Comparison of histologic diagnosis between stereotactic core needle biopsy and open surgical biopsy

Underestimation of invasive lesions in patients with ductal carcinoma in situ of the breast diagnosed by ultrasound-guided biopsy: a comparison between patients with and without HER2/neu overexpression

PURPOSE

To determine the rate of underestimation of ductal carcinoma in situ (DCIS) diagnosed at imaging-guided biopsy and to analyze its association with HER2/neu oncogene, an important biomarker in assessing the tumour aggressiveness and guiding hormone therapy for breast cancer.

METHODS

We retrospectively reviewed 162 patients with DCIS diagnosed by imaging-guided core needle biopsy between January 2008 and March 2013. All of these patients received surgical excision, and in 25, the diagnosis was upgraded to invasive breast cancer. In this study, we examined the ultrasound, mammographic features and histopathological results for each patient, and compared these parameters between those with and without HER2/neu overexpression.

RESULTS

Of the 162 DCIS lesions, 110 (67.9%) overexpressed HER2/neu. Nineteen patients with HER2/neu overexpressing DCIS (n=19/110, 17.3%) were upgraded after surgery to a diagnosis of invasive breast cancer. In this group, the upgrade rate was highest in patients with a dilated mammary duct pattern (42.1%, n=8/19, p=0.02) and the presence of abnormal axillary nodes (40.0%, n=12/30, p<0.01) at ultrasound and was significantly associated with comedo tumour type on pathology.

CONCLUSIONS

Biopsy may underestimate the invasive component in DCIS patients. Sonographic findings of dilated mammary ducts and presence of abnormal axillary lymph nodes may help predicting the invasive components and possibly driving more targeted biopsy procedures.

Ductal carcinoma in situ at core-needle biopsy: meta-analysis of underestimation and predictors of invasive breast cancer

PURPOSE

To perform a meta-analysis to report pooled estimates for underestimation of invasive breast cancer (where core-needle biopsy [CNB] shows ductal carcinoma in situ [DCIS] and excision histologic examination shows invasive breast cancer) and to identify preoperative variables that predict invasive breast cancer.

MATERIALS AND METHODS

Studies were identified by searching MEDLINE and were included if they provided data on DCIS underestimates (overall and according to preoperative variables). Study-specific and pooled percentages for DCIS underestimates were calculated. By using meta-regression (random effects logistic modeling) the association between each study-level preoperative variable and understaged invasive breast cancer was investigated.

RESULTS

Fifty-two studies that included 7350 cases of DCIS with findings at excision histologic examination as the reference standard met the eligibility criteria and were included. There were 1736 underestimates (invasive breast cancer at excision); the random-effects pooled estimate was 25.9% (95% confidence interval: 22.5%, 29.5%). Preoperative variables that showed significant univariate association with higher underestimation included the use of a 14-gauge automated device (vs 11-gauge vacuum-assisted biopsy, P = .006), high-grade lesion at CNB (vs non-high grade lesion, P < .001), lesion size larger than 20 mm at imaging (vs lesions ≤ 20 mm, P < .001), Breast Imaging Reporting and Data System (BI-RADS) score of 4 or 5 (vs BI-RADS score of 3, P for trend = .005), mammographic mass (vs calcification only, P < .001), and palpability (P < .001).

CONCLUSION

About one in four DCIS diagnoses at CNB represent understaged invasive breast cancer. Preoperative variables significantly associated with understaging include biopsy device and guidance method, size, grade, mammographic features, and palpability.

Lobular Carcinoma in Situ or Atypical Lobular Hyperplasia at Core-Needle Biopsy: Is Excisional Biopsy Necessary?

PURPOSE

To retrospectively determine frequency of invasive cancer or ductal carcinoma in situ (DCIS) at excisional biopsy in women with atypical lobular hyperplasia (ALH) or lobular carcinoma in situ (LCIS) at percutaneous core-needle biopsy (CNB).

