The occurrence of breast changes, benign or malignant, are some of the most emotionally upsetting health problems confronting women. Breast cancer is the most common cancer in women (Weaver, 2009); it accounts for nearly one of every three cancers diagnosed. The probability of developing breast cancer increases with age. Estimates are that one in eight women in the United States will develop breast cancer during her life. If the cancer is detected early, there is a 97% 5-year survival rate. Breast cancer risk increases if a woman’s mother, sister, or daughter had breast cancer, especially if the cancer developed before menopause. Early menarche (before 12 years of age) and a late natural menopause (after 50 years of age) are associated with a slightly increased risk for developing breast cancer. Further, a woman who has cancer in one breast is at increased risk for cancer in the other breast (American Cancer Society, 2009). Heightened public awareness, an increased number of women practicing self-examination, and early detection of breast masses by mammography have started to slow the annual increase in breast cancer mortality.

The breasts are bilateral mammary glands that lie on the pectoralis major fascia of the anterior chest wall. They are surrounded by a layer of fat and are encased in an envelope of skin. The breasts extend from the second to the sixth rib and horizontally from the lateral edge of the sternum to the anterior axillary line. The largest part of the mammary gland rests on the connective tissue of the pectoralis major muscle and laterally on the serratus anterior (upper outer quadrant of the breast), with a normal globular contour occurring as a result of fascial support (Cooper’s ligaments). An elongation of mammary tissue normally extends laterally on the pectoralis major toward the axilla and is known as the tail of Spence (Figure 8-1).

Three major arterial systems (Figure 8-2) supply the mammary glands with blood. The two main sources are branches of the internal mammary and lateral branches of the anterior aortic intercostal arteries, all of which form an extensive network of anastomoses over the breast. The third source is the pectoral branch, deriving from a branch of the axillary artery. The veins that mainly drain the breasts follow the course of the arteries. Superficial veins frequently dilate during pregnancy.

Lymph drainage generally follows the course of the vessels. Lymphatics drain into two main areas represented by the axillary nodes and the internal thoracic chain of nodes (Figure 8-3). The internal thoracic nodes are few, but are responsible for most lymph drainage from the inner half of the breast. Thus the lymph system can also be a channel for the spread of malignant disease from the breast to associated areas of the chest wall or to the axilla.

Fibrocystic change in the breast is an all-encompassing term used to describe many different breast changes. Examples of benign lesions that are generally considered when fibrocystic changes are discussed are multiple lesions of fibrous disease, intraductal papillomas, cysts, and solid masses, such as fibroadenomas (Table 8-1). These changes affect almost all women at some time in their lives. Frequently pain is present, which calls attention to the problem. Pain, fluctuations in size, and multiple lesions are common features that help differentiate these generally benign lesions from cancer.

Breast cancer affects primarily women, although it can occur in the mammary gland of men. Until it can be prevented, early detection is the best hope for cure. All women should practice monthly self-examination to detect palpable lesions, and they should immediately report any changes or masses to a physician. External physical changes, such as dimpling of the skin, can also indicate the presence of a benign or malignant pathologic process. The older the patient, the more likely it is that a mass is malignant. The most common form of breast cancer is infiltrating ductal carcinoma (Table 8-2).

The cause of breast cancer remains unknown. Many factors, including environmental, dietary (National Cancer Institute, 2007), and familial influences, have been suggested as contributors to its development (Table 8-3). The belief that breast cancer spreads by direct extension from its initial site in the breast to adjacent lymph nodes may not always be correct. Breast cancer may be a systemic condition at the time of diagnosis (History box). Distant metastases may have already occurred without adjacent lymph node involvement at the time of its palpable detection. This could explain why radical breast surgery of the past, which involved removal of the affected breast and all axillary and thoracic lymph nodes, did not greatly lower mortality. Survival from breast cancer is best when detected early, reducing axillary lymph node involvement and improving long-term survival. Tumor size can usually be correlated with involvement of lymph nodes. The larger a tumor is, the more likely it is that lymph nodes are involved.

Less radical surgery is the treatment of choice today. Surgical excision of the tumor, the use of radiation therapy alone, or a combination of surgery, chemotherapy, and radiation therapy are current treatment recommendations. The use of adjuvant chemotherapy is particularly recommended for premenopausal women with axillary-node metastasis. Studies show that similar therapy can benefit node-negative breast cancer patients. New studies and new therapeutic options are continually being developed and tested. Clinical use of accelerated partial breast irradiation (APBI) is the subject of ongoing clinical trials. In APBI the radiation is focused on the area of greatest risk for tumor recurrence, the lumpectomy site, instead of whole breast irradiation (WBI). Such focused radiation treatment therapies reduce the traditional 6-week radiation treatment plan to 1 week (Fearmonti et al, 2007).

