DIAGNOSIS:

I. Self-examination: Monthly breast self exam is recommended, ideally just after the menses.
II. Physical examination: By a physician is imperative to supplement breast self examination and radiography studies because mammograms are negative for 15% of proven B.C.

Screening programs using physical and mammography examination of asymptomatic women, have detected many early cancers without axillary node involvement.

Ø Retraction or inversion of a nipple may be cause by carcinoma involving the mammary ducts and causing duct shortening.
Ø Observable skin dimpling is due to involvement and retraction of the Cooper ligaments. If fascia is involved, the dimpling may be enhanced.
Ø Involvement and obstruction of subcutaneous lymphatic by a tumor result in lymphatic dilatation and lymph accumulation in the skin. The resultant edema creates the "orange peel" appearance.

Initial palpation with the flat of the hand is performed in a systematic fashion. After palpation has been concluded the supraclavicular space an anterior/posterior cervical lymph nodes chains can be assessed while the patient is sitting.

With the patient pushing inward on her hips (pectoral muscle contraction) raising the arms above the head, it should be possible to examine the tail of the breast and axils regarding the size consistency, and mobility of any palpable lymph nodes.
The breast should be examined with the patient in the supine position (patient's hand on side of breast, small cushion behind ipsolateral shoulder) to look for abnormal thickening, nodularity and density.
The nipple areola complex most be squeezed to detect masses and/or a discharge.


Suspicious physical features include:

1. Mass that are firm.
2. Indistinct borders to the mass.
3. A mass that is attached to skin or deep fascia.
4. Lack of tenderness.
5. Dimpling of the skin.
6. Retraction or inversion of the nipple.
7. Bloody discharge.
8. Axillary supra or infraclavicular nodes.

Normal structures that can simulated a mass include:

Ø Prominent ribs.
Ø Costocondral junctions.
Ø Firm margins at the edge of the breast or at the edge of a defect due to a biopsy.
Ø A lobulate circular terminus of firm breast tissue at the border of the areola.
Ø A prominent fat lobule (most frequently seen along the inferior margin of the breast or over the axillary tail).
Ø Intramammary lymph nodes (usually confine to the axillary tail).

III. Mammography (using low dose radiation) reveals breast architecture:

Suspicious signs of malignancy are:

Ø Asymmetry.
Ø Skin thickening.
Ø Irregular masses.
Ø Architecture distortion.
Ø Clustered pleomorphic micro calcification.

Mammography is useful:

Ø To support the clinical impression of no evidence of malignancy.
Ø To follow patient with a previous history of B.C.
Ø To screen for sub clinical tumors.


Current recommendation of the American Cancer Society for screening mammography are a baseline study between ages 35 to 40, a study every one to two years for women between ages 40 and 50, and yearly mammography after age 50.
These guidelines apply to all women, not just to those with risk factors, who should have a baseline mammogram at age 30 and be considered for mammogram every one to two years there after, depending on the density of the breast.
As the density of the breast tissue decreases, the sensitivity of the mammogram to earlier cancers increases.

IV. Ultrasound is most useful in determining whether a mass (palpable or nonpalpable) is solid or cystic. Experience with using magnetic resonance imaging to evaluate the breast is also increasing.
V. Biopsy of solid breast masses is necessary for diagnosis. Several types of biopsies are available.
1. Any palpable breast mass should be aspirated.
Ø If the lesion is cystic the mass usually resolves when the fluid is completely aspirated. Recurrence of the mass of bloody fluid in the cyst requires further evaluation.
Ø If the lesion is solid a fine needle aspirated can be used to extract cells, which can be examinated cytologically. The specimen should contain ductal cells to be considered adequate. If the cytology is negative or undetermined, definitive open biopsy may be necessary.
Ø Observation is indicated for selecting young women whose nodularity of breast lumps appear to be physiologic. These women may be safely watched through one or two menstrual cycles and followed if no change occurs in the physical findings.
2. For large, locally advanced.
Core needle biopsy can be performed.
3. For palpable lesions:
Excisional biopsy is most common.
3. For nonpalpable mammography abnormalities, approaches to biopsy are available.
· A needle guided biopsy after the radiologist places a localizing wire in the abnormality.
· A steroestaxis biopsy with computed mammographic equipment.

Core needle biopsy:
This is office procedure done under local anesthesia through a two mm incision. In the majority of instances, not enough tissue is obtained for hormone receptor assay.

Incisional biopsy:
This involves the removal of a portion of the mass (reserved for lesion too larged to be easily excised ).

Excisional biopsy:

The entire lesion is removed allowing for optimal diagnostic evaluation. It can be performed either as a one step or two step procedure. A one step procedure involves biopsy under general anesthesia, diagnosis based on examination of frozen section and immediate treatment of any cancer is diagnosed with certainty by F.N.A. and standing has been performed, a one step procedure is justifiable.

Standing:

When preoperative evaluation is complete, the patient with B.C. should be clinically staged because standing guides treatment.

Clinical standing of B.C.

Primary tumor:

T1=T 2cm or less in greatest dimension
T2=T greater then 2cm but not more than 5cm
T3=T greater than 5cm in greatest dimension
T4=T of any size with direct extension to chest wall (not pectorals major) or skin.

Regional lymph nodes

N0= no palpable axillary nodes
N1= metastases to mobile axillary nodes.
N2= metastases to fixes matted axillary nodes.

Distant metastases:

M0= no distan metastases.
M1= distant metastases including ipsolateral supraclavicular nodes.