breast cancers that are detected clinically or by breast self

8/4/2019 Breast Cancers That Are Detected Clinically or by Breast Self

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Importance of Breast Lump:

• In 33% of breast cancer cases, the woman discovers a lump inher breast

• Breast cancer identified in 11% of patients with “lump”, and 4%

of women with any complaint.

• Breast cancers that are detected clinically (as compared to

mammography) are typically of more advanced stage.

Cancer Detection

• 2nd

most common malignancy

• 2nd

leading cause of cancer death

• 16% of women ages 40-69 sought advice from a physician

related to a breast complaint

• A woman's risk of breast cancer increases with age.

• The median age at breast cancer diagnosis in women is 61 years

• 95% of all breast cancer cases being identified in women >40years old.

• 2nd

most common malignancy

• 2nd

leading cause of cancer death

• 16% of women ages 40-69 sought advice from a physician

related to a breast complaint

• A woman's risk of breast cancer increases with age.• The median age at breast cancer diagnosis in women is 61 years

• 95% of all breast cancer cases being identified in women >40

years old.

History

• Length of time present



• Presence of pain

• Change in size or texture

• Relationship to menstrual cycle

• Nipple discharge• Family history of breast or ovarian cancer and ages

• Age at first live birth, menarche, menopause

• Previous surgical procedures, including previous breast biopsies

and their pathologies

• Any drug history especially hormone replacement therapy or

the use of OCP.

• If cancer is likely, inquiry about

o constitutional symptoms,

o bone pain,

o weight loss,

o respiratory changes,

for clinical indications of metastatic disease.

Physical examination

Inspection

• Inspect the woman's breast with her arms by her side, with her

arms straight up in the air, and with her hands on her hips (with

and without pectoral muscle contraction).

• Symmetry, size, and shape of the breast are recorded, as well

as any evidence of edema (peau d'orange), nipple or skin

retraction, and erythema.



• Examination of the patient in the supine position is best

performed with a pillow supporting the ipsilateral hemithorax.

• A systematic search for lymphadenopathy then is performed.

Patient with large

breast mass and

retraction at 6

o'clock of left breast,

noted on elevating

arms

Physical examination alone cannot establish a mass as benign or

malignant. However look for:

• Skin thickening (e.g., peau d'orange) or nipple changes.:

• Fungating masses

• Dimpling or retraction of the skin

• Nipple inversion or excoriation

• Paget's disease of the breast



PAGET’S DISEASE

Breast Cancer: Classic exam characteristics:

• Single lesion• Hard

• Immovable

• Irregular border

• Skin dimpling

• Size >2 cm

• 90% are found by the patient!!



Obvious mass with skin involvement on left breast

Obvious mass with skin involvement on right breast



o Women aged below 50 years with:

Bilateral discharge sufficient to stain clothes

Blood-stained nipple discharge

Persistent discharge from a single duct

•

Family history

Triple assessment

Triple assessment comprises of

• Clinical examination• A radiological assessment – mammography or ultrasound

• A pathological assessment – cytology or biopsy

0.7% with cancer if all three suggest benign disease

99.4% with cancer if all three suggest malignancy.

If there is discordance between the three steps, open biopsy or core

needle biopsy should be done.

Evaluation

U/S for patients with dense breasts

Mammography

Digital vs. Conventional MRI, PET scan???

Referral for biopsy for palpable mass.

Evaluation of a Palpable Mass



Serial examination

• If physical exam does not confirm presence of a dominant

mass, then repeat exam should be done in 2-3 months.

• If patient <35 without risk factors, reexamine 3-10 days after

onset of menses for resolution.

Ultrasound

• Patient <35 yrs with breast complaint.

o The false-negative rate for mammography has been reported as high as 52%

in patients <35 years old with a palpable malignant breast mass

• Determine solid vs. cystic, simple or complex.

Suggested management for patients with "probably benign" masses on breast

ultrasound includes:

• Clinical and ultrasonographic surveillance every 6 months for 2 years, to

document stability

• Core needle biopsy to make a definitive diagnosis while leaving the

lesion in situ

• Surgical removal of the mass, particularly if the lesion is bothersome to

the patient.