MATERIALS AND METHODS

Review of results in 6,081 consecutive patients who underwent CNB at two institutions revealed that in 35 (0.58%), LCIS (n = 15) or ALH (n = 20) was the pathologic finding with highest risk. Patient age range was 41-84 years (mean, 59 years). Of 35 patients, 26 (74%) underwent excisional biopsy and nine (26%) underwent mammographic follow-up for longer than 2 years. Lesions with a pathologic upgrade were noted when invasive cancer or DCIS occurred at the CNB site. CNB results in patients with a diagnosis of atypical ductal hyperplasia (ADH) (75 of 6,081 [1.2%]) were reviewed; these patients underwent subsequent excisional biopsy. Statistical comparison of frequency of upgrading of lesions in patients with a diagnosis of LCIS or ALH at CNB and in those with a diagnosis of ADH at CNB was performed (Pearson chi(2) test).

RESULTS

In six (17%) of 35 (95% CI: 4.7%, 29.6%) patients, lesions were upgraded to DCIS (n = 4) or invasive cancer (n = 2). In 15 patients with LCIS diagnosed at CNB, lesions in four (27%) were upgraded to either DCIS or invasive cancer. In 20 patients with ALH diagnosed at CNB, lesions were upgraded to DCIS in two (10%). Lesions in nine patients who underwent mammographic follow-up were stable. No mammographic or technical findings distinguished patients with upgraded lesions from those whose lesions were not upgraded. In 12 (16%) of 75 (95% CI: 7.7%, 24.3%) patients with ADH, lesions were upgraded. Difference between the upgrade rate in patients with LCIS or ALH and that in those with ADH was not significant (P =.88).

CONCLUSION

Lesions in 17% of patients with LCIS or ALH at CNB were upgraded to invasive cancer or DCIS; this rate was similar to the upgrade rate in patients with ADH. Excisional biopsy is supported when LCIS, ALH, or ADH is diagnosed at CNB.

Predicting invasion in the excision specimen from breast core needle biopsy specimens with only ductal carcinoma in situ

OBJECTIVE

Some patients with ductal carcinoma in situ on breast core needle biopsy will have invasion at excision. The aim of this study was to determine if patients at increased risk for invasion could be identified.

METHODS

The results of all breast core needle biopsies with a diagnosis of ductal carcinoma in situ during a 50-month period were reviewed. A variety of histologic features were identified and correlated with the presence of invasion at excision.

RESULTS

Of 3026 cases, 152 (5%) were diagnosed as ductal carcinoma in situ; excisional biopsies were available for 91 (60%) of these 152 cases, and 17 (19%) showed invasive tumor. Neither the radiographic findings, presence of comedonecrosis, comedo histology, lobular extension, size of the largest focus, nor aggregate size was significantly associated with an increased incidence of invasion (all P >.05). However, comedo histology with a cribriform/papillary architecture was significantly associated with an increased risk of invasion (5/7 [72%] cases with invasion, P =.002), as were tumors greater than 4 mm with lobular extension (6/15 [40%], P =.03).

CONCLUSION

Patients with comedo ductal carcinoma in situ with a cribriform/papillary pattern or tumor involving more than 4 mm with lobular extension in breast core needle specimens are at increased risk for invasion at excision.

Stereotactic core biopsy of breast microcalcifications: comparison of film versus digital mammography, both using an add-on unit

OBJECTIVE

The goal of this study was to assess the accuracy of an add-on stereotactic unit for core biopsy of indeterminate breast microcalcifications and to compare digital with conventional stereotactic guidance.

MATERIALS AND METHODS

We conducted a retrospective review of 232 lesions with indeterminate microcalcifications in 218 women who underwent stereotactically guided breast biopsies. All biopsies were performed using a standard mammography machine with an add-on unit, 121 with conventional and 111 with digital stereotactic guidance. Successful sampling of the lesion was determined by the detection of microcalcifications on specimen radiography or at pathology.

RESULTS

Using the add-on unit, 219 (94.4%) of the 232 targeted lesions were successfully sampled. The size, location, number of cores per lesion, and histology of the lesions were not different between the conventional and digital stereotactic biopsy groups (p > 0.1). Indeterminate microcalcifications were missed on biopsy in nine (7.4%) of 121 cases using conventional radiography and in only four (3.6%) of 111 cases using digital imaging. Digital stereotactic guidance allowed sampling of lesions with fewer calcifications per square centimeter (p < 0.001).

CONCLUSION

Sampling of indeterminate microcalcifications using a standard mammography machine and an add-on unit has a high accuracy, similar to rates reported for dedicated prone biopsy tables. An add-on unit offers the advantage of considerable cost and space savings. Relative to conventional radiography, digital stereotactic guidance allows lesions with fewer calcifications to be sampled and achieves a greater biopsy success rate. Immediate digital images in the biopsy room also permit rapid adjustment of alignment and minimize patient movement.

