Good for Juniors

1. Presenter ;
Dr Mziray

2. Outlines
 History taking in breast diseases
 Physical examination
 Imaging
 Biopsies

3. Patient History
 The patient’s age
 Reproductive history
(age at menarche,age at menopause, and history of pregnancies, including age
at first full-term pregnancy.)
 History of breast biopsies, a hysterectomy and whether the ovaries were
removed, a recent history of pregnancy and lactation
 History of HRT or hormones for contraception.
 The family history of the breast and ovaries cancers.

4.  History of a mass, breast pain, nipple discharge and any skin changes
,duration and its relation to the menstrual cycle.
 Constitutional symptoms, bone pain, weight loss, respiratory changes

5. RISK FACTORS

6. Physical Examination
 Visual inspection :
Inspects the woman’s breast with her arms by her side (Fig. 17-18A), with her
arms straight up in the air (Fig. 17-18B), and with her hands on her hips
(with and without pectoral muscle contraction).
Look for :
Symmetry, size, and shape of the breast , as well as any evidence of edema
(peau d’orange), nipple or skin retraction, or erythema.
With the arms extended forward and in a sitting position, the woman leans
forward to accentuate any skin retraction.

7. Palpation : With the patient in the supine position (see Fig. 17-18C) the clinician
gently palpates the breasts, making certain to examine all quadrants of the
breast from the sternum laterally to the latissimus dorsi muscle and from the
clavicle inferiorly to the upper rectus sheath.
The examination is performed with the palmar aspects of the fingers, avoiding a
grasping or pinching motion. The breast may be cupped or molded in the
examiner’s hands to check for retraction.
 Breast mass size, shape, consistency, location and fixation to the skin or
underlying musculature.
 the presence of enlarged axillary lymph nodes, the supraclavicular and
infraclavicular spaces
 Any tenderness

10. BREAST IMAGING
 Mammography
 Primary imaging modality for screening asymptomatic women
 a screening mammogram uses mediolateral oblique and craniocaudal views.
 A diagnostic mammogram is indicated for further evaluation of abnormalities
identified on a screening mammogram or of clinical findings or symptoms.
 Magnification views are obtained to evaluate calcifications and compression
views are used to provide additional detail when a mass lesion is suspected.
 Mammographic sensitivity is limited by breast density, with as many as 10% to
15% of clinically evident breast cancers having no associated mammographic
abnormality.

11. Ultrasonography
 Useful in determining whether a lesion detected by mammography is
solid or cystic.
 Useful for discriminating lesions in the patient with dense breasts.
 Combined with mammography, increases the diagnostic yield

12. Magnetic Resonance Imaging
 Useful for identifying the primary tumor in the breast in patients who
present with axillary lymph node metastases without mammographic
evidence of a primary breast tumor (unknown primary).
 Useful for assessing the extent of the primary tumor, particularly in young
women with dense breast tissue
 Useful for evaluating invasive lobular cancers.
 Useful in determining eligibility for breast conservation

13. Magnetic Resonance Imaging
 Useful as a screening tool in patients with known BRCA gene mutations
and for detecting contralateral breast cancers in women diagnosed with a
unilateral cancer on mammography.
 The sensitivity of MRI for invasive cancer is higher than 90%, but is only
60% or less for DCIS.
 The specificity of MRI is only moderate, with significant overlap in the
appearance of benign and malignant lesions

14. Nonpalpable Mammographic Abnormalities
 Abnormalities that cannot be detected by physical examination i.e
clustered microcalcifications and areas of abnormal density (e.g., masses,
architectural distortions,asymmetries)
 Diagnostic biopsy is by image-guided core needle biopsy.

15. Nonpalpable Mammographic Abnormalities
 Breast Imaging Reporting and Data System (BI-RADS) is used to
categorize the degree of suspicion of malignancy
 To avoid unnecessary biopsies for low-suspicion mammographic findings
, probably benign lesions are designated BI-RADS -3 and are monitored
with a schedule of short-interval mammograms over a 2-year period.
 Biopsy is performed only for lesions that progress during follow-up

16. Non palpable Mammographic Abnormalities

17. Goals of Therapy and Determination of
Risk of Harm
 For stages I to III invasive breast cancer, the goals of treatment for patients
are curative.
 The volume (extent) of disease at diagnosis and the biologic
characteristics of an individual tumor affect the risk of cancer recurrence
 Biomarkers—ER, PR, and HER-2—affect prognosis and are also predictive
of response to different therapies.
 Tumors that have low levels of expression of estrogen and PR, as well as
tumors with high levels of HER-2, are associated with worse cancer
outcomes when compared with tumors that are strongly estrogen- and
PR-positive and HER-2–negative or normal.

18. Biopsy
 Fine-Needle Aspiration Biopsy
 Usefulness at differentiation of solid from cystic masses
 Does not discriminate between noninvasive and invasive breast cancers

19. Core Needle Biopsy
 Method of choice to sample non palpable, image-detected breast
abnormalities
 Preferred for the diagnosis of palpable lesions
 Can determine the histologic subtype, grade, and receptor status of a
malignant lesion

20. 
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