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Advanced Practice Nursing Issues
Jennifer C. Ewing, RN, MSN, NP-C, AOCNP®—Associate Editor
Tumor Cell Dissemination Secondary to Surgical Interventions in the Breast Stacy McClelland, RN, MSN, BSN, and Patricia Weiss, RN, MSN, OCN®, CCRP
Dissemination secondary to surgical interventions is an issue that arises in conversations between patients and providers prior to breast biopsy. Research supports needle biopsies over incisional or excisional biopsies in most situations. Tumor cell dissemination is a rare occurrence. However, the fear of dissemination as experienced by the patient is very real. That fear may influence the patient’s decision to proceed with a recommended biopsy. Stacy McClelland, RN, MSN, BSN, is a radiation therapy nurse at Tampa General Hospital Cancer Center in Florida, and Patricia Weiss, RN, MSN, OCN®, CCRP, is a clinical systems analyst at the Cleveland Clinic in Ohio. The authors take full responsibility for the content of the article. The authors were participants in the Clinical Journal of Oncology Nursing (CJON) Writing Mentorship Program. Weiss received honorarium from the Oncology Nursing Society for her role as a mentor in the CJON Writing Mentorship Program. No financial relationships relevant to the content of this article have been disclosed by the editorial staff. McClelland can be reached at [email protected], with copy to editor at [email protected]. Digital Object Identifier: 10.1188/13.CJON.667-668
T
he proper diagnosis and treatment of cancer requires a tissue sample obtained either through a biopsy or a surgical intervention. Microscopic evaluation via histologic analysis guides treatment, particularly in the initial presentation of the disease. Some of the factors influencing biopsy type are risk to the patient, patient willingness to consent to a procedure, or the ability to obtain a sufficient sample because of tumor size or location. Types of biopsies that may be used in diagnosing breast cancer can include fine-needle aspiration biopsy, core-needle biopsy, excisional biopsy, or incisional biopsy (Vogel, 2011). American Cancer Society and National Comprehensive Cancer Network (NCCN) (2007) guidelines for breast biopsy indicate a needle biopsy as the preferred method of tissue sampling for most cases.
Literature Review Several studies have focused on whether tumor cell dissemination occurred during biopsies. Michalopoulos et al. (2008) prospectively studied breast biopsies,
with 2 of 31 participants having benign cells disseminated. Of the various types of biopsies, vacuum-assisted biopsies were the least associated with tumor seeding (Loughran & Keeling, 2011). Researchers noted that even if tumor cells were disrupted and dissemination occurred, tumor cells were not seeded or proliferating after the disturbance (Carter, Jensen, Simpson, & Page, 2000). Three specific cases of tumor cell seeding resulting in localized recurrence were examined from stereotactic core breast biopsies that did not have adjuvant radiation (Chao et al., 2001). Although confirmation exists for tumor dissemination post-biopsy, the risk is very low. In a study by Uriburu et al. (2006), the authors noted that although needle tract seeding exists, the incidence of dissemination is about 0.005%. In a review of 15 other studies, displacement of epithelial cells in a core needle biopsy did occur. However, the displacement of cells did not translate into an increase in morbidity. Radiation for some and follow-up for all will continue to be recommended for patients with breast cancer (Liebens et al.,
2009). Fitzal et al. (2006) concluded that core needle biopsy did not change recurrence or survival of patients, particularly when biopsy was followed by surgery and radiation. In addition, a biopsy confirming cancer allows options such as neoadjuvant or adjuvant chemotherapy that might otherwise be unavailable if a biopsy was not performed (Fitzal et al., 2006). Micrometastasis in areas such as the axilla can exist and go undetected at the time of core biopsy (Filippakis & Zografos, 2007), which makes findings of dissemination hard to interpret as initial time of tumor spreading cannot be determined. In a study by Nagi, Bleiweiss, and Jaffer (2005), 53 cases of epithelial displacement occurred from a total of 13,334 biopsies, which confirms that dissemination with breast biopsy is a rare occurrence and, therefore, difficult to study.