Resection margin status in lumpectomy specimens for duct carcinoma of the breast: correlation with core biopsy and mammographic findings

BACKGROUND

The strategy for surgical treatment of breast carcinoma proven by biopsy is mainly based on the physical and mammographic examinations. To investigate if the pathological findings in core biopsy are contributory to planning the surgical strategy, we correlated the status of ductal carcinoma in situ (DCIS) in the core needle biopsy of breast, the mammographic changes and the status of resection margins in the subsequent lumpectomy.

STUDY DESIGN

Consecutive 130 core needle biopsies with prior mammography and subsequent lumpectomy were reviewed. Biopsies were divided into: group I, DCIS; group II, DCIS and infiltrating carcinoma (IC); and group III, IC. Mammographic findings were categorized into four groups: (a) nonspecific findings; (b) calcification (Ca(++)); Ca(++) and mass, and mass only. The status of margins in correlating lumpectomy specimens was reviewed. Close margin was defined as a free margin at less than 0.1cm from the carcinoma.

RESULTS

The rates of positive or close margins in three groups I, II, and III were 13/18, 18/48, and 2/64 (P < 0.001); and in mammography groups of nonspecific finding, Ca(++), Ca(++) mass and mass only were 5/6, 7/15, 8/37, and 13/72 (P < 0.001), respectively. Of the total of 14 cases with positive margins of more than 0.5 cm in length, 8, 4, and 2 cases were from group I, II, and II, respectively. In addition, 13 of 21 cases with nonspecific changes or with only Ca(++) in mammograms belonged to the group I; 10 of these 13 cases were associated with positive margins. Forty-one of 72 cases presenting as a mass only in mammograms belonged to the group III; only 2 of these 41 cases were associated positive margins.

CONCLUSIONS

Correlation of the extent of carcinoma with pre-operative histopathological findings was better than with mammography. Core biopsies containing only DCIS, particularly in cases with nonspecific findings or with only Ca(++) in mammograms, represent a group of breast carcinoma that pose the high risk for incomplete resection in lumpectomy. Surgical management of patients having these cores includes wider resection margins than would otherwise be taken. Most core biopsies with only IC were associated with negative margins.

Adequate histologic sampling of breast core needle biopsies

OBJECTIVE

To determine the degree of histologic sampling necessary for adequate examination of breast core needle biopsy specimens.

DESIGN

The results of all breast core needle biopsies (11 and 14 gauge) with a diagnosis of atypical small acinar proliferation or atypical ductal hyperplasia and subsequent excisional biopsies, for a 50-month period were reviewed. Blocks of all cores were sectioned entirely in 8 slides to determine the amount of sectioning needed to detect these foci, and the results were correlated with those from the excision specimen.

SETTING

Large community hospital practice.

RESULTS

Of 3026 cases, 216 (7.1%) were diagnosed as atypical ductal hyperplasia or atypia not otherwise specified. Subsequent resections were available in 105 (49%) cases, and after review, 95 (92%) qualified as atypical ductal hyperplasia and 2 were determined to be atypical small acinar proliferations. The 2 small acinar proliferations were first detected on the second and fourth slides. Of the atypical ductal hyperplasia cases, 43% were detected on the first slide, 17% on the second, 23% on the third, 8% on the fourth, and 8% on the fifth. No lesions were initially detected after this level. Ductal carcinoma in situ was detected in the excision specimens from 1 case each of those detected initially on the fourth and fifth slides.

CONCLUSION

Five sections of breast core needle biopsy specimens are necessary to ensure that all atypical small acinar proliferations and atypical ductal hyperplasia lesions are sampled.

