I heard that open biopsy is the initial prodecure for breast palpable breast mass lesions in most of our hospitals. Can you write down the initial or first procedure used for these women in your hospitals?

A. Fine needle aspiration biopsy

B. Core needle biopsy

C. Open biopsy

Hospitals in China

In most situation or in most cases.

Also what is the initial procedure for most non-palpable breast lesions.

Palpable lesions: one of A, B, C

Non-palpable lesions:one of A, B, C. 

Thanks,

cz

谢谢赵博士！明白了。大致翻译如下：

 感谢mingfuyu老师让我了解了另一种工作状态，中国病理医生工作环境和受训练比美国病理医生差距大，水平差距更大，当然中国也有许多病理大师级人物，水平非常高。但是，实事求实的说中国的病理医生多数人几乎没有进行过职业培训，直接上岗，有的一辈子都没有受过正式训练，也混着干了一辈子，有许多虽然已经当上了病理主任医师（病理医生的最高级），其中不少的人的实际水平最多相当于美国的普通病理职业医师，有的研究生导师连英文都不认识，这些都是非常可笑的，属于体制性差距，不是医生本人的错，不在这里展开。中国病理报告规定常规是三个工作日，免疫组化应该在一周之内，这比美国三天还是慢了。尸体解剖的出报告时间和美国一样。乳腺包块处理，中国看起来多数医院还是以手术开大刀切开活检，加术中冰冻诊断为主，这是美国30年前的方法。我们是落后多了。问题估计是很复杂的，很难弄明白，有病人无钱的原因、有医生利益问题，也有认识等等多方面的问题，另外中国医生可能也认为我这样做病人结果也很好，我们这样开大刀取活检治疗的乳腺癌也都有非常高的存活率。因此他们目前还没有接受美国医生的方法，中国也没有规定不能开大刀取乳腺的活检。

想问mingfuyu老师，为什么要早知道乳腺癌的免疫组化结果，因为我们是半年后做内分泌tamoxifen and herceptin治疗。

1. The chance of metastesis by FNA and core bx is rare. It should not been considered as a risk factor.

2. Both FNA and core biopsy need patients to sign the content in the US.

3 Core bx accuracy

 我们这儿啥都是快快快，有时并不知道为啥。但我并不觉得这儿的tamoxifen and herceptin一定是半年之后。美国刚出了乳腺癌的诊断治疗guideline,上班去查查。If you really want to know why the doctors want to know the receptors/Her2 fast, i have to ask them.  With breast core biopsy, we report H&E diagnose the second day and ER/PR/Her2 the day after, that is day 3 of the biopsy. 

When we call the clinicians to tell them a malignant diagnosis next to the microsope, we are 120% sure about the diagnoses.  We never put our reputation or patients' benefit in jeopardy.  So, please relax, we are very cautious, we cannot afford to make mistakes!

We practice with guidelines, pathologists as well as clinicians. But we also put our training, experience and personal preference into our work.  Some doctors are just forever in a big hurry, want to know everything right away.  If we can accomodate them, we do, they are our clients.  One breast surgeon i worked with promises her patients FNA diagnosis after 4 pm on the day of office visit.  We try our best to report to her before 4 pm, of course, always by phone.

For autopsies, we have to give preliminary diagnoses within 24 hours after the autopsy.  Patients are dead already, why are we in a hurry to give a report?  I don't know, but i do.  I believe that is the CAP (college of american pathologists) guideline..  We also have to give a complete report of autopsy in 30 days.

 理论上是先穿刺，后做手术，手术中要做冰冻。

但是现在一些医院穿刺如果能诊断癌就直接手术了。不再送冰冻。

总觉得这不是规范的，如果穿刺诊断癌就切，万一切错了，怎么办？！

 谢谢赵老师！对粗细针穿刺的优缺点阐释的清晰明了。

想请教：细针穿刺一般不引起恶性肿瘤的转移（未见文献报道），粗针会不会引起转移呢？粗针穿刺要签知情同意书吗？乳腺粗针穿刺确诊率是多少？

 先回答1楼赵老师的问题：

对于乳腺肿块，我们一般细针细胞学检查，结合触摸和进针感，如果恶性，直接手术，如果可疑，术中冰冻。

良性肿瘤或病变，由外科医师决定。

 很有意思的讨论！美国都讲快，快，快，快出诊断，快出IHC结果，有时并不知道为什么？比如我工作过的医院当天出50%以上的活检报告，恶性诊断有时显微镜边就报告给临床医生了。 I think it is mostly to prove to our clinicians, clincians prove to their patients, our efficiency and commitmemt to prompt and quality patient care.