Implications for Practice Current guidelines for most breast cancers involve excision of remaining tumor followed by radiation in some scenarios; in addition, radiation after excision is recommended if the tumor is 5 cm or larger, the margins were either close or positive, or with positive nodal involvement (NCCN, 2012). Many of the studies reviewed noted that when seeding occurred after biopsy, it was mostly in patients who had not received breast radiation. If a core breast biopsy and excisional breast biopsy can yield the same results, and the core biopsy does not pose significant risk of tumor cell dissemination, a core biopsy may be a better overall choice compared to an excisional biopsy. Patients may fear seeding of their tumor post-biopsy; however, biopsy has not been clearly shown to spread breast cancer. Tumor cells found in lymphatic
Clinical Journal of Oncology Nursing • Volume 17, Number 6 • Advanced Practice Nursing Issues
667
tissue could have been present either before or after a breast biopsy and, if prior to biopsy, may not have been detectable by palpation. Although a small risk exists for tumor cell dissemination, whether these displaced cells will amount to anything more is not known (Uematsu & Kasami, 2008).
Conclusion Risk is a factor in all areas of medicine. However, risk is more acceptable in areas such as medication; a patient is not likely to refuse their antibiotic because of the possibility of side effects. These medications are prescribed because the benefit outweighs the risk for most and the risks are discussed and known. Similarly, the benefit of information obtained from a minimally invasive breast tumor biopsy outweighs the risk of treating an unknown situation. Carcinoma identification is an important and critical initial step in the treatment of cancer. Based on the current research and NCCN (2012) guidelines, it remains good practice to use various biopsy methods. Selection of the method of biopsy should be individualized to each patient. Less emphasis should be placed on excisional or incisional biopsies for most patients because of the increased risks associated with surgery. In addition, the opportunity to have more medical interventions such as neoadjuvant chemotherapy may be lost with excisional or incisional biopsy. When a patient has concerns about the possibility of tumor dissemination with biopsy, it should not be dismissed, but rather acknowledged and discussed with the surgeon. Obtaining consent and in-
668
forming the patient of potential risks and complications is the responsibility of the surgeon. The surgeon may find it appropriate to discuss that tumor dissemination is possible from a biopsy, but is an extremely rare occurrence—and, if it occurs, does not appear to alter long-term outcomes. The authors gratefully acknowledge John Kiluk, MD, FACS, for his expertise and time spent suggesting improvements to this article.
References American Cancer Society and National Comprehensive Cancer Network. (2007). Breast cancer: Treatment guidelines for patients. Retrieved from http://www .nch.org/medical-services/breast-center/ pdf/acs_breastcancer.pdf Carter, B.A., Jensen, R.A., Simpson, J.F., & Page, D.L. (2000). Benign transport of breast epithelium into axillary lymph nodes after biopsy. American Journal of Clinical Pathology, 113, 259–265. Chao, C., Torosian, M.H., Boraas, M.C., Sigurdson, E.R., Hoffman, J.P., Eisenberg, B.L., & Fowble, B. (2001). Local recurrence of breast cancer in the stereotactic core needle biopsy site: Case reports and review of the literature. Breast Journal, 7, 124–127. Filippakis, G.M., & Zografos, G.C. (2007). Contraindications of sentinel lymph node biopsy: Are there any really? World Journal of Surgical Oncology, 5(10), 1–11. Fitzal, F., Sporn, E.P., Draxler, W., Mittlböck, M., Taucher, S., Rudas, M., . . . Gnant, M. (2006). Preoperative core needle biopsy does not increase local recurrence rate in breast cancer patients. Breast Cancer Research and Treatment, 97, 9–15.
