Diagnosis Procedures for Breast Cancer

How is breast cancer diagnosed?

It is important to remember that a lump or other changes in the breast, or an abnormal area seen on a mammogram, may be caused by cancer or, more often, by other, less serious problems. To determine the cause of any signs or symptoms you may have, your physician will perform a careful physical exam that includes a personal and family medical history, as well as questions about your current overall health status. In addition, an examination may be done which includes the following: Palpation - carefully feeling the lump and the tissue around it - its size, its texture, and whether it moves easily. Benign lumps often feel different from cancerous ones. Nipple discharge examination - fluid may be collected from spontaneous nipple discharge and then sent to the lab to look for cancer cells. Most nipple secretions are not cancer, as an injury, infection, or benign tumor may cause discharge. For women who are at high risk for breast cancer, a procedure called ductal lavage may be used. Ductal lavage is a procedure that collects cells from inside the milk ductal system - the location where most breast cancers begin. In addition to a physical examination by your physician, imaging tests will be performed. Imaging tests may include one or more of the following: Diagnostic mammography - a diagnostic mammogram is an x-ray of the breast used to diagnose unusual breast changes, such as a lump, pain, nipple thickening or discharge, or a change in breast size or shape. A diagnostic mammogram is also used to evaluate abnormalities detected on a screening mammogram. More pictures are taken for a diagnostic mammogram than for a screening mammogram. It is a basic medical tool and is appropriate in the workup of breast changes, regardless of a woman's age. Digital mammography (Also called full-field digital mammography, or FFDM) - a type of mammography in which the images are electronically captured and stored on a computer, rather than x-ray film. The images are viewed on a computer screen. Images can be changed, such as the degree of magnification, brightness or contrast, to help visualization. They can also be transmitted electronically. While this procedure currently costs more than standard mammography, studies are being done to see which type of mammography will be of more benefit to women for the long term. Some studies have found FFDM to be more accurate in finding cancers in women younger than 50. Also, it has been found that women undergoing digital mammography do not have to return for additional studies as often as with standard mammography because the digital images have fewer questionable spots needing more investigation. However, not all hospitals and mammography facilities have digital equipment available. Still, women should not miss their regular mammogram if a digital mammogram is not available. Ultrasonography - uses high-frequency sound waves, not heard by humans. The sound waves enter the breast and bounce back. The pattern of their echoes produces a picture called a sonogram, which is displayed on a screen. This exam is often used along with mammography. Scintimammography - a specialized radiology procedure sometimes used to assess the breasts when other examinations have been inconclusive. Scintimammography, or a molecular breast scan, is a type of nuclear radiology procedure. This means that a tiny amount of a radioactive substance is used during the procedure to assist in the examination of the breasts. The radioactive substance, called a radionuclide (radiopharmaceutical or radioactive tracer), is absorbed by certain types of body tissues. the exact role of scintimammography is unclear at this time.

 Magnetic resonance imaging (MRI) - a diagnostic procedure that uses a combination of large magnets, radiofrequencies, and a computer to produce detailed images of organs and structures within the body. In early 2007, the American Cancer Society (ACS) recommended new guidelines which include screening MRI with mammography for certain high-risk women. According to the ACS, contrastenhanced MRI of the breasts has been shown to have a high sensitivity for detecting breast cancer in women both with or without symptoms. MRI scans along with annual mammography should be considered for the following: o Women with BRCA1 or BRCA2 mutation o Women with a first-degree relative (mother, sister, and/or daughter) with a BRCA1 or BRCA2 mutation, if they have not yet been tested for the mutation o Women with a 20 percent to 25 percent or greater lifetime risk of breast cancer, based on one of several accepted risk assessment tools that look at family history and other factors o Women who were treated with radiation therapy to the chest area between the ages of 10 and 30 years o Women with Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley syndrome or may have the syndrome based on a history of the syndrome in a first-degree relative It is recommended that high-risk women begin screening mammography and screening MRI at the age of 30, unless they and their physicians agree that a different age is more appropriate. Based on these exams, your physician may decide that no further tests are needed and no treatment is necessary. In such cases, your physician may want to check you regularly to watch for any changes. Often, however, the physician must remove fluid or tissue from the breast to be sent to the lab to look for cancer cells. The procedure is called a biopsy. It can be done using a needle to get a piece of the area of concern, or it can be done with surgery. A biopsy removes tissue or cells from the body for examination under a microscope. It is the only way to determine for sure if cancer or other abnormal cells are present. Biopsies may be done under local or general anesthesia. Local anesthesia means drugs are used to numb the area of the breast that the needle will be put into. General anesthesia means you will be given drugs to put you into a deep sleep while the biopsy is being done. There are several types of breast biopsy procedures. The type of biopsy performed will depend on the location and size of the breast lump or abnormality. Types of breast biopsy procedures include, but are not limited to, the following: Fine needle aspiration biopsy - a very thin needle is placed into the lump or suspicious area to remove a small sample of fluid and/or tissue. No incision is necessary. A fine needle aspiration biopsy may be performed to help to differentiate a cyst from a lump. Core needle biopsy - a large needle is guided into a lump or suspicious area to remove a small cylinder of tissue (also called a core). No incision is necessary. Surgical biopsy (also called an open biopsy) - a surgeon removes part or all of a lump or suspicious area through an incision into the breast. There are two types of surgical biopsies. During an incisional biopsy, a small part of the lump is removed; whereas during an excisional biopsy, the entire lump is removed. In some cases, if the breast lump is very small and deep and is difficult to locate, the wire localization technique may be used during surgery. With this technique, a special wire is placed into the lump under x-ray guidance. The surgeon follows this wire to help locate the breast lump. There are special instruments and techniques that may be used to guide the needles and to assist with biopsy procedures. These include, but are not limited to, the following:

 Stereotactic biopsy - stereotactic biopsy finds the exact location of a breast lump or suspicious area by using a computer and mammogram results to create a three-dimensional (3D) picture of the breast. A sample of tissue is removed with a needle. Mammotome breast biopsy system (also called vacuum-assisted biopsy) - a type of tube is inserted into the breast lump or mass. The breast tissue is gently suctioned into the tube, and a rotating knife removes the tissue. In 1999, the US Food and Drug Administration (FDA) approved the use of the hand-held Mammotome device. Ultrasound-guided biopsy - a technique that uses a computer and a transducer that sends out ultrasonic sounds waves to create images of the breast lump or mass. This technique helps to guide the needle biopsy. Advanced breast biopsy instrumentation (ABBI) - uses a rotating knife and cylinder to remove a large sample of tissue. Although this type of procedure has not received widespread acceptance, it is often possible to remove the entire breast lesion with this method. A procedure, called sentinel node biopsy, is used to determine if cancer cells have spread to the lymph nodes. This surgical procedure may be performed during the initial diagnostic period to aid in staging of the breast cancer. This procedure involves injecting a dye and/or radioactive substance near the tumor. This injection helps to locate the lymph node closest to the tumor (sentinel node) - the one that is most likely to have cancer cells present if the cancer has spread. The surgeon removes the lymph node that absorbs the dye and radioactive substance and sends it to the pathologist to examine it closely for the presence of cancer cells.

