Download DISCOVERY The FEMALE BREAST THRU PHYSICAL EXAMINATION

DISCOVERY The FEMALE BREAST
THRU PHYSICAL EXAMINATION
A training module for health workers
Compiled by CA Ngelangel
Medical Oncology Section
University of the Philippines
2008 March
1
Training Yourself How to do Breast Examination
FIRST:
Read from 1st to last page of this resource material to enrich yourself on:
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•
•
•
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the female breast, its anatomy, development, and
changes during hormonal phases
the clinical breast examination
the breast self-examination
the benign breast disorders
breast cancer
which are the content background you need to know before training yourself on how to
do breast examination.
SECOND:
Come to the group training session (you will be with trainor-facilitators) –
1. you will be given a post-test on the knowledge you acquired from the resource
material given to you for study before this group session, then
2. you will watch a training audio-visual presentation of how to breast examination –
watch attentively, and while watching try to do the breast exam technique on
yourself, then
3. you will join others to form 10 per group
a. you will be given dummy breasts for training, then
b. you will be paired off, same sex
i. you will take turn in examining your partner’s breasts
ii. you will use the breast exam data form at the back of your resource
material for inputting data of the results of your examination
4. you will be given a post-test on the breasts models, trying to find the smallest
lesion/s
5. you will be given the results of your tests
THIRD:
Finally, the training is over and you will be given a certificate by ICANSERVE or
PHILIPPINE CANCER SOCIETY INC.
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BREAST CANCER BURDEN & RISK FACTORS
Breast Cancer in the Philippines
Cancer is the third leading cause of mortality among Filipinos, behind communicable
and cardiovascular diseases. Based on the 2005 Cancer Facts and Estimates jointly
compiled by the Department of Health - Rizal Cancer Registry and the Philippine Cancer
Society – Manila Cancer Registry, lung, breast, colon/rectal, liver and cervix/uteri
malignancies are most prevalent – equally leading the list as the top sites for cancerrelated deaths. Age also figures significantly in the demographics, with a higher cancer
incidence rate in the older population. Cancer survival rates have also hardly improved in
the past two decades.
Breast Cancer
Breast cancer is the most common type of cancer in women, and the second most
common cause of cancer death in women (lung cancer is most common cause of cancer
death). Approximately one in ten women develops breast cancer at some point in her
life. During a woman's lifetime, the risk of breast cancer is approximately 1 in 9.
Cancer cases occur mostly in women; however men could also be afflicted of the disease.
Risk Factors of Breast Cancer
The exact cause of breast cancer is not known but there are high risk factors for this
disease. The most significant are 1) sex, 2) age, 3) family history, and 4) personal history.
Seventy-five percent of breast cancer cases occur in women with no known risk factors.
At the same time, having one or even several risk factors doesn't mean you'll develop the
disease. The following factors may increase the risk of breast cancer development:
o Sex & Estrogen Exposure
Being a woman is the greatest risk factor in developing breast cancer. Although men
can develop breast cancer, it's 100 times more common in women.
Normal breast development and physiology
•
•
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At puberty the breast develops under the influence of the hypothalamus, anterior
pituitary, and ovaries and also requires insulin and thyroid hormone
During each menstrual cycle 3 to 4 days before menses, increasing levels of
estrogen and progesterone cause cell proliferation and water retention. After
menstruation cellular proliferation regresses and water is lost.
During pregnancy cellular proliferation occurs under the influence of estrogen
and progesterone, plus placental lactogen, prolactin and chorionic gonadotropin.
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•
At delivery, there is a loss of estrogen and progesterone, and milk production
occurs under the influence of prolactin.
At menopause involution of the breast occurs because of the progressive loss of
glandular tissue.
In premenopausal women, about 60% of circulating estrogen is from the ovaries in the
form of estradiol. The remaining 40% is estrone formed primarily in the adipose (fat)
tissue via aromatization of androstenedione from the adrenal glands. After menopause,
this adipose cell production of estrone is the main source of estrogens and the level of
estrone is maintained approximately at premenopausal levels. Blood sampling in women
age 35-65 years showed higher levels of estrone, total estradiol, and free estradiol, and
lower level of estradiol bound to sex hormone-binding globulin in women who developed
breast cancer than in women who remained free of breast cancer.
Many risk factors are related to the duration of estrogenic stimulation of the breast:
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Early menarche/ menstruation (before age 12) and late menopause (after age
55) are positive risk factors.
Estrogen hormone replacement therapy (longer estrogen exposure) / oral
contraceptive estrogen therapy
No children (no pregnancies, more exposed to estrogen, no exposure to
prolactin) or whose first pregnancy occurred when they were age 35 or older.
