Preoperative assessment of the patient with breast cancer.

The clinical assessment of patients with Stages I and II breast cancer is outlined in Figure 1. A chest x-ray film and serum alkaline phosphatase are the only routine studies indicated. If the serum alkaline phosphatase is abnormal in the presence of otherwise normal liver function studies, a bone scan, liver scan, and CEA 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 x-ray film or show radiographic evidence of metastases are considered to be positive for metastatic disease. The results of the liver scan are correlated with the level of CEA. Focal areas of decreased radioactivity associated with a CEA greater than 5 ng per ml are considered to be metastases. In the absence of elevation of the CEA, focal areas of increased radioactivity should be biopsied prior to any further considerations as to definitive therapy. The clinical assessment of patients with Stage III disease is outlined in Figure 2. Patients with this stage of disease have a much greater chance of having clinically occult metastases of sufficient size to be detected by chest x-ray film, serum alkaline phosphatase, and bone scan. If the serum alkaline phosphatase is abnormal, a liver scan and CEA are obtained in an effort to detect liver metastases. The same sequence of events is then followed as suggested for patients with Stages I and II disease. Several new techniques of detecting occult metastases are being evaluated. Biomarkers are the subject of another article in this volume. The use of computerized axial tomography is also being evaluated as a means of detecting lung, liver, and mediastinal metastases. The results of these initial clinical trials should be carefully followed.