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BREAST CANCER DIAGNOSIS

Mammary pain, nipple discharge and evidence of a mammary nodule represents the main clinical symptoms and signs of breast benign and malign pathologies.

Mammary pain ( mastalgia ) is the mammary symptom most frequently found in women from the puberty to the menopause. As a rule, breast pain is not a worrisome symptom and has usually a benign meaning ( for example acute mastitis or presence of fibrocistic mastopathy, fibroadenoma or phyllodes tumor).

Especially in young patients, the presence of a cyclical , unilateral or bilateral mammary pain - that usually get worse in proximity of the menstrual cycle - absolutely doesn't have to alarm: diagnostic procedures are not necessary in these cases.

With more attention has to be considered a localized, fixed and persistent mammary pain in a post-menopausal woman. In a little percentage of cases, in fact, this mammary pain may be the first symptom of a breast carcinoma in initial phase. In these patients the execution of a mammography is an useful diagnostic test.

Nipple discharge, if bilateral, pluriorifitials and of lactescent or yellow-brown-greenish color, is related to benign pathologies (for example intraductal papilloma of the nipple) and doesn't have to alarm. Instead, monoorifitials hematic or sero-hematic mammary secretions need further diagnostic tests ( cytologic examination, echography, mammography ), to exclude the presence of breast cancer.

The presence of a mammary nodule require the execution of opportune diagnostic tests (ecography, mammography, cytologic or histologic examination) to distinguish benign and malign lesions.

Diagnostic Procedures

About 80% of patients with breast cancer discover the malignant tumor by themselves. It is important therefore to teach women how to perform a self breast examination.

The results of randomised trials suggest however that screening-breast self examination is not effective in reducing mortality from breast cancer.

Clinical breast examination by the physician represents the most important means of diagnosing breast carcinoma in general practice.

Clinical breast examination evaluates breast tissue and differentiates physiologic nodularity from pathologic breast masses.

The U.S. Breast Cancer Detection Demonstration Project (BCDDP) revealed that 39% of breast cancers <1cm in size were detected by clinical breast examination.

After visual inspection, the whole gland, including the retroareolar and the axillary regions, has to be systematically palpated.

When a breast nodule is discovered, the clinician has to assess its consistency, volume, margins and adherence to the mammary parenchyma and skin.

Clinical suspicion of malignancy has to be confirmed with mammography, ecography and needle aspiration or surgical biopsy.

Mammography is the most important radiological examination for the diagnosis of breast lesions.

Focal increased density (due to stromal fibrous reaction associated to infiltrating carcinomas), architectural distorsion, spiculated margins and presence of clusters of irregular microcalcifications represents the main radiological signs of the presence of breast cancer.

The radiographic appearance of the breast varies among patients of the same age because of differences in glandular composition. Adipose tissue is radiographically lucent (dark on mammograms), whereas connective and epithelial components of the mammary gland are radiographically dense (light on mammograms).

Younger patients tend to have denser breasts than older patients.

Denser breasts are more difficult to analyze with mammography. Early breast cancers presenting as masses of focal increased density, without microcalcifications or spiculations, are often missed in dense breasts. In women with dense breasts ultrasonography represents therefore a good adjunctive diagnostic method

Breast cancer is usually an echographically ipoechogenic mass, with irregular margins and back attenuation of the ultrasound echo.

When mammography and echography are both inconclusive, in presence of clinical suspicion of malignancy, fine needle aspiration citology or ultrasound-guided micro/macrobiopsy or surgical biopsy with histological examination are mandatory.

Histological examinationallow to determine the exact nature of the lesion and to differentiate cancers into no special types (NOS. not otherwise specified: ductal and lobular carcinoma) or special types (tubular,mucoid, papillary, medullary, cribriform). This aspect has clinical relevance in that certain special type cancers (for example mucoid or medullary cancers) have a much better prognosis than cancers that are of no special type.

Breast Cancer Screening

Because breast cancers in earlier clinical stages have a better outcome, breast cancer screening has to be encouraged.

Various clinical studies showed that mammographic screening in asymptomatic women reduced breast cancer mortality rates among patients aged 40 to 74 years, with the greatest risk reduction among older patients.

With current technology, high quality mammography may be performed with very low radiation doses.

The U.S. Preventive Service Task Force (USPSTF) recommends a mammographic screeening every one to two years in women aged 40 to 74 years.

Sufficient screening informations may be obtained performing one high quality x-ray in mediolateral oblique projection (single view mammography); in some screening programmes one cranio-caudal projection is also included (two-view mammography).

Because the sensitivity of mammography declines significantly with incresing breast radiological density, among women with dense breasts an ultrasonography is also performed, maximizing breast cancer screening sensitivity.