Oophorectomy resulting in early menopause is a negative factor.
o Excess weight
Weighing more than what is healthy for one’s age range and height increases the risk
especially if she/he had gained the weight as an adult, or for women, more so after
menopause. Although women usually have more fat in their thighs and buttocks, they
tend to gain weight in their abdomens starting in their 30s, and this weight gain can
increase their risk. This factor may be related with estrogen exposure.
o Age
The chances of developing breast cancer increase as a person grows old. The
disease rarely affects women under 25 years of age, whereas close to 80 percent of breast
cancers occur in women over age 50. At age 40, a woman has a one in 252 chance of
developing breast cancer. By age 85, the chance is one in eight. Risk increases as women
get older - over two-thirds of breast cancer occurs in women over age 50.
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Age risk in normal population as probability of development in the ensuing 10 years
per 1000 women:
Age _ _ _ _ _ _ _Risk
20__________0.5
30 _________4.3
40 ________ 14.3
50 ________ 25.1
60 ________ 35.1
70_________38.8
o Personal history of breast cancer
If a person has had breast cancer in one breast, she/he has an increased risk of developing
cancer in the other breast.
o Family history & Genetic Predisposition
If a person has relatives with breast
cancer, she/he has a greater chance of
developing breast cancer. In general, the
more relatives a woman has with premenopausal diagnosed breast cancer, the
higher the woman’s risk of developing
the disease. If a woman has one close
relative with breast cancer, her risk is
doubled. Life probabilities with two
first degree relatives having breast
cancer is 15% for example in the sister
of a breast cancer patient whose mother
or sister had breast cancer. The risk is
25% if either had bilateral breast cancer.
Cancer in 2nd degree relatives increased risk only slightly. Fig. 1 beside shows how
much of breast cancer is hereditary.
Women who have a family history of breast cancer, or who have a history of benign
breast cysts are high risk.
Family genes increase the risk of breast cancer. They are called BRCA1 and BRCA2.
Defects in one of several genes, especially BRCA1 or BRCA2, put men and women at
greater risk of developing the disease. Usually these genes help prevent cancer by making
proteins that keep cells from growing abnormally. But if these genes mutate, the genes
aren't as effective at protecting a person from cancer.
Only 5-10% of all breast cancers may be due to genetic defects or changes:
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BRCA1 and BRCA2 are breast cancer genes that are implicated in 3 to 5%
of breast cancers. Both are familial autosomal dominant.
The ataxia-telangectasia gene predisposes those carrying it to cancer (100
fold in homozygotes). It is autosomal recessive. Heterozygotes (1.4% of
population) have a breast cancer risk factor of 5.1 and this is increased by an
additional 5.8 times in those having a history of exposure to ionizing radiation
(4). Such a condition is implicated in 10% of breast cancers.
Lesser risks that may be genetic include starting menstruation before age 12, late age at
menopause (after 55).
Molecular biology of breast cancer also shows that patients with Her-2-neu antigens on
the breast cancer lesion denotes an aggressive type of cancer, non-responsiveness to
methotrexate therapy but responsiveness to doxorubicin and anti-Her2-neu antibody
therapy (e.g., trastuzumab).
o
Personal History
Personal history also plays a role in breast cancer risk. This can include exposure to:
•
Environmental contaminants
Polycyclic aromatic hydrocarbons (PAHs) are chemicals found mainly in
cigarette smoke and charred red meat. Studies have shown that exposure to these
chemicals can significantly increase chances of developing breast cancer. Exposure to
certain pesticides also may increase risks, but more research needs to be done to establish
a clear link.
•
Excessive use of alcohol
Women who consume more than one alcoholic drink a day have a 20 percent
greater risk of breast cancer than women who don't drink. Like all simple pleasures in
life, everything must be taken in mo Alcohol, high fat in diet, increased fiber diet,
smoking, obesity, and having previous ovarian or colon cancer.
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Diet high in fat remains an investigational risk factor
Unusual sleep patterns
Women may have an increased risk of breast cancer if they work the graveyard shift or
are up often during the night. The risk seems to be greatest if they don't sleep between 1
a.m. and 2 a.m., when levels of melatonin — a sleep-regulating hormone — are highest.
Researchers speculate that suppression of melatonin by exposure to light may increase
the release of estrogen by the ovaries
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The FEMALE BREAST
Breast Anatomy
Epithelial and stromal
elements compose the
breast of the normal adult
female. The lobules are the
structural and functional
units of the breast. These
are connected to the nipple
by the epithelial structures
and elements forming
series of branching ducts.
Variable amounts of
adipose tissue and fibrous connective tissue compose the
stroma which comprises much of the non-lactational
breast volume. See Figs. 1a-b: A ducts, B lobules, C
dilated section of duct to hold milk, D nipple, E fat, F pectoralis major muscle.
There are 15 to 20 lobes in each breast arranged in a circular fashion. The subcutaneous
adipose or fat tissue covering the lobes gives size and shape to the breast. Many lobules
comprise each lobe (Fig 2); each lobule has tiny bulb like sacs, where milk is produced
upon hormonal stimulation. The breast gland crawls towards the axilla forming its
axillary tail (Fig. 3).
