Tuesday, July 3, 2018

All about PET CT scan for Breast Cancer

Pet CT in our country has become a house hold name when cancer is diagnosed or suspected. It is ironic that there is so much reservation about having a mammogram done since it involves some exposure to radiation, but when a cancer is diagnosed there is so much fear that no one questions about the radiation involved with Pet CT scans.  Pet CT is overused in breast cancer in our country.

breast cancer diagnosis in chennai

 

What is a PET CT scan?


PET CT scan is a procedure in which a small amount of radioactive glucose (sugar) is injected into a vein. Then a scanner is used to make detailed and computerized pictures of areas inside the body where the glucose is taken up. The pictures can be used to find cancer cells in the body, because cancer cells often take up more glucose than normal cells.
It usually difficult to find lesions that a very small (ie less than 1 cms) on a Pet CT scan because of lack of spatial resolution.

Is it necessary in early breast cancer?


Stage 1 and 2 breast cancers are considered as early breast cancer. The probability of spread is so low that a Pet CT scan to look for spread is not required.

Pet CT scan sometimes cause confusion. As the radioactive glucose accumulates in tissues where there is higher metabolism, there can be a false alarm if there is some inflammation or infection as this tissue also will pick up the tracer and can be mistaken for a cancer. This might lead to anxiety, more tests to clear the confusion, delay treatment unnecessarily and adds to cost as well.
The radiotracer gives very small levels of radiation, which go away very quickly. But for the rest of the day patients should be instructed not to have close contact with pregnant women, babies or young children.

So when is Pet Ct useful?


It is particularly useful to plan treatment when the cancer is locally advanced. The probability of having metastatic disease is higher in locally advanced breast cancer. If there is evidence of cancer in other parts of the body (ie) liver, lung or brain, then the treatment is planned differently.

What is the role of Pet Ct scan after treatment?


Pet Ct scans usually don’t help people who have completed cancer treatments and don’t have symptoms. For most breast cancer patients, these tests don’t help patients live longer or with a better quality of life. Pet Ct scans done without a good reason can lead to anxiety, false alarms, wrong diagnoses, unneces­sary procedures, and more costs. Also frequent scans lead to high levels of radiation. The effects of radia­tion add up over one’s lifetime. It is more useful in clinical situations where metastatic disease is suspected. FDG PET has high accuracy for the diagnosis of recurrent or metastatic breast cancer. Pet Ct scan will be recommended for patients treat­ed for advanced cancer to find out the response to the treatment.

Conclusion


Pet Ct scan costs close to 20,000 to 25,000 rupees. Our society assumes that any technology with a high price tag has value, but the latest technology is not necessarily the required technology for all patients. The NCCN Breast Cancer Panel also discourages the use of PET or PET/CT scanning in the work-up of staging early breast cancer.

Reference


http://snmmi.files.cms-plus.com/images/NCCN%20Narrative%20Summary%20Feb%202016.pdf

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Thursday, June 14, 2018

Mammogram : Getting it right matters

Master health checks have become very attractive for providers and patients. A set of tests are put together under various packages ranging from 600 rupees to 25,000 or called bronze, silver, gold, diamond and platinum checks!!!

A mammogram or ultrasound or both are thrown in for women depending on age.

mammography in chennai

The films and reports are usually packaged very nicely and given to the patient. The interpretation, reporting, and discussion of the results are usually discussed by general medical or gynaecology colleagues. They may not be equipped with the decision making tools and hence the patient is left with a lot of anxiety and stress seeking second or third opinions.

What can go wrong with Mammograms?

 

1. Technology:

Using the right technology has its advantage. Digital technology, tomosynthesis, workstation that has a high resolution helps in spotting early disease. There are tools to measure breast density and computer-aided diagnosis which add to the information.

The newer machines also deliver less radiation dose and the resolution is fantastic. Like the 18 megapixel camera as against the 3-megapixel cameras of the earlier versions.

Many centres may not have all the facilities. Although this is a disadvantage, a good mammogram can still be done with older analog machines with a little attention to detail.