Diagnosing breast cancer Tests and procedures used to diagnose breast cancer include: Breast exam. Your doctor will check both of your breasts, feeling for any lumps or other abnormalities. Your doctor will likely check your breasts in varying positions, such as with your arms above your head and at your side. Mammogram. A mammogram is an X-ray of the breast. Mammograms are commonly used to screen for breast cancer. If an abnormality is detected on a screening mammogram, your doctor may recommend a diagnostic mammogram to further evaluate that abnormality. Breast ultrasound. Ultrasound uses sound waves to produce images of structures deep within the body. Your doctor may recommend an ultrasound to help determine whether a breast abnormality is likely to be a fluid-filled cyst or a solid mass, which may be either benign or cancerous. Breast ultrasound is helpful to guide radiologic biopsy to get a sample of breast tissue if a solid mass is found. Removing a sample of breast cells for testing (biopsy). A biopsy to remove a sample of the suspicious breast cells helps determine whether cells are cancerous. The sample is sent to a laboratory for testing. A biopsy sample is also analyzed to determine the type of cells involved in

the breast cancer, the aggressiveness (grade) of the cancer and whether the cancer cells have hormone receptors. Breast magnetic resonance imaging (MRI). An MRI machine uses a magnet and radio waves to create pictures of the interior of your breast. Before a breast MRI, you receive an injection of dye. This test may be ordered after a breast biopsy confirms cancer, but before surgery to give your doctor an idea of the extent of the cancer and to see if there's any evidence of cancer in the other breast. Other tests and procedures may be used depending on your situation. Staging breast cancer Once your doctor has diagnosed your breast cancer, he or she works to establish the extent (stage) of your cancer. Your cancer's stage helps determine your prognosis and the best treatment options. Complete information about your cancer's stage may not be available until after you undergo breast cancer surgery. Tests and procedures used to stage breast cancer may include: Blood tests, such as a complete blood count Mammogram of the other breast to look for signs of cancer Chest X-ray Breast MRI Bone scan Computerized tomography (CT) scan Positron emission tomography (PET) scan

Not all women will need all of these tests and procedures. Your doctor selects the appropriate tests based on your specific circumstances. Breast cancer stages range from 0 to IV, with 0 indicating cancer that is very small and noninvasive. Stage IV breast cancer, also called metastatic breast cancer, indicates cancer that has spread to other areas of the body.

Imaging studies such as mammogram and MRI, often along with physical exams of the breast, can lead doctors to suspect that a person has breast cancer. However, the only way to know for sure is to take a sample of tissue from the suspicious area and examine it under a microscope. A biopsy is a small operation done to remove tissue from an area of concern in the body. If your doctor feels anything suspicious in your breast, or sees something suspicious on an imaging study, he or she will order a biopsy. The tissue sample is examined by a pathologist (a doctor who specializes in diagnosing disease) to see whether or not cancer cells are present. If cancer is present, the pathologist can then look at the cancers characteristics. The biopsy will result in a report that lays out all of the pathologists findings. Biopsy is usually a simple procedure. In the United States, only about 20% of women who have biopsies turn out to have cancer. By contrast, in Sweden, where cost accounting is much stricter and only the most suspicious lesions are biopsied, 80% of biopsies turn out to be cancerous (malignant).

Biopsy techniques
Different techniques can be used to perform biopsy, and its likely that your surgeon will try to use the least invasive procedure possible the one that involves the smallest incision and the least amount of scarring. However, the choice of procedure really depends on your individual situation. Biopsy can be done by placing a needle through the skin into the breast to remove the tissue sample. Or, it can involve a minor surgical procedure, in which the surgeon cuts through the skin to remove some or all of the suspicious tissue.

Fine needle aspiration biopsy

Fine needle aspiration (FNA) is the least invasive method of biopsy and it usually leaves no scar. You will be lying down for this procedure. First, an injection of local anesthesia is given to numb the breast. The surgeon or radiologist uses a thin needle with a hollow center to remove a sample of cells from the suspicious area. In most cases, he or she can feel the lump and guide the needle to the right place.

In cases where the lump cannot be felt, the surgeon or radiologist may need to use imaging studies to guide the needle to the right location. This is called ultrasound-guided biopsy when ultrasound is used, or stereotactic needle biopsy when mammogram is used. With ultrasound-guided biopsy, the doctor will watch the needle on the ultrasound monitor to guide it to the area of concern. With stereotactic mammography, mammograms are taken from different angles to pinpoint the location of the breast mass. The doctor then inserts the hollow needle to remove the cell sample.

Core needle biopsy

Core needle biopsy uses a larger hollow needle than fine needle aspiration does. If you have this type of biopsy, youll be lying down. After numbing the breast with local anesthesia, the surgeon or radiologist uses the hollow needle to remove several cylindershaped samples of tissue from the suspicious area. In most cases, the needle is inserted about 3 to 6 times so that the doctor can get enough samples. Usually core needle biopsy does not leave a scar. If the lesion cannot be felt through the skin, the surgeon or radiologist can use an imageguided technique such as ultrasound-guided biopsy or stereotactic needle biopsy. A small metal clip may be inserted into the breast to mark the site of biopsy in case the tissue proves to be cancerous and additional surgery is required. This clip is left inside the breast and is not harmful to the body. If the biopsy leads to more surgery, the clip will be removed at that time. In addition to offering quick results without significant discomfort and scarring, both fine needle aspiration and core needle biopsy give you the opportunity to discuss treatment options with your doctor before having any surgery. In some cases, needle biopsy can be performed right in the doctors office, unless your doctor needs the help of imaging equipment to guide the biopsy. However, needle biopsy has a higher risk of a false negative result a result suggesting that cancer is not present when it really is. This is likely because needle biopsy removes a smaller amount of tissue than surgical biopsy does and may not pick up the cancer cells. Your doctor may recommend a surgical biopsy in follow up to, or instead of, a needle biopsy. Together you can decide what is best for your situation.

