Breast Surgery

EVALUATION OF PALPABLE BREAST DISEASE

AND THE ABNORMAL MAMMOGRAM

RICHARD E COOPER MD

APPROXIMATELY 180,000 WOMEN WERE DIAGNOSED WITH BREAST CANCER LAST YEAR IN THE US. MOST OF THESE CASES PRESENTED AS A PALPABLE MASS USUALLY FOUND FIRST BY THE PATIENT. THE EVALUATING PHYSICIAN MUST TAKE AN ACCURATE AND EFFICIENT APPROACH TO BOTH PALPABLE AND NONPALPABLE (MAMMOGRAPHIC ABNORMALITY) BREAST DISEASE. ONLY 15% OF BIOPSIES WILL BE MALIGNANT, BUT WORKUP OF BREAST DISEASE INVOLVES A MULTIMODALITY APPROACH. THE GOAL OF THIS SESSION IS TO GIVE THE PRIMARY CARE PHYSICIAN THE TOOLS AND PROTOCOL FOR EVALUATING BREAST DISEASE AND FOR KNOWING WHEN TO CONSULT A SURGEON AS WELL AS WHAT THE PATIENT WILL EXPERIENCE DURING THIS WORKUP.

DIAGNOSIS OF THE PALPABLE MASS

A THOROUGH HISTORY AND PHYSICAL EXAMINATION ARE REQUIRED IN THE EVALUATION OF ANY BREAST LUMP. AGE, FAMILY HISTORY, PERSONAL HISTORY OF BREAST CARCINOMA AND CHANGES IN PHYSICAL CHARACTERISTICS SUCH AS SIZE, PAIN ETC. ARE ALL IMPORTANT CONSIDERATIONS. PAIN ASSOCIATED WITH MASS SHOULD NOT EXCLUDE THE DIAGNOSIS OF BREAST CANCER. PHYSICAL FINDINGS SUGGESTIVE OF CANCER INCLUDE HARD IRREGULAR MASS WITH FIXATION OR SKIN DIMPLING, NIPPLE RETRACTION AND BLOODY NIPPLE DISCHARGE.

PALPABLE BREAST LESIONS MANDATE THE NEED FOR BILATERAL SCREENING MAMMOGRAM TO ASSESS CHARACTERISTICS OF THE MASS AND TO LOOK FOR OTHER MULTIFOCAL LESIONS IN THE IPSILATERAL OR SYNCHRONOUS LESIONS IN THE CONTRALATERAL BREAST. THE ABSENCE OF A MAMMOGRAPHIC ABNORMALITY WITH A PALBABLE MASS SHOULD NOT ALTER ONE’S EVALUATION OF A LESION OF THE BREAST. MAMMOGRAMS ARE NORMAL IN 10-20% OF CASES WITH FRANK CARCINOMA. THEREFORE A NORMAL MAMMOGRAM DOES NOT EXCLUDE THE DIAGNOSIS OF MALIGNANCY.

PALPABLE LESIONS SHOULD BE ASPIRATED. FINE NEEDLE ASPIRATION IS SAFE AND SIMPLE AND ACCOMPLISHES TWO THINGS. ASPIRATION OF A PALPABLE MASS THAT IS CYSTIC IS BOTH DIAGNOSTIC AND THERAPEUTIC. TYPICAL FIBROCYSTIC FLUID IS NONBLOODY AND RANGES FROM SEROUS TO TURBID. CYTOLOGY OF THIS FLUID IS EXTREMELY LOW YIELD. THE INDICATIONS FOR EXCISIONAL BIOPSY FOLLOWING ASPIRATION OF A CYST INCLUDES BLOODY ASPIRATE, RESIDUAL MASS AND REACCUMULATION AFTER A SHORT INTERVAL. CLOSE FOLLOWUP AND REEXAMINATION IS REQUIRED AFTER CYST ASPIRATION.