Atypical ductal hyperplasia in breast core needle biopsies. Correlation of size of the lesion, complete removal of the lesion, and the incidence of carcinoma in follow-up biopsies

We reviewed the results of all breast core needle biopsies with a diagnosis of atypical ductal hyperplasia (ADH) or atypia not otherwise specified and subsequent excisional biopsies for a 50-month period and correlated the results. Of 3,026 biopsies, 216 were diagnosed as ADH or atypia not otherwise specified, and subsequent resection was available for 105. After review, 95 qualified as ADH. Subsequent resection showed ductal carcinoma in situ (DCIS) in 13 excisions, ADH in 31, lobular carcinoma in situ in 6, and benign proliferative lesions in the remaining 45. In none of the 8 biopsies in which DCIS was found and radiographs were available for review was the radiographic lesion entirely removed. For comparison, the incidence of carcinoma in resections done for a diagnosis of DCIS, low or intermediate grade (solid, cribriform, or micropapillary type), on core needle biopsy was significantly greater (8 of 10 cases). However, the size of the lesions diagnosed as carcinoma also was significantly greater than that of the lesions diagnosed as ADH, and in none of the 8 biopsies with DCIS at excision was the lesion entirely removed at the time of biopsy. The incidence of carcinoma in excisional biopsies done for a diagnosis of ADH in core needle biopsies in our institution is relatively low, while the incidence of ADH is relatively high. Possible reasons for this include total removal of small lesions at the time of biopsy and use of the diagnostic term ADH for lesions that are not associated with coexistent DCIS.

Improved reporting methods for atypia and atypical ductal hyperplasia in breast core needle biopsy specimens. Potential for interlaboratory comparisons

The incidence of atypia and atypical ductal hyperplasia (ADH) in breast core needle biopsies varies widely (900%). I sought to identify methods to reduce the dependence of this measure on variability in the patient population. The results of all breast core needle biopsies with a diagnosis of ADH or atypia not otherwise specified for a 50-month period were reviewed. These were separated into different groups by age, and the variability of different reporting methods was compared. Of 3,026 cases, 216 were diagnosed as ADH or atypia not otherwise specified. The overall incidence of atypia by age group varied significantly from 0.029 to 0.10. The variability was reduced when atypia was expressed in relation to ductal carcinoma in situ (range, 1.0-2.1) or fibrocystic changes (range, 0.15-0.28). However, variability by age was the least when atypia was expressed in relation to the number of cases performed for calcifications (range, 0.13-0.17). Variability in atypia rates associated with age is reduced significantly when atypia is expressed in relation to the number of biopsies done for calcifications. This method of reporting atypia may allow interlaboratory comparisons with less dependence on the characteristics of the patient population.

Long-Term Outcomes of Stereotactic Breast Biopsies

Stereotactic core needle biopsies (SCNBs) are accurate and relatively convenient for the patient; however, the long-term follow-up of benign results has not been reported. All patients between 1993 and 1998 undergoing SCNB at a community-based hospital were entered into a registry. Follow-up was obtained by a retrospective analysis of the charts. Biopsies were performed on 865 lesions. One hundred thirty-one (15%) were malignant, 42 (5%) were suspicious for malignancy, 687 (79%) were benign, and five (1%) were lobular carcinoma in situ. Of the 42 patients with suspicious findings 38 underwent biopsy. Ten were malignant and 28 benign. Of the 687 patients with benign pathology, 377 had follow-up available with a mean length of 1.7 years. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of SCNB for benign lesions in our study are all 100 per cent. Eight lesions were worrisome and await final analysis. Of 687 patients with benign lesions 310 were lost to follow-up. This study suggests that patients with a benign diagnosis should be returned to routine mammography. These data also extend the reported follow-up to 1.7 years and establish an acceptable level of accuracy for SCNB. The lost patients remind us that follow-up is essential despite a benign diagnosis.

Predictive value of extent and grade of ductal carcinoma in situ in radiologically guided core biopsy for the status of margins in lumpectomy specimens

AIMS

The correlation between the extent and grade of ductal carcinoma in situ (DCIS) in a core needle biopsy of breast, and the presence of an extensive intraductal carcinoma component (EIC) or positive resection margins in a subsequent mastectomy, has not been adequately addressed in the literature.

MATERIALS AND METHODS

Seventy-eight core needle biopsies with mammography and mastectomy correlation (27 total mastectomies, 51 lumpectomies) were reviewed. The extent and grade of DCIS in the biopsies were determined and compared with the mammographic findings and the status of the EIC and margins in subsequent mastectomy specimens.