Vacuum-assisted breast biopsy

Vacuum-assisted breast biopsy, also known by the brand names Mammotome or MIBB (which stands for Minimally Invasive Breast Biopsy), is a newer way of performing breast biopsy. Unlike core needle biopsy, which involves several insertions of a needle through the

skin, vacuum-assisted biopsy uses a special probe that only has to be inserted once. The procedure also is able to remove more tissue than core needle biopsy does. For vacuum-assisted breast biopsy, youll lie face down on an exam table with special round openings in it, where you place your breasts. First, an injection of local anesthesia is given to numb the breast. Guided by mammography (stereotactic-guided biopsy) or ultrasound, the surgeon or radiologist places the probe into the suspicious area of the breast. A vacuum then draws the tissue into the probe. A rotating cutting device removes a tissue sample and then carries it through the probe into a collection area. The surgeon or radiologist can then rotate the probe to take another sample from the suspicious lesion. This can be repeated 8 to 10 times so that the entire area of concern is thoroughly sampled. In some cases, a small metal clip is placed into the biopsy site to mark the location, in case a future biopsy is needed. This clip is left inside the breast and causes no pain or harm. If the biopsy leads to more surgery, the clip will be removed at that time. Vacuum-assisted biopsy is becoming more common, but it is still a relatively new procedure. If you are having this form of biopsy, make sure that the surgeon or radiologist is experienced at using the equipment.

Incisional biopsy
Incisional biopsy is more like regular surgery. After using local anesthesia to numb the breast and giving you an injection to make you drowsy, the surgeon uses a scalpel to cut through the skin to remove a piece of the tissue for examination. As with needle biopsy, if the surgeon cannot feel the lump or suspicious area, he or she may need to use mammography or ultrasound to find the right spot. Your surgeon also may use a procedure called needle wire localization. Guided by either mammography or ultrasound, the surgeon inserts a small hollow needle through the breast skin into the abnormal area. A small wire is placed through the needle and into the area of concern. Then the needle is removed. The doctor can use the wire as a guide in finding the right spot for biopsy. Your doctor may recommend incisional biopsy if a needle biopsy is inconclusive that is, the results are unclear or not definite or if the suspicious area is too large to sample easily with a needle. As with needle biopsy, there is some possibility that incisional biopsy can return a false negative result. However, you do get the results fairly quickly. Given that

it is a surgical procedure, incisional biopsy is more invasive than needle biopsy, it leaves a scar, and it may require more time to recover.

Excisional biopsy
Excisional biopsy, the most involved form of biopsy, is surgery to remove the entire area of suspicious tissue from the breast. In addition to removing the suspected cancer, the surgeon generally will remove a small rim of normal tissue around it as well, called a margin. As with incisional biopsy, if the surgeon cannot feel the lump or suspicious area, he or she may need to use mammography or ultrasound to find the right spot. Your surgeon also may use needle wire localization to mark the right area for biopsy. Excisional biopsy is the surest way to establish a definite diagnosis without getting a false negative result. Also, having the entire lump removed may provide you with some peace of mind. However, excisional biopsy is more like regular surgery, and it will leave a scar and require more time to recover. Like incisional biopsy, excisional biopsy is performed with local anesthesia.

Before your biopsy

Biopsies are not medical emergencies and can be scheduled at your convenience. But for peace of mind, most people want their biopsies done "yesterday." Medical guidelines say that about 90% of biopsies should be needle biopsies, the least invasive procedure. Still, research has shown that about 70% of breast biopsies are surgical biopsies. This means that many women who don't have cancer are having unnecessary surgery. It also means that women who are diagnosed with breast cancer have to have a second operation to remove the cancer. Before proceeding with a biopsy, be sure to ask your doctor to:

review the results of your mammogram and any other imaging studies with you show you the area in question explain the type of biopsy that's recommended for you and explain why that type of

biopsy is recommended; if surgical biopsy is recommended ask if needle biopsy can be done

discuss how and why the biopsy will be performed answer any of your questions arrange for you to sign required consent forms tell you when and how you can get the biopsy results

A few days to a week after biopsy, your doctor should give you a pathology report that explains what was found in the tissue sample. See Your Diagnosis for more information.

MRI, or magnetic resonance imaging, is a technology that uses magnets and radio waves to produce detailed cross-sectional images of the inside of the body. MRI does not use x-rays, so it does not involve any radiation exposure. Breast MRI has a number of different uses for breast cancer, including:

screening high-risk women (women known to be at higher than average risk for gathering more information about an area of suspicion found on a mammogram or monitoring for recurrence after treatment

breast cancer, either because of a strong family history or a gene abnormality)

ultrasound

How Breast MRI is Performed

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Unlike a mammogram, which uses x-rays to create images of the breast, breast MRI uses magnets and radio waves to produce detailed 3-dimensional images of the breast tissue. Before the test, you may need to have a contrast solution (dye) injected into your arm through an intravenous line. Because the dye can affect the kidneys, your doctor may perform kidney function tests before giving you the contrast solution. The solution will help any potentially cancerous breast tissue show up more clearly. Some people experience temporary discomfort during the infusion of the contrast solution. Cancers need to increase their blood supply in order to grow. On a breast MRI, the contrast tends to become more concentrated in areas of cancer growth, showing up as white areas on an otherwise dark background. This helps the radiologist determine which areas could possibly be cancerous. More tests may be needed after breast MRI to confirm whether or

not any suspicious areas are actually cancer. two discrete areas of abnormaliLarger Version

MRI images showing

For the breast MRI, you will need to pull down your hospital gown to your waist or open it in front to expose your breasts. Then you lie on your stomach on a padded platform with cushioned openings for your breasts. Each opening is surrounded by a breast coil, which is a signal receiver that works with the MRI unit to create the images. The platform then slides into the center of the tube-shaped MRI machine. You wont feel the magnetic field and radio waves around you, but you will hear a loud thumping sound. You will need to be very still during the test, which takes around 30 to 45 minutes. If youre claustrophobic, being confined within an MRI machine for a long period of time can be difficult. Some facilities have an open MRI machine to avoid this problem, or you may be given a mild sedative. Because the technology uses strong magnets, it is essential that you remove anything metal jewelry, snaps, belts, earrings, zippers, etc. before the test. The technologist also will ask you if you have any metal implanted in your body, such as a pacemaker or artificial joint.

Where to have breast MRI

Its important to have breast MRI done at a facility with:

MRI equipment designed specifically for imaging the breasts. Not all hospitals

and imaging centers have this; instead, many have MRIs used for scanning the head, chest, or abdomen.