FNA is really fast.  We give on-site diagnosis sometimes.  It means the patients get a pathologic report during their doctors' visit.

美国妇女有不少保乳的。乳腺全切不很多，很多是包块切除加前哨淋巴结（lumpectomy with sentinel lymph node).现在乳腺癌很多都是早期诊断。

 译上楼：To answer 月新's questions: 回答月新问题：Overall, both FNAB and CNB can provide excellent opportunity to avoid unnecessary open biopsies. 粗针和细针活检都有优点，都可以避免不必要的手术切开活检。No single procedure is good for everyone. 没有一个方法能适合所有的人。Goal must be to choose the right procedure for every patient who puts her trust in our hands. 目的是选择一个合适的方法，Should consider the cost, patients' comfort (physical and psychological).同时也考虑患者的费用，心理，身体等等。FNA advantages:细针活检优点：Cost effective, Economic value 经济实用，Less pain 痛苦小，Speed and psychosocial value 出结果快，心理容易接受。Reliable and accurate 可靠性准确性也好。Flexibility in various clinical settings开展场地也随意。Integral part of any mass breast screening program 任何查到的乳腺包块都可以开展。Reduction in the surgical excision rate in benign breast disease可以明显减少良性乳腺病的手术切除机会。FNA disadvantage细针的缺点：Difficult to separate DCIS from invasive cancer 不能区别导管原位癌和浸润癌。-False positive and false negative 假阳性假阴性，-Inability to make a diagnosis of papillary lesion 不能做出乳头状病变的病理诊断。-Cannot identify lymph-vascular invasion不能区别淋巴和血管浸润。Advantage of core needle biopsy:粗针的优点：are the above disadvantage of FNA even though the sensitivity and specifity are similar.与细针相比准确性差不多。In addition, FNA interpretaion needs well trained cytopathologists.细针穿刺诊断医生训练要求高点， CNB is relative easy to interpretate.粗针诊断一般的病理医生都行。Good in non-palpable breast mass摸不清包块用粗针效果好。Disadvantage of Core biopsy 粗针的缺点。More expensive than FNA比细针贵的多，花费用高，More tranmatic for patients 创伤大。Longer time病人等时间长。Possibility of seeding the biopsy tract?有可能有活检口的肿瘤种殖。Open biopsy should not be used as the initial procedure in most breast lesions even though it may be used in most hospitals in China.虽然在中国多数医院仍然是以手术切开活检为主，但是实际上手术切开活检不应该再被用于大多数的乳腺肿瘤，不能做为乳腺肿块的活检首选， It is too bad.效果太差， Open biopsy with fozen was used as initial procedure for breast mass 30 years ago in the US.手术切开活检，术中冰冻切片确诊，这是美国30年前的老方法。I have not any intention to discuss this topic here.关于这点不在此展开讨论，也没有必要。 But I have to based on the requirement of Dr. 月新.但是根据月新的提问我说了几句。 However there is few persons in China who responsed my requirment. 我的回答可能对中国的少数医生（喜欢做切开乳腺取活检的人）有帮助。

       这是一个非常好的帖子，尽管如此简单，大家没有太多的回帖，主要是不知道什么是最标准的处理方法。我们医院也是因人而异，比如一个病人摸起来非常象乳腺癌，就直接手术，手术台上做冰冻切片，证实癌直接做大手术，保乳的人非常少，有些癌很小我让外科医生保乳，他们问病人，病人坚决不保，也就不保了。还有些特殊类型的癌，如胶样癌，小管癌，我坚持让病人保乳，也是费半天劲，不落好。有时也保不住乳腺。

     如果摸的包块不很象癌，就做细针吸活检细胞学诊断，如果有问题再做手术大切，没有做粗针活检的习惯。

     如果是摸不清的乳腺包块，基本是都是观察， 不做病理检查。

     有一个医生可疑乳癌，喜欢切开取活检，我说他好几次，现在也没有这样的人了。     请赵老师讲一讲粗针活检的优点。也想问mingfuyu 老师，为什么要快速知道PR ER HER2的结果？一般内分泌治疗都是在化疗放疗半年后，早知道免疫组化结果有什么治疗用途？