Fig. 2: Breast gland lobe and lobule
Fig. 3: Axillary tail
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Fig 4: Breast gland ducts
A network of ducts (Fig.4) links the lobes, lobules and milk sacs. Ducts carry milk from
the sacs, toward the areola, a dark skin area surrounding the nipple. Ducts join together
into larger ducts ending at the nipple, where milk becomes available to the baby.
Fig 5: Breast gland stroma
Stroma (fatty tissue, suspensory ligaments and connective tissue) fills-up the spaces in
between the lobes, lobules,milk sacs and ducts, making up the breast size and shape (Fig.
5).
The normal breast acinar histology (Fig. 6 a-b) is composed of lobules that consist of
many acini within a connective tissue stroma.
.
Fig 6. (a- low magnification; b- high magnification): Acinar normal histology
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Fig 7a-b: Muscles of the Breast
The breasts are supported by and attached to the
front of the chest wall on either side of the
sternum by ligaments. The pectoralis major muscle (a major chest muscle) lie outside and
underneath the breasts, separating them from the ribs (Fig 7a-b).
Fig. 8a-b: Blood & lymph vessels network in the breast.
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Blood and lymph vessels form a network throughout each breast. The breasts have their
own network of lymphatic vessels, lymph ducts and lymph nodes.
Fig. 9a-b: Lymphatic system of the Breast
There are three levels of lymph node areas draining the breasts (Fig. 9a-b): a) Level I –
low & brachial axillary lymph nodes (B&C), b) Level II – deep & interpectoral axillary
lymph nodes (D), c) Levels III - supraclavicular (E) and internal mammary lymph nodes
(F). These lymph nodes are important in cancer metastasis from the breast to distant
organ sites. The axillary lymph nodes are the primary lymphatic drainage. The
secondary lymphatic drainage is to the internal mammary nodes, which is involved in
13% of medial cancers and in 4% of lateral cancers, in the absence of axillary lymph
node metastases.
Breast Development
Breast development occurs in distinct stages throughout a woman's
life, before birth, at puberty and during childbearing years. Changes
also occur to the breasts during menstruation and menopause.
The first developmental stage begins at five-six weeks of fetal
development with a thickening forming the mammary ridge or milk
line. By six months, this extends all the way down to the groin (Fig.
10), and then regresses. At this time, solid columns of cells form
from each breast bud, with each column becoming a separate sweat
gland. Each of these has its own separate duct leading to the nipple.
By the final fetal development months, these columns become hollow. At birth, a nipple
and the beginnings of the milk-duct system have formed; colostral milk can be secreted
the nipple for 4-7 days postpartum in either sex, declining over the next 3 to 4 week
period.
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The breast changes that take place are directly related to age (Fig. 11). There are three
development phases: lobule development (between ages 10-25); glandular development,
under the influence of menstrual hormones (between ages 13-45), and involution, or
shrinkage of the milk ducts (from about age 35 on).
By one year prior to the onset of menses, females develop a breast bud (Table 1), an area
of firmness under the nipple areola, which may be sensitive and tender, under the
influence of pituitary (FSH and LH) and ovarian hormones (estrogen and progesterone).
By adolescence, when the ovaries start to secrete estrogen, fat in the connective tissue
begins to accumulate causing the breasts to enlarge. The duct system also begins to grow.
The onset of these breast changes is accompanied by pubic and armpit hair appearance.
Upon ovulation and menstruation, the breasts mature continuously with the formation of
secretory glands at the end of the milk ducts, at different rates for each woman.
Table 1: Female Breast Developmental Stages (Tanner)
Stage 1
Pre-adolescent/ Pre-pubertal Stage: Only the tip of the nipple is raised.
Stage 2
Bud Stage: Buds appear, breast and nipple raised, and the areola (dark area of skin that surrounds
the nipple) enlarges
Stage 3
Breasts are slightly larger with glandular breast tissue present
Stage 4
Areola and nipple become raised and form a second mound above the rest of the breast
Stage 5
Mature Adult Breast Stage: Breast becomes rounded and nipple is raised
The breast continues to mature throughout the adolescent years, but is never fully
developed until lactation (milk production).
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Breast Changes: Menstrual, Pregnancy, Menopause
The female breast undergoes natural changes during menarche, menstrual, pregnancy and
menopausal periods, under a complex interplay of hormones.
o Ovarian Cycle
At puberty the breast develops under the influence of the hypothalamus, anterior
pituitary, and ovaries and also requires insulin and thyroid hormone
During each menstrual cycle 3 to 4 days before menses, increasing levels of estrogen
and progesterone cause cell proliferation and water retention. After menstruation cellular
proliferation regresses and water is lost.
In many women, the breast changes significantly according to the ovarian cycle. The
tissue responds to the secretion of progesterone in the latter half of the ovarian cycle, with
the dilatation of vessels and ducts and subsequent engorgement (Fig. 12 a,b).