The ability to perform MRI-guided breast biopsy. If the breast MRI reveals an

abnormality, youll want to have an MRI-guided breast biopsy (a procedure to remove any suspicious tissue for examination) right away. Otherwise, youll need to have a breast MRI again at another facility that offers an immediate MRI-guided breast biopsy. If your doctor recommends that you have breast MRI for screening, diagnosis, or follow-up, ask for help in finding the best place to have the test done. The American College of Radiology is working on a system for accrediting breast MRI centers, which should make it easier to find high-quality breast MRI facilities in the future.

Breast Physical Exam

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A breast physical exam is a careful manual examination of the breasts by a doctor or other health professional. This exam can help find lumps that women may miss with their own self-exams. While it's true that most lumps are found by women themselves, the abnormality in a breast can be so difficult to feel that only someone with experience would recognize it. Lumps, thickening, asymmetry (a difference in appearance between the two breasts) changes in your breasts that you may not notice or think are normal may be detected by a health professional who examines many breasts regularly. About 20% of the time, breast cancers are found only by physical exam and not seen on a mammogram. The American Cancer Society recommends that women in their 20s and 30s have a physical breast exam as part of a periodic (regular) health exam by a health professional, preferably every 3 years. After age 40, women should have a breast exam by a health professional every year.

During and after treatment

If you are being treated for breast cancer, your doctor will likely recommend that you come in for a breast physical exam every 3 to 4 months. Regularly scheduled physical exams will continue after you finish treatment, gradually decreasing in frequency to once a year. Work with your doctor to figure out what is best for your situation.

Breast Self-Exam (BSE)

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Breast self-exam (BSE), or regularly examining your breasts on your own, can be an important way to find a breast cancer early, when it's more likely to be treated successfully. Not every cancer can be found this way, but it is a critical step you can and should take for yourself. Over the years, there has been some debate over just how valuable BSE is in detecting breast cancer early and increasing the likelihood of survival. For example, in summer 2008, one study of nearly 400,000 women in Russia and China reported that breast selfexamination does not reduce breast cancer mortality and may even cause harm by prompting unnecessary biopsies (removal and examination of suspicious tissue). Because of the ongoing uncertainty raised by this and other studies, the American Cancer Society has chosen to advise women that BSE is an optional screening tool. Breastcancer.org still believes that BSE is a useful and essential screening strategy, especially when used in combination with regular physical exams by a doctor and mammography. About 20% of the time, breast cancers are found by physical examination rather than by mammography. We recommend that all women routinely perform breast selfexams as part of their overall breast cancer screening strategy. Read what Marisa Weiss, M.D., president and founder of Breastcancer.org, has to say about the July 2008 study of breast self-exam.

Tips for performing BSE

Few women really want to do a breast self-exam, or BSE, and for many the experience is frustrating you may feel things but not know what they mean. However, the more you examine your breasts, the more you will learn about them and the easier it will become for

you to tell if something unusual has occurred. Breastcancer.org believes that BSE is an essential part of taking care of yourself and lowering your risk of breast cancer. Some tips for BSE:

Try to get in the habit of doing a breast self-examination once a month to familiarize

yourself with how your breasts normally look and feel. Examine yourself several days after your period ends, when your breasts are least likely to be swollen and tender. If you are no longer having periods, choose a day that's easy to remember, such as the first or last day of the month.

Dont panic if you think you feel a lump. Most women have some lumps or lumpy

areas in their breasts all the time. In the United States, only 20% of women who have a suspicious lump biopsied turn out to have breast cancer.

Breasts tend to have different neighborhoods. The upper, outer area near your

armpit tends to have the most prominent lumps and bumps. The lower half of your breast can feel like a sandy or pebbly beach. The area under the nipple can feel like a collection of large grains. Another part might feel like a lumpy bowl of oatmeal. Whats important is that you get to know the look and feel of YOUR breasts' various neighborhoods. Does something stand out as different from the rest (like a rock on a sandy beach)? Has anything changed? Bring to the attention of your doctor any changes in your breasts that last over a full month's cycle OR seem to get worse or more obvious over time.

You may want to start a journal where you record the findings of your breast self-

exams. This can be like a small map of your breasts, with notes about where you feel lumps or irregularities. Especially in the beginning, this may help you remember, from month to month, what is normal for your breasts. It is not unusual for lumps to appear at certain times of the month, but then disappear, as your body changes with the menstrual cycle (if you are still menstruating). Only changes that last beyond one full cycle, or seem to get bigger or more prominent in some way, need your doctor's attention.

Step 1: Begin by looking at your breasts in the mirror with your shoulders straight and your arms on your hips. Here's what you should look for:

Breasts that are their usual size, shape, and color Breasts that are evenly shaped without visible distortion or Breast Self-Exam - Step 1Larger Version

swelling If you see any of the following changes, bring them to your doctor's attention:

Dimpling, puckering, or bulging of the skin A nipple that has changed position or an inverted nipple

(pushed inward instead of sticking out)

Redness, soreness, rash, or swelling

Step 2: Now, raise your arms and look for the same changes.

Breast Self-Exam - Steps 2 and 3Larger Version Step 3: While you're at the mirror, look for any signs of fluid coming out of one or both nipples (this could be a watery, milky, or yellow fluid or blood). Step 4: Next, feel your breasts while lying down, using your right hand to feel your left breast and then your left hand to feel your right breast. Use a firm, smooth touch with the first few finger pads of your hand, keeping the fingers flat and together. Use a circular motion, Breast Self-Exam - Step 4Larger Version

about the size of a quarter. Cover the entire breast from top to bottom, side to side from your collarbone to the top of your abdomen, and from your armpit to your cleavage. Follow a pattern to be sure that you cover the whole breast. You can begin at the nipple, moving in larger and larger circles until you reach the outer edge of the breast. You can also move your fingers up and down vertically, in rows, as if you were mowing a lawn. This up-anddown approach seems to work best for most women. Be sure to feel all the tissue from the front to the back of your breasts: for the skin and tissue just beneath, use light pressure; use medium pressure for tissue in the middle of your breasts; use firm pressure for the deep tissue in the back. When you've reached the deep tissue, you should be able to feel down to your ribcage.

Step 5: Finally, feel your breasts while you are standing or sitting. Many women find that the easiest way to feel their breasts is when their skin is wet and slippery, so they like to do this step in the shower. Cover your entire breast, using the same hand movements described in Step 4.

