Breast Disease: A Gynecologic Perspective

SELF-EXAMINATION

Many breast cancers are detected by women themselves, and monthly breast self-examination should be promoted. Written information should be supplemented by practical training. There is no solid evidence that breast self-examination reduces breast cancer mortality, but it is reasonable to assume that a woman’s increased awareness of her own breasts may lead to an earlier diagnosis.

MAMMOGRAPHY

Radiologic examination of the breast is an important component of the screening process carried out in asymptomatic women and should be performed in conjunction with a thorough physical examination. Densities and fine calcifications constitute suspicious findings, and clinically inapparent malignancies less than 1 cm in diameter may be detected.

Mammograms of high quality can be made with about 0.3 cGy or less of radiation, so there is little, if any, risk for this technique causing breast cancer.

In the Breast Cancer Detection Demonstration Project carried out by the American Cancer Society and the National Cancer Institute, 89% of 3557 cancers were correctly identified by mammography, 42% of which were not clinically detectable.

The American Cancer Society recommends annual mammograms starting at age 40 years.

ULTRASONOGRAPHY

Ultrasonography can differentiate cystic from solid masses and may demonstrate solid tissue that is potentially malignant within or adjacent to a cyst. It is also useful for imaging palpable focal masses in women younger than 30 years, reducing the need for x-ray studies in this population.

MAGNETIC RESONANCE IMAGING

Magnetic resonance imaging is a useful adjunct in breast imaging. Reported advantages include improved staging and treatment planning, enhanced evaluation of the augmented breast, better detection of recurrences, and possibly improved screening of high-risk women.

FINE-NEEDLE BIOPSY

Fine-needle aspiration biopsy of the palpably suspicious lump in the breast can be performed in the outpatient clinic. Smears are prepared from the aspirate to allow cytologic evaluation. In experienced hands, the test is both sensitive and specific. A negative result should never be accepted as definitive when there are clinical or mammographic indications that the lesion may be malignant. In the presence of a palpable lump, fine-needle aspiration cytology should make it possible to diagnose breast cancer without formal excisional biopsy in about 90% of cases, allowing the definitive management of the patient to be discussed preoperatively.

OPEN BREAST BIOPSY

Small masses may undergo excisional biopsy, whereas large masses should undergo incisional biopsy, or occasionally core-cutting needle biopsy. Absolute indications for open breast biopsy are listed in Box 29-1. Relative indications for breast biopsy include those women with a clinically benign mass but a positive family or personal history of breast cancer, a history of atypical hyperplasia, or an equivocal finding on mammography or cytology.

Open breast biopsy may be performed as an outpatient procedure under local anesthesia or as an inpatient procedure under general anesthesia. Women with large breasts who have small, deeply situated lesions are not good candidates for outpatient biopsies, nor are those who have a nonpalpable lesion detected by mammography.

FIBROCYSTIC CHANGES

The earlier term fibrocystic disease has little clinical value, and the term was abandoned by the College of American Pathologists in 1985. Lesions formerly grouped together under the designation of fibrocystic disease represent a pathologically heterogeneous group of diseases that can be divided into three separate histologic categories: nonproliferative lesions, proliferative lesions (hyperplasia) without atypia, and atypical hyperplasias.

HYPERPLASIA

Hyperplasia is the most common benign breast disorder and is present in about 50% of women. Histologically, the hyperplastic changes may involve any or all of the breast tissues (lobular epithelium, ductal epithelium, and connective tissue). When the hyperplastic changes are associated with cellular atypia, there is an increased risk for subsequent malignant transformation.

It is postulated that the hyperplastic changes are caused by a relative or absolute decrease in production of progesterone or an increase in the amount of estrogen. Estrogen promotes the growth of mammary ducts and the periductal stroma, whereas progesterone is responsible for the development of lobular and alveolar structures. Patients with hyperplasia improve dramatically during pregnancy and lactation because of the large amount of progesterone produced by the corpus luteum and placenta and the increased production of estriol, which blocks the hyperplastic changes produced by estradiol and estrone.