Older machines have to pass the QA and QC and calibrated periodically to ensure radiation dose is not exceeding the permissible limits and safety. AERB monitors these details. But seldom these are done properly.

2. Technique of performing mammogram


A. Compression: Unfortunately the test involves some breast compression which might be uncomfortable. The compression can last up to 4 to 5 seconds.
If the compression is inadequate then the image quality will suffer.

B. Positioning: The entire breast has to be included in the study. If the whole breast is not included then parts of breasts will not be imaged. There is a risk of missing details or cancer in the area which gets missed out in the image. This leads to a false negative mammogram. A missed opportunity to detect cancer. So the technologist’s role is very important in ensuring a good mammogram.

It can be very intimidating for a woman to undress in front of a stranger in a cold room for the procedure. As rule mammograms are always done by a lady technologist. A good technologist can make the entire procedure comfortable and painless for the patient.

C. Interpretation: the mammograms should be read in a room where there is very little distraction with suitable lighting. The monitors displaying the images should be medical grade monitors with resolution of at least 5 megapixels.

3.Interpretation

What the mind doesn't know the eyes cannot see.

Training to understand the normal anatomy, physiology, pathology and imaging features is important to recognize the various breast conditions.

mammography in chennai
Mammographic interpretation needs specialist radiologists. Otherwise, there is a serious risk of missing cancer diagnosis and creating false alarms. It is also important to compare with previous studies to see if there is any new change.

Diagnostic mammograms in conjunction with breast ultrasound and MRI sometimes will give all the necessary information to plan surgery.

Even in the best of health, there is a 10% probability of missing cancer, therefore mammograms should not be just another master health check. And when cancer is diagnosed mammogram provides a roadmap for further surgical planning.

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Thursday, May 24, 2018

Will my cancer spread after a breast biopsy?

A common patient concern is that biopsies may cause cancer to spread. Many patients ask me if removal of the lump straight away is better.

My answer to the question starts off with an example. If you get transferred  from Chennai to Delhi , would you prefer to land up in Delhi Railway station with family , bags and baggage straight away or would you like to visit the place a couple of times, find out about possible housing, schools and other facilities and then plan to shift the family ?

chennai breast cancer centre

Likewise, before removing the lump we need a diagnosis followed by a clear plan based on the diagnosis and further information. A biopsy removes a bit of tissue by using a specially designed core needle from the suspicious area of the breast. The tissue is then fixed and studied under a microscope to see if cancer is present. This is done with a local anaesthetic.

If it is benign lump, then surgery may not be required at all. Therefore unnecessary surgery and scar on the breast can be avoided.

If the breast lump is cancerous, then it is staged and tested for hormone receptor sensitivity and Her 2 status. We then assess the possibility of preserving the breast and axillary lymph nodes. Surgical plan including breast conservation, sentinel lymph node biopsy and reconstruction are possibilities that can be discussed and decided upfront with best possible results. Repeat surgeries are avoided with good planning and information for further treatment planning is complete and adequate without any undue time delay.

breast cancer biopsy

Does the needle biopsy cause the cancer to spread?


No. this is a myth and studies have shown that needle track seedling or displacement of cancer cells do not increase the risk of recurrence or spread. The chance that surgery or biopsy will cause cancer to spread to other parts of the body is extremely low. Doctors use special methods and take many steps to prevent cancer cells from spreading during biopsies or surgery to remove cancer.

Breast Biopsy is an incredibly important step in the diagnosis for the patient, as having a definitive cancer diagnosis is important in determining and planning the correct treatment for the patient. The potential gain from a breast biopsy outweighs the risks such as discomfort and bruising.

Can a needle biopsy miss a cancer?


A needle biopsy can sometimes miss breast cancer if the needle takes a sample of tissue or cells from the wrong area. Ultrasound or stereotactic guidance is immensely useful to target the correct area. The sample should be fixed immediately in buffered formalin. A delay in fixing or improper fixing can cause diagnostic difficulties.

Sometimes false negative results can occur due to errors in interpretation. If there is a cause for concern about the possibility of a false negative result ( ie ) if the lesion is suspicious on clinical examination and imaging studies , then a repeat biopsy or surgical excision should be carried out.

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