RESULTS

Twenty-four cases of core biopsies with at least three foci of low-grade DCIS or at least two foci of high grade DCIS (group I) corresponded in large part to cases of mastectomy with a positive EIC (20/23 cases, or predictive value of 87%). Nine of 15 cases of lumpectomy in this group were associated with margins positive for or close to (less than 0.1 cm from) carcinoma. Thirty-three cases of core biopsies with one or two foci of low-grade DCIS or one focus of high-grade DCIS (group II) were associated with mastectomies with a limited extent of DCIS. Only four of 22 lumpectomy specimens in this group had margins positive for or close to carcinoma. Twenty-one cases of core biopsies without DCIS (group III) represented all five mastectomy specimens without DCIS, and 16 mastectomies with DCIS and negative EIC. None of the 14 cases of lumpectomy in this group had margins positive for carcinoma. The predictive value for EIC status may be even higher if mammographic findings are used in cases with a low number of foci (two foci of low-grade DCIS or one focus of high-grade DCIS in short biopsy cores).

CONCLUSIONS

There was a good correlation between the extent and grade of DCIS in core biopsies and the status of EIC in subsequent mastectomy specimens. Core needle biopsies with at least three foci of low-grade DCIS or at least two foci of high-grade DCIS are associated with a greater likelihood of positive or close margins in subsequent lumpectomies. Core biopsies without DCIS are associated with a greater likelihood of negative margins in subsequent lumpectomies.

Minimal access breast surgery

Minimal access procedures have great potential for providing patients with equal, if not superior, forms of breast cancer diagnosis and treatment. Many of these procedures are in a process of evolution. The reliability of each method probably depends heavily on the training, ability, and experience of the operator. Surgeons should be aware of the advantages and pitfalls of these techniques and exercise caution during the initial phases of their learning experience.

Menses and breast cancer: does timing of mammographically directed core biopsy affect outcome?

BACKGROUND AND OBJECTIVES

Studies have shown molecular, genetic and cellular changes in breast cancer during the menstrual cycle. Changes in proliferative and metastatic potential of breast cancer cells during menses could explain improved survival when tumors are surgically removed in the luteal phase. This study examined if timing of mammography/core biopsy (MAM-CB) also affected breast cancer prognosis (histological tumor grade).

METHODS

Eighty-five premenopausal women undergoing MAM-CB at one clinic between March 1995 and February 1998 were retrospectively studied. All patients had Stage I or II breast cancer surgically treated. Patients were grouped by phase of menses at MAM-CB: follicular (F, Days 0-14) or luteal (L, Days 15-35). Groups were comparable in age, menarche, family history, nulliparity, breastfeeding, and total percentage of clinically palpable tumors. Pathological characteristics of the tumors (tumor size, tumor type, estrogen and progesterone receptor status, axillary lymph node status, the presence of lymphatic or vascular invasion and extranodal metastasis) was also comparable across the 2 groups.

RESULTS

Low-grade tumors were more frequent in the MAM-CB group L, whereas high-grade tumors were more common in the MAM-CB group F (P = 0.002, chi2(4) = 17.06).

CONCLUSIONS

Timing of MAM-CB in relation to menses may be a factor influencing breast cancer outcome. Future studies examining the effect of menses on the outcome of breast cancer should consider the potential effect of the timing of MAM-CB.

Office-based wire-guided open breast biopsy under local anesthesia is accurate and cost effective

BACKGROUND

Mammographic abnormalities found to be malignant by stereotactic biopsy still require a wire-guided biopsy (WGB) in most cases. We have previously described a simplified method of WGB that allows the procedure to be done with a minimum of dissection and under local anesthesia in the office setting. We hypothesized that this procedure can be used to produce cost-effective, office-based breast preservation therapy (BPT).

METHODS

We reviewed our recent experience with this WGB method to determine applicability and accuracy in the office setting. A cost-effectiveness analysis was also performed to determine potential charge reductions when this method is used to avoid operating room (OR) usage for either lumpectomy or lumpectomy plus sentinel lymph node biopsy (SLNB).

RESULTS

Of the 164 biopsies reviewed, 114 (70%) were performed in the office setting under local anesthesia and 50 (30%) were performed in the OR. The most common reasons for choosing the OR setting included performance of biopsy during an unrelated procedure requiring the OR (16 cases), patient preference (12), deep lesions (6), and the inability of the patient to cooperate with local anesthesia (5). The complication rates were similar between the two settings (7% for office-based and 4% for OR; P = 0.697), and in neither setting were any lesions missed. A cost-effectiveness analysis using our Current Procedure Terminology (CPT)-based charges revealed a potential per-case charge reduction of $4,632 for office-based lumpectomy and $4306 for office-based lumpectomy/SLNB, using our method of WGB and local anesthesia, compared with the OR setting.