Consequently, the breasts may be very nodular and tender during the luteal phase of the
cycle.
Figure 42a. Physiologic effects of ovarian cycle on
breast tissue. Tissue changes that occur during luteal
phase, including dilated vessels and engorgement, may
make examination results difficult to interpret. Reprinted
with permission from Osuch JR: Screening and
Diagnosis of Breast Cancer for Primary Care Physicians,
Slide Lecture Program: Slide 19, Copyright © 1994,
American Medical Women's Association.[13]
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Clinical breast examination (CBE) should be done in the premenopausal woman 5-10
days after the onset of menses (Fig.13).
Figure 13. Timing of clinical breast exam
according to ovarian cycle. Optimal time for
breast examination in premenopausal
woman is 5 to 10 days after onset of
menses. Reprinted with permission from
Osuch JR: Screening and Diagnosis of
Breast Cancer for Primary Care Physicians,
Slide Lecture Program: Slide 20, Copyright
© 1994, American Medical Women's
Association.[7]
For a premenopausal woman who has had her uterus removed, do CBE in approximately
6 weeks when she is in a different cyclic phase.
o Pregnancy and Lactation
During pregnancy cellular proliferation occurs under the influence of estrogen and
progesterone, plus placental lactogen, prolactin and chorionic gonadotropin. At delivery,
there is a loss of estrogen and progesterone, and milk production occurs under the
influence of prolactin.
Breast cancer is the most common malignancy diagnosed during pregnancy and lactation.
A baseline clinical breast examination (CBE) should be documented at the first prenatal
visit, as the examination becomes more difficult as pregnancy progresses. Any palpable
mass requires further workup, regardless of the pregnancy. During pregnancy,
abnormalities are usually evaluated with ultrasound and fine needle aspiration biopsy
(FNAB); mammography is deferred. In a lactating woman, a more accurate clinical breast
examination is possible 10 to 15 minutes after she has emptied her breasts.
o Menopausal Status
At menopause involution of the breast occurs because of the progressive loss of
glandular tissue.
A woman's breast tissue is also affected by her menopausal status. Premenstrual women
tend to have denser and/or more nodular breast tissue. Postmenopausal women have
smoother, less nodular breast tissue.
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Clinical Breast Examination
The clinical breast examination (CBE) is performed to evaluate the patient's specific
symptom and to identify any abnormalities of the breasts or its regional lymphatic
system. CBE uses the "7 Ps": positions, palpation, perimeter, pattern of search, pads of
fingers for palpation, pressure, and patient education (W Wohlberg).
1. Position with arms at side for inspection (Fig. 12): Visually inspect the breasts
with the patient sitting and with arms at sides. Include frontal and lateral views;
look at size, shape, symmetry, color, texture, and condition of nipples.
Look for dimpling or nipple deformity with the patient in a sitting position. Tension is
placed on the suspensory ligaments first with the hands pressing on the hips (Fig. 13).
.
2. Position with arms overhead for inspection: Repeat step 1 with arms overhead
(Fig 14).
Check the axillae for lymph node enlargement (1 to 2% of breast cancers initially present
as axillary lymph node enlargement).
3. Position with hands on hips for
inspection: Repeat step 1 with hands on hips,
contracting pectoralis major. Look for skin
dimpling with this maneuver (Fig. 15).
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4. Position upright for palpation: While the patient is sitting, palpate axillary
lymph nodes and supra-/infra-clavicular lymph nodes (Figs. 16 a, b). If the
woman identified a palpable abnormality on self-examination, ask her to point
with 1 finger to exactly where she feels the mass. Examine her in the position in
which she detected the lump.
5. Position supine for palpation: Help patient lie supine. Cover breast not being
examined. Place ipsilateral arm overhead. Examine from ipsilateral side of table
(Fig 17).
The patient lies back and places her hand behind her
head. Examine the asymptomatic side first and
examine from across the table. Examine the right
breast from the left side of the table and visa versa.
Start the examination in the lower inner quadrant
where there is the least breast tissue. When examining
this quadrant also note the sub-mammary fold.
The right hand stays in the central portion of the breast while the left hand defines the
outer boundary of the breast glandular tissue. The glandular tissue is denser and is to be
distinguished from the softer fatty tissue. The
glandular tissue is kneaded between the hands as the
examination progresses in a clockwise direction (Fig.
18). There is a deficit of glandular tissue beneath the
nipple-areolar complex. The right hand is kept in this
area to facilitate the kneading of the glandular tissue.
Note the loss of pliability and effacement of the
"ropey" consistency of normal glandular tissue.
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6.
Pattern of search: This should be vertical strip, wedge radial, or circular (Fig.
19).
7. Use pads of 3 middle fingers and examine in overlapping dime-sized circles (Fig.
20 a-b).
8. Palpate the entire breast using the
appropriate palpation techniques and
sequential depths of pressure; light,
medium, and deep (Fig. 21).