Liebens, F., Carly, B., Cusumano, P., Van Beveren, M., Beier, B., Fastrez, M., & Rozenberg, S. (2009). Breast cancer seeding associated with core needle biopsies: A systematic review. Maturitas, 62, 113–123. Loughran, C.F., & Keeling, C.R. (2011). Seeding of tumour cells following breast biopsy: A literature review. British Journal of Radiology, 84, 869–874. doi:10.1259/ bjr/77245199 Michalopoulos, N.V., Zagouri, F., Sergentanis, T.N., Pararas, N., Koulocheri, D., Nonni, A., . . . Zografos, G.C. (2008). Needle tract seeding after vacuum-assisted breast biopsy. Acta Radiologica, 49, 267–270. Nagi, C., Bleiweiss, I., & Jaffer, S. (2005). Epithelial displacement in breast lesions: A papillary phenomenon. Archives of Pathology and Laboratory Medicine, 129, 1465–1469. National Comprehensive Cancer Network. (2012). NCCN Clinical Practice Guidelines in Oncology: Breast cancer [v.1.2012]. Retrieved from http://www .nccn.org/professionals/physician_gls/ pdf/breast.pdf Uematsu, T., & Kasami, M. (2008). Risk of needle tract seeding of breast cancer: Cytological results derived from core wash material. Breast Cancer Research and Treatment, 110, 51–55. Uriburu, J.L., Vuoto, H.D., Cogorno, L., Isetta, J.A., Candas, G., Imach, G.C., & Bernabo, O.L. (2006). Local recurrence of breast cancer after skin-sparing mastectomy following core needle biopsy: Case reports and review of the literature. Breast Journal, 12, 194–198. Vogel, W.H. (2011). Diagnostic evaluation, classification, and staging. In C.H. Yarbro, D. Wujcik, & B.H. Gobel (Eds.), Cancer nursing: Principles and practice (7th ed., pp. 166–194). Sudbury, MA: Jones and Bartlett.
December 2013 • Volume 17, Number 6 • Clinical Journal of Oncology Nursing
Copyright of Clinical Journal of Oncology Nursing is the property of Oncology Nursing Society and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Advanced Practice Nursing Issues
Jennifer C. Ewing, RN, MSN, NP-C, AOCNP®—Associate Editor
Tumor Cell Dissemination Secondary to Surgical Interventions in the Breast Stacy McClelland, RN, MSN, BSN, and Patricia Weiss, RN, MSN, OCN®, CCRP
Dissemination secondary to surgical interventions is an issue that arises in conversations between patients and providers prior to breast biopsy. Research supports needle biopsies over incisional or excisional biopsies in most situations. Tumor cell dissemination is a rare occurrence. However, the fear of dissemination as experienced by the patient is very real. That fear may influence the patient’s decision to proceed with a recommended biopsy. Stacy McClelland, RN, MSN, BSN, is a radiation therapy nurse at Tampa General Hospital Cancer Center in Florida, and Patricia Weiss, RN, MSN, OCN®, CCRP, is a clinical systems analyst at the Cleveland Clinic in Ohio. The authors take full responsibility for the content of the article. The authors were participants in the Clinical Journal of Oncology Nursing (CJON) Writing Mentorship Program. Weiss received honorarium from the Oncology Nursing Society for her role as a mentor in the CJON Writing Mentorship Program. No financial relationships relevant to the content of this article have been disclosed by the editorial staff. McClelland can be reached at [email protected], with copy to editor at [email protected]. Digital Object Identifier: 10.1188/13.CJON.667-668
T
he proper diagnosis and treatment of cancer requires a tissue sample obtained either through a biopsy or a surgical intervention. Microscopic evaluation via histologic analysis guides treatment, particularly in the initial presentation of the disease. Some of the factors influencing biopsy type are risk to the patient, patient willingness to consent to a procedure, or the ability to obtain a sufficient sample because of tumor size or location. Types of biopsies that may be used in diagnosing breast cancer can include fine-needle aspiration biopsy, core-needle biopsy, excisional biopsy, or incisional biopsy (Vogel, 2011). American Cancer Society and National Comprehensive Cancer Network (NCCN) (2007) guidelines for breast biopsy indicate a needle biopsy as the preferred method of tissue sampling for most cases.
