Table of Contents
Page created on October 14, 2021. Last updated on October 22, 2021 at 09:40
Introduction
For introduction, etiology, types, and pathology, see the corresponding pathology 2 topic.
Screening
Mammography screening is a part of most countries’ cancer screening programmes. In Hungary, it’s recommended annually for ages between 40 and 65, and has reduced mortality by 21%. In Norway, it’s recommended every second year for ages 50 – 69 and has reduced mortality by 20 – 30%.
The rationale behind mammography screening is that some cancers (both invasive and non-invasive) which are too small to be palpated are visible with mammography as calcifications, masses, or asymmetries. Two views are obtained, craniocaudal (CC) and mediolateral oblique (MLO) view. Screening may detect both cancer and precancerous lesions.
Ultrasound is not used for screening but may be used to supplement it if mammography findings are suspicious.
Healthy women who are suspected to have BRCA mutation should be genetically tested for this. BRCA positive healthy women should be offered prophylactic mastectomy.
Clinical features
Breast cancers are usually detected during routine mammography screening of postmenopausal women, or in women with self-palpated breast lump. Thanks to mammography screening, presentation by a palpable mass is becoming more and more rare. Encouraging women to perform breast self examination regularly is also important for screening.
The breasts are usually asymmetric as the breast with the tumor changes size or shape. Cancers are usually hard, painless, have irregular surface, cause skin or areola dimpling, and may cause nipple discharge. If the tumour is fixed to skin or the chest wall, it may be advanced. Eczematous lesion on the nipple or areola may be suggestive of Paget’s disease of the nipple. DCIS and LCIS rarely cause symptoms and are mostly discovered during screening.
Mammography can detect calcifications, which occurs in most breast cancers. Calcifications can also be present in benign conditions like fat necrosis and sclerosing adenosis.
Diagnosis and evaluation
Patients presenting with a lump or positive findings should undergo thorough history and physical examination, imaging (mammography and/or ultrasound), as well as tissue diagnosis. Histology is mandatory for diagnosis and can be accomplished with FNAB or core biopsy.
After diagnosis, we must determine the histological subtype and molecular characteristics. Biopsy should be taken of any suspicious lymph nodes. CT of the chest, abdomen, and pelvis should be performed.
We distinguish early and advanced breast cancer. Early breast cancer is non-invasive or has not spread beyond nearby lymph nodes. Advanced breast cancer has spread beyond nearby lymph nodes or to other organs.
Treatment
The main treatment is surgical (some form of surgery is performed in all cases which are operable), however oncological therapies are also important. DCIS is managed like breast cancer.
Surgical therapy may be breast-conserving surgery or mastectomy. Breast-conserving surgery removes the mass and as little of the breast as possible and preserves the rest of the breast. Breast-conserving surgery should always be followed up by radiation therapy. Staging of axillary lymph nodes must always be performed during surgery. Breast reconstruction may be performed later for cosmetic purposes.
LCIS requires no surgery if histology determines that it’s of the “classic” type. Nonclassic LCIS requires surgery.
If the cancer is hormone positive, hormonal therapy is indicated, often with tamoxifen. If the cancer is HER2-positive, anti-HER2 therapy (trastuzumab) is indicated.
Neoadjuvant chemotherapy and adjuvant chemotherapy/radiotherapy may be used for advanced breast cancer.