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9. Position breast toward midline: Centralize the breast
(manually or with a towel under the shoulder) (Fig 22).
The position of the right and left hands is changed as the
examination progresses to avoid crossing the hands (Fig. 23a).
The examination is completed in the upper inner quadrant (Fig.
23b).
10. Perimeter of the breast: Inspect and palpate the perimeter (Fig. 24).
The distribution of the breast glandular tissue is
outlined (Fig. 25). The glandular tissue is most
abundant in the upper outer quadrant and tapers
off toward the midline.
17
In practice, the glandularr tissue
t
pattern is drawn in the medical record
d rather
r
than on the
patient (Fig. 26).
The examiner goes to the other
er side
s of the
examining table and examiness the
th other breast in
a similar fashion.
The glandular tissue
distribution is typical
in this individual and
is quite symmetrical
(Fig. 27). The
glandular tissue
distribution does not
change through life althou
ough it undergoes varying degrees of
atrophy at menopause.
Position of the breast lesio
sion is described given the clock and quadrantt locations
lo
in the
breast (Fig. 28)
Approximately half of all
ll breast
b
cancers occur in the upper, outer region
ion of the breast
toward the armpit (Fig. 29).
29
Ap
Approximate
percentage of breast cancers found
und in each area:
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41% in the upper, outer quadrant
14% in the upper, inner quadrant
5% in the lower, inner quadrant
34% in the area behind the nipple
6% in the lower, outer quadrant
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11. Patient education: During the process, the patient should be asked:
1.
2.
3.
4.
if she is comfortable
if the pressure is causing any discomfort
if she performs BSE, how often, and her level of confidence
if she has any questions or concerns
12. Emphasize to the patient the importance of the triad of clinical breast
examination, breast self-examination, and mammography for early detection of
breast problems.
Breast Self-Examination (BSE)
BSE is a visual and manual examination of the breast that can be easily carried out by
women on a monthly basis. BSE helps women familiarize themselves with the
characteristics of their breasts. Women begin BSE in their teens.
Monthly BSE technique is similarly to the CBE technique. The best time to examine the
breasts is right after menstrual period, when they are not tender or swollen. If with
irregular periods, do BSE on the same day of every month. Any persistent breast lump or
abnormality of the breast or nipple should be reported to a physician as soon as possible.
BSE is best performed lying down (see illustrations under CBE).
1. Lie down and put a pillow under the right shoulder. Place right arm
behind the head.
2. Use the finger pads of the three middle fingers on the left hand to feel
for lumps or thickening in the right breast.
3. Apply 3 pressures-light, medium, and deep-in dime-sized circles to feel the entire
thickness of the breast.
4. Move around the breast in a set way. Choose either the circle (A),
the up and down (B), or the wedge (C).
5. Do a similar exam on the left breast, using the right hand.
6. Press firmly enough to know how the breast feels. Try to copy the way the
health care provider uses the finger pads during a breast exam. Learn what
the breast feels like most of the time. A firm ridge in the lower curve of each
breast is normal.
7. Repeat the examination of both breasts
while standing, with one arm behind the
head. Check the upper and outer parts of
the breasts (toward the armpit). Check
breasts for any dimpling of the skin,
changes in the nipple, redness, or swelling
while standing in front of a mirror (Fig. 30
19
a-b). Can also do BSE when during a shower.
The breast changes and warning signs to watch for with breast self-exam are:
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•
•
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Any new lump
Any lump or thickening that does not shrink or lessen after the next period
Any change in the size, shape or symmetry
A thickening or swelling
Any dimpling, puckering or indention
Dimpling, skin irritation or other skin/ nipple change
Skin/ nipple redness or scaliness
Nipple discharge, particularly if bloody, clear and sticky, dark
Nipple tenderness or pain
Nipple retraction
Any untoward breast change
About 80% of breast lumps found by self-examination are benign. Early detection of
breast cancer can lead to greater likelihood of cure. Guidelines for the detection of breast
cancer in women who are asymptomatic are:
•
•
•
BSE (breast self exam)- Women 20 years of age and older; be aware
of how the breasts normally feel and report any new breast change
to a health professional immediately.
CBE (clinical breast exam) & BSE - Women 20-39 should have CBE at
least every one-three years with a cervical Pap smear; do monthly
BSE.
CBE, BSE, mammography - Women 40-50 should have CBE every year
with a cervical Pap smear; do monthly BSE.
Mammography can be done for high risk women
aged 40-<50, otherwise ultrasound can be done.
Beginning at age 50, do yearly mammography. A
mammogram can detect a <1/4 inch or ½ cm
tumors; physical examination usually can detect
>1/2 inch or 1 cm tumors. Mammography can
detect non-palpable calcifications, which may
indication malignancy.