Literature Review Several studies have focused on whether tumor cell dissemination occurred during biopsies. Michalopoulos et al. (2008) prospectively studied breast biopsies,
with 2 of 31 participants having benign cells disseminated. Of the various types of biopsies, vacuum-assisted biopsies were the least associated with tumor seeding (Loughran & Keeling, 2011). Researchers noted that even if tumor cells were disrupted and dissemination occurred, tumor cells were not seeded or proliferating after the disturbance (Carter, Jensen, Simpson, & Page, 2000). Three specific cases of tumor cell seeding resulting in localized recurrence were examined from stereotactic core breast biopsies that did not have adjuvant radiation (Chao et al., 2001). Although confirmation exists for tumor dissemination post-biopsy, the risk is very low. In a study by Uriburu et al. (2006), the authors noted that although needle tract seeding exists, the incidence of dissemination is about 0.005%. In a review of 15 other studies, displacement of epithelial cells in a core needle biopsy did occur. However, the displacement of cells did not translate into an increase in morbidity. Radiation for some and follow-up for all will continue to be recommended for patients with breast cancer (Liebens et al.,
2009). Fitzal et al. (2006) concluded that core needle biopsy did not change recurrence or survival of patients, particularly when biopsy was followed by surgery and radiation. In addition, a biopsy confirming cancer allows options such as neoadjuvant or adjuvant chemotherapy that might otherwise be unavailable if a biopsy was not performed (Fitzal et al., 2006). Micrometastasis in areas such as the axilla can exist and go undetected at the time of core biopsy (Filippakis & Zografos, 2007), which makes findings of dissemination hard to interpret as initial time of tumor spreading cannot be determined. In a study by Nagi, Bleiweiss, and Jaffer (2005), 53 cases of epithelial displacement occurred from a total of 13,334 biopsies, which confirms that dissemination with breast biopsy is a rare occurrence and, therefore, difficult to study.
Implications for Practice Current guidelines for most breast cancers involve excision of remaining tumor followed by radiation in some scenarios; in addition, radiation after excision is recommended if the tumor is 5 cm or larger, the margins were either close or positive, or with positive nodal involvement (NCCN, 2012). Many of the studies reviewed noted that when seeding occurred after biopsy, it was mostly in patients who had not received breast radiation. If a core breast biopsy and excisional breast biopsy can yield the same results, and the core biopsy does not pose significant risk of tumor cell dissemination, a core biopsy may be a better overall choice compared to an excisional biopsy. Patients may fear seeding of their tumor post-biopsy; however, biopsy has not been clearly shown to spread breast cancer. Tumor cells found in lymphatic
Clinical Journal of Oncology Nursing • Volume 17, Number 6 • Advanced Practice Nursing Issues
667
tissue could have been present either before or after a breast biopsy and, if prior to biopsy, may not have been detectable by palpation. Although a small risk exists for tumor cell dissemination, whether these displaced cells will amount to anything more is not known (Uematsu & Kasami, 2008).
Conclusion Risk is a factor in all areas of medicine. However, risk is more acceptable in areas such as medication; a patient is not likely to refuse their antibiotic because of the possibility of side effects. These medications are prescribed because the benefit outweighs the risk for most and the risks are discussed and known. Similarly, the benefit of information obtained from a minimally invasive breast tumor biopsy outweighs the risk of treating an unknown situation. Carcinoma identification is an important and critical initial step in the treatment of cancer. Based on the current research and NCCN (2012) guidelines, it remains good practice to use various biopsy methods. Selection of the method of biopsy should be individualized to each patient. Less emphasis should be placed on excisional or incisional biopsies for most patients because of the increased risks associated with surgery. In addition, the opportunity to have more medical interventions such as neoadjuvant chemotherapy may be lost with excisional or incisional biopsy. When a patient has concerns about the possibility of tumor dissemination with biopsy, it should not be dismissed, but rather acknowledged and discussed with the surgeon. Obtaining consent and in-
668
forming the patient of potential risks and complications is the responsibility of the surgeon. The surgeon may find it appropriate to discuss that tumor dissemination is possible from a biopsy, but is an extremely rare occurrence—and, if it occurs, does not appear to alter long-term outcomes. The authors gratefully acknowledge John Kiluk, MD, FACS, for his expertise and time spent suggesting improvements to this article.