Breast Self-Exam - Step 5Larger Version

Mammograms are probably the most important tool doctors have not only to screen for breast cancer, but also to diagnose, evaluate, and follow people whove had breast cancer. Safe and reasonably accurate, a mammogram is an x-ray photograph of the breast. The technique has been in use for about 40 years. Screening mammograms are typically done every year to check the breasts for any early signs of breast cancer. Diagnostic mammograms are different from screening mammograms in that they focus on getting more information about a specific area (or areas) of concern usually due to a suspicious screening mammogram or a suspicious lump. Diagnostic mammograms take more pictures than screening mammograms do. A mammography technician and a radiologist would coordinate to get the images your doctor needs to address that concern. The technician may need to magnify a suspicious area to produce a more detailed picture that will help your doctor make the diagnosis.

Ultrasound is an imaging test that sends high-frequency sound waves through your breast and converts them into images on a viewing screen. The ultrasound technician places a sound-emitting probe on the breast to conduct the test. There is no radiation involved. Ultrasound is not used on its own as a screening test for breast cancer. Rather, it is used to complement other screening tests. If an abnormality is seen on mammography or felt by physical exam, ultrasound is the best way to find out if the abnormality is solid (such as a benign fibroadenoma or cancer) or fluid-filled (such as a benign cyst). It cannot determine whether a solid lump is cancerous, nor can it detect calcifications.

Ultrasound image showing dark irregular massLarger Version

If youre under age 30, your doctor may recommend ultrasound before mammography to evaluate a palpable breast lump (a breast lump that can be felt through the skin). Mammograms can be difficult to interpret in young women because their breasts tend to be dense and full of milk glands. (Older womens breasts tend to be more fatty and are easier to evaluate.) In mammograms, this glandular tissue looks dense and white much like a cancerous tumor. Some doctors say that locating an abnormality in the midst of dense gland tissue can be like finding a polar bear in a snowstorm. Most breast lumps in young women are benign cysts, or clumps of normal glandular tissue. Doctors also can use ultrasound to guide biopsy needles precisely to suspicious areas in the breast.

is necessary to confirm or rule out cancer. Needle biopsy or fine-needle biopsy can provide a core of tissue or a fluid aspirate, but needle biopsy should be restricted to fluid-filled cysts and advanced malignant lesions. Both methods have limited diagnostic value because of the small and perhaps unrepresentative specimens they provide. Open biopsy provides a complete tissue specimen, which can be sectioned to allow more accurate evaluation.
A breast biopsy can usually be done on an outpatient basis under local anesthesia; however, an excisional open biopsy may require general anesthesia. In sufficient tissue is obtained and the mass is found to be a malignant tumor, specimens are sent for estrogen and progesteronereceptor assays to assist in determining future therapy and the prognosis. Purpose Breast Biopsy

Breast biopsy

To differentiate between benign and malignant breast tumors.

Breast Biopsy Procedure Patient Preparation 1. 2. 3. 4. 5. 6. Make sure the patient has signed a consent form. Note and report all allergies. If the patient is to receive a local anesthesia, tell her she need not restrict food or fluids. If the patient is to have a general anesthesia, tell her she is to have nothing by mouth after midnight or Obtain and report abnormal results of prebiopsy studies, such as blood tests, urine tests, and radiographs of Explain that the test takes 15 to 30 minutes.

before the procedure. the chest. Implementation Needle Biopsy 1. 2. 3. 4. 5. 6. Instruct your patient to undress to the waist. After guiding her to a sitting or recumbent position with her hands at her sides, tell her to remain still. The doctor then prepares the biopsy site, administers a local anesthetic, and introduces the syringe (luerFluid aspirated from the breast is expelled into a properly labeled, heparinized tube; the tissue specimen is Send both specimens to the laboratory immediately. (With fine needle aspiration, a slide is made and viewed Because breast fluid aspiration isnt diagnostically accurate, some doctors aspirate fluid only from cysts. If

lock syringe for aspiration, Vim-Silverman needle for tissue specimen) into the lesion. placed in a labeled specimen bottle containing normal saline solution or formalin. immediately under a microscope). such fluid is clear yellow and the mass disappears, the aspiration is both diagnostic and therapeutic, and the aspirate is discarded. If aspiration yields no fluid or if the lesion recurs two or three times, an open biopsy is then considered appropriate. 7. After the procedure, pressure is exerted on the biopsy site and, after bleeding has stopped, an adhesive bandage is applied. Open Biopsy 1. 2. 3. 4. The site is prepared and draped, and the patient is given a local or general anesthetic. An incision is made in the breast to expose the mass. A portion of tissue or the entire mass is extracted. Benign-appearing masses smaller than (2cm) in diameter are usually excised. The specimens are placed in properly labeled specimen bottles containing 10% formalin solution.

5. 1.

The malignant-appearing tissue is sent for frozen suction and receptor assays. If the patient has received a general or local anesthetic, monitor the patients vital signs regularly. If she has

Nursing Interventions received a general anesthetic, check her vital signs every 15 minutes for 1 hour, every 30 minutes for 2 hours, every hour for the next 4 hours, and then every 4 hours. 2. 3. 4. 5. Administer analgesics for pain, as ordered, and provide ice bags for comfort. Instruct the patient to wear a support bra at all times until healing is complete. Observe for and report bleeding, tenderness, and redness at the biopsy site. Provide emotional support to the patient awaiting diagnosis.

Interpretation Normal Results 1. 2. Breast tissue consists of cellular and noncellular connective tissue, fat lobules, and various lactiferous ducts. Breast tissue is pink, more fatty than fibrous, and shows no abnormal development of cells or tissue

elements. Abnormal Results 1. 2. Benign tumors may suggest fibrocystic disease, adenofibroma, intraductal papilloma, mammary fat necrosis, Malignant tumors may suggest adenocarcinoma, cystosarcoma, intraductal and infiltrating carcinoma, or plasma cell mastitis. inflammatory carcinoma, medullary or circumscribed carcinoma, colloid carcinoma, lobular carcinoma, sarcoma, or Pagets disease. Precaution

Breast biopsy is contraindicated in the patient with a condition that precludes surgery. Failure to obtain an adequate tissue specimen or to place the specimen in the proper solution container

Interfering Factors interfering with test results.

