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	Breast Cancer
	- Introduction - Causes - Clinical Picture - Screening - Diagnosis - Pathology - Staging - Treatment

Breast self examination

The American Cancer Society (ACS) recommends that:

• Beginning in their 20s, women should be told about the benefits and limitations of breast self-examination (BSE).

Benefits:

• There is no data to suggest that breast self examination reduces the risk of mortality from cancer.

• Women who performed breast self-examination were found to be more likely to have smaller tumors and less likely to have axillary node metastases than those who did not.

A major problem with breast self-examination as a screening technique is that it is rarely performed well.

Clinical breast examination

The ACS recommends clinical breast examination for women:

• Between ages 20 and 39 - every 3 years

• Beginning at age 40 -  every year

The clinical examination should include inspection and palpation of the breast and regional lymph nodes. If the clinician detects an abnormality, the patient should then undergo diagnostic imaging rather than screening.

Benefits:

• There is no data to suggest that clinical breast examination reduces the risk of mortality from cancer.
• Approximately 20% of breast cancers are detected by clinical breast examination.

Mammography

Screening mammography is performed in the asymptomatic patient to detect an occult breast cancer. Currently, the American Cancer Society recommends:

• Beginning at age 40 years - annual mammography and examination by a physician

Benefits:

• Mammography has a sensitivity and specificity of 90% if there is a palpable mass.

• In impalpable cases the sensitivity and specificity are reduced to 50%.

• It detects the majority of cases an average of 2 years prior to any perceptible clinical signs or symptoms.

• Multiple prospective randomized controlled trials have demonstrated that mammography can reduce the mortality from breast cancer by 24% in women aged 50-74.

This, however, does not apply to younger women, particularly those aged younger than 40 years. In addition, the sensitivity of mammography is decreased significantly in young patients with dense breast tissue and possibly with augmentation prosthesis. Mammography seldom is recommended in patients younger than 30 years. Exceptions to this rule would be young women with extensive family histories for breast cancer.

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Mammographic findings & suggestive lesions

1. Breast masses: Stellate shape, irregular or spiculated margins suggest cancer.
2. Evaluating the breast for calcifications: Pleomorphic calcifications less than 0.5 mm (microcalcifications).
3. Architectural distortion and asymmetry suggest cancer.
4. Skin thickening
5. Nipple changes
6. Axillary adenopathy

BI-RADS

The American College of Radiology established the standard for classification of radiographic abnormalities, known as the Breast Imaging Reporting and Data System
(BI-RADS), as follows:

Ultrasound

As an adjunct to mammography, ultrasonography (US) can be particularly useful in younger patients or women with fibrocystic change and should be the initial investigation for palpable lesions in women younger than 35 years. Its main use remains in distinguishing solid from cystic lesions. In the workup of nonpalpable lesions, US can be used to guide a needle biopsy or to place a localizing wire to direct an excisional biopsy.

Benefits

• In palpable masses it sensitivity and specificity are about 95%.

Magnetic Resonance Imaging (MRI)

MRI is a particularly useful modality for detailing architectural abnormalities in the breast and can help detect lesions as small as 2-3 mm. MRI should be used in scarred breasts, implants, multifocal lesions, and for borderline lesions planned for breast conservation.

Benefits

• Has a sensitivity approaching 100% but its specificity is only 50%.

Scintigraphy

The label typically used is technetium Tc 99m Sestamibi, a compound that concentrates in mitochondria and whose efflux is related to expression of the multidrug resistance protein. Therefore, the size of the signal distinguishes the high metabolic rate of a malignant tumor and may help predict resistance to chemotherapy.

Scintimammography is less sensitive than MRI for lesions smaller than 1 cm, is more specific for palpable lesions and is useful for detecting axillary involvement. It can also be useful in cases with impalpable masses due to its high specificity in this setting.

Benefits

• Has a sensitivity and specificity of 90% in detection of impalpable masses.

Positron emission tomography (PET)

PET is the most sensitive and specific of all the imaging modalities for breast disease. However, it is also one of the most expensive and least widely available. PET is useful in axillary assessment, scarred breasts, and multifocal lesions.

Benefits

• Has a sensitivity of 95% and specificity of 100%.

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