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Approach to the breast mass. By : Dr. Faramarz Shahri Resident of surgery. DIAGNOSING BREAST CANCER. In 33% of breast cancer cases, the woman discovers a lump in her breast.
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Approach to the breast mass By : Dr. Faramarz Shahri Resident of surgery
DIAGNOSING BREAST CANCER • In 33% of breast cancer cases, the woman discovers a lump in her breast.
Other less frequent presenting signs and symptoms of breast cancer include (I) breast enlargement or asymmetry; (2) nipple changes, retraction, or discharge; (3) ulceration or erythema of the skin of the breast; (4) an axillary mass; and (5) musculoskeletal discomfort.
up to 50% of women presenting with breast complaints have no physical signs of breast pathology. • Breast pain usually is associated with benign disease.
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.
Sab History • The examiner should determine the patient’s age and obtain a reproductiv history. • The age of menarche ,menstrual irregulaities ,and the age at menopause should be sougth .
Sab • Previous surgical procedures should be recorded ,including previous breast biopsies and their pathologies and wether the ovaries were removed if a hysterectomy was performed.
Sab • Because hysterectomy is a common procedure, accurate determination of menopause may be difficalt . • It is usefull to inquire abaut menopausal symptoms in these patients .
Sab • In younger women, a recent history of pregnancy and lactation shoud be recorded . • A drug history shoud pay attention to hormone replacment therapy or the use of hormones for contraception .
Sab • The family history should be directed to cancer of the breast and ovaries (parents, siblings, offspring) . • In questioning the patient about the specific breast problem, it is worthwhile to inquire about breast pain, nipple discharge, and new masses in the breast.
Sab • If the mass is present, it helps to know how it was found, how long it has been present, what has happened scince it’s discovery, and if it changes with the menstrual cycle .
Sab • If cancer is likely, inquiry about constitutional symptoms, bone pain, weight loss, respiratory changes, and similar clinical indications of metastatic disease may occasionally reveal unsuspected distant spread .
Inspection • The surgeon inspects 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. • With the arms extended forward and in a sitting position, the woman leans forward to accentuate any skin retraction.
Palpation • Examination of the patient in the supine position is best performed with a pillow supporting the ipsilateral hemithorax.
The surgeon gently palpates the breast from the ipsilateral side, making certain to examine all quadrants of the breast from the sternum laterally to the latissimus dorsi muscle, and from the clavicle inferiorly to the upper rectus sheath.
Sab 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.
Sab • The examination begins with the patient in the upright sitting position with careful visual inspection for abvious masses, asymetries,and skin changes.
Sab • The nipples are inspected and compared for the superficial epidermis in Paget’s disease. • The use of indirect lighting can unmask subtle dimpling of the skin or nipple caused by the scirrhous reaction of a carcinoma placing Cooper’s ligament under tention .
Sab • Simple maneuvers such as gently lifting the patient’s breast may accentuate asymmetries and dimplling .
Sab • Peau d’orang when combined with tenderness and warmth ,these signs and symptoms are the hallmark of Inflammatory carcinoma and may be mistaken for acute mastitis.
Sab • Flattening or actual inversion of the nipple can be caused by fibrosis in certain benign conditions, especially subareolar duct ectasia.
Sab • In these cases , the finding is frequently bilateral and the history confirms that the condition has been present for many years. • Unilateral retraction or retraction that develops over weeks or months is more suggestive of carcinoma.
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 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.
The presence of blood is usually obvious, but in cysts with dark fluid, an occult blood test or microscopy examination will eliminate any doubt.
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 either of these conditions is not met, then ultrasound, needle biopsy, and perhaps excisional biopsy are recommended,
Sab FNA • Cystic fluid is usually turbid dark green or amber and can be discarded if the mass totally disappears and the fluid is not bloody.
Sab • By using fine-needle aspiration in the routin examination of the breast ,unnecessary open biopsy of cystic change is avoided.
Sab • 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 :
Sab • 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.
Sab • Other surgeons have added the frequent reappearance of the cyst in the same location and the rapid accumulation of fluid after initial aspiration (less than 2 weeks).
Sab • If the mass is solid and the clinical situation is consistent with carcinoma, a cytologic examination of the aspirated material is performed.
Sab • 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.
Sab • However, a positive result allows for informed discussions with the patient, definitive plans for treatment, and appropriate consultations or second opinions.
Ductography • The primary indication for ductography is nipple discharge, particularly when the fluid contains blood.
With the patient in a supine position, 0.1 to 0.2 mL of dilute contrast media is injected and CC and MLO mammography views are obtained without compression.
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 • Conventional mammography delivers a radiation dose of 0.1 centigray (cGy) per study.
By comparison, a chest x-ray delivers 25% of this dose, there is no increased breast cancer risk associated with the radiation dose delivered with screening mammography.
With screening mammography, two views of the breast are obtained, the craniocaudal (CC) view and the mediolateral oblique (MLO) view.
