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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: • • • • • 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. 2 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 • • • 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. 3 • 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: • • • • 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. 4 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: 5 • • 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. • • 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 6 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 7 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 8 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. 9 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. 10 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). 11 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] 12 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. 13 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). 14 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. 15 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). 16 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: • • • • • 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 18 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: • • • • • • • • • • • 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 22 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