F.

DIAGNOSIS

1. Symptoms

The symptoms that most often include (Moningkey and Shirley Ivonne, 2000):

a. Patients feel a change in the breast or the milk nipples

i. Lump or thickening in or around the breast or in the armpit area
ii. The nipple feels hard
b. Patients see changes in the breast or in their milk nipples
i. Changes in the size and shape of the breast
ii. Nipples are attracted to the breast
iii. The skin of the breast, areola, or nipple is scaly, red or swollen. The skin may
wrinkle like orange peel.
c. Secret discharge or fluid from the nipple

At the beginning of breast cancer sufferers usually do not feel pain. If cancer cells have
spread, usually cancer cells can be found in the lymph glands around the breast. Cancer cells can
also spread to various other body parts, most often to the bones, liver, lungs, and brain
(Brunicardi FC, 2015).

In 33% of cases of breast cancer, patients find a lump in their breasts. Other rare signs and
symptoms of breast cancer include breast enlargement or asymmetry, changes in the nipple can
be either retraction or discharge, ulceration or erythema of the breast skin, underarm mass,
musculoskeletal discomfort. 50% of women with breast cancer do not have any symptoms. Pain
in the breast is usually associated with benign abnormalities (Bickley LS, 2009).

Symptoms that are felt Possible Causes

Pain: Pain is more typical of infections than tumors
- Changes according to the Physiological causes, such as premenstrual stress or
menstrual cycle fibrocystic disease
- Pain persists, does not depend on Can be caused by infection, sometimes a benign tumor, or a
the menstrual cycle malignant tumor

Breast lumps
- hard · Slippery surface on fibroadenoma or cyst
 · Rough surface, bumpy, or attached to cancer or non-
infective inflammation
- Chewy Fibrocystic disorders
- soft Lipoma
Skin Change Withdrawal of the skin / chest wall is more typical of tumors
than benign diseases
- bercawak Very suspicious carcinoma
- The lump is visible Cysts, carcinoma, enlarged fibroadenoma
- Orange peel Above lump: cancer (distinctive sign)
- redness Infection (if there is a sign of heat)
- ulcer Old cancer (normal in old age)
Nipple / Areola abnormalities
- Retraction Fibrosis due to cancer
- New Inversion Retraction of fibrosis due to cancer (sometimes fibrosis due
to ductal dilation)
- Eczema Unilateral: Paget's disease (a typical sign of cancer)
Liquid Exit
- like milk Pregnancy or lactation
- clear Normal
- green - (Elves) menapouse
- Ductal dilation
- Fibrocystic abnormalities
- Hemorrhagic Carcinoma
Intraductus papilloma

2. History Taking

Lumps in the breast usually encourage the patient to see a doctor. In general, main complaints:
painless mammary tumors (66%), mammary pain tumors (11%), bleeding / fluid from nipples
(9%), local edema (4%), nipple retraction (3%). The consistency of malignant is usually hard.
Dispensing fluid from the nipple usually leads to papilloma or intraductal carcinoma, whereas
pain leads to more fibriocystic abnormalities.

a. Complaints in the breast or armpit and history of the disease

- Lumps

- Speed of growth

-Pain

- Nipple discharge

- Nipple retraction

- Crust on the areola

- Skin disorders; dimping, peau d’orange, ulceration, venasiasi

- Change in skin color

- Armpit bumps

- Edema arm

b. Complaints elsewhere related to metastasis

- Brain  headache, nausea, vomiting, epilepsy, ataxia, paresis and paresthesia

- Pleura  effusion, shortness of breath

- Lungs  cough

- Liver - sometimes asymptomatic but can be found mass and icterus

- Bone  pain, broken bones

c. There are risk factors

-Elderly

- First child born at mother age > 35 years

-Not married

- Menarke age <12 years

- Age of menopause > 55 years

- History of surgery for benign breast tumors

- Get long hormonal therapy

- Contralateral breast cancer

- History of chest wall radiation

- Family history of cancer

3. Physical examination

It is recommended that a breast examination be carried out when hormonal influences are
minimal (after 1 week of the last day of menstruation). For inspection, patients can be asked to
sit up or lie down, or both. Then note the shape of both breasts, skin color, mass, grooves,
retractions, the presence of speckled skin such as orange skin, ulcers and lumps. With arms
raised straight up, abnormalities appear more clearly.

i. Generalist status  performance status

ii. Localist status

- Tumor: location, size, consistency, surface, shape and boundary of the tumor, number of
tumors, fixed or not to the tissue around the breast

- Skin changes: redness, dimpling, edema, nodules, satellite, ulceration, peau d’orange

- Nipple / nipple: interested, erosion, crusting, discharge

iii. Status of lymph nodes

Examine the axillary, infraclavicular and supraclavicular lymph nodes. Matters assessed:
number, size, consistency, mobile or fixed to one another or to the surrounding network

iv. Examination of areas suspected of metastasis

Or it can also be divided into:

a. Inspection
Inspection of the shape, size, and symmetry of both breasts, whether there is edema (peau
d’orange), retraction of the skin or nipples, and erythema (Bickley LS, 2009).