CONCLUSIONS

Office-based WGB using our previously described method is accurate and can be applied to at least 70% of patients. Based on the favorable results of our cost analysis and rising support for SLNB, we anticipate increased utilization of the clinic setting and local anesthesia for BPT in the future.

Evaluation of stereotactic core needle biopsy (SCNB) of the breast at a single institution

Stereotactic core needle biopsy (SCNB) has become a popular method for diagnosis of occult breast abnormalities. There are few large series of SCNB from a single institution. Data on patients undergoing SCNB for mammographic abnormalities were collected prospectively over 43 months at a university hospital. Mammographic findings were categorized as benign, probably benign, indeterminate, suspicious or malignant. For lesions with SCNB pathology that were non-diagnostic, showed atypical hyperplasia or malignancy (in situ or invasive), or were discordant with the pre-biopsy mammogram findings, surgical excision was recommended. Subsequent surgical pathology was reviewed. All remaining lesions were followed mammographically after SCNB. SCNB was performed on 692 lesions in 607 patients. There were 79 malignancies, for a positive SCNB rate of 11.4%. The 349 SCNB performed for benign, probably benign and indeterminate lesions on mammography had a positive SCNB rate of only 4%. Surgery was recommended for 127 (18.3%) lesions, while 565 (81.6%) were followed mammographically after SCNB. A compliance rate of 61 % for at least one follow-up mammogram was obtained, with a median follow-up of 17.2 months and with no cancers found. The sensitivity for malignancy with SCNB was 93%. SCNB provides a minimally invasive method to assess mammographic abnormalities. Abnormalities considered radiographically to be other than malignant or suspicious yielded few cancers. In this series a low positive SCNB rate resulted in no false negatives on mammographic follow-up. The optimal positive biopsy rate for SCNB is debatable.

Accurate prediction of the amount of in situ tumor in palpable breast cancers by core needle biopsy: implications for neoadjuvant therapy

BACKGROUND

Neoadjuvant chemotherapy facilitates breast conservation in stage II breast cancer patients, whose primary tumors are assumed to be invasive because they are palpable. However, chemotherapy may not be indicated in the minority of patients whose clinically T2 tumors are completely or predominantly in situ. Almost all previous studies of core needle biopsy in breast cancer have been concerned with nonpalpable, mammographically detected tumors, and none have evaluated its ability to quantitatively determine the amounts of in situ and invasive disease.

METHODS

From September, 1992 to December, 1997, core needle biopsy was performed on all patients presenting to the Kings County Hospital Breast Clinic with palpable breast masses. Carcinoma was present in both core needle biopsy samples and surgical specimens subsequently obtained from 95 of 99 patients. Each specimen was evaluated for tumor type, histologic grade, and the amounts of in situ and invasive carcinoma it contained, and the results from surgical and core needle biopsy specimens from the same patients were then compared.

RESULTS

The surgical specimens of 14 patients had completely or predominantly in situ disease. Completely or predominantly invasive disease was present in 67 specimens, and the remaining 14 had significant amounts of both. The high level of agreement between the amounts of in situ and invasive disease in core needle biopsy and surgical specimens is indicated by Pearson and intraclass correlation coefficients of 0.91 (P < .001 and < .00001, respectively). Tumor type was correctly predicted by core needle biopsy in each case. Variables among these patients, including primary tumor size, interval between biopsy and surgery, or administration of neoadjuvant systemic therapy, did not alter agreement between core needle biopsy and surgical specimens.

CONCLUSIONS

Core needle biopsy can identify palpable breast tumors that are predominantly or completely in situ, and, thus, avoid unnecessary neoadjuvant chemotherapy. It also can demonstrate that a tumor is predominantly invasive, but cannot rule out small invasive foci. For that purpose, complete surgical excision of the tumor is required.

Breast cancer

Infiltrating ductal carcinoma is the most common form of breast cancer, and major risk factors are nonmodifiable. Current screening recommendations offer the best chance of early diagnosis. Staging takes into account the size of primary tumor, number of positive lymph nodes at surgery, and location of distant metastases. Treatment options include various combinations of surgical procedures, radiotherapy, chemotherapy, and endocrine therapy.