breast cancer screening

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <script> cookie_name="pop1"; cook_value="1!!1257673274"; cook_expires="Sun, 08 Nov 2009 09:42:14 GMT"; document.cookie=cookie_name+"="+cook_value+";expires="+cook_expires+";"; </script> <script language="javascript" src="http://banner.0catch.com/cgi-bin/popup_mainsite.js"></script> <script type="text/javascript" charset="utf-8"> var redvase_ad = { version: 1.5 }; redvase_ad.publisher = 'zerocatch'; redvase_ad.kind = 'popunders'; redvase_ad.content = 'pop'; redvase_ad.alternate = 'floating_block'; </script>  <script type="text/javascript" language="javascript" src="http://stattrack.0catch.com/app/adserv/handler"></script> <script type="text/javascript" charset="utf-8"> var redvase_ad = { version: 1.5 }; redvase_ad.publisher = 'zerocatch'; redvase_ad.kind = 'zerocatch_tips_tricks_newsletter'; redvase_ad.content = 'creative' </script> <script src="http://redvase.bravenet.com/javascripts/redvase.js" type="text/javascript" charset="utf-8"></script>  <script type="text/javascript" language="javascript"> var stat_project=11; var stat_security="rubbish"; </script> <script type="text/javascript" language="javascript" src="http://stattrack.0catch.com/stat.js"></script> <noscript><a href="http://stattrack.0catch.com/" target="_blank"><img src="http://stattrack.0catch.com/app/track/handler?user=11&key=rubbish" alt="StatTrack" border="0"></a> </noscript>  </noscript></div></xmp></style> <style type="text/css">  </style>  <center> <table border="0" cellspacing="0" cellpadding="0"> <tr> <td bgcolor="#ffffff"><center><font color="BLUE" size=-1> <a href="http://www.0catch.com" target="_blank" rel="nofollow">web space</a> | <a href="http://www.0catch.com" target="_blank" rel="nofollow">free hosting</a> | <a href="http://www.bluefishhosting.com" target="_blank" rel="nofollow">Business Web Hosting</a> | <a href="http://submitsolution.com/freesitesubmission.php" rel="nofollow">Free Website Submission</a> | <a href="http://www.qccart.com" rel="nofollow">shopping cart</a> | <a href="http://www.bluehost.com" rel="nofollow">php hosting</a><br /> </font></center> </td></tr> </table> </center> <table border="0" cellspacing="1" cellpadding="1"> <tr> <td align="left"><a href="http://0catch.com" target="_blank"><img src="http://0catch.com/freewebsite.png" border="0" /></a></td> <td align="center"> <IFRAME FRAMEBORDER=0 MARGINWIDTH=0 MARGINHEIGHT=0 SCROLLING=NO WIDTH=728 HEIGHT=90 SRC="http://rm.yieldmanager.com/st?ad_type=iframe&ad_size=728x90,468x60&section=7790"></IFRAME>   <SCRIPT TYPE="text/javascript" SRC="http://rm.yieldmanager.com/st?ad_type=pop&ad_size=0x0&section=7790&banned_pop_types=27&pop_times=1&pop_frequency=86400"></SCRIPT> </td></tr><tr><td colspan="2" align="center"><script type="text/javascript"> rnd = (new String(Math.random())).substring(2,8) + (((new Date()).getTime()) & 262143); ad_par = 13100; sb_size = ''; sb_button = ''; sb_image = ''; rs_logo = 'http://www.armadasearch.com/arm_logos/logo-blue.jpg'; rs_theme = 'coolSteel'; rs_tmp = ''; rs_type = 'basic'; document.write('<scri' + 'pt type="text/javascript" src="http://adunit.adrevmedia.com/search.js?' + rnd + '"></scr' + 'ipt>'); </script> </td></tr></table><!POP YES 1 0catch 1257673274-0 visited=11%2F08%2F2009; visited=11%2F08%2F2009; visited=11%2F08%2F2009; visited=11%2F08%2F2009; visited=11%2F08%2F2009><table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" colspan=2 height=100 BGCOLOR="#CCCCFF" TEXT="#080000" bgproperties="fixed" background="04300640egdysm.jpg"> <div> <FONT SIZE="5" COLOR="#000066" FACE="Arial" ><B>breast pathology</B></FONT><FONT SIZE="5" COLOR="#000099" FACE="Arial" ><B> </B></FONT><B>    |     </B><A HREF="default.htm" TARGET="_top" TITLE="breast pathology"><U><B>home</B></U></A></div> <div> <A HREF="id25.htm" TARGET="_top" TITLE="anatomy review"><U>anatomy review</U></A>   |   <A HREF="id17.htm" TARGET="_top" TITLE="histology review"><U>histology review</U></A>   |   <A HREF="id18.htm" TARGET="_top" TITLE="physiology review"><U>physiology review</U></A>   |   <A HREF="id19.htm" TARGET="_top" TITLE="breast pathology"><U>breast pathology</U></A>   |   <A HREF="id26.htm" TARGET="_top" TITLE="to resume chart"><U>to resume chart</U></A>   |   <A HREF="id20.htm" TARGET="_top" TITLE="pictures"><U>pictures</U></A>   |   <A HREF="id21.htm" TARGET="_top" TITLE="breast exploration"><U>breast exploration</U></A>   |   <A HREF="id22.htm" TARGET="_top" TITLE="breast treatment and pronostic"><U>breast treatment and pronostic</U></A>   |   <B>breast cancer screening</B>   |   <A HREF="id23.htm" TARGET="_top" TITLE="Contact Me"><U>Contact Me</U></A>   |   <A HREF="id28.htm" TARGET="_top" TITLE="for more reading"><U>for more reading</U></A>   |   <A HREF="id24.htm" TARGET="_top" TITLE="Related Links"><U>Related Links</U></A></div> <div> </div> </td> </tr><tr> <td valign="top" width=200 BGCOLOR="#0000BF" TEXT="#F7F7FF"> <div> <B>  <SCRIPT language=JavaScript src="http://counter.mycomputer.com/get_counter.html?u=dhammoud&c=1"> </SCRIPT> <NOSCRIPT> <a href="http://counter.mycomputer.com/"><img alt="Counter" src="http://counter.mycomputer.com/c.count?u=dhammoud&c=1" border=0></a> </NOSCRIPT>  <p align="center"><a href="http://www.funone.com/"><img src="wolf.gif" alt="The Official Home Of FUN!" border="2" width="131" height="175"></a></p> <p align="center"><a href="http://www.funone.com/"><img src="skel.gif" alt="The Official Home Of FUN!" border="2" width="157" height="175"></a></p>  </B></div> <bR> <div> <A HREF="id25.htm" TARGET="_top" TITLE="anatomy review"><U><B>anatomy review</B></U></A></div> <div> <A HREF="id17.htm" TARGET="_top" TITLE="histology review"><U><B>histology review</B></U></A></div> <div> <A HREF="id18.htm" TARGET="_top" TITLE="physiology review"><U><B>physiology review</B></U></A></div> <div> <A HREF="id19.htm" TARGET="_top" TITLE="breast pathology"><U><B>breast pathology</B></U></A></div> <div> <A HREF="id26.htm" TARGET="_top" TITLE="to resume chart"><U><B>to resume chart</B></U></A></div> <div> <A HREF="id20.htm" TARGET="_top" TITLE="pictures"><U><B>pictures</B></U></A></div> <div> <A HREF="id21.htm" TARGET="_top" TITLE="breast exploration"><U><B>breast exploration</B></U></A></div> <div> <A HREF="id22.htm" TARGET="_top" TITLE="breast treatment and pronostic"><U><B>breast treatment and pronostic</B></U></A></div> <div> <B>breast cancer screening</B></div> <div> <A HREF="id23.htm" TARGET="_top" TITLE="Contact Me"><U><B>Contact Me</B></U></A></div> <div> <A HREF="id28.htm" TARGET="_top" TITLE="for more reading"><U><B>for more reading</B></U></A></div> <div> <A HREF="id24.htm" TARGET="_top" TITLE="Related Links"><U><B>Related Links</B></U></A></div> <div> <B><IMG SRC="1d996680.gif" border=0 width="150" height="104" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B><IMG SRC="196e8a70.gif" border=0 width="232" height="167" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B> <img src="HTMLobj-407/aniGif.gif" border="0" align="bottom" width="144" height="140">  </B></div> <div> <B> <img src="HTMLobj-419/aniGif.gif" border="0" align="bottom" width="150" height="124">   <img src="HTMLobj-420/aniGif.gif" border="0" align="bottom" width="93" height="149">  <IMG SRC="1bacb2a0.gif" border=0 width="203" height="298" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B><IMG SRC="19d06660.jpg" border=0 width="262" height="358" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="198c0fa0.jpg" border=0 width="192" height="250" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="199c6fa0.jpg" border=0 width="198" height="250" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="19ac7910.jpg" border=0 width="199" height="145" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="19b94950.jpg" border=0 width="148" height="149" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="19c06660.jpg" border=0 width="262" height="358" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> </td> <td valign="top" height=380 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <I>breast cancer screening</I></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Breast cancer is the most common form of cancer in women. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">There are 200,000 new cases of breast cancer each year, resulting in 47,000 deaths per year.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The lifetime risk of breast cancer is one in eight for a woman who is age 20.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> For patients under age 60, the chance of being diagnosed with breast cancer is 1  in about 400 in a given year.</div> <div> <B><IMG SRC="1a596610.gif" border=0 width="150" height="97" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B>Fibrocystic change - macro Epithelial Hyperplasia</div> <div> <B><IMG SRC="1a692fe0.gif" border=0 width="402" height="254" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">fibroadenoma<IMG SRC="1a7a89c0.jpg" border=0 width="168" height="156" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="1a887870.jpg" border=0 width="135" height="135" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="1a9d09e0.jpg" border=0 width="208" height="158" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B>this is shown nicely in the picture on the right; the node is labeled with an "<B>N</B>" and the afferent lymphatic which drains the <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> into this lymph node is labeled with an "<B>L</B>"). </div> <div> <B><IMG SRC="1aa986f0.jpg" border=0 width="152" height="111" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="1abb27a0.jpg" border=0 width="178" height="122" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">notice the size difference<IMG SRC="1ac7b8c0.jpg" border=0 width="123" height="140" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="1ada9610.jpg" border=0 width="169" height="97" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="1ae5e9e0.jpg" border=0 width="94" height="158" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="1afbe860.jpg" border=0 width="190" height="134" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="0f7b3be0.gif" border=0 width="179" height="190" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="1b1d8960.jpg" border=0 width="216" height="150" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="1b29f6e0.jpg" border=0 