Practical Mammopathology in Medical Practice
Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg
1999;2000
INTRODUCTION
A complaint in the breast is a very common cause for medical consultation. All physicians should, therefore, know at least how to evaluate patients with a breast problem. They should know how to manage the cases that fall within the capability of general practice. They should know when and what cases to refer to breast specialist.
Complaints on the breast may be any of the following:
- Pain
- Lump
- Nipple discharge
- Breast enlargement
- Nipple erosions
The most common complaints are pain and lump.
To investigate a breast complaint, a physician starts off by asking questions about the breast complaint. He then does a physical examination on the breast, which is the most important part of the investigation.
Examination starts with inspection of the breasts. A physician looks for any gross abnormality that may suggest or indicate the presence of a pathology. Examples of gross abnormalities are the following:
- Unilateral gigantic breast
- Erosions of the nipples
- Skin retractions
- Ulcerations
- Fungating mass
- Erythema
- Discharge on the nipple
After inspection comes palpation of the breast. Before palpation, it is a good practice to ask the female patient if she palpated a lump in her breast before. If she did, she should be asked to point to the area where she palpated the said lump.
On palpating the breast, the physician should look for a lump which is considered pathologic. S/he looks for the so-called “dominant mass”, one that stands out prominently from the rest of the breast tissue. S/he should try to distinguish a pathologic lump from a lump that is part and parcel of fibrocystic changes. Fibrocystic changes are physiologic and not pathologic. They usually present as multiple mini-lumps or minute nodulations on the surface of the breast.
Once a pathologic lump is detected, it should be evaluated as to the following:
- Size
- Nature of the lump – whether solid or cystic
- Consistency – whether hard or not hard
- Tumor border – whether well-defined or ill-defined
- Presence of tenderness
- Mobility – whether fixed or mobile
After palpating the breast proper for any lump, the nipple should then be squeezed gently for any discharge. If there is discharge, its color and character should be noted down, whether serous, milky, or sanguinous.
A complete examination of the breast should include examination of the axillae. These areas should be palpated for any mass. The mass could be enlarged lymph node or a tumor in the tail of Spence (part of the breast).
MAMMOPATHOLOGY
There are ten breast disorders which all physicians should be familiar with. It is sufficient that they know when to suspect them after physical examination.
These ten breast disorders are the following:
- Breast cancer
- Fibroadenoma
- Macrocyst
- Galactocoele
- Mastitis and breast abscess
- Intraductal papilloma
- Benign cystosarcoma phyllodes
- Tuberculosis of the breast
- Paget’s disease of the nipple
- Mammomegaly
BREAST CANCER AND PAGET’S DISEASE OF THE NIPPLE
Breast cancer should be suspected in a palpable breast lump of any size that is SOLID and that has ILL-DEFINED BORDERS. This is especially so if any of the following is also present:
- HARD CONSISTENCY
- FIXED TO SKIN OR UNDERLYING CHEST WALL
- SKIN ULCERATION
- FUNGATING MASS
- ENLARGED LYMPH NODES IN THE IPSILATERAL AXILLA
Paget’s disease of the nipple is a special kind of breast cancer. It should be suspected in patients with NIPPLE OR AREOLAR EROSIONS. A subareolar mass may or may not be present.
Breast cancer usually starts to appear after age 30. Rarely, a younger patient as young as 25 years old or even younger, may be afflicted with breast cancer.
FIBROADENOMA
Fibroadenoma should be suspected in a palpable breast lump of any size that is FIRM, SOLID, NONTENDER, VERY MOVABLE, and that has VERY WELL-DEFINED BORDERS. This is especially so if there are no enlarged lymph nodes in the ipsilateral axilla and if the patient is 25 years old or younger.
MACROCYST
Macrocyst should be suspected in a palpable breast lump of any size that is CYSTIC in nature and that is seen in a patient with NO HISTORY OF RECENT LACTATION. By cystic nature is meant the wall of the lump is depressible as to suggest a sac containing fluid.
GALACTOCOELE
Galactocoele should be suspected in a palpable breast lump of any size that is CYSTIC in nature and that is seen in a patient with a HISTORY OF RECENT LACTATION.