20
The size of tumors found by BSE can be compared to sizes found by mammography
(Table 2):
Table 2: Size of Tumors Found by Mammography and BSE
Average-size lump detected with routine
mammogram (0.43 inches / 1.1 cm)
Average-size lump detected with first
mammogram (0.59 inches / 1.5 cm)
Average-size lump found by regularly practicing
breast self-exam (0.83 inches / 2.1 cm)
Average-size lump found accidentally (1.42 inches
/ 3.6 cm)
Benign Breast Disorders
Most breast disorders are not cancerous. Fig. 32 shows the
commonly occurring types of breast disorders.
Common benign breast conditions include:
1. Breast cystic lumps
•
Fibrocystic changes. Fibrocystic breast “disease” is
characterized by an increase in the fibrous and glandular tissues resulting in small,
nodular cysts, non-cancerous lumpiness, granularity, and
tenderness (Fig. 33 a-b). Fibrocystic changes occur in at least
half of all women.
Fig. 34 is low power
magnification of the
cysts (A) arising
from the lobules,
with
apocrine
epithelial
lining (B).
Fig 35
21
The cysts are non-palpable microcysts. In premenopausal women, most
microcalcifications (C) are due to fibrocytstic disease rather than cancer. Fig 35
above is the gross appearance of fibrocystic breast changes, with a 1.5 cm cyst,
palpable as an ill- defined breast lump. Sometimes, fibrocystic changes produce a
more diffusely lumpy breast.
•
Cysts. Fluid-filled frequently in breasts of
women ages 35-50, ranging from (Fig. 36) very
tiny to egg size, increasing in size with pain and
tenderness just before menstrual period, and
disappearing after.
Some women may have atypical fibrocystic
hyperplasia of the breast (Fig. 37) characterized
by marked proliferation and atypia of the
epithelium, either ductal or lobular, found in
3% of benign breast biopsies and associated
with a 13% subsequent development of breast
cancer.
•
•
Galactocoele. Milk containing cystic formation, oftentimes with thick milky nipple
discharge from a painful enlarged breast.
Fat necrosis of the breast. Often due to trauma, presenting as a localized, firm area
with scarring that can mimic a breast
carcinoma. Microscopically (Fig. 38), consists
of irregular steatocytes with no peripheral
nuclei and intervening pink amorphous
necrotic material and inflammatory cells,
including foreign body giant cells responding
to the necrotic fat cells.
• Infections. Breast
infections (mastitis) are common among women who are
breast-feeding or who recently have stopped breast-feeding.
The breast is red, warm, tender and lumpy, with tender axillary
lymphadenopathy and fever. Breast abscess (Fig. 39 a-b) can
result. A subareolar or periarealar abscess can occur,
unrelated to nursing. It may be sterile but frequently with
aerobic and anaerobic bacteria. Only one ductal system in
one breast is usually involved and rarely multiple ductal
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systems. Chronically, it is the most frequent cause of nipple discharge in
premenopausal women.
2. Breast nodular lumps
•
Fibroadenomas. Fibroadenomas are firm, solid,
smooth, rubbery, fibrous, movable, usually
painless (pain fluctuates with menstrual cycle),
benign breast lumps, with well-defined shape,
often occurring in women during their
reproductive years (Fig. 40). It has a long-term
risk factor of 2.17 for the subsequent
development of breast cancer.
Figure 41 shows low magnification
proliferation of (A) epithelial and (B)
connective tissue elements of a
fibroadenoma.
•
Phyllodes tumor. A fibroepithelial tumor of unpredictable behavior, 10% of which
metastasize, occurring from either histologically malignant or benign variants.
Presents as a nodular firm non-painful solid breast mass often times larger than
fibroadenomas. Fig. 42 is low magnification showing characteristic cellularity of the
phyllodes tumor (c.f. fibroadenoma).
There is proliferation of both (A)
epithelial and (B) connective tissue
elements.
Fig. 43 shows high magnification, with few
mitotic figures (A), placing this tumor in the
benign category; the stromal nuclei (B) are
plumper than are found in a fibroadenoma.
23
•
Papilloma. Small (<1 cm) solitary or multiple intraductal growths, frequently
with nipple discharge and
fibrovascular tissue core. More
papillomas may develop with/without
cancer. Under high magnification (Fig.
44), the fibrovascular core and the two
types of epithelial cells are apparent.
3. Disorders of Breast Development
•
•
•
•
•
Amazia or Amastia. Congenital absence of breast.
Hypoplasia. Breast underdevelopment; may be congenital (rare) or due to lack/ delay
of hormonal stimulation.
Macromastia or Hypertrophy. Excessive or massive breast
development (Fig. 45a-b); may be
asymmetrical; occur during puberty,
pregnancy or in association with
penicillamine therapy.
Polythelia/ Polymastia/
Supernumerary Breasts. Formation of extra nipples (Fig. 46) with or
without breast tissue, in 2-6% of women; may be functional. Accessory
breast tissue is susceptible to breast disease processes.
Gynecomastia. Enlargement of the male breast (Fig.
47), largely due to hormonal disorder or imbalance.
