Introduction

Breast cancer remains one of main cancer in women. An early diagnosis and treatment have proved to improve the survival and outcome. The incidence is increasing annually although the mortality rate is decreasing due to the aggressive screening and treatment.

Triple assessment

Any patient with breast symptoms should be evaluated by a physician and referred immediately to a specialist if indicated. The assessment includes history taking and examination, breast imaging and pathological evaluation.

History taking should include the symptoms, risk factors and menstrual history

Risk factors for breast carcinoma

  • Early menarche
  • Late menopause
  • Strong family history
  • History of hormone ingestion or administration
  • Nulliparous
  • Lack of breastfeeding (less than 2 years)

Physical examination

A breast examination should comprise the breast and axillae. Any obvious lump or ill-defined mass should be documented with regards to its location, size, surface and fixation. Changes to the skin or nipple should be observed. Lymph nodes should be palpated in the axillae and determined the texture and fixation. Both breast and axillae should be examined.

Common features suggestive of a carcinoma include:

  • Ill-defined mass
  • Fixation of the skin or muscle
  • Peau d’orange
  • Tethering
  • Skin or nipple colour change
  • Bloody discharge

The examination should be continued to assess any possibility of metastases. This exam includes the abdomen for liver metastases, lungs for pleural effusion and any spine tenderness for spinal metastases.

Radiological assessment.

Mammogram (MMG)

  • Used mainly in a patient more than 35 years old. Younger women have a denser breast tissue which restricts the detection by MMG
  • It has a sensitivity up to 90% in elderly women
  • Two views are routinely assessed; cranio-caudal and mediolateral oblique view.

Ultrasound (USG)

  • Used for patients less than 35-year-old.
  • In patients over 35-year-old, its usage complements the MMG, especially in disputed cases.
  • It is useful in obtaining biopsy and aspiration of lesions.
  • It is also used to evaluate the axilla for any lymph nodes.

Magnetic resonance imaging (MRI)

  • Not routinely used to assess breast lesion. However, it may prove useful in cases with discrepancy findings between USG and MMG.
  • Can be used with reasonable accuracy in patients with breast augmentation.

Pathological evaluation or biopsy

FNAC: In small lesion, a fine needle aspiration (FNAC) is a reasonable choice. However, the assessment is usually limited to the presence of dysplastic or neoplastic cells. The pathologist would not be able to differentiate between in-situ or invasive carcinoma and unable to assess the breast receptors.

Tru cut/ core biopsy: This type of biopsy is performed on lesions with a reasonable size (in our centre, it is used mainly in lesions >2cm due to easy identification and palpation). It is much better than FNAC with more information can be provided. However, the procedures require local anaesthesia and a need for small incision before using the biopsy instrument. Patients should be explained with regards to the invasiveness of this procedure and caution is exercised at high risk for bleeding patients.

Surgical open biopsy: Commonly used in patients with impalpable lesion after the failure of a routine technique of biopsy. This method is used with the aid of a hook wire under stereotactic or USG visualisation. Once the hook wire is applied, the patients are immediately brought to operating theatre and a wide local excision is made inclusive the region of the wire.

Punch biopsy: This method is used mainly in cutaneous lesions, recurrence and Paget’s disease of the nipple.

Other important investigation

  • CT thorax, abdomen to assess for any distance metastases
  • Ultrasound abdomen and Chest X-ray can be used if not CT available

 

Management

Breast-conserving surgery (BCS)

  • Reserved for lesion less than 4cm.
  • It is important to determine a good margin to prevent recurrence.
  • A combination of BCS and radiotherapy has similar recurrence rate compared to mastectomy.
  • Usually offered to young patients if indicated.

Mastectomy

  • Indicated in lesions more than 4cm and multifocal diseases
  • It is also used in recurrence diseases or patients who want to avoid radiotherapy
  • Male breast cancer

Axillary surgery

Any suspicious axillary lesion should be investigated and evaluated. Surgery is performed if the axillary is involved. Methods of axillary assessment and surgery include:

  • Axillary node clearance; most common surgery performed by general surgeons in cases of axillae involvement. A minimum set of lymph nodes should be removed during the dissection. Dissection is divided into level 1,2 or 3 in relation to the pectoralis minor. However, this method is associated with increased risk of lymphoedema, stiffness and paraesthesia.
  • Axillary node sample; this technique involved removing a minimum of 4 lymph nodes at random. Not used anymore especially with the introduction of sentinel lymph nodes.
  • Sentinel lymph node biopsy; this method involved removing the first chain of the lymph nodes draining the involved breast. It is the idea that if the first lymph node is not involved, most likely the others are not. If the sentinel is involved, a complete axillary clearance is indicated. This technique requires a sufficient training hence only surgeons with adequate experience and certification is privileged to perform it.

Other adjuvant treatment

Chemotherapy

  • Indicated in positive lymph node patients and high-risk type of tumours
  • It can also be used to downstage inoperable cancers
  • Palliative chemotherapy in advanced stage diseases.

Hormonal therapy

  • Beneficial in positive breast receptors disease (ER, PR and HER2)
  • Tamoxifen or Aromatase inhibitor
  • Reduces risk of recurrence by suppressing and manipulating the hormone stimulation.
  • Side effects include premenopausal symptoms and osteoporosis
  • Increase risk of endometrium carcinoma in long-term use.

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