Breast Cancer

Unfortunately, just like any part of the body, there are many things that can go wrong with the breasts, a major one being breast cancer.  This lecture will cover the clinical aspects to evaluating and assessing a patient with a breast problem whether it be tenderness, a lump, secretions, etc. 

We’ll start off with a case: A 56-year-old woman G0P0 made an appointment to see her gynecologist because she was concerned about a small lump in her right breast that she has been able to feel for 2 months.  She has not had breast problems in the past and does not have a family history of breast cancer. 

The patient is obviously worried about breast cancer because of the ominous statistic that 1:8 women will be diagnosed with breast cancer over their lifetime.  This is a true statistic, yet it varies from patient to patient based on their past medical and family history.  However, any woman who feels a lump thinks of this statistic and automatically panics about the possibility of it being cancerous. 

The presenting symptoms of breast cancer are:

• Painless breast mass – 66%
• Painful breast mass – 11% (the notion that all breast tumors are painless is false)
• Nipple discharge – 9%
• Other (skin changes, etc.) – 14%

How do we go about evaluating this patient?

1. Take a thorough history!!!  Ask about things like onset, changes in size of the lump, if it comes and goes, tenderness, does the tenderness vary with the menstrual cycle, and previous breast problems or operations.  Ask about any family history of breast cancer.
2. Physical exam
3. Imaging studies

Now lets discuss these three steps in more detail…

1. Risk Factors for Breast Cancer

• Increasing age
• White race (however, women of color are more likely to die of breast cancer due to lack of healthcare)
• Menarche < 11 y.o. (↑ exposure to estrogen à ↑ risk)
• Menopause > 55 y.o. (periods end later in life à ↑ exposure to estrogen)
• Nulliparity (↑ exposure to estrogen)
• 1^st term pregnancy > 30 y.o. (↑ exposure to estrogen)
• Lactation history – if you first breast feed when you are younger than 30 y.o. there is a ↓ risk
• Use of exogenous hormones, specifically estrogen
• FamHx of breast cancer – 1^st and 2^nd degree relatives
• FamHx of ovarian cancer (pts. tend to ovulate longer à ↑ exposure to estrogen)
• Previous breast cancer
• Previous breast problem (2x risk in women w/fibrous adenomas)
• Previous breast surgery
• Previous radiation exposure (esp. as a child)

From a clinical perspective, the BRCA genes don’t play a lot into the evaluation of someone coming in with a breast complaint.  It’s important in terms of preventative screening, when you’re thinking about what this person is at risk for.
 

2. Physical Exam for Breast Cancer

When conducing a breast exam, spend adequate time (> 5 mins) doing it.  Have the patient sitting with her arms to her sides.  Observe the contour of the breasts.  Then ask her to raise her hands above her head.  As she does this, observe for symmetry, dimpling/skin-fixation or puckering of the skin indicating an increased possibility of a malignancy.  When palpating the breasts do it while the patient is sitting, especially if her breasts are large because it makes it easier.  Do the palpation in a supine position as well.  Feel for the all the lymph nodes: axillary, infraclaviculars, supraclaviculars, and down the sternum.  Other signs to look for: peu d’orange (skin of breast looks like an orange peel), nipple retractions, inflammation, erythema.  Malignant masses tend to be very firm, have irregular borders, and are fixed in position.
 

3. Imaging Studies for Breast Cancer - Mammograms, Ultrasounds, and MRI

These are adjunct tests, they should not be done at the end of the exam but in conjunction with breast evaluation.  Why?  Because 10-15% of malignancies are NOT picked up on mammograms, so you MUST follow-up.  Mammograms help identify synchronous lesions and non-palpable calcifications.  Use ultrasounds to distinguish a solid mass from a cyst (fluid-filled).  Use MRIs to detect silicone leaks from breast implants.  MRIs are also good to pick up occult lesions if you feel a LN on physical exam, but don’t feel anything else abnormal. 

A mammogram is taken from 2 angles –  cranial to caudal and medial to lateral.  The breast sits in a device which compresses it to flatten it.  The patient will feel pressure but in rare instances she will feel pain, so be sure to warn your patient.

Mammogram:    Normal breast (left) vs. mass (right)

  

Malignancies show spiculations around the calcification, they’re not nice and round like fibroadenomas.  Cysts and masses both look opaque on a mammogram so they are distinguished with an ultrasound.  However, on a mammogram the difference that can be observed is that a cyst has much more regular borders than a mass.

Ultrasound: Cyst (left) vs. mass (right) 

Fluid on an ultrasound looks black.  Solids are echogenic and easily seen. 

MRI: Implant (left) vs. implant w/cancer (right)

Implants are usually placed behind the muscle or behind the tissue.  In the second picture, the implant is deformed by a cancer in front of it, not by a leak.
 

4. Biopsy of Breast Cancer

1. Steriotactic – The radiologist sees opacities upon mammography and then puts in several needles through the skin and points them towards the calcification.  The woman is sent to surgery where the surgeon will excise the tissue at the end of the needles.  She’s then sent back to radiology where another mammogram is taken to make sure all the calcifications have been removed because they are not felt on physical exam.
2. Fine needle aspiration – The ob/gyn feels a mass and then puts a needle with a syringe into the mass and draws back on the syringe.  If fluid comes out, it’s a cyst.  If there is nothing, it is probably a solid mass.  If nothing comes up the first time, the needle is passed in multiple parts of the mass to confirm its solidity.  In doing this, the ob/gyn will also collect cells from the mass.  They are placed on a slide and sent to pathology to analyze them.
3. Excisional biopsy – The whole mass is removed.  This is a highly invasive procedure and may cause permanent breast deformity, especially if it’s not necessary when there is just a benign lesion (i.e. fibroadenoma).
4. Incisional biopsy – Part of the mass is removed and the tissue specimen is sent to pathology.  This is less invasive than an excisional biopsy and more commonly performed.  If a bigger specimen is needed after pathogical examination, she’s sent into surgery to obtain one.

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