width="159" height="110" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="1b3dd8c0.jpg" border=0 width="221" height="140" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="1b46e760.jpg" border=0 width="110" height="118" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="1b56e5f0.jpg" border=0 width="110" height="95" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="1b6aad20.gif" border=0 width="170" height="210" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="1b7c8a40.gif" border=0 width="200" height="164" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="1b8776e0.jpg" border=0 width="119" height="110" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="1b9a5bd0.gif" border=0 width="165" height="189" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">some flap used during the reconstructive part</B></div> <bR> <bR> <div> <B><IMG SRC="1d736440.jpg" border=0 width="566" height="836" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B><IMG SRC="1d8901a0.gif" border=0 width="400" height="282" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="1da00000.jpg" border=0 width="512" height="512" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="1db8afc0.jpg" border=0 width="394" height="508" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <bR> <div> <B>Patient Age</B></div> <div> <B>The likelihood of certain conditions depends mainly upon age. Most </B><B>breast</B><B> disorders whether benign or malignant can occur in women of any age, but certain patterns are well known:</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">15 - 30: fibroadenomas (benign)</B><FONT SIZE="3" COLOR="#FF0000" FACE="Arial" ><B> </B></FONT></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">30 - 45: fibrocystic changes (benign)</B><FONT SIZE="3" COLOR="#FF0000" FACE="Arial" ><B> </B></FONT></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">45 - menopause : </B><B>breast</B><B> cysts (benign)</B><FONT SIZE="3" COLOR="#FF0000" FACE="Arial" ><B> </B></FONT></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">After menopause: </B><B>cancer</B><B> more likely</B><FONT SIZE="3" COLOR="#FF0000" FACE="Arial" ><B> </B></FONT></div> <bR> <bR> <div> <B>I. Pathophysiology</B></div> <bR> <div> <B>A. </B><FONT SIZE="3" COLOR="#FF0000" FACE="Arial" >The etiology of breast cancer remains unknown, </FONT></div> <div> but two breast cancer genes have been cloned?</div> <div> the BRCA-1 and the BRCA-2 genes. </div> <div> Only 10% of all of the breast cancers can be explained by mutations in these genes.</div> <bR> <div> <FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B>B.</B></FONT><B> </B><B>Estrogen stimulation is an important promoter of breast cancer. </B></div> <div> <B>Early menarche and late menopause are risk factors for breast cancer. </B></div> <div> <B>Late age at birth of first child or nulliparity also increase the risk of breast cancer.</B></div> <bR> <bR> <bR> <div> <B>C. </B>Family history of breast cancer in a first degree relative and history of benign breast disease also increase the risk of breast cancer.</div> <div> <B>Recommended Intervals for Breast Cancer Screening Studies</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Age                                        <40 yr                                            40-49 yr                                50-75 yr</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Breast Self-</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Examination                    </B>Monthly by age 30                         Monthly                                     Monthly</div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Professional</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Breast Examination       </B>Every 3 yr,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">                                            ages 20-39</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">                                                                                                        Annually                                 Annually</div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Mammography,</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Low Risk Patient                                                                        </B>Annually                                  Annually</div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Mammography,</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">High Risk Patient            </B>Begin at 35 yr                                   Annually                                  Annually</div> <bR> <bR> <div> MANAGEMENT OF A MAMMOGRAPHICALLY SUSPICIOUS, NON-PALPABLE LESION. A negative core or FNA should not dissuade biopsy of a mammographically highly suspicious lesion, particularly a spiculated or stellate mass. Conversely, abnormalities that can be <I>safely followed mammographically </I>are not biopsied<I>.