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BREAST CANCER


Currently breast cancer strikes more than 135,000 American women annually. One out of nine women will be diagnosed with breast cancer during her lifetime. Every woman should take the time to examine her breasts for signs of possible cancer. All women, not only those with prior breast lumps, benign or malignant, should learn and practice monthly breast self-examination (BSE). Breast cancer cannot be prevented; therefore, early detection is your best protection against breast cancer.

 

Malignant Breast Lumps

Malignant lumps develop most often from mammary ducts or lobules. Unlike benign lumps, malignant lumps continue to grow in an uncontrolled manner and in time, if left untreated, will spread beyond the breast.
The basic structure of the breast is composed of

 

1) Lobules

which when appropriately stimulated will produce and secrete milk,

 

2) Ducts

which carry the milk from the lobules to a network of ducts and then eventually to the nipple

 

3) Supporting tissue.

Breast cancer can arise from each of these structures. The most common site is the ducts, and secondarily is the lobules. The terminology of ductal carcinoma and lobular carcinoma is derived from the location of their origin.
When breast cancer begins within the ducts of the breast, this is referred to as intraductal carcinoma in situ (DCIS) and it is considered to be the earliest, detectable stage of breast cancer.

The most common progression of DCIS is that it may, and in most cases, will become an invasive carcinoma. It will go beyond the duct into the breast tissue. Once this has spread through the breast, it will spread to the lymph nodes. From the lymph nodes it may spread to other parts of the body, such as the bones, lungs, liver or brain.

If the breast cancer originates in the lobules of the breast it is called lobular carcinoma in situ (LCIS). The evolution of this cancer is similar to DCIS, but it has specific characteristics. These characteristics are:

1) It is not as aggressive as DCIS, and

2) It is viewed as a marker for breast cancer. This means that in patients found with LCIS they are at increased risks of developing cancer in both breasts.

There are other forms of breast carcinoma that are not discussed at this setting because of their rare occurrence.
Early breast cancer can be a nonpalpable lesion or a very small tumor located within the breast.

A breast cancer most likely has been growing for several years before it is large enough to be felt. Women who examine their breasts each month, go to their doctor for routine breast examinations, and after age thirty-five have a baseline (your first) mammogram, are more likely to detect an early breast cancer.

Advanced breast cancer is a tumor that has spread beyond the breast to the lymph nodes or to another part of the body. Cancer cells break off from the primary tumor and are carried in the lymphatic system and/or the bloodstream to a distant part of the body where they will grow into a new tumor or metastasis.

 

How a breast lump or a mammographic lesion is evaluated

It is important for any patient to understand the difference between a "palpable lump or breast mass or lesion" and a "non palpable or mammographic lesion". 

A palpable lump or breast mass or lesion is a lump or mass that can be readily felt by palpation by your physician.
A non palpable or mammographic lesion is a lump or mass (also be called a lesion) which cannot be felt by palpation by your physician. It is a lump or lesion which has been detected by a routine, screening mammogram. If this lesion does not have the hallmarks of a benign lesion on mammogram, it will be called a suspicious mammographic lesion.
Your surgeon can evaluate a breast lump or a mammographic lesion in a variety of ways:

 

Palpation

Is the physical examination of the breast. A surgeon is well trained to thoroughly examine your breasts in order to evaluate the tissue. Both breasts will be examined while you are lying down. The surgeon will also examine your underarm lymph nodes. If your examination is normal and there are no physical findings, your surgeon will suggest you schedule a follow-up appointment to reexamine the area you were concerned about. Until your next visit, it is important you continue to do your breast self-examination (BSE) on a routine basis.

 

Aspiration

Aspiration allows the surgeon to know immediately if a lump is fluid-filled or is a solid mass. The procedure is done in the surgeon’s office. The surgeon inserts a needle into the lump and, if it is a cyst, withdraws the fluid and collapses the cyst. The aspirated contents of the cyst are sometimes sent to pathology for a diagnosis. This is not a painful procedure.

 
Fine Needle Aspiration

This is performed once the surgeon has determined the mass is solid. A needle is inserted into the area in question in the breast, and cells are aspirated (taken out). A technician from the pathology department is present for this procedure and prepares slides with the aspirated fluid. These slides are analyzed by a pathologist. The procedure is brief and well tolerated by the patient.

