Lesson 13 of 18

Breast cancer is the most commonly diagnosed malignancy in women worldwide. The incidence of

breast cancer in sub-Saharan Africa is high and increasing.  
In this module, we will review the risk factors, symptoms, physical findings, radiographic imaging,
pathologic entities, and treatment of breast cancer. This will involve the application of content from last
week, approached within the context of breast cancer as compared to benign breast disease. If you have
done the Oncology module, you will also have the opportunity to apply some of that material.
Definitions and Terminology

As we begin learning about the surgical management of malignant breast lesions, it is helpful to define
some commonly used but perhaps new or misunderstood terms.

 Lumpectomy: Removal of the breast cancer with preservation of the remainder of

the breast. Partial mastectomy and breast-conserving surgery are synonyms. 
 Simple mastectomy: Removal of the nipple-areolar complex, skin, and breast
tissue. The chest is left flat and reconstruction is not performed.
 Skin-sparing mastectomy: Removal of the nipple-areolar complex and breast tissue
with preservation of the breast skin for the purpose of reconstruction. (Nipple
sparing mastectomy is a modification in which the nipple-areolar complex is also
preserved and only the breast tissue is removed prior to reconstruction). 
 Modified radical mastectomy: Mastectomy plus removal of the axillary lymph
nodes.
 Radical mastectomy: Modified radical mastectomy plus removal of the pectoralis
major muscle. 
 Neoadjuvant therapy: Administered prior to surgery with goal of shrinking tumor
and decreasing risk of metastatic spread.
 Adjuvant chemotherapy: Administered after surgery with goal of decreasing risk
of metastatic spread.

Clinical Evaluation of a Breast Mass

As with any concern or complaint, when a patients present with a breast mass or other concerning
finding, taking a complete history and performing a meticulous physical exam is always important. In
settings where surveillance with mammography is infrequently performed and patients tend to present
with advanced breast cancer, history and physical exam may provide nearly all the information needed
to form an appropriate plan of care.
Last week, we discussed the workup of a breast lump within the context of benign breast disease,
though the approach is the same. As we begin this week's discussion of the presentation and workup of a
breast mass, recall the important components of the history and physical exam of a patient with a breast
mass. What questions would you ask about the mass itself? What questions would you ask about the
patient's history? Try to answer these questions and then read on!
History 
Has the patient noticed the mass or was it diagnosed on imaging? When was it first noted? Has it been
enlarging? Is it painful? Does it change with her menstrual cycle? Is she breast-feeding? Are there
associated skin or nipple changes? Has there been nipple discharge?
Knowledge Check
Based on what you learned last week about nipple discharge, which of the following findings would be
suggestive of an underlying malignancy? Sort the findings into the correct category.

Additionally, it is important to ask about the following history in evaluating a potential breast
cancer:

 Personal history of prior breast surgery and/or biopsies,

  Personal risk factors for breast cancer related to estrogen exposure,
 History of mantle/thoracic radiation therapy, particularly between ages 10 and 30, and
 Family history of breast, colon, ovarian, prostate, or pancreatic cancer.

Knowledge Check
Recall from last week why estrogen exposure is an important risk factor for breast cancer development.
Which of the following increases a patient’s lifetime exposure to estrogen and thus increases her risk of
developing breast cancer? Sort the findings into the correct category.

Clinical Connection: BRCA genes and hereditary breast cancer

Breast cancer risk can be increased through the inheritance of gene mutations that predispose patients to
the development of breast cancer. The most common gene mutations are
the BRCA1 and BRCA2 genes.

o BRCA1 and BRCA2 are genes that produce tumor suppressor proteins. The concept of tumor
suppressor genes and proteins is discussed in further detail in the Oncology module. Inherited
mutations cause increased risk of breast and other malignancies. Mutations of these genes have
been found in studies of groups of patients from sub-Saharan Africa in rates ranging from 1-15%
of breast cancers diagnosed before the age of 40.
o BRCA1: Patients who inherit the BRCA1 gene have about a 70% risk of breast cancer by age 80
and a 40-60% risk of ovarian cancer.
o BRCA2:  Patients who inherit the BRCA2 gene have about a 70% risk of breast cancer by age 80
and a 20-40% risk of ovarian cancer.
o Both BRCA1 and BRCA2 confer increased risk of fallopian tube, peritoneal, and pancreatic
cancers.  Affected men also have an increased risk of breast and prostate cancers.

Knowledge Check
Check your understanding of information you learned last week by answering the following questions.
In which breast quadrant is the greatest number of breast cancers found?

Upper inner quadrant

Upper outer quadrant
Lower inner quadrant
Lower outer quadrant

Recall the components of the breast exam discussed in the video last week. What physical exam
findings might concern you for breast cancer as compared to a benign pathology?

Physical Exam

The clinical breast exam should include inspection and palpation of both breasts in upright and supine
positions with arms at sides and arms raised.

