The contribution of the preoperative diagnosis is very important, as it helps us to choose the appropriate treatment or treatments that we will need to apply and the sequence that we will follow.
What is the preoperative diagnosis of breast cancer?
Preoperative diagnosis is the histological analysis of the tumor which is done before the treatment of breast cancer.
The ways in which the pre-operative diagnosis is carried out are either by taking cells with a fine needle (FNA) and cytology, or by taking tissue with a cutting needle with a biopsy brush (core biopsy). The second technique is advantageous because it provides us with more information about the biological subtype of the tumor, while the first technique usually captures whether the lesion is benign or malignant. Preceding, of course, imaging diagnostic methods, such as mammography, ultrasound, and magnetic resonance imaging.
When is preoperative diagnosis performed?
In the past, the diagnosis was made during the operation through a rapid biopsy, but today this tends to be abandoned and we prefer to have all the information regarding the specific cancer before the operation. In addition to the valuable information we receive to decide on the treatment to follow, we have the knowledge and time to properly inform the patient and make the decisions of our manipulations together.
The identification of the biological subtype is very important for the selection of the appropriate therapeutic manipulations and the order to be followed. So will the surgery be done first or the systemic treatment first?, usually chemotherapy and then the surgery will follow?.
Of course, this procedure is preceded by the staging of the disease in order to know whether or not there are systemic metastases.
Identification of the biological subtype through histological examination
As mentioned, when we take tissue with the hair dryer, a histological examination of it is done. In the histological examination we receive information about the type of cancer, whether it is porogenic or lobular. These types are characterized by the arrangement of cancer cells in the tissue and have different clinical features.
We also recognize the degree of differentiation, i.e. whether the cancer cell looks like a normal one or is more atypical. So we have highly differentiated cells, which are those that look like normal (grade I), moderately differentiated (grade II) and poorly differentiated, the most atypical (grade III). Be careful not to confuse the degree of differentiation with the stage of the disease.
The stage in early breast cancer is determined by the size of the tumor and whether or not we have positive lymph nodes. If metastases are present the stage is IV. A tumor up to 2 cm without infiltrated lymph nodes is characterized as stage I, while a tumor 2 to 5 cm or with positive lymph nodes is stage II.
We also find out if the cells are positive for estrogen receptors, progesterone receptors, if there is an overexpression of a gene shown by HER2 positivity which is a protein and the proliferation marker, usually Ki67.
Depending on the expression of these prognostic factors we recognize the biological subtype of the cancer.
Cancers that are negative for hormone receptors, i.e. estrogen and progesterone, and also negative for Her2, are characterized as triple negative. They are usually of low differentiation and have a high proliferation index.
We recommend chemotherapy for triple negative cancers as well as for Her2 positive ones. This in very small cancers can be done after the surgery, while in those that are more than two centimeters or have positive lymph nodes, we recommend that the chemotherapy be done first and that the surgery follows after that.
This tactic enables us to check the effectiveness of the treatment and possibly change it. Also, when surgery is performed, a group of patients who have residual cancer cells in the breast or lymph nodes after preoperative chemotherapy are identified. In these patients we recommend additional treatment, a tactic that increases their survival.
Hormone-dependent cancers
The majority of patients have hormone-dependent cancers and are Her2 negative. In early cancers of this category, surgical treatment precedes. For the choice of systemic treatment, i.e. chemotherapy or hormone therapy, the characteristics of the tumor and gene signatures eg Oncotype DX help us. There, additional genes in the tumor are analyzed and they tell us whether the particular patient will benefit from chemotherapy or not. Several patients, in this way, avoided chemotherapy in this biological subtype, while some with relatively good histological characteristics seem to be ultimately high risk and benefit from it.
in conclusion
The contribution of the preoperative diagnosis is very important, as it helps us to choose the appropriate treatment or treatments that we will need to apply and the sequence that we will follow.
In addition, by knowing the biological characteristics of the tumor, we can clearly and precisely inform the patient about the treatment process, make our decisions together, which affects the psychological acceptance and treatment of the disease.
She writes:
Christina Tsionou
Gynecologist – Breast Surgeon
Director of the First MITERA Breast Clinic
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