References American Cancer Society and National Comprehensive Cancer Network. (2007). Breast cancer: Treatment guidelines for patients. Retrieved from http://www .nch.org/medical-services/breast-center/ pdf/acs_breastcancer.pdf Carter, B.A., Jensen, R.A., Simpson, J.F., & Page, D.L. (2000). Benign transport of breast epithelium into axillary lymph nodes after biopsy. American Journal of Clinical Pathology, 113, 259–265. Chao, C., Torosian, M.H., Boraas, M.C., Sigurdson, E.R., Hoffman, J.P., Eisenberg, B.L., & Fowble, B. (2001). Local recurrence of breast cancer in the stereotactic core needle biopsy site: Case reports and review of the literature. Breast Journal, 7, 124–127. Filippakis, G.M., & Zografos, G.C. (2007). Contraindications of sentinel lymph node biopsy: Are there any really? World Journal of Surgical Oncology, 5(10), 1–11. Fitzal, F., Sporn, E.P., Draxler, W., Mittlböck, M., Taucher, S., Rudas, M., . . . Gnant, M. (2006). Preoperative core needle biopsy does not increase local recurrence rate in breast cancer patients. Breast Cancer Research and Treatment, 97, 9–15.
Liebens, F., Carly, B., Cusumano, P., Van Beveren, M., Beier, B., Fastrez, M., & Rozenberg, S. (2009). Breast cancer seeding associated with core needle biopsies: A systematic review. Maturitas, 62, 113–123. Loughran, C.F., & Keeling, C.R. (2011). Seeding of tumour cells following breast biopsy: A literature review. British Journal of Radiology, 84, 869–874. doi:10.1259/ bjr/77245199 Michalopoulos, N.V., Zagouri, F., Sergentanis, T.N., Pararas, N., Koulocheri, D., Nonni, A., . . . Zografos, G.C. (2008). Needle tract seeding after vacuum-assisted breast biopsy. Acta Radiologica, 49, 267–270. Nagi, C., Bleiweiss, I., & Jaffer, S. (2005). Epithelial displacement in breast lesions: A papillary phenomenon. Archives of Pathology and Laboratory Medicine, 129, 1465–1469. National Comprehensive Cancer Network. (2012). NCCN Clinical Practice Guidelines in Oncology: Breast cancer [v.1.2012]. Retrieved from http://www .nccn.org/professionals/physician_gls/ pdf/breast.pdf Uematsu, T., & Kasami, M. (2008). Risk of needle tract seeding of breast cancer: Cytological results derived from core wash material. Breast Cancer Research and Treatment, 110, 51–55. Uriburu, J.L., Vuoto, H.D., Cogorno, L., Isetta, J.A., Candas, G., Imach, G.C., & Bernabo, O.L. (2006). Local recurrence of breast cancer after skin-sparing mastectomy following core needle biopsy: Case reports and review of the literature. Breast Journal, 12, 194–198. Vogel, W.H. (2011). Diagnostic evaluation, classification, and staging. In C.H. Yarbro, D. Wujcik, & B.H. Gobel (Eds.), Cancer nursing: Principles and practice (7th ed., pp. 166–194). Sudbury, MA: Jones and Bartlett.
December 2013 • Volume 17, Number 6 • Clinical Journal of Oncology Nursing
Copyright of Clinical Journal of Oncology Nursing is the property of Oncology Nursing Society and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