Figure 11. Position of the patient while carrying out inspection

b. Palpation

Palpation of the breast to detect if there is a mass, including palpation of the lymph glands in the
axilla, supraclavicular and parasternal. Any palpable mass or a lymphadenopathy, must be
assessed for its location, size, consistency, shape, mobility or fixation (Bickley LS, 2009).
Palpation is better in patients who lie down with thin pillows on their backs, so that the breasts
are flat. Palpation with the palm of the hand being moved slowly without pressure on each breast
quadrant. What is considered basically is the same as tumor assessment elsewhere. In a sitting
posture, a mass that is not palpable when the patient is lying down, is sometimes easier to find.
Axillary are also easier in the sitting position. Examination of regional lymph nodes is done by
palpation of groups of lymph nodes around the breast.
Figure 12. Position of the patient when performing a palpation examination

4. Diagnostic Approach

a. Mammography

Mammography is the most reliable examination to detect breast cancer before the lump or mass
can be palpated. Slow-growing carcinoma can be identified by mammography for at least 2 years
before reaching a size that can be detected by palpation (Brunicardi FC, 2015).

At the age of 40 years, breast examinations are carried out every year accompanied by
examination of mammography. In a study of screening mammography, it showed a reduction of
40% in stage II, III and IV mammary carcinomas in the population screened by mammography
(Brunicardi FC, 2015).

b. Ultrasonography

Second only to mammography in frequency of use for breast imaging, ultrasonography is an

important method of resolving equivocal mammographic findings, defining cystic masses, and
demonstrating the echogenic qualities of specific solid abnormalities. On ultrasound
examination, breast cysts are well circumscribed, with smooth margins and an echo-free center.
Benign breast masses usually show smooth contours, round or oval shapes, weak internal echoes,
and welldefined anterior and posterior margins. Breast cancer characteristically has irregular
walls but may have smooth margins with acoustic enhancement. Ultrasonography is used to
guide fine-needle aspiration biopsy, core-needle biopsy, and needle localization of breast lesions.
Its findings are highly reproducible and it has a high patient acceptance rate, but it does not
reliably detect lesions that are ≤1 cm in diameter. Ultrasonography can also be utilized to image
the regional lymph nodes in patients with breast cancer. The sensitivity of examination for the
status of axillary nodes ranges from 35% to 82% and specificity ranges from 73% to 97%. The
features of a lymph node involved with cancer include cortical thickening, change in shape of the
node to more circular appearance, size larger than 10 mm, absence of a fatty hilum and
hypoechoic internal echoes (Brunicardi FC, 2015).
c. Magnetic Resonance Imaging (MRI)

In the process of evaluating magnetic resonance imaging (MRI) as a means of characterizing

mammographic abnormalities, additional breast lesions have been detected. However, in the
circumstance of negative findings on both mammography and physical examination, the
probability of a breast cancer being diagnosed by MRI is extremely low. There is current interest
in the use of MRI to screen the breasts of high-risk women and of women with a newly
diagnosed breast cancer (Brunicardi FC, 2015).

MRI has been advocated by some for routine use in surgical treatment planning based on the fact
that additional disease can be identified with this advanced imaging modality and the extent of
disease may be more accurately assessed. Some clinical scenarios where MRI may be useful
include the evaluation of a patient who presents with nodal metastasis from breast cancer without
an identifiable primary tumor; to assess response to therapy in the setting of neoadjuvant
systemic treatment; to select patients for partial breast irradiation techniques; and evaluation of
the treated breast for tumor recurrence. (Brunicardi FC, 2015).

d. Biopsi

Nonpalpable Lesions.
Image-guided breast biopsy specimens are frequently required to diagnose nonpalpable lesions.
Ultrasound localization techniques are used when a mass is present, whereas stereotactic
techniques are used when no mass is present (microcalcifications or architectural distortion
only). The combination of diagnostic mammography, ultrasound or stereotactic localization, and
fine-needle aspiration (FNA) biopsy achieves almost 100% accuracy in the preoperative
diagnosis of breast cancer. However, although FNA biopsy permits cytologic evaluation, core-
needle permits the analysis of breast tissue architecture and allows the pathologist to determine
whether invasive cancer is present. This permits the surgeon and patient to discuss the specific
management of a breast cancer before therapy begins. Core-needle biopsy is preferred over open
biopsy for nonpalpable breast lesions because a single surgical procedure can be planned based
on the results of the core biopsy. The advantages of core-needle biopsy include a low
complication rate, minimal scarring, and a lower cost compared with excisional breast biopsy
(Brunicardi FC, 2015).
Palpable Lesions.
FNA or core biopsy of a palpable breast mass can usually be performed in an outpatient setting.
When a breast mass is clinically and mammographically suspicious, the sensitivity and
specificity of FNA biopsy approaches 100%. In some cases the entire lesion is removed with the
biopsy technique and clip placement allows for accurate targeting of the site for surgical
resection. Tissue specimens are placed in formalin and then processed to paraffin blocks.
Although the false-negative rate for core-needle biopsy specimens is very low, a tissue specimen
that does not show breast cancer cannot conclusively rule out that diagnosis because a sampling
error may have occurred. The clinical, radiographic, and pathologic findings should be in
concordance. If the biopsy findings do not concur with the clinical and radiographic findings, the
multi-disciplinary team (including clinician, radiologist, and pathologist) should review the
findings and decide whether or not to recommend an image-guided or open biopsy to be certain
that the target lesion has been adequately sampled for diagnosis (Brunicardi FC, 2015).