 

Mammography or xeromammography

This is an X-ray technique using low levels of radiation to create an image or picture of the breast on film or paper. Mammography has made it possible to detect breast cancer at very early stages. There are several types of mammographic lesions that are suspicious and associated with early cancer. Mammograms can be helpful in determining whether a lump is benign or malignant. In fact, at times it can detect cancer in the breast before a lump can be felt. Mammography is recommended by our office on a yearly basis for women over 35 years old or for high-risk patients as a means for detecting a breast cancer before it can be felt.

 
Ultrasound

This is another method of evaluating the breast. This procedure creates a picture of the breast from sound waves. Although useful, this method is not reliable enough to be used alone. It is helpful when combined with other methods.

 

Stereotactic Breast Biopsy

In some patients, some nonpalpable, suspicious (cannot be felt) breast lesions/masses can only be seen on mammography. This will now be called a suspicious mammographic lesion or mass. Using a special X-ray device (stereotactic biopsy table), a biopsy of this mass can be done under local anesthesia with a special needle. The only problem with this technique is that it is not 100% accurate and only removes small pieces of this lesion/mass.

 

ABBI Biopsy

This breast biopsy device is the newest and most advanced method to perform a breast biopsy under local anesthesia. It resembles the stereotactic biopsy technique, but uses a sophisticated computer system to remove large portions of abnormal breast tissue. In some patients, it can even remove the entire section of abnormal breast tissue. It is best used for non palpable breast lesions or mammographic lesions.

 

Excisional or Surgical Breast Biopsy

This is the most accurate way to diagnose a lump or a mammographic lesion. The breast biopsy is usually performed as an outpatient procedure in a hospital setting under general or local anesthesia. The surgeon removes the entire lump. This is referred to as an excisional biopsy. The tissue is sent to the pathologist for microscopic analysis.

Your surgeon may select one or a combination of these procedures to evaluate a breast lump or other changes in your breast. Or he may choose to "wait and watch" the lump before recommending a biopsy. As mentioned before, many lumps are due to normal hormonal changes in the breast, and can be safely watched.

 

Breast biopsy: what you should know

A surgical biopsy is indicated when doubts exist regarding the nature of a persistent lump, nipple discharge, rash, or puckering of the skin or nipple. A biopsy may also be indicated for abnormalities seen on mammograms, even if a lump cannot be felt. Biopsy with microscopic examination of the tissue by a pathologist remains the only accurate method of diagnosis at this time.

 

Informed consent for surgical biopsy

When a surgical biopsy is recommended, most health care facilities require patients to sign a form stating their willingness to permit diagnosis and medical treatment. This is to certify that you understand what procedures will be done and that you have consented to have them performed.

The breast biopsy is performed in a hospital setting under general anesthetic. It is considered to be an "outpatient procedure". You do not spend the night in the hospital; you go home the same day. Prior to surgery you will sign a consent form for the scheduled surgery. Do not be frightened by the terminology, PARTIAL MASTECTOMY. This is the technical term for a breast biopsy. It means a "part" of the breast tissue is being removed. If the entire breast were going to be removed, the consent would read "MODIFIED RADICAL MASTECTOMY". Biopsy, lumpectomy and partial mastectomy all refer to the same procedure: removal of a portion of breast tissue not the entire breast.

During the biopsy procedure, the surgeon removes the entire suspicious tissue to have it examined by a pathologist. The pathologist will determine if it is benign or malignant. If malignant, the pathologist will identify the type of cancer cell, how fast they reproduce (flow cytometry), if the cancer’s growth is affected by hormones (estrogen-receptor tests) and other prognostic indexes. All of this information will enable the surgeon and you to determine the best treatment for you.

There are two ways a pathologist prepares the tissue for examination. The first method is the "frozen section" in which the tissue is frozen into a block of ice so it can be sliced and carefully examined under the microscope by the pathologist while you are still under anesthesia. If the tissue is benign, as it is in four out of five cases, no further surgery is needed.

The second way that a pathologist prepares the tissue for examination is the "permanent section". The permanent section is performed to confirm the findings of the frozen section. It is a more thorough analysis. It takes approximately forty-eight hours to obtain the results of the permanent section. In this process, the tissue is treated by a series of chemical solutions that provide a high-quality slide.
 

One-step and two-step procedures

When a surgical biopsy is necessary, you have a choice of two procedures that should be discussed and agreed upon by you and your surgeon: the One-Step and the Two-Step procedures.