FINE NEEDLE ASPIRATION OF A SOLID MASS IS ALSO SAFE AND ACCURATE. FALSE POSITIVE RATES OF LESS THAN 2% AND FALSE NEGATIVE RATES APPROACH 10% WITH AN OVERALL ACCURACY OVER 95%. THE DIAGNOSIS OF CANCER BY FINE NEEDLE ASPIRATION AFFORDS THE ADVANTAGE OF BEING ABLE TO DISCUSS TREATMENT OPTIONS PRIOR TO EXCISIONAL BIOPSY. THUS THE DEFINITIVE SURGICAL PROCEDURE COULD BE PRECEDED BY EXCISIONAL BIOPSY WITH FROZEN SECTION AS CONFIRMATION. SUSPICIOUS PATHOLOGY OR PATHOLOGY WITH SIGNIFICANT ATYPIA SUGGESTS THE NEED FOR EXCISIONAL BIOPSY. SPARSELY CELLULAR ASPIRATES USUALLY POINT TO BENIGN DISEASE. THE EXCISION OF THESE MASSES VERSUS OBSERVATION IS CONTROVERSIAL AND DEPENDS ON THE HORMONAL STATUS OF THE PATIENT. POSTMENOPAUSAL PATIENTS WITH THIS FINE NEEDLE ASPIRATION CYTOLOGY MUST BE BIOPSIED SINCE MASSES IN THE POSTMENOPAUSAL PATIENT ARE RARELY DUE TO FIBROCYSTIC CHANGES.

EXCISIONAL BIOPSY IS DONE AS AN OUTPATIENT PROCEDURE WITH LOCAL ANESTHESIA AND INTRAVENOUS SEDATION. A TWO STEP PROCEDURE ALLOWS FOR DISCUSSION OF TREATMENT OPTIONS (LUMPECTOMY, AXILLARY NODE DISSECTION AND RADIATION THERAPY VS. MODIFIED RADICAL MASTECTOMY VS. MRM AND RECONSTRUCTION). ONE STEP BIOPSY WITH FROZEN SECTION AND DEFINITIVE PROCEDURE IS APPROPRIATE IN THOSE PATIENTS WITH POSITIVE FINE NEEDLE ASPIRATES OR HIGHLY SUSPICIOUS LESIONS. THE BIOPSY SHOULD BE PLANNED AS IF THE LUMP IS CANCER. THE PLACEMENT OF THE INCISION SHOULD BE SUCH THAT IT WOULD BE INCLUDED IN THE MASTECTOMY SITE AND 1-2 CM MARGINS OBTAINED TO PLAN BIOPSY AS THE LUMPECTOMY SPECIMEN OBVIATING THE NEED FOR REEXCISION.

EVALUATION OF THE PALPABLE BREAST LUMP INCLUDES THE HISTORY AND PHYSICAL , MAMMOGRAPHY , FINE NEEDLE ASPIRATION CYTOLOGY AND EXCISIONAL BIOPSY WHICH IS WELL PLANNED AND EXPERTLY EXECUTED TO SERVE EITHER AS THE LUMPECTOMY SPECIMEN OR TO FALL WITHIN THE BOUNDARIES OF A MASTECTOMY WOUND. ULTRASOUND HAS LITTLE ROLE IN THE EVALUATION OF PALPABLE BREAST MASSES.

EVALUATION OF THE PATIENT WITH AN ABNORMAL SCREENING MAMMOGRAM

MAMMOGRAMS ARE THE SECOND MOST COMMON RADIOGRAPHIC STUDY BEHIND THE CHEST XRAY. THEREFORE THERE HAS BEEN A GREAT INCREASE IN NONPALBABLE MAMMOGRAPHIC ABNORMALITIES AS THE PRESENTING COMPLAINT. TWO PERCENT OF SCREENING MAMMOGRAMS WILL BE SUSPICIOUS ENOUGH TO WARRANT BIOPSY. OF THESE CLOSE TO 90% ARE BENIGN LEAVING 10-15% MALIGNANT. THE AMERICAN COLLEGE OF RADIOLOGY HAS ATTEMPTED TO STANDARDIZE THE REPORTING OF MAMMOGRAPHIC FINDINGS TO SEVERAL CATEGORIES. THEY ARE:

