Diagnostic

Several objectives must be achieved:
- Confirm the diagnosis of cancer
- Characterize the identified tumor (histological type, biological characteristics, aggressiveness)
- Take stock (extension, ie stage; general pre-treatment check-up)

Several stages are linked in different ways depending on the initial presentation and the mode of discovery. The sequence is not necessarily that described below.

The "diagnostic time" includes at least:
1- A clinical examination by a doctor specializing in the treatment of breast cancer.

The goal is to make a clinical assessment of the disease and the patient. Age, hereditary and personal history of cancer, other pathologies (comorbidity) in particular those which can influence treatment, size, weight, breast size, etc. are registered.

Clinical examination of both breasts and armpits allows a clinical description of the disease, leading to the establishment of the TNM stage:
T : tumor size and adhesion to the skin or pectoral muscle,
N : axillary lymph node involvement,
M : presence of metastasis (rarely clinically detectable).

This time is very important to explain the disease to the patient and her entourage, to detail the performance of the other examinations, the foreseeable treatment program, the known elements and those to be specified.
The sequence and type of treatment may change from the first consultation depending on the results of the different exams.
Finally, the psychological and social consequences of the disease should be considered from this first consultation so as not to be limited to the treatment of somatic disease.

2- A mammography + ultrasound.
The objective is to characterize the anomaly identified by clinical examination. It is often the same "time" with a screening part and a "diagnostic" part.
The mammogram and ultrasound will describe the lesion in terms:
o of location (side, quadrant, radius, distance from the nipple, depth),
o of maximum size,
o of suspected axillary ganglion,
o if there are other anomalies.
It is usual that the sizes described by the two examinations are not the same. It is usual that the lesion is not as clearly visible on the two examinations.

The report uses the American College of Radiology (ACR) BIRADS system, which classifies mammographic images into 6 categories, depending on the risk of malignancy.

ACR 0 : waiting classification, when further investigations are needed
ACR 1 : normal mammography
ACR 2 : There are mild (i.e. minor) anomalies that do not require further monitoring or examination
ACR 3 : there is probably a slight anomaly for which short-term monitoring (3 or 6 months) is advised
ACR 4 : there is an unknown or suspicious anomaly
ACR 5 : there is an anomaly suggestive of cancer
In case of ACR 4 or ACR 5 images, biopsy samples are required.

3- A breast MRI.
This review is not systematic.
It is generally offered to young women, women with dense breasts whatever their age, in case of infiltrating lobular carcinoma, etc.
MRI specifies location, size, presence of other abnormalities, presence of suspect axillary nodes.

There is also a BIRADS ACR classification for MRI

4- A direct debit.
This “biopsy” makes it possible to diagnose cancer and to give the prognostic parameters used for treatment decisions.

Depending on the case, microbiopsies or macrobiopsies are used. These two examinations are distinguished by the size of the needles used and therefore the size of the samples.
Microbiopsies are rather used for the diagnosis of masses and macrobiopsies for microcalcifications.
These samples are taken after local anesthesia, with clinical guidance (palpable mass), ultrasound, mammography (stereotaxic) or by MRI. The indication depends on the type of lesion identified (mass or microcalcification), on the examination which best shows the anomaly, on its location in the breast, etc.
A metallic marker (clip or coil) can be put in place during the sampling, to guide any treatments that may be necessary (surgery, radiotherapy). They remain visible (unless removed during an intervention) and are safe.
It is also possible to take a sample from a lymph node (s) clinically or by imaging.

Surgical biopsies or cytological punctures are rarely used today. Surgery can be offered for lesions not technically accessible to a radio-guided sample, or in the event of a discrepancy between the radiology which shows a suspicious image and the biopsy which gives a diagnosis of normal tissue.

At the end of this time, it is necessary to know:
- The diagnosis: invasive carcinoma, carcinoma in situ, ductal hyperplasia with or without atypia, lobular carcinoma in situ, other diagnosis.
- In case of cancer:
      o The histological type (ductal (most often called carcinoma without specific type NST) or lobular,
      o The histo-prognostic grade,
      o The presence of estrogen and progesterone receptors,
      o The presence of an over-expression of HER2
      o The Proliferation Index (KI67)
      o The maximum clinical and radiological size of the lesion; the presence of associated lesions, lymph node extension and possibly metastatic.

5- The "extension assessment" is no longer systematically carried out.
It is indicated if a metastatic risk is estimated taking into account the results of the diagnostic assessment and / or of the intervention.

It includes:
o a biological assessment (marker CA153, hepatic assessment)
o an imagery which can associate a thoraco-abdominal scanner, a bone scintigraphy, a PET scan.

It is obvious that the extension assessment is always carried out in the event of a symptom which may evoke metastasis.

Breast course.
The succession and the sequence of the different exams can waste time. The Institut Curie (www.curie.fr) has developed "Breast paths" which make it possible to speed up and optimize the completion of this assessment.
The patient is taken care of upon arrival by a nurse coordinator. The patient completes the medical history questionnaires.
The patient is then seen successively by the surgeon and the radiologist who reviews the pictures, can do an ultrasound and / or a complementary mammography and provides an MRI if necessary.
New biopsies can then be performed, especially on additional lesions (30% of cases). Part of the samples can be taken for a tumor bank.

Four different routes are possible:
- palpable with previously performed biopsy
- palpable without biopsy
- not palpable with previously performed biopsy - not palpable without previously performed biopsy