Minimally invasive cryoablation technology to freeze and destroy core biopsy–proven fibroadenomas has been approved by the U.S. Food and Drug Administration (FDA) and is now performed safely in an office setting (Bland et al, 2009). Another breast surgery alternative is focused ultrasound (FUS) with magnetic resonance guidance (MRgFUS), which allows for imaging and tissue temperature monitoring while controlling the FUS beam direction during ablation of breast lesions (Bland et al, 2009).

Imaging methodologies, such as mammography and ultrasonography, have helped to detect breast masses too small for clinical detection (Hulvat et al, 2009). The American Cancer Society recommends clinical breast exams by a physician every 3 years for women ages 20 to 39 years and annual clinical breast exams and mammograms for women 40 and older (Table 8-4). The American College of Physicians recommends that women who are not at high risk for breast cancer should have regular mammograms starting at age 50. High-risk women, such as those who have a family history of breast cancer or who have detected a lump in the breast, should start annual mammograms at age 40 (Zuckerman, 2007).

The most common screening mechanism for asymptomatic women is x-ray (film-screen) mammography (Figure 8-4). In mammography, the entire breast is visualized as x-ray beams are directed in several planes through it. Mammograms detect abnormal-appearing densities, irregular or spiculated margins, microcalcifications, and clusters of calcium deposits that are clinically nonpalpable. These masses may be as small as 1 cm in diameter (Mulholland et al, 2006). Often, previous mammograms are used for comparison. Screening mammography has led to identification of more nonpalpable breast masses. The accuracy of mammography depends on careful x-ray technique and breast size, structure, and density. Radiation dosage varies with individuals and techniques. As a result of improved radiologic techniques, radiation exposure in a mammogram is very low. The benefits of this screening mechanism far outweigh the minute risks of radiation exposure. Advances in computer-assisted detection allow the computer to analyze the mammogram, placing asterisks and triangles on small potential problem areas, which a radiologist then reviews. If screening mammography reveals a suspicious area, the patient is asked to return for diagnostic mammography (explained in the following paragraphs).

Digital mammography takes an electronic image of the breast and stores it directly in a computer. Digital mammography uses less radiation than film mammography and improves image storage and transmission, as images are stored and sent electronically. Radiologists also can use software to interpret digital mammograms. One obstacle to greater use of digital mammography is its cost, currently about 1.5 to 4 times more than film systems. Digital screening mammograms are more accurate than film screening mammograms, with a 70% detection rate compared with 55% for film screens. Women most likely to benefit from digital screening are those younger than 50 with dense breast tissue and who are premenopausal or perimenopausal (Hulvat et al, 2009).

When there is a palpable mass or other abnormality identified on screening mammography, a diagnostic imaging evaluation is done (Mikula, 2008). Additional diagnostic mammographic views are obtained, and the radiologist assigns a BI-RADS (Breast Imaging Reporting and Data System) score (Box 8-1). An ultrasound may then be ordered.

Magnetic resonance imaging (MRI) is another technique used as an adjunct to mammography in the detection of breast lesions. Breast MRI can image dense breast tissue, which shows poorly with conventional mammography. There is interest in the use of MRI to improve selection for breast-conserving therapy (BCT). In 2007 the American Cancer Society recommended that MRI be used for women at high risk. Such women include those who have known breast cancer–associated BRCA1 or BRCA2 gene mutations, have a first-degree relative with a BRCA1 or BRCA2 gene mutation, have a lifetime risk of breast cancer of 20% to 25% or greater according to risk assessment tools, had radiation therapy to the chest between 10 and 30 years of age, or have certain rare syndromes. The 2008 study by Martinez-Cecilia found that preoperative MRI improved tumor staging and changed the surgical approach for 13% of study patients; MRI discovered an additional malignant lesion in 8% of patients, and showed a tumor larger than originally believed in 16 patients, altering the planned surgery.

Molecular breast imaging (MBI) involves injection of a short-lived radiotracer, which is absorbed by breast tissue and preferentially so by breast tumors. MBI is especially useful in detecting breast cancer in women with dense breasts and who are at higher risk of developing the disease. This new technique has shown good promise as a helpful adjunct to screening mammography (U.S. Department of Health and Human Services, 2008).

Positron emission tomography (PET) scans with the glucose analog 2 are also being used for breast cancer detection. This scan is about 88% accurate for large breast tumors. For lesions less than 1 cm, the sensitivity of PET is 57% (Hulvat et al, 2009).