1. NEGATIVE

2. BENIGN

3. PROBABLY BENIGN- SHORT TERM FOLLOW-UP RECOMMENDED

4. SUSPICIOUS- SURGICAL CONSULT RECOMMENDED

5. HIGHLY SUSPICIOUS

IN ATTEMPTS TO DECREASE THE NUMBER OF BIOPSIES FOR BENIGN DISEASE IN CATEGORY THREE, BUT STILL DETECT AS MANY MALIGNANCIES EARLY IN THEIR COURSE, STUDIES HAVE BEEN DESIGNED TO ASSESS EFFECTIVENESS AND RISKS ASSOCIATED WITH CLOSE MAMMOGRAPHIC FOLLOW-UP. BIOPSY IS REQUIRED FOR ANY LESION THAT CHANGES DURING THE STUDY PERIOD. AGAIN, THE PATIENT’S PERSONAL AND FAMILY HISTORY MUST BE CONSIDERED WHEN DECIDING ON BIOPSY OR OBSERVATION. PROSPECTIVE STUDIES OF OVER 3500 PATIENTS FOLLOWED FOR PROBABLE BENIGN DISEASE SHOWED 0.5 TO 1.1% MALIGNANCY RATES. MOST OF THESE CAME TO BIOPSY BASED ON MAMMOGRAPHIC CHANGES. THESE REPORTS SUGGEST THE SAFETY OF CLOSE FOLLOW-UP AND BIOPSY WHICH MINIMIZES MORBIDITY. EMOTIONAL, FINANCIAL AND LEGAL ISSUES ALSO SURROUND THE CHOICE OF EARLY BIOPSY VS. OBSERVATION AND SHORT TERM FOLLOW-UP.

ONCE THE DECISION HAS BEEN MADE TO PERFORM A BIOPSY ON THE MAMMOGRAPHIC ABNORMALITY TWO OPTIONS ARE AVAILABLE AT THIS TIME. THE GOLD STANDARD IS NEEDLE LOCALIZATION AND OPEN BREAST BIOPSY USING THE MAMMOGRAPHICALLY PLACED NEEDLE OR HOOK WIRE. THIS PROCEDURE IS SIMILAR IN MORBIDITY AND PATIENT ACCEPTANCE TO SIMPLE EXCISIONAL BIOPSY DESCRIBED ABOVE. THE SECOND OPTION IS CORE NEEDLE BIOPSY OR STEREOTACTIC BREAST BIOPSY ALSO KNOWN AS MAMMOTEST. DEVELOPED IN RESPONSE TO QUESTIONS OF SAMPLING ERROR AND CYTOLOGIC MISINTERPRETATION OF MAMMOGRAPHIC DIRECTED FINE NEEDLE ASPIRATION, THE TECHNIQUE OF STEREOTACTIC CORE NEEDLE BIOPSY USING A 14 GAUGE NEEDLE WAS BORNE. THE PROCEDURE IS MINIMALLY INVASIVE, CAUSES LITTLE PAIN AND LESSER COSMETIC PROBLEMS THAN OPEN BIOPSY.

THE PATIENT LIES PRONE ON THE DEDICATED MAMMOGRAPHIC TABLE WITH THE BREAST PROTRUDING FROM THE CIRCULAR PORT. THE TECHNIQUE INCLUDES BREAST COMPRESSION, RIGHT AND LEFT VIEWS 15° APART FOR STEREOTACTIC LOCALIZATION. THEN THE COMPUTER DETERMINES THE COORDINATES AND WITH LOCAL ANESTHETIC AND A 2mm WOUND, THE NEEDLE IS PASSED TO THE LESION. THE NEEDLE IS THEN FIRED SEVERAL TIMES AND POSTFIRE FILMS ARE TAKEN TO CONFIRM PROPER SAMPLING.

CANDIDATES FOR STEREOTACTIC CORE NEEDLE BIOPSY SHOULD HAVE A NONPALPABLE ABNORMALITY ON MAMMOGRAM, A SUSPICIOUS LESION THAT IS ONLY SEEN ON A SINGLE VIEW, HAS CONSIDERABLE CONCERN OVER OPEN BIOPSY OR HAVE PROBABLE BENIGN CLASS LESION WHERE OPEN BIOPSY MAY NOT BE WARRANTED. PATIENTS WITH RELATIVE CONTRAINDICATIONS TO STEREOTACTIC CORE NEEDLE BIOPSY INCLUDE FINDINGS OF DIFFUSE OR MULTIFOCAL DISEASE, LESIONS CLOSE TO THE CHEST WALL, PATIENT’S INABILITY TO LIE PRONE AND MOTIONLESS FOR 30 MINUTES AND PATIENTS WITH VERY THIN BREASTS ONCE COMPRESSED.

