Tissue Diagnosis of Advanced Breast Cancer

Explanation

An enlarging hard irregular mass with bloody nipple discharge, nipple inversion, skin thickening and palpable axillary nodes is highly suspicious for locally advanced breast cancer. Clinical assessment and imaging are complete, so the remaining component of triple assessment is tissue diagnosis, and no treatment can be planned without it. Image guided needle core biopsy is the gold standard because it removes intact cores of tissue that preserve architecture, allowing the pathologist to confirm malignancy, grade it, and crucially distinguish invasive carcinoma from ductal carcinoma in situ. The cores also supply enough material for oestrogen receptor, progesterone receptor and HER2 testing, which determine whether the patient should receive endocrine therapy, chemotherapy or HER2-directed treatment, and whether that treatment should be given before surgery. The suspicious axillary node should be sampled at the same sitting, usually by ultrasound guided core biopsy or fine needle aspiration, because nodal status changes the operative plan. Fine needle aspiration of the primary yields only cells, cannot separate invasive from in situ disease, and often provides insufficient material for receptor testing, which is why it has been superseded for solid masses. Discharge cytology has a high false negative rate and cannot exclude cancer. Excisional biopsy is an outdated approach for a suspicious mass, since operating without a diagnosis compromises oncological planning and may commit the patient to inappropriate surgery.

Why each option

A.

Fine needle aspiration provides only cytology, cannot confirm invasion, and often yields too little material for receptor testing.

B.

Excisional biopsy is a surgical procedure that should not precede a tissue diagnosis, as it compromises planning for definitive oncological surgery.

C.

Correct. Core biopsy gives histological confirmation, distinguishes invasive from in situ disease, and provides tissue for receptor and HER2 testing.

D.

Nipple discharge cytology has a high false negative rate and cannot exclude malignancy in the presence of a palpable suspicious mass.

More Surgery questions

• Achalasia Management
• Acute Limb Ischemia and Venous Thromboembolism
• Bethesda IV Follicular Neoplasm Management
• Diagnosis of Inhalation Injury
• Disseminated Intravascular Coagulation in Sepsis
• Emergency Decompression of Tension Pneumothorax