Cysts



On ultrasound examination cysts have:

• Smooth walls

• Sharp anterior and posterior borders

• Black hypoechoic centres without internal echoes

• Ultrasonographic image of a simple cyst

• Ultrasonographic image of a complex cyst

Solid lesions

• Solid lesions have internal echoes

• Malignant tumours have:



o Hypoechoic areas interspersed between brighter echoes

o Irregular edges

o Cast hypoechoic shadows

• Benign tumours have:

o Isoechoic or hypoechoic patterns

o Smooth well defined borders

o Cast no hypoechoic shadows

• Ultrasonographical image of a fibroadenoma

Malignant Solid lesion



Mammogram

Indicated for screening starting at age 40.

Diagnostic mammogram if U/S suggests complex or solid lesion,

or if exam suspicious for cancer and patient >35 yrs.

Mammography

Abnormalities detected on mammography are classified as:

Spiculated masses

Stellate lesions

Circumscribed masses

Microcalcification

Spiculated masses

Soft tissue mass with spicules extending into surrounding

tissue

95% of spiculated masses are due to invasive cancer

Other causes of spiculated masses include:o Ductal carcinoma in-situ (DCIS)

o Radial scar / complex sclerosing lesion

o Fat necrosis

o Fibromatosis

o Granular cell myoblastoma



Magnification view demonstrating irregular speculated mass with associated calcifications

Stellate lesions

Localised distortion of the breast parenchyma with no

perceptible mass lesion

Differential diagnosis of stellate lesions includes:

o Radial scar

o Invasive cancer

o DCISo Surgical scar



Circumscribed masses

Circumscribed masses should be analysed according to

density, outline and size Differential diagnosis of circumscribed masses includes:

o Fibroadenoma

o Cyst

o Mucinous or medullary carcinoma

o Lipoma

o Abscess

CA

Popcorn calcification (Fibroadenoma)



Microcalcification

Microcalcification is due to debris within the duct wall or

lumen

Sole feature of 33% of screen-detected cancers

Malignant microcalcification is usually linear or branching

Benign microcalcification is usually rounded and punctate

Differential diagnosis of microcalcification includes:

o DCIS

o Invasive cancer

o

Papillomao Fibroadenoma

o Fat necrosis

Breast aspiration and biopsy

A definitive diagnosis of breast carcinoma requires a breast

biopsy. Three main types of biopsies are commonly

performed:

Fine-needle aspiration (FNA)



Core-needle biopsy

Excisional biopsy.

Fine needle aspiration

Performed with a 22-24 gauge needle.

If fluid clear and cyst resolves, patient can be reassured and

reevaluated in 4-6 weeks for recurrance.

If fluid bloody, send for cytology and consider further workup.

If no fluid, further work-up necessary.

The two cardinal rules of safe cyst aspiration are

(I) the mass must disappear completely after aspiration, and

(2) The fluid must not be bloodstained.



If the fluid that is aspirated is not bloodstained, then the cyst is aspirated

to dryness, the needle is removed, and the fluid is discarded as cytologic

examination of such fluid is not cost-effective.

After aspiration, the breast is carefully palpated to exclude a residual

mass.

If one exists, ultrasound examination is performed to exclude a

persistent cyst, which is reaspirated if present.

If the mass is solid, a tissue specimen is obtained.

When cystic fluid is bloodstained, 2 mL of fluid are taken for cytology.

The mass is then imaged with ultrasound and any solid area on the cyst

wall is biopsied by needle.

CRITERIA OR OPEN BIOPSY AFTER FNAC:

Needle aspiration produces no cyst fluid and a solid mass is

diagnosed.

The cyst fluid produced is thick and blood tinged.

Fluid is produced but the mass fails to resolve completely.

The frequent reappearance of the cyst in the same location and the

rapid accumulation of fluid after initial aspiration (< 2 weeks).

Most authors do not recommend definitive treatment based on a

cytologic examination. In addition, the presence of carcinoma cells on

fine-needle aspiration dose not differentiate between in situ andinvasive breast cancer.