MASTITIS AND BREAST ABSCESS
Mastitis should be suspected in any ERYTHEMATOUS, TENDER, and WARM BREAST WITH NO PALPABLE LUMP.
Breast abscess should be suspected in a PALPABLE BREAST LUMP of any size that is TENDER, WARM, and associated with ERYTHEMATOUS overlying skin.
Mastitis and breast abscess are usually encountered in lactating women. They may also be seen in nonlactating women at any age.
BENIGN CYSTOSARCOMA PHYLLODES
Benign cystosarcoma phyllodes should be suspected in a palpable breast lump that is GIGANTIC, NOT FIXED TO THE UNDERLYING CHEST WALL, AND THAT IS NOT ASSOCIATED WITH ENLARGED LYMPH NODES IN THE IPSILATERAL AXILLA. The tumor may be fixed to the overlying skin.
TUBERCULOSIS OF THE BREAST
Tuberculosis should be suspected in a breast with CHRONIC SINUSES. There may or may not be an underlying lump.
INTRADUCTAL PAPILLOMA
Intraductal papilloma should be suspected when there is BLOODY NIPPLE DISCHARGE WITH NO PALPABLE BREAST LUMP.
MAMMOMEGALY
Mammomegaly should be suspected of a GIGANTIC BREAST WITH NO UNDERLYING LUMP. Mammomegaly may be unilateral or bilateral.
DIAGNOSTIC WORK-UP OF A MAMMOPATHOLOGY
The diagnostic tools that may be utilized in a patient with a breast problem consist of the following:
- Interview
- Physical examination
- Diagnostic procedures
- Monitoring and constant analysis
The initial tools used in investigating a breast problem consist of the interview and physical examination. After the physical examination, a clinical impression or a diagnosis should be formulated. Depending on the certainty of the diagnosis formulated, a diagnostic procedure may or may not be instituted. Another option is monitoring and constant analysis (what is commonly known as observation).
The diagnostic procedures that have been utilized in the work-up of patients with mammopathology consist of the following:
- Needle evaluation
- Open biopsy
- Mammography
- Ultrasound
NEEDLE EVALUATION
Needle evaluation uses a hypodermic needle, usually G 19 and 1.5 inch long attached to a 20cc plastic syringe, to evaluate a lump palpated in the breast. There are three parts in a needle evaluation. One is needling the lump to check its actual presence; to check its nature, whether solid or cystic; and lastly, to determine its real consistency, whether gritty or rubbery. Second is aspirating the lump to get samples for gross examination. Third is preparing a smear out of the samples aspirated for microscopic examination. The third step is what is commonly known as needle aspiration biopsy.
Needle evaluation can be done right after the physical examination in the clinic or office.
The advantages of a needle biopsy are the following:
- It can give a more definite diagnosis than the physical examination, mammography,
and ultrasound.
- It is a more cost effective diagnostic procedure than mammography and ultrasound.
- It can give a more definite diagnosis right after or soon after the physical
examination.
- It can avoid an operation.
- It can be therapeutic in galactocoeles and macrocysts.
A real-life situation is given below:
A 45-year-old female presented with a hard nontender breast mass with ill-defined borders. Breast cancer was suspected. A needle evaluation was done and serous fluid was aspirated and the mass completely disappeared and did not recur thereafter. The initial impression of breast cancer was changed right away to a definitive diagnosis of macrocyst.
The macrocyst, although a cyst, did not feel cystic on palpation. It felt hard because it was a tense cyst filled with fluid.
If a needle evaluation was not done and an operation (open biopsy) was performed, the patient would end up with an operation which would be considered unnecessary. The needle evaluation performed had avoided the operation, scar, pain, expenses, and other problems that would accompany the operation if it were instituted.
If a mammography were done, it would just show the shadow of the lump. No definite diagnosis could be given. The patient would be spending Php 1000.00 and be exposed to radiation.
If an ultrasound were done, it should show a cystic lump. A needle aspiration would still have to be done. Also, it would take sometime before a definitive diagnosis and treatment could be gotten. With needle evaluation, the diagnosis and treatment were completed soon after the physical examination.
