EVALUATION OF BREAST SIGNS AND SYMPTOMS
A timely evaluation of the patient who presents with a breast complaint is important if for no other reason than to relieve patient anxiety. A systematic approach to evalu-ating a breast-related complaint will efficiently yield the proper diagnosis.
The two most common presenting complaints related to the breast are pain and concern about a mass. Gynecologistsshould be aware of the different etiologies of breast pain and be able to offer reassurance, follow-up, and potential treatment. One study has found that breast cancer was diagnosed in 6% of patients with breast complaints (most commonly a mass). Therefore, it is important that breast signs and symptoms be properly evaluated.
The patient interview is considered the single most impor-tant step in the initial evaluation of any disease process. In the case of complaints related to the breast, questions that will aid in deciding the next step include the location of complaints, duration of symptoms, how it was first discov-ered, presence or absence of nipple discharge, any changes in size, and association with menstrual cycle. In addition, theclinician should ask about the presence of risk factors that would increase the likelihood of malignancy (Box 31.1).
A complete breast exam should evaluate both breasts in a systematic fashion, both axillae, and the entire chest wall.
The best time to perform a breast exam is in the follicular phase of the menstrual cycle.
If the initial exam fails to yield a dominant mass, the options (based on the patient’s risk factors) include either performing a repeat exam in 3 months or referral to a spe-cialized breast care clinic.
· Personal history of breast cancer
· History of atypical hyperplasia (ductal or lobu-lar) on past biopsies
· Inherited genetic mutations
· First-degree relatives with breast or ovarian cancer diagnosed at an early age
· Early menarche (age >12 years)
· Late cessation of menses (age >55 years)
· No term pregnancies
· Late age at first live birth (>30)
· Never breastfed
· Alcohol consumption
· Recent oral contraceptive use
· Use of hormone therapy
· Personal history of endometrial, ovarian, or colon cancer
· Jewish heritage
After performing a complete history and physical exami-nation, a number of modalities can be used to help locate and characterize a breast mass.
Mammography is an x-ray technique used to study thebreast.
Mammography is able to detect lesions approximately 2 years before they become palpable (Fig. 31.3).
Mammography can be done either as a screening or a diag-nostic test. During a screening mammogram, the patient stands or sits in front of the x-ray machine. Two smooth plastic plates are placed around the breast and subsequently compressed to allow for complete visualization of the tis-sue. A standard four-image screening mammogram involvestwo craniocaudal and two mediolateral images. The images areevaluated for defects suspicious of cancer, microcalcifi-cations, distortion of the normal architecture, and any dis-crete nonpalpable lesion. Lobular carcinoma is more difficultto detect with routine screening mammography.
In collaboration with the National Cancer Institute and the FDA, the American College of Radiology has standardized the reporting of mammographic results through a system known as the Breast Imaging Reporting and Data System (BI-RADS®). This system helps clearly communicate the final assessment and recommendations to referring physicians (Table 31.1).
A diagnostic mammogram is done to supplement an abnor-mal screening mammogram. In women older than 40 yearsof age, mammography is often used as the first-line study in evaluating a patient presenting with a breast mass, even if not palpable on clinical breast examination. Spot com-pressions and magnified views are used to further localize any lesions, along with providing dimensions of the surrounding tissue (Fig. 31.4). The contralateral breastshould also be imaged in cases of a clinically apparent mass. If possible, the lymph nodes are also imaged to search for unrecog-nized abnormalities.
Ultrasonography has come to play an important role in the evaluation of breast lesions. It is useful in evaluating the breasts of young women and others with dense tissue, differentiating between a solid and cystic mass, and in guiding tissue core-needle biopsies. An anechoic defect found on ultrasound is consistent with a simple cyst and can be drained for symptomatic relief. In women youngerthan 40 years of age, ultrasonography is the recommended ini-tial modality to evaluate a breast mass.
Magnetic resonance imaging (MRI) can be a useful adjunct to diagnostic mammography. The use of MRI for screeningthe general population is limited by the cost of the exam, lack of standard examination technique, and inability to detect micro-calcifications. However, MRI is being used for early detec-tion of breast cancer in women at very high risk.
Fine-needle aspiration is useful in determining if apalpable lump is a simple cyst. The procedure is per-formed in the office with the aid of local anesthesia. The sus-pected mass is stabilized between two fingers of one hand and aspirated using a 22-gauge to 24-gauge nee-dle. Clear aspirated fluid does not need to undergo pathologic evaluation, and the patient may return for a clinical breast evaluation within 4 to 6 months if the mass disappears. If it reappears, the patient is managed with diagnostic mammography and ultrasonography. Bloody aspirated fluid should be evaluated pathologi-cally, and the patient should undergo diagnostic mam-mography and ultrasonography.
In a core-needle biopsy, a large needle (14 to 16 gauge) is used to obtain samples from larger, solid breast masses. Three to six samples of tissue approximately 2 cm long are obtained and are evaluated for abnormal cells in relation to the surrounding breast tissue taken in the sample.
If a breast mass is found through a clinical breast exami-nation, self-examination, or historically by a patient, the clinician must clearly document the finding and assign appropriate follow-up care. Figure 31.5 presents a practi-cal algorithm for the evaluation and follow-up of a patient with a breast mass.