Test: Breast Biopsy The breast biopsy is performed to confirm or rule out breast cancer after clinical examination, mammography, or thermography has identified a mass. Fine-needle aspiration is usually done on a mass that has been identified by ultrasonography as being fluid-filled. Solid masses are assessed by one of four methods: Ultrasound-guided core biopsy; needle or wire localization biopsy; or excisional biopsy. An incisional biopsy is seldom performed. Stereotactic breast biopsy immobilizes the breast and allows the computer to calculate the exact location of the mass, based on x-rays from two angles. Needle or wire localization biopsy is used to localize a nonpalpable lesion for excisional biopsy. All four techniques require only local anesthesia, although an excisional biopsy may be done under general anesthesia. If sufficient tissue is obtained and the mass is found to be a malignant tumor, specimens are sent for estrogen and progesterone receptor assays to assist in determining future therapy and the prognosis. Because breast cancer remains the most prevalent cancer in women, genetic researchers are continually working to identify women at risk. Procedure and Preparation:

The nurse should be sure that the procedure has been explained to the patient and all questions answered. Explain any food, fluid, or medication restrictions (usually few restrictions if local anesthesia is used). Offer emotional support if the patient appears anxious or expresses concerns. Ultrasound-guided core biopsy: 1. The gowned patient will lie on her back on the ultrasound table. The patient will then be repositioned according to the location of the mass. 2. Ultrasonography is performed, the mass is localized, and its position is marked on the skin. 3. The area is cleaned and local anesthetic is injected. 4. The biopsy needle is inserted at the marked spot and a tissue specimen is obtained. 5. When the needle is withdrawn, apply pressure for 10 minutes and then apply a dressing and an ice bag. Stereotactic breast biopsy: 1. The gowned patient is instructed to lie face down on a special breast biopsy table; position breast through the round opening in the table. Mammography equipment located under the table is used for the procedure. 2. The breast is compressed by a paddle, as with a regular mammogram, and remains compressed throughout the procedure. Films are then taken from two angles and visualized on the computer. 3. The computer calculates the exact position of the mass and the insertion site for the needle. 4. Next, the skin is cleaned and the local anesthesia is injected. 5. The biopsy probe is inserted, and x-ray images are taken to confirm proper placement. 6. Tissue specimen obtained using punch biopsy needle or Mammotome probe. 7. After the probe is removed, apply pressure for 10 minutes, dress the site, and apply ice. Needle or Wire Localization Biopsy: 1. The suspicious area is identified, using craniocaudal and medolateral x-ray views of the breast. 2. The area is anesthetized and a double-lumen needle is inserted. 3. X-rays are obtained to ensure proper needle placement, and areas may be marked with blue dye or a radiopaque contrast medium. 4. The outer needle is then removed, leaving in place a small hooked wire. The wire is taped to the patient's skin to identify the excisional biopsy site. Excisional biopsy: 1. After the patient receives an anesthetic, her skin is prepared and draped. 2. A curvilinear incision is made over the palpable mass or the area identified by the localization wire. 3. The mass as well as a margin of normal tissue around it are removed, and the skin is sutured. 4. A dressing is applied, and the patient is observed for at least one hour before discharge. All procedures: 1. Tissue specimens are placed in 10% formaldehyde solution and sent for frozen-section and receptor assays. 2. Check vital signs, and provide analgesia if needed. If the patient has received general anesthesia, check vital signs every 30 minutes for the first 4 hrs, every hour for the next four hours, and then every 4 hours. 3. Observe for and report bleeding, tenderness, redness at the biopsy site. 4. Provide emotional support to the patient who is awaiting diagnosis.

Normal breast tissue consists of cellular and noncellular connective tissue, fat lobules, and various lactiferous ducts. It's pink, more fatty than fibrous, and shows no abnormal development of cells or tissue elements. Abnormal breast tissue may exhibit a wide range of malignant or benign pathology. Breast tumors are common in women and account for 32% of female cancers; such tumors are rare in men. Benign tumors include fibrocystic disease, adenofibroma, intraductal papilloma, mammary fat necrosis, and plasma cell mastitis (mammary duct ectasia). Malignant tumors include adenocarcinoma, cystosarcoma, intraductal carcinoma, infiltrating carcinoma, inflammatory carcinoma, medullary or circumscribed carcinoma, colloid carcinoma, lobular carcinoma, sarcoma, and Paget's disease.

Nursing Implications for Diagnostic Tests Breast Biopsy PREPARATION OF THE WOMAN All Biopsies Ensure that the consent form is signed. Acknowledge that preoperative anxiety is normal. It is important to remember that 80% of all breast lesions are benign. WOMAN AND FAMILY TEACHING Aspiration Biopsy (Fine-Needle Aspiration Biopsy) A needle will be used to remove tissue and/or fluid from the breast lesion. This procedure may be done in the surgeons office and takes only a few minutes. Aspirated tissue is sent for histologic examination to determine whether it is cancerous. Results are sent to the surgeon within a few days. Mild analgesics are usually sufficient to relieve postbiopsy pain. Stereotactic Core Biopsy (Tru-Cut Biopsy) The woman lies face down on a special stereotactic biopsy table with a hole through which her breast protrudes. The

breast is anesthetized, the lesion located by mammography, and a computer-guided hollow-core needle enters the breast at high speed and withdraws a core of tissue. The tissue is sent for histologic examination to determine whether it is cancerous. Results are available within 36 hours. Mild analgesics are usually sufficient to relieve postbiopsy pain. Incisional or Excisional Biopsy The needle-wire localization procedure provides a guide for the surgeon to follow. This procedure involves a mammogram followed by insertion of a hollow needle and one or more wires into the lesion. Dye may be injected through the hollow needle; the dye may cause a stinging sensation. The woman is then taken to the operating room with the wires in place for the biopsy. The biopsy is generally performed in an ambulatory surgery center using local anesthesia. If the woman has large breasts or is at high risk for complications, the surgeon may prefer to use the standard operating room. In an incisional biopsy, a section of tissue is removed from the breast lesion and sent for histologic examination. In an excisional biopsy, the entire lesion is removed along with a surrounding margin of normal-looking tissue. The specimen is then sent for mammographic and histologic analysis, to be sure that the entire lesion has been removed and to determine whether it is cancerous. A screen shields the operative area from view. A nurse stands

within view of the woman to explain whats happening, answer questions, and offer emotional support. If there is any painful sensation, the woman needs to ask for additional anesthesia. The surgeon closes the internal incision with absorbable sutures and secures the skin with sutures or tape. A gauze dressing is applied to protect the area. Postoperative pain, bruising, or scarring varies according to the surgeons technique and the womans tissue. It is helpful to wear a bra and to apply ice packs periodically. Mild analgesics are generally sufficient to control pain. Results of the biopsy are usually available within a few days.