e. Biomarker

Breast cancer biomarkers are of several types. Risk factor biomarkers are those associated with
increased cancer risk. These include familial clustering and inherited germline abnormalities,
proliferative breast disease with atypia, and mammographic densities. Exposure biomarkers are a
subset of risk factors that include measures of carcinogen exposure such as DNA adducts.
Surrogate endpoint biomarkers are biologic alterations in tissue that occur between cancer
initiation and development. These biomarkers are used as endpoints in shortterm
chemoprevention trials and include histologic changes, indices of proliferation, and genetic
alterations leading to cancer. Prognostic biomarkers provide information regarding cancer
outcome irrespective of therapy, whereas predictive biomarkers provide information regarding
response to therapy. Candidate prognostic and predictive biomarkers and biologic targets for
breast cancer include

(a) The steroid hormone receptor pathway;

(b) Growth factors and growth factor receptors such as human epidermal growth factor receptor
2 (HER-2)/neu, epidermal growth factor receptor (EGFR), transforming growth factor,
platelet-derived growth factor, and the insulin-like growth factor family;
(c) Indices of proliferation such as proliferating cell nuclear antigen (PCNA) and Ki-67;
(d) Indices of angiogenesis such as vascular endothelial growth factor (VEGF) and the
angiogenesis index;
(e) The mammalian target of rapamycin (mTOR) signaling pathway;
(f) Tumor-suppressor genes such as p53;
(g) The cell cycle, cyclins, and cyclin-dependent kinases;
(h) The proteasome;
(i) The COX-2 enzyme;
(j) The peroxisome proliferator-activated receptors (PPARs);
(k) Indices of apoptosis and apoptosis modulators such as bcl-2 and the bax:bcl-2 ratio
(Brunicardi FC, 2015).

G. Screening of Breast Cancer

These recommendations represent guidance from the American Cancer Society (ACS) for
women at average risk of breast cancer: women without a personal history of breast cancer, a
suspected or confirmed genetic mutation known to increase risk of breast cancer (eg, BRCA), or
a history of previous radiotherapy to the chest at a young age (Oeffinger et al, 2015).

The ACS recommends that all women should become familiar with the potential benefits,
limitations, and harms associated with breast cancer screening.

Recommendations

1. Women with an average risk of breast cancer should undergo regular screening mammography
starting at age 45 years.

1a. Women aged 45 to 54 years should be screened annually.

1b. Women 55 years and older should transition to biennial screening or have the
opportunity to continue screening annually.

1c. Women should have the opportunity to begin annual screening between the ages of 40
and 44 years.
2. Women should continue screening mammography as long as their overall health is good and
they have a life expectancy of 10 years or longer.

3. The ACS does not recommend clinical breast examination for breast cancer screening among
average-risk women at any age.

H. Breast Cancer Prognosis

Survival rates for women diagnosed with breast cancer in the United States can be obtained from
the SEER Program of the National Cancer Institute. Data have been collected since 1973 and is
updated at regular intervals. The overall 5-year relative survival for breast cancer patients from
the time period of 2003–2009 from 18 SEER geographic areas was 89.2%. The 5-year relative
survival by race was reported to be 90.4% for white women and 78.7% for black women. The 5-
year survival rate for patients with localized disease (61% of patients) is 98.6%; for patients with
regional disease (32% of patients), 84.4%; and for patients with distant metastatic disease (5% of
patients), 24.3%. Breast cancer survival has significantly increased over the past two decades due
to improvements in screening and local and systemic therapies. Data from the American College
of Surgeons National Cancer Data Base can also be accessed and reports survival based on stage
of disease at presentation using the AJCC staging system (Brunicardi FC, 2015).

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Walter, L. C., Church, T. R., Flowers, C. R., LaMonte, S. J., Wolf, A. M. D., DeSantis, C.,
Tieulent, J. L., Andrews, K., Baptiste, D. M., Saslow, D., Smith, R. A., Brawley, O. W., and
Wender, R. (2015). Breast cancer screening for women at average risk. 2015. guideline
update from the American Cancer Society. Jama, 314(15), 1599-1614.
2. Brunicardi, F. C., Andersen, F. K., Billiar, T. R., Dunn, D. L., Hunter, J. G., Matthews, J. B.,
and Pollock, R. E. 2015. Schwartz’s: Principles of surgery tenth edition. Chicago: McGraw-
Hill.