Core needle biopsy

Performed with a 14-18 gauge needle, generally using U/S or

stereotactic mammography.

Histologic specimen obtained.



Correlates with open biopsy 94% of the time, with less cost.

Causes of Nipple Discharge

Blood

o malignancy vs papilloma

Purulent

o infection, usually related to lactation

Milky

o after childbearing up to one year

o hypothyroidism, prolactinomas

o medications: OCPs, tricyclic antidepressants,

dopamine agonists

Grey, brown, green, sticky

o Duct ectasia. Common 5th

decade, with nipple tenderness and

pain.

Spontaneous, bloody, unilateral, from one duct = more likely cancer Non-spontaneous, non-bloody, bilateral = less likely cancer

Ductogram demonstrating multiple intraductal papillomas



APPROACH:



SUMMARY:

Differential diagnosis

Fibroadenoma Macrocysts

Galactoceles

Lipoma

Abscess

Rare causes- sclerosing adenosis, cystosarcoma phyllodes

Malignancy

Work up

Exam

Imaging-

o Diagnostic mammogram- less sensitive in younger women

due to breast density

o Ultrasound- can distinguish cystic lesions from solid

masses (require further evaluation)

o Consider referral to breast surgeon

Biopsy-

o FNAC, Core needle biopsy, Open biopsy

If a young woman (age 45 years or less) presents with a palpable

breast mass and equivocal mammography finding, ultrasound

examination and biopsy are used to avoid a delay in diagnosis.



Ph-Ex

If

Discharg

If

Nonpalp

If Palp

mass

Solid or

combcyst

FNAB

Asp

Mamo

FNAB

LCNB Re Asp

Ex Biop

CT Scan MRI



Just to Summarize

Evaluation

U/S for patients with dense breasts

Mammography

Digital vs. Conventional

MRI, PET scan???

Referral for biopsy for palpable mass.

Mammography

Able to detect lesions down to 1mm, ~2 years prior to palpated mass.

Diagnostic: for palpable masses.

Screening: age 40 q 1-2 years, age 50+ every year.

Features suggestive of cancer:

Increased density.

Irregular border.

Spiculation.

Clustered irregular microcalcifications

BI-RADS Classification:

0: Needs more imaging

1: Negative

2: Benign findings

3: Probable benign, repeat imaging



4: Suspicious abnormality

5: Highly suspicious

Biopsy Techniques

Cyst aspiration (cytology FN 20%)

Fine needle aspiration (FN 20%)

Stereotactic core biopsy

Open biopsy



A mass

History

Breast examination

• Breast examination shoud be done with respect for privacy and patient comfort in a well-

lighted room , preferably whith an available indirect light source.

FNA

Because needle biopsy of breast masses may produce artifacts that make mammography

assessment more difficult, many radiologists prefer to image breast masses before needle biopsy.

However, in practice, the first investigation of palpable breast masses is frequently needle biopsy,

which allows for the early diagnosis of cysts.



If either of these conditions is not met, then ultrasound, needle biopsy, and perhaps excisional

biopsy are recommended,

By using fine-needle aspiration in the routin examination of the breast ,unnecessary open biopsy of

cystic change is avoided.

As a result of adding fine-needele aspiration to the routin examination of breast masses , a restating

of criteria for open biopsy is done when :

• 1) needle aspiration prodiuces no cyst fluid and a solid mass is diagnosed.

• 2) the cyst fluid produced is thick and blood tinged.

• 3) fluid is prodiuced but the mass fails to resolve completely. • the frequent reappearance of the cyst in the same location and the rapid accumulation of

fluid after initial aspiration (less than 2 weeks).

• Most authors do not recommend definitive treatment based on a cytologic examination. In

addition, the presence of carcinoma cells on fine-needle aspiration dose not differentiate

between in situ and invasive breast cancer.

Imaging Techniques

Ductography

• The primary indication for ductography is nipple discharge, particularly when the fluid

contains blood.

• Intraductal papillomas are seen as small filling defects surrounded by contrast media.