Breast self-examination

(BSE) is a method of finding abnormalities of the breast, for early detection of breast cancer. The method involves the woman herself looking at and feeling each breast for possible lumps, distortions or swelling.
BSE was once promoted heavily as a means of finding cancer at a more curable stage, but randomized controlled studies found that it was not effective in preventing death, and actually caused harm through needless biopsies and surgery. 1. The self-exam is performed by standing in front of a mirror with the torso exposed to view. 2. The woman looks in the mirror for visual signs of dimpling, swelling, or redness on or near the breasts. This is usually repeated in several positions, such as while having hands on the hips, and then again with arms held overhead. 3. The woman then palpates her breasts with the pads of her fingers to feel for lumps (either superficial or deeper in tissue) or soreness. To be effective, this process needs to cover the entire breast, including the axillary tail of each breast that extends toward the axilla (armpit). This is usually done once while standing in front of the mirror and again while lying down. 4. Some guidelines suggest mentally dividing the breast into four quadrants and checking each quadrant separately. Finally, women that are not breastfeeding gently squeeze each nipple to check for any discharge. The 7 Ps of Breast Self Examination (BSE) 1. Position: Inspect breasts visually and palpate in the mirror with arms at various positions. Then perform the examination lying down, first with a pillow under one shoulder, then with a pillow under the other shoulder, and finally lying flat.

2. Perimeter: Examine the entire breast, including the nipple, the axillary tail that extends into the armpit, and
nearby lymph nodes. 3. Palpation: Palpate with the pads of the fingers, without lifting the fingers as they move across the breast. 4. Pressure: First palpate with light pressure, then palpate with moderate pressure, and finally palpate with firm pressure. 5. Pattern: There are several examination patterns, and each woman should use the one which is most comfortable for her. The vertical strip pattern involves moving the fingers up and down over the breast. The piewedge pattern starts at the nipple and moves outward. The circular pattern involves moving the fingers in concentric circles from the nipple outward. Dont forget to palpate into the axilla. 6. Practice: Practice the breast self-exam and become familiar with the feel of the breast tissue, so you can recognize changes. A health care practitioner can provide feedback on your method. 7. Plan: Know what to do if you suspect a change in your breast tissue. Know your family history of breast cancer. Have mammography done as often as your health care provider recommends. For premenopausal women, BSE is best done at the same stage of their period every month to minimize changes due to the menstrual cycle. The recommended time is just after the end of the last period when the breasts are least likely to be swollen and tender. Older, menopausal women should do BSE once a month, perhaps on the first or last day of every month.

Mammography

is a radiographic technique used to detect breast cysts or tumors, especially those not palpable on physical examination. In xeromammography, a specially charged plate records the radiographic images and transfers them to a special paper. Biopsy of suspicious areas may be required to confirm malignancy. Although 90% to 95% of malignant breast tumors can be detected bymammography, this test produces many false positive results. Mammography may follow such screening procedures as ultrasonography or thermography.
Purpose of Mammography To screen for malignant breast tumors. To investigate breast masses, breast pain, or nipple discharge. To differentiate between benign breast disease and malignant tumors. To monitor patients with breast cancer who are treated with breast-conserving surgery and radiation. Mammography Procedure Patient Preparation 1. Instruct the patient to avoid using underarm deodorant or powder the day of the exam. 2. Explain that the test takes about 15 minutes. 3. Explain to the patient that she may be asked to wait while the films are checked. 4. When scheduling the test, inform the staff if patient has breast implants. 5. Make sure the patient has signed an appropriate consent form. 6. Note and report all allergies. Implementation 1. The patient rests one breast on a table above the X-ray cassette. 2. The compressor is placed on the breast.

3. The patient holds her breath until the X-ray is taken and shes told to breathe again. 4. An X-ray of the cranicaudal view is taken. 5. The machine is rotated, and the breast is compressed again. 6. An X-ray of the lateral view is taken. 7. The procedure is repeated for the other breast. 8. The film is developed and checked for quality. Nursing Intervention 1. Answer the patients questions about the test. 2. Encourage the patient to deep breathe to alleviate fear and anxiety. 3. Make the patient feel comfortable after the procedure. 4. Prepare to educate the patient about her diagnosis. 5. Prepare the patient for further testing or surgery, as indicated. Interpretation Normal Results The test reveals normal ducts, glandular tissue, and fat architecture. No abnormal masses or calcifications are present. Abnormal Results Irregular, poorly outlined, opaque areas suggest malignant tumors, especially if solitary and unilateral. Well-outlined, regular, clear spots may be benign, especially if bilateral. Interfering Factors Powders, deodorants, or salves on the breast and axilla that may cause false positive results. Failure to remove jewelry and clothing (possible false-positive results or poor imaging). Glandualr breasts that are common in patients younger than age 30, active lactation and previous breast surgery (possible poor imaging). Breast implants (possible hindrance in detecting masses). Comlications Vasovagal reaction during compression.

ULTRASONOGRAPHY

Description: The process of imaging deep structures of the body by measuring and recording the reflection of pulsed or continuous high-frequency sound waves. It is valuable in many medical situations, including the diagnosis of fetal abnormalities, gallstones, heart defects, and tumors. Also calledsonography.

Materials/ Equipments Needed: Clear gel towel

Procedures:

1. 2.

Explain to patient the procedure and its purpose. The mother lies on an examining table and is draped for privacy but with her abdomen exposed. To prevent supine hypotension syndrome, place a towel under her right buttock to tip her body slightly so the uterus will roll away from the vena cava. A gel is applied to the abdomen to improve the contact of the transducer. (be certain that the gel is at room temperature or even slightly warmer- rationale: to avoid uncomfortable uterine cramping) The transducer is then applied to the abdomen and moved both horizontally and vertically until the uterus and its contents are fully scanned. Wipe the clear gel gently with a towel at the end of the procedure.

3.

4.

5.

6.

Diagram/ Illustration:

Nursing Responsibilities:

BEFORE Procedure:

Before an ultrasound, the woman needs a good explanation of what will happen. Also tell her that it is safe for the father of the baby to remain in the room during the test. To ensure that the mother has a full bladder at the time of the procedure, she should drink a full glass of water every 15 minutes beginning an hour and a half before the procedure. Instruct the mother not to void before the procedure.

DURING Procedure: Explain to patient the procedure and its purpose. The ultrasound technician may apply a clear gel to the skin in order to help the transducer more freely over the body. Ask the patient to relax while the procedure is going on.

AFTER Procedure: Allow mother to void. Allow the mother to take home a photograph of the sonogram image which can enhance bonding because it is a proof that the pregnancy exists and that the fetus appears well.

Self Breast Examination

Description:

Breast self examination (BSE) is to be performed each month in addition to an annual mammogram or a clinical exam. Knowing your cyclical changes, what is normal for you, and what regular monthly changes in the breast feel like is the best way to keep an eye on your breast health. Breast tissue extends from under your nipple and areola up toward your armpit.

