Dr. Dorscher – Breast Exam Lecture 2 – March 1, 2010
1
Paget’s Disease
-Characteristics
¤Long standing eczematous appearing rash of nipple and areola complex, Itching, tenderness, burning, occ
bldy discharge, skin dimpling, peau d’orange
-Treatment: As eczema (high dose steroids 6-8 wks) then biopsy
In Situ Cancer
-LCIS-- lobar
¤From a terminal lobular apparatus
¤Diffuse throughout the breast
¤Non palpable
¤90-100% multicentricity
¤10-37% develop invasive carcinoma (bilateral)
-DCIS--ductal
¤Originates in ductal luminal cells
¤Invasive cancer develops in 30-50% over a 10 years-usually in same location as original biopsy
Breast Self Examination – derecommendation cuz doesn’t add years of life
Clinical Breast Examination
•No studies show it is helpful or not helpful
•Annual 21+ years
•Quality of breast exam is related to the amt of time spent on each breast
- visualize breast, palpate, check for nipple discharge
o Lump or contour change
o Skin tethering
o Nipple inversion
o Dilated vessels
o Ulceration
o Nipple scaling (Paget’s disease)
o Edema or Peau d’orange- Dermal edema, follicles have dimples, skin of orange
- Nature of Palpable Lesions
-Firmness, Irregularity of borders, size
-Focal Nodularity
-Fixation to skin or underlying muscle
-Location-quadrant/clock, distance from nipple
Method
When to use
Pros
Cons
Mammography1
Asymptomatic, >35
Screening tool, accessible.
Controversy – when to start
screening, micro& stop, annual, false positives
calcifications
-quality related to
technician’s experience,
exposure, need to get tail of
breast on med-lat view,
positioning, x-ray exospure
Ultrasound
Women < 35yo, cystic
Not a screening tool
structures.
-Diagnosis with dense
breasts
-Young women & teens
Breast implants and ruptures
MRI
Scar, implants, multiple
-no standards yet
Highly sensitive to small
lesions, borderline
-Time consuming
abnormalities
-Expensive
-Used effectively in dense
-Contrast agent (allergy or
breasts
preg)
-Evaluate the extent of breast
-Tolerate any claustrophobia
cancer
-MRI can be non-specific-2X
-Can help determine type of
bx
surgery needed
-May detect breast cancer
-Minimally invasive breast
recurrences and residual tumors biopsy techniques need to be
-Locate primary tumor in
further developed
women with axillary lymph
-Cannot image calcifications
nodes
-MRI centers cannot always
-Useful in screening women at
produce results cited in
high risk for breast cancer
research studies
-Equivocal mammogram
2
Dr. Dorscher – Breast Exam Lecture 2 – March 1, 2010
Scintography
>1cm axilla asses., predict
drug resis.
PET
Axilla assessment, scar,
multifocal
1.
-Uses Tc99m Sestamibi
which concentrates in the
mitochondria
-Differences in uptake
between normal and
abnormal cells
-Best when used for palpable
lesions
-May provide more
functional information (drug
resistance)
-Metabolic activity
-Vascularization
-Oxygen consumption
-Tumor receptor sites
-Inability to lie prone
-Extremely large breasts
-Has no value as a screening
test
expensive
Use Breast Imaging Reporting and Data System (BI-RADS)
a. Category 0-6
b. Discuss results
c. Assess risk
d. Establish plan: Additional films, Routine interval,
Short term F/U, Biopsy
e. can use spot compression to visualize lesion better
Obtaining Tissue/Fluid
method
Fine Needle Aspiration (FNA)
Pro
Use on Palpable lesion: Cystic structures
And Solid masses
-As long as not bldy & doesn’t recur &
goes away completely = benign
-Quick, Painless, Inexpensive, No
incision
-Minimal chance of infection or
bruising
Core Needle Biopsy
Excisional Biopsy
Incisional Biopsy
-Quick, Painless, Inexpensive, Small
incision, Minimal chance of
bruising/infection
-Can distinguish in situ vs. invasive
-May avoid surgery
-If palpable> office procedure
-Histologic assessment: ER, PR,
Her2Neu
-Accurate
-Provide complete information about
tumor
-Rare false negative
-May be treatment
Use to Dx extent of cancer prechemo/radiation
Con
-Malignant cells are loosely cohesive
-lose architecture
-Less accurate
-Palpable lesion
-In situ vs. invasive – loss arch of
sample
-Cytotechnologist, cytospin and slides
-Can’t use with implants or lesions near
chest wall  pneumothorax
-Slightly less accurate
-May not provide complete description
of the tumor
-If not palpable> hospital and possibly
may still need surgery
-Can not be used with breast implants
or coumadin therapy or near chest wall
-Expensive
-Invasive/painful
-Time to heal
-Greater chance of infection/bruising
-Change feel/look of the breast
-Hospital procedure
Need more Tx – surgery or chemo, etc.
Localization of Nonpalpable Lesions
-Needle Localization
-A wire is placed by radiologist for the surgeon to know what section of breast is abnormal
-Can remove the tissue with the needle tip intact
-Stereotactic Biopsy: Use MRI to get sample, or US