed by breast imaging specialists in this field.

Breast Cancer: Breast Biopsy

A biopsy is the removal of cells or tissue from a suspicious mass. The tissue or cells are then examined under a microscope to check for cancer cells. A biopsy may be performed when an abnormal breast change is found during a mammogram, ultrasound or physical examination. A biopsy is the only way to determine if a potential trouble spot is cancerous or benign.

There are many types of biopsy procedures. The method recommended by your doctor will depend on how large the breast lump or abnormal area is; where in the breast it is located; how many lumps or abnormal areas -- such as suspicious calcifications -- are present; if you have any other medical problems; and what your personal preferences are.

Breast Cancer: MRI

Breast MRI (magnetic resonance imaging) is a test that may be used to distinguish between benign (noncancerous) and malignant (cancerous) lesions. Performing this test may reduce the number of breast biopsies done to evaluate a suspicious breast mass. Although MRI can detect tumors in dense breast tissue, it cannot detect tiny specks of calcium (known as microcalcifications), which account for half of the cancers detected by mammography.

Is the Breast MRI Test Safe?
Yes. MRI examination poses no risk to the average patient if appropriate safety guidelines are followed.

People who have had heart surgery and people with the following medical devices can be safely examined with MRI:

Surgical clips or sutures.
Artificial joints.
Most heart valve replacements.
Disconnected medication pumps.
Vena cava filters.
Brain shunt tubes for hydrocephalus.
Some conditions may make an MRI examination inadvisable. Tell your doctor if you have any of the following conditions:

Heart pacemaker
Cerebral aneurysm clip (metal clip on a blood vessel in the brain)
Implanted insulin pump (for treatment of diabetes), narcotics pump (for pain medication), or implanted nerve stimulators ("TENS") for back pain
Metal in the eye or eye socket
Cochlear (ear) implant for hearing impairment
Implanted spine stabilization rods
Severe lung disease
Uncontrolled gastroesophageal reflux (a condition causing severe heartburn)
In addition, tell your doctor if you:

Are pregnant.
Weigh more than 300 pounds.
Are not able to lie on your back for 30 to 60 minutes.
Have claustrophobia (fear of closed or narrow spaces).
How Long Is the Breast MRI Test?
Allow 1 1/2 hours for your MRI exam. In most cases, the procedure takes 45 to 60 minutes, during which time several dozen images may be obtained.

What Happens Before the Exam?
Personal items such as your watch, wallet -- including any credit cards with magnetic strips (they will be erased by the magnet) -- and jewelry should be left at home if possible, or removed prior to the MRI scan. Hearing aids should be removed before the test since they can be damaged by the magnetic field. Secured lockers are typically available to store personal possessions.

What Happens During the Exam?
You will be asked to wear a hospital gown during your breast MRI.

As the MRI scan begins, you will hear the equipment making a muffled thumping sound that will last for several minutes. Other than the sound, you should experience no unusual sensations during the scanning.

Certain MRI exams require that you receive an injection of a contrast material. This helps identify certain anatomic structures on the scan images.

Feel free to ask questions or tell the technologist or the physician if you have any concerns.

What Happens After the Exam?
Generally, you can resume your usual activities and normal diet immediately.