Materials/Equipment Needed:

A mirror which lets you see both breasts A pillow for your head and shoulders Privacy

Procedures:

1. Make a regular date for your BSE If you are pre-menopausal: Set a regular time to examine your breasts a few days after your period ends, when hormone levels are relatively stable and breasts are less tender. If you are already menopausal (have not had a period for a year or more): Pick a particular day of the month to do the exam, and then repeat your BSE on that day each month. 2. Hands on Hips n the privacy of your bathroom, strip to the waist and stand before a mirror. You will need to see both breasts at the same time. Stand with your hands on your hips and check the appearance of your breasts. Look at size, shape, and contour. Note changes, if any, in the skin color or texture. Look at the nipples and areolas, to see how healthy they look. 3. Arms Over Your Head Still standing in front of the mirror, raise your arms over your head and see if your breasts move in the same way, and note any differences. Look at size, shape, and drape, checking for symmetry. Pay attention to your nipples and areolas, to see if you have any dimples, bumps, or retraction (indentation). Look up toward your armpits and note if there is any swelling where your lymph nodes are (lower armpit area). 4. Stand and Stroke Raise your left arm overhead, and use your right-hand fingers to apply gentle pressure to the left breast. Stroke from the top to the bottom of the breast,

moving across from the inside of the breast all the way into your armpit area. You can also use a circular motion, being sure to cover the entire breast area. Take note of any changes in texture, color, or size. Switch sides and repeat. This is best done in the shower, as wet skin will have the least resistance to the friction of your fingers. 5. Manual Exam - Check Your Nipples Still facing the mirror, lower both arms. With the index and middle fingers of your right hand, gently squeeze the left nipple and pull forward. Does the nipple spring back into place? Does it pull back into the breast? Note whether or not any fluid leaks out. Reverse your hands and check the right nipple in the same way. 6. Manual Exam - Recline and Stroke This is best done in your bedroom, where you can lie down. Place a pillow on the bed so that you can lie with both your head and shoulders on the pillow. Lie down and put your left hand behind your head. Use your right hand to stroke the breast and underarm, as you did in step 4. Take note of any changes in texture, color, or size. Switch sides and repeat.

Diagram / Illustration:

Nursing Responsibilities:

Before Procedure: Wash hands before the procedure Introduce yourself and verify the clients identity Explain the procedure to the patient

Assess the clients overall condition Percuss the bladder to check for fullness or distension Assess when the client last voided or was last catheterized Assess if the client can be positioned supine, head relatively flat. Check the sterility and integrity of the materials

During Procedure: keep the sterility of the catheter

After Procedure: Wash hands after the procedure Discard all materials that has been use Document the size of catheter inserted, amount of water in balloon, patient's response to procedure, and assessment of urine Reassure the patient

Biopsy Description: Biopsy is a medical procedure where a sample of tissue is taken from a patient for examination and diagnosis of an illness or medical condition. Many different biopsy procedures exist depending on the location of the tissue under investigation. Once the tissue has been removed, it is usually placed in a preservative and sent to a pathology laboratory where it is set in wax and finely sliced. The slices are mounted on a glass slide and stained with various dyes which highlight different types and characteristics of cells. Abnormal cells can be identified and treatment can be decided according to the results. These tests usually take at least 24 hours to process before a pathologist can examine them. Purpose:

Biopsies are particularly important in the diagnosis of cancer. This procedure will often be performed when there is a lump, tumour, cyst or swelling for which there is no apparent cause. In these cases, the doctor feels the only way to reach an accurate diagnosis is to take a piece of that lump and examine the cells directly. Materials/ Equipments needed: Depending on the kind of biopsy Medical issues to consider Before the procedure, you need to discuss a range of issues with your doctor or surgeon including: Medical history, including any prescription drugs, over-the-counter drugs, herbs, vitamin or mineral supplements you may be taking. Some preparations can interact with surgical medications and need to be avoided. Other tests, such as blood tests or ultrasound scans, may need to be done prior to the biopsy (depending on the nature of the condition under investigation). Biopsy procedure: There are various kinds of biopsy procedure, including: Bone marrow biopsy - a small sample of bone marrow (usually from the hip) is removed via a slender needle. This type of biopsy helps to diagnose diseases such as leukaemia. Colposcopy-directed biopsy - a colposcope is a small microscope used to examine a womans cervix while a tissue sample is taken. This biopsy is usually performed to investigate the reasons for an abnormal Pap test result. Endoscopic biopsy - the endoscope is a flexible tube that can be inserted into an orifice (such as the mouth or anus) or through a small skin incision. Once the lump is reached, cutting tools are threaded through the endoscope so that a sample of tissue can be taken. Excisional biopsy - the lump is entirely removed. Depending on the location of the lump, the patient may need to undergo general anaesthesia. This type of biopsy may be used for breast lumps. Incisional biopsy - only a small slice of the lump is removed. Depending on the location of the lump, a general or local anaesthetic may be needed. This type of biopsy may be used for lumps located in connective tissue such as muscle. Needle biopsy - a small sample of the lump is removed via a slender hypodermic needle. This can be done either with or without local anaesthetic. This type of biopsy may be used to diagnose conditions of the liver or thyroid. Punch biopsy - a special tool is used to punch a hole through the uppermost layers of the skin. The anaesthetic used may be local or topical. This type of biopsy can help diagnose various skin conditions.

Stereotactic biopsy - a series of x-rays help to guide the surgeons needle to the lump. This type of biopsy is usually performed whenever the lump is hard to see or feel. Diagram/ Illustration: Nursing Responsibilities: Immediately after the biopsy How you feel after the biopsy depends on what sort of procedure was performed. Generally, you can expect after a biopsy: Some pain around the biopsy site. This should resolve, or at least ease over the next two or three days. Your doctor will prescribe appropriate pain relieving medication. Nurses monitor your condition for some hours and check for bleeding from the biopsy site. You may have a blood count test to double-check that you are not bleeding internally from the biopsy site. You may undergo other tests to make sure all is well, for example, a chest x-ray (or two) if you had a lung biopsy. Surgical medications can sometimes make you drowsy so you should not drive yourself home; ask a friend or relative to pick you up or take a taxi Taking care of yourself at home Be guided by your doctor or surgeon but general suggestions include: Rest as much as you can in the next day or two. Limit using the body part, if this is possible. For example, if you had a biopsy performed on your arm or leg try to rest and raise the limb for the next day or so. Avoid vigorous exercise and lifting heavy objects. You may need to keep your wound (and its dressing) dry for around one week to 10 days. If possible, hold the affected area out of the shower or bath, or cover the dressing in plastic wrap. Alternatively, it may be easier to sponge bath for the first few days. Dressings can usually be removed one week to 10 days after the procedure.