• Cancers may appear as irregular masses or as multiple intraluminal filling defects.

Mammography

• Mammography also is used to guide interventional procedures, including needle localization

and needle biopsy

Specific mammography features that suggest a diagnosis of a breast cancer include a solid mass with

or without stellate features, asymmetric thickening of breast tissues, and clustered

microcalcifications

Ultrasonography



• Second only to mammography in frequency of use for breast imaging ultrasonography is an

important method of resolving equivocal mammography findings, defining cystic masses,

and demonstrating the echogenic qualities of specific solid abnormalities.

• On ultrasound examination, breast cysts are well circumscribed, with smooth margins and

an echo-free cent.

• Benign breast masses usually show smooth contours, round or oval shapes, weak internal

echoes, and well-defined anterior and posterior margins.

• Breast cancer characteristically has irregular walls, but may have smooth margins with

acoustic enhancement.

• It is highly reproducible and has a high patient acceptance rate, but does not reliably detect

lesions that are 1cm or less in diameter.

MRI

• In the process of evaluating MRI as a means of characterizing mammography abnormalities,

additional breast lesions have been detected.

MRI is the imaging method of choice to evaluate implant rupture

• Its efficacy as a screening tool remain unproven , though studies in population at increesed

risk for breast cancer appear promising .

• MRI sensitivity for invasive cancer approches 100%, but is only 60% at best for DCIS .

Specificity remain low , with significant overlap in the appearance of benign and malignant lesions

Breast Biopsy

• When a breast mass is clinically and mammographically suspicious, the sensitivity and the

specificity of FNA biopsy approaches 100%.

• Core-needle biopsy of palpable breast masses is performed using a 14-gauge needle, such as

the Tru Cut needle.

• While the false-negative rate for core-needle biopsy is very low, a tissue specimen that does

not show breast cancer cannot conclusively rule out that diagnosis because a sampling error

may have occurred.

Ph-Ex

If

Dischar

If Nonpalp

mass

If Palp

mass

Solid or

combcyst

FNABMamo

CT Scan MRI



Differential diagnosis

• Fibroadenoma

• Macrocysts

• Galactoceles

• Lipoma

• Abscess

• Rare causes- sclerosing adenosis, cystosarcoma phyllodes

• Malignancy

Work up

• Exam

• Imaging-

– Diagnostic mammogram- less sensitive in younger women due to breast density

– Ultrasound- can distinguish cystic lesions from solid masses (require further

evaluation)

– Consider referral to breast surgeon



• Biopsy-

– Fine needle aspiration, Core needle biopsy, Open biopsy

If a young woman (age 45 years or less) presents with a palpable breast mass and equivocal

mammography finding, ultrasound examination and biopsy are used to avoid a delay in diagnosis.

Fibroadenoma

• Second most common benign breast disease, most common benign solid tumor

• Firm, painless, mobile breast mass, 2-3 cm, commonly in upper outer quadrants

• Usually women aged 20-40

• Multiple in 15-20% of patients

• Slow growing, do not regress spontaneously

• Can be stimulated by exogenous estrogen, progesterone, lactation, pregnancy

• Management- biopsy or excision

Macrocysts

• Most often women age 35-50

• Fluid-filled sac

• Often solitary but can be multiple

• Can have associated nipple discharge

• Aspiration for diagnosis and therapy

Galactocele

• Milk-filled cyst

• Usually follows lactation

• Firm, tender mass

• Usually in upper quadrants

• Diagnostic aspiration often curative

Breast cancer

• 211,000 new cases per year (estimated from 2005)



• 40,000 deaths per year (estimated from 2005)

• Second leading cause of cancer-related death in women

• Lifetime risk of breast cancer 12%

• One in eight women will develop breast cancer

• 80% in women >50 yrs old, 20% in women <50 yrs old

• Early- mammo abnormality, painless, mobile tumor

• 80% present with mass

• Pain is not usually early symptom, more likely benign

• Later- borders less distinct, fixed to supporting ligaments or underlying fascia, nipple

discharge, skin changes (peau d’orange), retraction of nipple

breast cancers that are detected clinically or by breast self

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