STUDIES OF 14 GAUGE BIOPSIES FOLLOWED BY EXCISIONAL CONFIRMATION DEMONSTRATED SENSITIVITY OF 96-100% AND ACCURACY OF 96-100%. WITH THIS IN MIND, THE PROPERLY SELECTED PATIENT WILL BENEFIT FROM STEREOTACTIC CORE NEEDLE BIOPSY.

SURGICAL THERAPY OF DIAGNOSED BREAST CANCER

IN 1995, THERE ARE ESSENTIALLY TWO MODES OF LOCAL CONTROL OF BREAST CANCER. MODIFIED RADICAL MASTECTOMY (TOTAL MASTECTOMY AND AXILLARY NODE DISSECTION) HAVE BEEN SHOWN TO BE EQUIVALENT IN TERMS OF LONG TERM SURVIVAL TO SEGMENTAL MASTECTOMY (LUMPECTOMY) AND AXILLARY NODE DISSECTION WITH SUBSEQUENT RADIOTHERAPY. THE NATIONAL SURGICAL ADJUVANT BREAST AND BOWEL PROJECT (NSABP) B-06 PROTOCOL DEMONSTRATED THAT THE ADDITION OF RADIATION THERAPY POSTOPERATIVELY REDUCED THE RISK OF LOCAL RECURRENCE IN COMPARISON TO PATIENTS TREATED WITH SEGMENTAL MASTECTOMY ALONE. THERE IS NO SURVIVAL ADVANTAGE OF EITHER MRM OR LUMPECTOMY, NODE DISSECTION AND RADIATION THERAPY.

SURGICAL MEANS ARE BEST APPLIED TO THE CONTROL OF GROSSLY EVIDENT LOCAL DISEASE AND ATTEMPTS AT ERADICATION OF MICROSCOPIC DISEASE BY SURGERY ONLY SERVES TO INCREASE MORBIDITY. THE SUBCLINICAL DISEASE SEEMS TO BE BEST TREATED WITH RADIATION THERAPY WITHOUT INCREASED MORBIDITY DUE TO THE USE OF FRACTIONATED DOSES APPROXIMATING 50 GRAY.

ALL RECENT STUDIES LOOKING AT THE SURGICAL TREATMENT OF BREAST CARCINOMA HAVE SHOWN THAT THE TYPE AND EXTENT OF LOCAL AND REGIONAL TREATMENT DOES NOT SUBSTANTIALLY AFFECT SURVIVAL. THESE FINDINGS HAVE STRONGLY SUGGESTED THAT BREAST CARCINOMA MUST BE A SYSTEMIC ILLNESS EVEN AT ITS EARLIEST STAGES OF DIAGNOSIS. FURTHER STUDIES HAVE SHOWN THAT BREAST CANCER CELLS DO NOT METASTASIZE IN AN ORDERLY FASHION. THE STATUS OF REGIONAL LYMPH NODES IN THE BREAST CANCER PATIENT DOES LITTLE TO PREDICT OVERALL OUTCOME AND IS BEING UTILIZED LESS AND LESS IN THE DETERMINATION OF FUTURE THERAPEUTIC REGIMEN USE. MOST PATIENTS HAVE SOME POTENTIAL FOR SYSTEMIC SPREAD EVEN AT VERY EARLY STAGES OF DISEASE. THEREFORE, THE GREATEST CHANCE FOR CURE LIES IN THE APPROACH TO THE PATIENT AS ONE WITH PRESUMED SYSTEMIC DISEASE FROM THE ONSET OF THE DISEASE. HEREIN LIES THE JUSTIFICATION FOR THE CURRENT USE OF AGGRESSIVE CYTOTOXIC CHEMOTHERAPY, THE FUTURE USES OF IMMUNOTHERAPY AND MOLECULAR BIOLOGIC APPLICATIONS TO BREAST CANCER TREATMENT.

THE SURGEON HAS THUS BECOME AN INTEGRAL PART OF A MULTIDISCIPLINARY TEAM MANAGING THE PATIENT WITH BREAST CARCINOMA. THE EARLY DIAGNOSIS, TIMELY BIOPSY AND THE CONTROL OF LOCAL DISEASE ARE THE FIRST STEPS MADE IN THE TREATMENT OF BREAST CANCER.