OPEN BIOPSY
Open biopsy can either be section or excision biopsy. It may be done through a paraffin or a frozen technique.
Open biopsy is warranted if a needle biopsy is inconclusive.
For all breast masses, it is recommended that a needle evaluation be tried first before considering an open biopsy. The needle evaluation may be sufficient to establish a definitive diagnosis that an open biopsy is not necessary anymore.
Another disadvantage of needle evaluation over open biopsy beside avoiding the scar in the latter, is in the degree of tumor or cancer seeding, if the lump turns out to be cancer. Needle biopsy definitely is associated with less cancer seeding than open biopsy. Needle biopsy is a biopsy procedure of choice if a patient with breast cancer wants only a wide excision and not total mastectomy. Chances of local recurrence with a wide excision after an open biopsy are expected to be higher than those after needle biopsy.
MAMMOGRAPHY
Mammography is usually not needed in patients wit a palpable breast mass.
It is used in screening patients with no palpable breast lump for possible cancer. However, with its small yield, its high cost, the radiation exposure, and the high incidence of false positive and false negative readings, mammography is not cost-effective and therefore, should not be heavily depended on as a diagnostic screening procedure. Combined breast self-examination and breast specialist examination is more cost-effective in the screening of breast cancer.
ULTRASOUND
The needle evaluation has made the use of ultrasound in patients with a breast mass obsolete. The determination of solid versus cystic in a breast mass by ultrasound can be done using the needle right after the physical examination and with less cost.
SOME CLINICAL ISSUES IN MAMMOPATHOLOGY
- All females have a risk of developing breast cancer during their lifetime. The risk is not confined to females with a family history of breast cancer. So, all females should be on the look-out.
- The phrase “fibrocystic diseases” should be discarded. “Fibrocystic changes” is a better term. For laymen, a humpy breast is easier to understand and using this terminology can facilitate allayance of fear.
- Fibrocystic changes do not lead to cancer. Fibrocystic changes are physiologic changes. Operations done on the breast for fibrocystic changes are unnecessary.
- Breast pain without a breast lump is mastalgia. This is analogous to the dysmenorrhea in the uterus. Mastalgia, just like dysmenorrhea, is due to some hormonal mechanism the details of which are not known.
- Mastalgia is often wrongly associated by laymen with breast cancer. This wrong association and fear of cancer can aggravate the mastalgia. The approach to patient with mastalgia is first, to tell them they have no lump, therefore no cancer. Second, to explain the cause of mastalgia (see no.4). Third, to correct the mistaken association of pain and cancer. Lastly, to give a standby prescription of analgesics. With an adequate advice and explanation, the analgesics may not be needed at all.
- The presence of fibroadenoma (established clinically and by needle evaluation) does not constitute an absolute indication for excision. Operation is indicated when the fibroadenoma is big (at least 3 cm) and, in cases of smaller fibroadenomas, when patients wish to, despite the proper explanation by the physician. If no operation is decided upon, monitoring should be done. The rationale for monitoring with option to operate is that more fibroadenomas can occur in the future and if they do occur, they can be excised in one sitting. This has the advantage of less scar and less expense.
Outline of Clinical Breast Evaluation by the Primary Health Care Physician
Patient
without breast complaint (breast check)
with breast complaint – pain, lump, nipple discharge
|
|
|
Physician
|
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|
COMPLETE BREAST EXAMINATION
|
|
|
————————————————————–
| | |
| | |
Definite Lump Humpy Breast No Lump
| Nodular Breast |
| | |
| | ——————–
| +/- Pain | |
| | | |
| | Pain Discharge
| | | |
| | | |
Cancer Fibrocystic Hormonal Intraductal Papilloma
Fibroadenoma Changes Cause Fibrocystic Changes
Macrocyst | | Cancer
Gatactocoele | | Others
Others | | |
| | | |
| | | |
| ——————– |
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Breast Specialist Advice (allay fear) Breast Specialist
Analgesics
Monitor (Self-Exam)
Check-up
Second opinion
(Breast Specialist)
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