Preoperative assessment of the patient with breast cancer

In addition to a careful physical examination, the clinical assessment of patients with stage I and stage II breast cancer should include other procedures. Axillary nodal status is probably best evaluated by an axillary lymph node dissection and histologic examination of the axillary nodes. Mammograms are obtained of the contralateral breast in all patients. A chest radiogram and serum alkaline phosphatase are the only routine studies employed to detect distant metastases. If the ALP is abnormal in the presence of otherwise normal liver function studies, a bone scan and computed tomograms of the liver are obtained. If CT studies of the liver are not available, liver scintigraphy, and a CEA assay should be obtained. Areas of increased radioactivity on bone scan are always evaluated by additional radiographs, and, in some cases, tomograms. The majority of focal areas of increased radioactivity will demonstrate radiographic evidence of benign bone lesions, predominantly degenerative joint disease. Only those focal areas of increased radioactivity that are normal on radiographs or have radiographic evidence of metastasis are considered to be positive for metastatic disease. Computed tomograms of the liver are the preferred technique for screening the liver for metastasis. If liver scintigraphy is employed, the results should be correlated with the level of CEA. Focal areas of decreased radioactivity associated with a CEA level of greater than 5.0 ng per ml are considered as metastasis. In the absence of elevated CEA levels, focal areas of decreased radioactivity should be further evaluated by ultrasonography. If the lesions are cystic, they are not considered to be a metastasis. Solid lesions should be biopsied prior to any further considerations as to definitive therapy. The clinical assessment of patients with stage III disease is more extensive. Patients with this stage of disease have a much greater chance of having clinically occult metastases of sufficient size to be detected by various scanning procedures. In these patients, computed tomograms of the liver or liver scintigraphy combined with a CEA determination are obtained in all instances. In addition, all patients should have a bone scan prior to decisions regarding definitive therapy.