4. Disorders of Breast Function
•
•
Agalactia. Physiologic failure of lactation (rare).
Galacctorrhea. Inappropriate milk secretion most common in women but can happen
in men and children; may be due to pituitary tumors, hyperprolactinemia,
hypothyroidism, and drug use.
5. Other Breast Conditions
•
Trauma. A blow to the breast or chest can cause a bruise or lump (hematoma or
contusion).
24
•
Calcium deposits (microcalcifications). Small deposits of calcium can appear
anywhere in the breast and often show up on a mammogram, which may be caused by
secretions from cells, cellular debris, inflammation, trauma or prior radiation. The
calcium deposits may be related to cancer.
•
Mastodynia, mastalgia. Breast pain.
Breast Cancer
1. Occurrence & Risk Factors
Breast cancer (Fig. 48) is the most common
type of cancer among females in the
Philippines and the World.. During a
woman's lifetime, the risk of breast cancer is
~1 in 9. Women develop breast cancer 100
times more than men. Seventy-five percent of
breast cancer cases occur in women with no
known risk factors. Risk factors most be
explored during medical history taking.
Many risk factors are related to the duration
of estrogenic stimulation of the breast:
•
•
•
•
Early menarche/ menstruation (before age 12) and late menopause (after age
55)
Estrogen hormone replacement therapy (longer estrogen exposure) / oral
contraceptive estrogen therapy
No children (no pregnancies, more exposed to estrogen, no exposure to
prolactin) or whose first pregnancy occurred when they were age 35 or older.
Oophorectomy resulting in early menopause
The other significant risk factors are:
•
•
•
•
Excess weight - may be related with estrogen exposure.
Age - chances of developing breast cancer increase as a person grows
old; rarely affects women <25 years of age, whereas ~80% of breast cancers
occur in women >50.
Personal history of breast cancer - if a person has had breast cancer in one
breast, she/he has an increased risk of developing cancer in the other breast.
Family history & Genetic Predisposition - if a woman has one close relative
with breast cancer, her risk is doubled; if with two first degree relatives,
25
•
chances of having breast cancer is 15%. The risk is 25% if either had bilateral
breast cancer. Cancer in 2nd degree relatives increased risk only slightly.
Personal History - includes exposure to environmental contaminants
(polycyclic aromatic hydrocarbons in cigarette smoke and charred red meat),
excessive alcohol use, high fat diet, and unusual sleep patterns.
2. Breast Cancer Clinical Presentation
Cancer can develop in the lobules, ducts, and stroma of
the breast (Fig. 49).
A tumor (Fig. 50) that is
precancerous or cancerous usually shows up as a white
area on a mammogram even before it can be felt. A
cancerous tumor may be asymptomatic or with swelling,
tenderness, and nipple discharge or indentation, or
dimpled skin over the tumor. A breast biopsy is helpful in
determining whether a mass is cancerous.
When breast cancer is diagnosed and treated in its early
stages, the five-year survival rate is 95%.
Early stage breast cancer presents as a
small to very small painless breast. As it
becomes bigger or more advanced - other
signs of breast cancer develops (Fig. 51 ah):
o
o
o
o
Breast enlargement
Change in breast size or contours
Skin flattening or indentation over breast
Nipple retraction or indentation
26
o Spontaneous clear or bloody nipple discharge
o Red/ inflamed nipple
o Skin redness or pitting, like an orange skin
o Breast shrinkage
o Hard breast
o Metastatic signs and symptoms – enlarged regional lymph nodes, bone
pain, cough/ dyspnea (lung), headaches/ vomiting (brain), jaundice/
abdominal enlargement (liver)
The more common symptoms of cancer are - painless breast mass (66%), painful breast
mass (11%), and nipple discharge (9%).
The aim of early detection is to find the breast
cancer at the earliest stage possible – clinically any
sub-clinical change in the look or feel of the breast
and or its nipple – with mass size <2 cm (Fig. 52).
Breast cancer stages (Fig. 53) can be
early (Stage 0-II), advanced (Stage III)
or metastatic (Stage IV).
There are 2 theories on how breast
cancer can spread: a) Halstead Theory
– breast cancer originates in the breast,
spreads to local skin and/ or lymph
nodes, and then affects distant organs –
lymph nodes serve as barriers to
metastasis; b) Systemic Theory suggests
that breast cancer becomes metastatic very early in its course, once invasion through the
basement membrane of the duct or lobule has occurred – disease is systemic upon
diagnosis. Both theories are correct and applicable to subsets of breast cancer patients –
for example, patients under Halstead theory are those with ER/PR(+), Her-2neu(-) profile
against those ER/PR(-), Her-2neu (+) patient profile of the Systemic Theory.
27
It is only via a biopsy that breast cancer
diagnosis is confirmed and classified. Noninfiltrating (in situ) breast cancer, becomes
commonly intraductal and then invasive ductal
breast cancer (Fig. 54).