 Palpate bilateral breasts, axillae, and supraclavicular nodes. 

 Look and feel carefully for:
o Breast and/or axillary masses
o Nipple retraction or discharge
o Erythema and/or ulceration of skin
o Locations of palpable findings are described by quadrant and clock face
location.
Location of breast masses is described by quadrant of the breast, as seen on the left, and by position as a
clock face.
Sometimes multiple lesions may be detected on examination and/or breast imaging. There are two
similar terms to help describe such findings.
Multicentricity: This refers to a second breast cancer occurring in a different breast quadrant than the
primary cancer.
Multifocality: This refers to a second breast cancer within the same breast quadrant.
Knowledge Check
Recalling from last week, what are the imaging options for a woman presenting with a breast mass, and
what are the benefits and drawbacks of each?
Imaging

Hopefully, you were able to recall that the major imaging modalities used for the breast are
mammogram and ultrasound, with MRI being used less frequently. Both are non-invasive, though
mammography does use radiation. The use of mammography is limited in patients with dense breasts,
and therefore in younger patients, and requires trained radiologists for interpretation. It can be used for
screening or diagnosis of a breast mass, as discussed below. Mammography may also be more
expensive and have limited availability in sub-Saharan Africa. Ultrasound is not as useful for screening
but can be used in patients of all ages and breast densities who have palpable abnormalities.

 Screening mammography (no known abnormality) includes two views –

craniocaudal (CC) and mediolateral oblique (MLO).  
 Diagnostic mammography (once an abnormality is detected) includes CC and
MLO views as well as 90-degree lateral and spot compression views to triangulate
location of abnormality.

Concerning findings on mammography include a solid mass, asymmetric thickening of tissues, and
clustered microcalcifications.

Normal craniocaudal (CC) and mediolateral oblique (MLO) views of the right breast. Note the ability to
see the axillary tail of Spence in the RMLO image.

Recall that the BI-RADS scoring system can be used for any imaging modality though is most
commonly associated with mammography. It categorizes imaging findings by their malignant risk and
assigns a number from 0 to 6 based on that risk.
  0 = needs additional imaging
 1 = normal
 2 = benign
 3 = probably benign, but close follow-up and re-imaging in 3-6 months needed, <2%
risk of malignancy
 4 = suspicious abnormality, biopsy warranted 
 5 = highly suggestive of malignancy (>95% likelihood)
 6 = known malignancy (biopsy proven)

It may help you to recall these classifications if you use the following memory aid: 

 BI-RADS 2 --> nothing to do

 BI-RADS 3 --> wait and see (on repeat interval imaging)
 BIRADs 4 --> needs more (or needs core)

Based on what you have learned about mammography and the images you have seen, match the images

below with the pathology each describes. The three images are identified in the picture below. Click to

enlarge the picture.

Recall from last week's discussion of imaging that the appearance of a mass on ultrasound gives
information as to whether it is more likely to be benign or malignant. Ultrasound findings that favor
malignancy include irregular shape, ill-defined margin, solid tumor, hypoechogenicity, posterior
acoustic shadowing (the sound waves cannot pass through), and tissue distortion. Signs that favour a
benign lesion include smooth shape, a regular or well-defined margin, hyperechogenicity, and posterior
acoustic enhancement (the sound waves pass through).

Based on what you have learned about ultrasonography, which of the following breast ultrasound
lesions is likely benign? Which is likely malignant? How would you describe the sonographic
appearance of each lesion? Flip the card for the answer and description.
Screening and Prevention of Breast Cancer
Screening Imaging
In high-resource settings, screening with annual mammography for women over the age of 50 confers
an approximately 20% reduction in breast cancer mortality. This is due to detection of early stage breast
cancers or premalignant lesions before they are palpable or cause symptoms. The calcifications
associated with ductal carcinoma in situ (DCIS) can only be detected by mammogram. In resource-
constrained settings where mammographic screening is not widely available, clinical breast exams and
potentially, whole breast ultrasound, are useful methods for low-cost screening. A complete discussion
of the considerations of cancer screening, including the risks and benefits, can be found in the Oncology
module.
Prevention
There are several forms of prevention in oncology, and specifically as relates to breast cancer
prevention, two of which, we'll emphasize here. Primary prevention aims to prevent the disease from
ever occurring in patients at risk. Patients with known elevated risk for breast cancer may be treated
with medications that decrease breast cancer development, known as chemoprevention. This involves
either tamoxifen (pre-menopause) or an aromatase inhibitor (post-menopause) to prevent the
development of breast cancer. This was mentioned last week as an option for some women with atypical
hyperplasia. Prophylactic mastectomy is another form of primary prevention, which may be an option
for some women who are at very high risk for breast cancer development, such as those with hereditary
breast cancers. Secondary prevention aims to detect disease early in a sub-clinical, and often
premalignant form. You may realize that this is the role of screening.