DNA-based genetic testing for BRCA1 and BRCA2 is not reommended for women without family histories that suggest risk for these gene mutations. A recent meta-analysis estimated that the lifetime risk for breast cancer was 47% to 66% in carriers of BRCA1 and 40% to 57% in carriers of BRCA2. Other studies have shown even higher estimates. Managing breast cancer risk for women with these mutations includes frequent screening and prophylactic surgeries (Nelson, 2009).

In some instances, such as when a lesion previously detected by mammogram is too small to palpate, mammograms are repeated immediately before surgery. The lesion is localized by the insertion of a needle or a wire within a needle (the procedure is often referred to as “needle” or “wire” localization). The wire is placed within the suspect area, and the distal end is left on the outside of the skin. The needle may be left in place or removed after insertion of the wire (Figure 8-5). The needle or wire is then taped in place, and the patient sent to the OR for surgical biopsy. Wire localization and surgical biopsy occur on the same day. After biopsy, the specimen is sent to the radiology department for mammographic validation of correct surgical excision of the questionable breast tissue. The tissue is then sent for pathologic examination.

Once a mass is identified, the physician has multiple techniques to establish a diagnosis. During a fine needle aspiration biopsy (FNAB), the physician anesthetizes a small area of the breast with lidocaine. A 22- or 25-gauge needle attached to a 20-ml syringe is inserted into the mass, and a small amount of the contents is aspirated. Cytologic examination of the aspirate can assist in microscopic evaluation of the mass. FNAB yields greater diagnostic accuracy if the physician has been thoroughly trained in the technique. In a review of 31,340 procedures, FNAB sensitivity ranged from 65% to 98%. False-positive rates were less than 1%. As diagnosis of malignancy by FNAB is extremely reliable, treatment options can then be discussed with the patient and definitive surgery performed without the need for a surgical biopsy (Mulholland et al, 2006).

Advances in instrumentation now allow for simultaneous biopsy and removal of mammographic densities that are up to 20 mm in size using digital stereotactic imaging and minimally invasive instruments to locate and remove tissue for diagnosis. The patient is assessed preoperatively for neck or back problems. In addition, the patient should not be receiving anticoagulant therapy. Masses located near the patient’s areola, high in the axilla, or near the chest wall are not appropriate for this technique. The patient is placed on a specially designed table (Figure 8-6) in the prone position with the affected breast through the table’s 10-inch aperture to the work area below. The patient’s head is turned away from the physician. Padding is placed under bony prominences to improve comfort. When the suspicious area in the breast is located through stereotactic imaging, its coordinates are transferred to the table’s automated instrument. After preparing the skin with an antiseptic solution while the patient is administered a local anesthetic, the physician makes a small incision in the breast. The physician positions the disposable device to remove the identified tissue. Additional biopsies can be made if indicated, and coagulation can be used if necessary. A titanium vessel clip can be placed at the base of the biopsy specimen as a point of reference for future evaluations. A postoperative dressing is then applied to the area. The benefits to the patient include small incisions for cosmetic results, decreased disfigurement, shortened time between detection and diagnosis, and elimination of the need for more involved surgical intervention (Stephan, 2009).

Surgical treatment ranges from minimally invasive breast biopsy, lumpectomy, and wide excision of the tumor mass; to modified radical mastectomy involving the breast and axillary lymph nodes; to salpingo-oophorectomy (Research Highlight). The goal of surgery is removal of the cancerous mass with a margin of normal tissue and a good cosmetic result. When a specimen of breast tissue is sent to the laboratory, it is inked to mark the relationship between the tumor and the surgical margins of the excision. The pathologist evaluates these margins on all sides of the tumor for malignant cells. If a margin is positive, it indicates that malignant cells may remain in the breast. Additional surgery is usually required until the margins contain only normal tissue (Re-excision for Close Margins, 2008).

The choice of procedure depends on the size and site of the mass, the characteristics of the cells, the stage of the disease, and the patient’s choice. A breast cancer diagnosis is usually staged to measure the extent of the disease and to classify patients for possible treatment modalities (Figure 8-7). The TNM (T = tumor; N = node; M = metastasis) classification has been adopted as a mechanism to clinically stage this disease. Staging results are used in designing a specific treatment plan. Radiation therapy, chemotherapy, or hormonal therapy may be used with surgery or as alternative treatment methods. An intravenous (IV) access port may be surgically placed for later infusion of chemotherapeutic drugs, fluids, or nutrition as well as to withdraw blood and laboratory specimens (Ambulatory Surgery Considerations).

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