28
Breast Cancer Screening Activity Report (ARF)
PERSONAL INFORMATION
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Last Name /___________________________________/
First Name /_________________________________/
Middle Initial /___________________________/
Maiden Name /__________________________/
Client Identification Number /__/__/__/__/__/__/__/
Date of birth (mm/dd/yyyy) /__/__/-/__/__/-/__/__/__/__/
Age (yrs) /__/__/
Menopausal Status: /__/ pre /__/ peri /__/ post
G /__/ P /__/
Marital Status /_______________________/
BREAST HISTORY
1.
2.
3.
4.
5.
6.
7.
Family history of breast cancer /__/ No /__/ yes if yes, what degree /__/ 1st /__/ 2nd /__/ 3rd
Family history of other cancer /__/ No /__/ yes if yes, what degree /__/ 1st /__/ 2nd /__/ 3rd
Personal history of breast cancer? /__/ Yes /__/ No /__/ Unknown
Was there a surgery done on the breast/s? /__/ Yes /__/ No /__/ Unknown
a. If yes, which side? /__/ Right /__/ Left, What procedures? /__/ mastectomy /__/ Excision
/__/ Biopsy
What was the result of the biopsy? /______________________________________________/
Client reports breast symptoms? /__/ Yes /__/ No
If Yes, what are these symptoms? /_________________________________________________/
CLINICAL BREAST EXAM
1.
2.
3.
4.
5.
Was breast exam was completed? /__/ Yes /__/ No /__/ Refused by client
If breast exam not done, give reason____________________________
Provider / Clinic______________________________________________
City where performed__________________________________________
Date performed (mm/dd/yyyy)___________________________________
RESULT of CLINICAL BREAST EXAM (check all that apply; draw on breast illustrations )
/__/
Normal Exam
/__/ R breast
/__/ L breast
/__/
Benign Finding (Fibrocystic changes) /__/ R breast
/__/ L breast
/__/
Discrete Palpable Mass**
/__/ R breast
/__/ L breast
/__/
Bloody or Serous Nipple Discharge** /__/ R breast
/__/ L breast
/__/
Nipple or Areolar Scaliness**
/__/ R breast
/__/ L breast
/__/
Skin dimpling or Retraction**
/__/ R breast
/__/ L breast
/__/
Other, describe ____________________________________/__/ R breast /__/ L breast
/__/
**Diagnostic testing is required.
29
BREAST SCREENING RECOMMENDATION NOTES
/__/
/__/
/__/
/__/
/__/
/__/
/__/
/__/
Follow Routine Screening schedule___________________months.
Short term follow up _________months _________________procedure
Diagnostic Mammogram
Consultant’s Breast Exam
Ultrasound
Surgical consultation
Fine needle aspiration biopsy
Excision biopsy
BREAST SCREENING HISTORY (Check all that apply)
1. Was a Mammogram done for this patient? /__/ Yes /__/ No /__/ Unknown
If yes, . Date of last Mammogram (mm/dd/yyyy)__________________________
2. Did you refer this patient for mammogram? /__/ Yes /__/ No
Did the patient go for this mammogram? /__/ Yes /__/ No /__/ Unknown
If Yes, Provider / Clinic_____________________________________________
.
Date performed (mm/dd/yyyy)_________________________________
What type of Mammogram was done? /__/ Screening Mammogram /__/ Diagnostic Mammogram
What is the mammogram RESULT
/__/
Negative findings
/__/
Benign findings
/__/
Probably benign – Short Term follow up
/__/
Suspicious abnormality – consider biopsy**
/__/
Highly suggestive of malignancy**
/__/
Assessment incomplete (Findings requires additional imaging evaluation)**
/__/
Unsatisfactory (Cannot be interpreted)**
/__/
** Diagnostic testing required
3. Was a biopsy done for this patient? /__/ Yes /__/ No /__/ Unknown
If yes, . Date of biopsy (mm/dd/yyyy)__________________________
4. Did you refer this patient for biopsy? /__/ Yes /__/ No
Did the patient go for this biopsy? /__/ Yes /__/ No /__/ Unknown
If Yes, Provider / Clinic_____________________________________________
.
Date performed (mm/dd/yyyy)_________________________________
What type of biopsy was done? /__/ FNAB /__/ Excision biopsy /__/ with Mastectomy
What is the biopsy RESULT
/__/
Negative findings
/__/
Benign findings
/__/
Suspicious abnormality – consider biopsy**
/__/
Highly suggestive of malignancy**
/__/
Malignancy
/__/
Unsatisfactory (Cannot be interpreted)**
/__/
** Diagnostic testing required
5 Did this patient under treatment for her breast lesion? /__/ Yes, /__/ No /__/ Unknown
If yes, what treatment (check all that apply)
/__/ surgery Date ________________________
/__/ radiotherapy Date _____________________
/__/ chemotherapy Date _____________________
/__/ other, specify _______________________________________
6. If this patient is diagnosed with cancer, Maintain follow-up of this patient
30