CLINICAL WORKUP OF A PATIENT WITH BREAST LUMP

The sensitivity of breast FNA on palpable mass is 80 to 90 % (mean 90%). The specificity and predictive value of breast FNA is close to 100% as false positive results are exceptionally rare. The efficacy of the test ranges from 84% to 99.5%.

In clinically palpable breast lumps, comments on axillary lymph nodes are 30 % erroneous as being either false positive or false negative.

IMPALPABLE BREAST TUMOUR

In impalpable mammographically detected breast lesions, Needle core biopsy is more accurate then stereotactically guided/ directed FNA. Large needle biopsy has a false negative rate of upto 20% .

Needle localisation in bi-planar view, (needle guided into the lesion) followed by biopsy may be ideal in such a situation. 11% of patient undergoing screening will require such a procedure.

SURGERY IN BBD

More often than not surgery is not recommended in BBD (including Fibroadenoma) Fibroadenoma tend to regress with time. More than 25% resolve within two years. Cant et al demonstrated a probability of 0,46 for resolution after 5 years. Sainsbury reported 32 % resolution at 2 years. In Oxford, over 90% patients are treated conservatively as compared top South Africa where only 21% patients are treated conservatively. This depends upon counseling, facilities and aptitude of surgeon.

SURGERY IN BREAST LUMP SHOULD BE DEFERRED IF:-

• 1. Size is less than 3cm.

  2. FNA is benign on two separate events.

  3. No abnormal mammographic (Mx) pattern.

  4. Absence of localised soft tissue density on Mx,

  5. Absence of localised soft tissue density which changes on successive Mx,

  6. Absence of localised soft tissue density with illdefined borders on Mx,

  7. Absence of localised focus of microcalcification with stellate distortion of stroma on Mx,

NEWER SURGICAL MODALITIES FOR BBD

Interstitial Laser Hyperthermia as described by Bina Ravi, Som and Ravi Kant looks like an interesting alternative, as it avoids scar.

INCIDENCE OF MALIGNANCY IN BBD:

Non proliferative benign breast diseases (e.g. Adenosis, Cysts, Duct ectasia, Fibroadenoma, Mastitis, Fibrosis, Mild hyperplasia, Metaplasia- apocrine or squamous) have no increased risk of developing malignancy.

Proliferative diseases like moderate hyperplasia, papilloma with fibroadenosis core has 1.9 relative risk of developing malignancy.

Atypical hyperplasia has a 4.4 relative risk of developing malignancy.

Proliferative disorders e.g. atypical hyperplasia associated with family history of breast cancer has a 11.0 relative risk of developing malignancy. Cystic disease of breast has 2.5 to 7.5 times risk of developing cancer. Incidence is nearly 8 times higher if Epitheliosis is present. The risk appears to be greater in younger women. Under the age 45, the risk is 6.8 as compared to 3.3 in women aged 40–49 years. 3.34 in 50-54 age group and 1.99 in women over 54 years of age. The risk is higher in first year after aspiration (8.07) but remains higher after even 5 years (3.08). The risk is irrespective of type and number of the cyst.

SURGERY IN BBD

Appropriate incision under direct vision or via a laparoscope from an areolar incision should be used and subdermal thinning should be avoided.

LACTATIONAL ABSCESS

Breast abscess – lactational as well as non lactational abscess do not need general anaesthesia and disfiguring scars any more. If skin overlying breast is normal than repeated USG guided aspirations coupled with broad spectrum antiobiotic will produce satisfactory result. If overlying breast is thinned or dead than a very small incision under cover of topical anaesthesia cream or spray will give a good result. The days of disfiguring surgery (under general anaesthesia) are over. Patients should be encouraged to continue breast feeding as this reduces engorgement and pain. Units or individuals unable or unwilling to carry out such atreatment should hand over these patients to those who are willing to provide this improved service. The age of open surgery for this condition should have vanished.

TREATMENT OF MASTALGIA

Patients need counseling regarding the concept of ANDI, proof of it being benign based on USG, FNA (Mammography being excluded from age less than 30 years).

The need of correct bra size is explained to the patients. It is interesting that only 19% of patients wear correct size of bra. The patients are advised to wear the bra at night as well.

Medications for Mastalgia

A decision is to be made as to whether the pain is cyclical, non-cyclical or even non-breast (referral from chest wall, muscles, neck shoulder, or Tietze’s syndrome can all present as breast pain).

Evening Primrose Oil = Gamma Linoleic Acid (response rate 30-70%); It is more useful in women over 40 years of age and has fewer side effects.

Danazol (GLA)– Gonadotrophin release inhibitor has higher response rate but side effects are also higher. Bromocriptine- a long acting dopamine agonist has response rate similar to GLA but with higher side effects. GESTRINOME has similar response rate to GLA with fewer side effects. Tamoxifen is also effective but side effects mount to 60% at 6 months.

There is no place for use of diuretics or antibiotics. Misc. drugs used are Naferalin, Diosmin, Ru kuai xiao, and phytoestrogens.

CURRENT IMAGING MODALITIES

• 1. The current imaging modalities are Mammoscintigraphy by 99mTc SESTAMIBI Scanning, 99mTc tetrafosmin scanning;

  2. Lymphoscintigraphy and gamma probe for axilla

  3. FDG/ FES- PET (Positron Emission Tomography).

Mammography tends to underestimate tumour size, multifocality, & skips 5-15% of cancer. USG is of limited value in detection of tumour less than 1 cm, multifocality and intraductal disease. Mammography and USG are of limited value in assessment of response to chemotherapy and irradiated conserved breast.

• 1. Magnetic resonance (Gadolinium enhanced RODEO= rotating delivery of excitation off-resonance sequence) Magnetic resonance (Gadolinium enhanced RODEO = rotating delivery of excitation off-resonance sequence) or MR-CE-RODEO has shown sensitivity of 95%. MR is a method of choice in diagnosing muticentricity, as compared to USG and Mammography. MR does not underestimate tumor size in contrast to mammography and USG. MR imaging picked up 84% multifocal disease as compared to 44% by mammography, and even less by USG. MR imaging has a role in diagnosing axillary lymph nodes, as it enhances lymph nodes larger than five mm. MR-CE-RODEO is investigation of choice today in dense breast tissue, which is significantly depicted by mammo-graphy. This was proven in a series of 61 patients with breast cancer. MR-CE-RODEO is investigation of choice in diagnosing local recurrence in a conserved breast. MR-CE-RODEO is investigation of choice in assessment of response to neo-adjuvant chemotherapy, thus allowing patients to be selected for breast conservative therapy. MR accurately the pathological determination of residual disease in 97% of cases. MR is also presently investigation of choice in evaluating response to Interstitial Laser Photocoagulation of Breast cancer.

MR RODEO is more accurate than mammography and USG in local staging of breast cancer, diagnosis of local recurrence, assessment of response to neo-adjuvant chemotherapy and evaluation of silicon implants.

• 1. Mammoscintigraphy by 99mTc SESTAMIBI Scanning, 99mTc tetrafosmin scanning