In the ONE-STEP PROCEDURE, the biopsy, diagnosis of cancer and therapeutic treatment are completed in a single operation performed in the hospital under general anesthesia. Before the One-Step procedure, you and your surgeon must agree before surgery that you will undergo the therapeutic treatment during this surgery if the lump is malignant. You will be asked to sign a surgical consent for the biopsy and any additional surgery if the biopsy is positive (malignant). Your surgeon will explain the full details of a mastectomy (surgical removal of the breast) before the biopsy, even though the lump may not be malignant. Currently, the One-Step procedure is seldom recommended. Patients, who have had a previous history of breast cancer, may opt to undergo the One-Step procedure.

In most cases the surgeon recommends the TWO-STEP PROCEDURE for his patient. The first step of this method involves an excisional biopsy (lumpectomy, partial mastectomy) to obtain a diagnosis. Once this first step is completed the patient goes home. This is followed by a period of time to discuss treatment at a later date if a malignancy has been found. The biopsy and the treatment of the cancer are performed in two separate stages in this procedure. In the Two-Step procedure, if the lump is malignant, the patient has a more active part in the decision making process and has more time to think. This is emotionally beneficial for the patient. They feel as if they have more control over what is happening to them during this difficult time. In most cases, a patient feels the more they know the better it is.

If it is necessary for you to have a biopsy, discuss these two procedures with your surgeon. The two of you can decide which option is best for you.

 

Breast care

The consistency of breast tissue varies from woman to woman. By examining your breasts carefully at the same time each month, you will be able to notice any unusual changes, signs, or symptoms of breast cancer.

The following list will help you become aware of what to look for:

  1. A lump or thickening of the breast
  2. A discharge from the nipple
  3. Dimpling or puckering of the skin
  4. Retraction of the nipple
  5. Scaly skin around the nipple
  6. Other changes in skin color or texture, such as "Orange Peel" skin
  7. Swelling, redness, or heat in the breast
  8. A lump under the arm

The best approach to breast health care is three fold:

1) Monthly BSE (Breast Self-Exam),
2) A routine yearly exam by a doctor. An exception is for women with previous breast problems. These women should be examined by their doctor every three months.
3) After age thirty-five a baseline mammogram should be performed. A woman should have a mammogram every two years until age forty (our recommendation). Thereafter, it should be done annually, unless otherwise indicated by your doctor. Mammography is the single most accurate screening tool available to detect cancer in its earliest and most curable stages.

Mammograms are 80 to 85 percent accurate and can even detect lumps that are too small to be felt. In some instances a lump cannot be detected on the mammogram even though you or your surgeon can feel it. The reason for this is the lump is transparent and it will not appear on your mammogram. Mammograms are not 100 percent accurate; therefore, it is crucial to have a physical exam as well as a mammogram.
Mammograms can detect very small lumps- less than one quarter of an inch.

Most lumps cannot be felt until they are at least a half an inch. Precancers can also be found on mammograms. These are the earliest demonstrable forms of breast cancer.

It is best to have all your mammograms done at the same facility so that subtle changes can be detected more easily, and techniques, equipment and interpretation are less likely to vary. Once again, even if you get a clean bill of health from a mammogram, you should still do monthly BSE at home on a regular basis.

Remember the three "ams":
1) Mammogram,
2) Doctor’s exam, and
3) Breast Self-Exam.

Certain women are at a greater risk for developing breast cancer. These women need to be identified and followed more closely. The risk factors for women most likely to get breast cancer are as follows:
 

Major risks:

  1. Women 50 years or over
  2. Women whose mother or sister has had breast cancer, particularly if the disease occurred when the patient was premenopausal
  3. Women who have already had breast cancer
 

Other risks:

  • Women with precancerous breast disease
  • Women with breast cysts proven by aspiration or surgery
  • Women who have never had children
  • Women who had first child after age 30
  • Women who started first menstrual period at the age of 12 or younger
  • Women who have experienced menopause after 55
  • Women who are obese
  • Women who consumes large amount of alcohol

Each woman is a separate individual and her risk factors can be quite variable.

 

American Cancer Society Recommendations for Breast Cancer Detection in Asymptomatic Women

20-40 Years of Age

  • Breast Self examination monthly
  • Breast Clinical examination by a heathcare professional every 3 years
  • No recommended Mammography
  • 40 and older

  • Breast Self examination monthly
  • Breast clinical examination by a healthcare professional every 3 years
  • Mammography every year 

  • Cessation of annual screening is not considered to be age-dependent, but a function of co-morbidity; and no termination age was specified.
     
     
     
     
     
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