Senior Consultant, Surgical Oncology, Fortis Hospital, Noida
Part 4 of 9 in Diagnosis and Management of Breast Cancer
Biopsy Techniques and Receptor Testing in Breast Cancer
November 17, 2024
Once imaging raises suspicion, a pathological diagnosis is required, and the biopsy method chosen depends on what earlier attempts have or have not confirmed.
From FNAC to surgical biopsy
Fine needle aspiration cytology, or FNAC, uses a fine needle to aspirate cells from the tumor for a cytological diagnosis, though it has largely been replaced in most centers by core biopsy, which uses a larger, specialized biopsy needle to remove an actual piece of tissue for a histological diagnosis. If neither FNAC nor core biopsy provides an answer, an incisional biopsy, a surgical biopsy taking a piece of the tumor under anesthesia, or an excisional biopsy, surgical removal of the whole tumor, follows. A frozen section, available only at larger, specialized hospitals, gives a result within half an hour during surgery itself.
Immunohistochemistry and triple-negative disease
Once tissue is available, immunohistochemistry tests it for three receptors: estrogen receptor, progesterone receptor, and HER2. A tumor negative for all three is called triple negative breast cancer, the most aggressive of the receptor combinations and the one that carries the worst prognosis among them.
This article is based on a Jivo Masterclass session conducted by Dr. Jalaj Baxi, Senior Consultant, Surgical Oncology, Fortis Hospital, Noida. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording
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This guide is based on a live Jivo Masterclass: Dr. Jalaj Baxi taught doctors across Africa on November 17, 2024.
FROM THE LIVE Q&A
Moderator
What are the natural causes of breast cancer?
Dr. Jalaj Baxi
There is no true natural cause; the underlying event is always a gene mutation. About 80% of cases are sporadic mutations with no identifiable cause, while 10 to 15% are genetic or familial. Smoking, alcohol, and tobacco all contribute to mutation risk generally and should be avoided, though this applies to cancer as a whole rather than being specific to breast cancer.
Frequently Asked Questions
On an evolutionary level, how does breast cancer differ between men and women?▼
There is no meaningful difference. The same hormone receptors, estrogen, progesterone, and HER2, apply in both male and female breast cancer, and treatment remains the same regardless of sex.
Is there a correlation between certain cosmetics, such as talc or lipstick, and the development of breast cancer?▼
Various myths and misconceptions exist around this, including the use of talc in the axilla. Some print media point to possible links, but there is no confirmatory or corroborative evidence for a connection between cosmetics and breast cancer.
A 65-year-old woman has metastatic breast cancer and mastectomy is not feasible; she is currently on chemotherapy. What chemotherapy regimens are appropriate?▼
The regimen depends on the tumor's biology, specifically its ER, PR, and HER2 status. Treatment is usually a combination approach built around anthracycline-based chemotherapy along with hormonal therapy where relevant, and HER2-targeted therapy is added when HER2 is positive. A typical course runs six to eight cycles, though HER2-directed therapy in HER2-positive disease can extend to around 18 to 20 cycles.
Can chemotherapy be combined with hormonal therapy, and what other management plans and success rates apply in metastatic disease?▼
Yes, combining chemotherapy with hormonal therapy is possible. Further management depends on how the patient responds to treatment. Roughly 30 to 35% of metastatic breast cancer patients respond well, and where the response is strong enough, it can become possible to address the metastatic sites and the primary tumor surgically as well.
If a patient remains symptomatic after eight cycles of chemotherapy, what other treatment options are available?▼
Immunotherapy can be added, and second-line or third-line chemotherapy regimens are available, including CDK4/6 inhibitors. Next-generation sequencing of the tumor helps identify which newer targeted drugs are likely to be effective for that specific patient.
What is the difference between FNAC and core biopsy?▼
FNAC uses a fine needle to aspirate cells for a cytological diagnosis, while core biopsy uses a larger needle to remove an actual piece of tissue for a histological diagnosis. Core biopsy has largely replaced FNAC in most centers.
What does triple-negative breast cancer mean?▼
It means the tumor tests negative for all three receptors checked on immunohistochemistry, estrogen receptor, progesterone receptor, and HER2. It is considered the most aggressive combination and carries the worst prognosis among the receptor subtypes.
In This Series: Diagnosis and Management of Breast Cancer
- 1.Diagnosis and Management of Breast Cancer
- 2.How Breast Cancer Presents: Warning Signs Every Referring Doctor Should Know
- 3.The Triple Assessment: Clinical, Radiological and Pathological Workup
- 4.Biopsy Techniques and Receptor Testing in Breast Cancer
- 5.Staging Breast Cancer and How Tumor Biology Drives Treatment Sequencing
- 6.Breast Conservation Surgery vs Mastectomy: When Each Is Appropriate
- 7.Axillary Management: Lymph Node Dissection vs Sentinel Node Biopsy
- 8.Radiation Therapy After Breast Cancer Surgery: When It's Needed
- 9.Chemotherapy, Hormonal and Targeted Therapy: Regimens and Managing Metastatic Disease