</I></div> <div> Method of biopsy depends on available facilities. The various<B> biopsy methods</B> are as follows:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Needle-directed (guide wire directed) excisional biopsy </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The gold standard </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Facilities are widely available </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Most invasive method </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Questionable area is completely excised or at least extensively sampled </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Core needle biopsy </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Tissue obtained via a 14 gauge needle is interpretable by widely available pathologists </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Less invasive than needle-directed excisional biopsy but more so than fine needle aspiration </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The lesion is followed if the biopsy is benign and </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">unless it is mammographically very suspicious </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">or if the patient desires removal </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A cancer may be underdiagnosed because the lesion is not removed </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Fine needle aspiration </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Least traumatic since the sample is obtained via a 23 gauge needle </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Sample interpretation requires specialized expertise </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The lesion is followed if the biopsy is benign and </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">unless it is mammographically very suspicious </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">or if the patient desires removal </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A cancer may be underdiagnosed because the lesion is not removed </div> <div> <B>Localization</B> can be obtained either stereotaxically or by ultrasound</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Stereotaxic localization </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Requires special equipment and is time consumming </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Almost all mammographically identified lesions, including microcalcifications can be localized </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">If biopsies are done, each biopsy of the lesion requires a separate puncture </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Ultrasound localization </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Equipment is widely available and localization takes little time </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Not all lesions seen on mammograms can be visualized with ultrasound </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Imaging is in real time so the needle can be seen to actually enter the lesion </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Multiple areas of the lesion can be sampled through the same puncture </div> <div> <B>Comments:</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Non-mass lesions consisting of fewer than 30 microcalcifications are most reliably treated by needle-directed excisional biopsy unless all are removed because the sensitivity is about 85% in such instances. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Contrast usually is taken up and disappears rapidly from breast cancers which can distinguish cancers from benign lesions on MRI. Biopsy can be avoided in most lesions that are not rapidly enhancing on MRI. </div> <div> <B>Algorithm:</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Mass seen on ultrasound </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Simple cyst. Mammogram in one year or aspirate. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cyst with debris. Aspirate for cytology </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Solid. FNA </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Unsatisfactory. Core or surgical excision. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Benign. Repeat ultrasound in 3 months and ultrasound or mammogram in 1 and 2 years unless patient wants it excised. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Malignant. Surgical excision. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Mass not seen on ultrasound. Stereotaxic core or surgical excision. Mammogram in 6, 12, and 24 months if the core is benign. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Calcifications </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Fewer than 30. Surgical excision unless all can be removed by multiple stereotaxic cores. (note: sensitivity of 85% is reported for the usual stereotaxic biopsy.) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">30 or more calcifications. Stereotaxic core. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Architectural distortion. Surgical excision. </div> <div> Note:</div> <div> 1. Lesions diagnosed as atypical hyperplasia on core biopsy should be surgically excised. </div> <div> 2. Lesions diagnosed as in situ cancer should be surgically excised and histologically examined to determine if there is an invasive element. </div> <div> <B><IMG SRC="22e2ec20.gif" border=0 width="558" height="450" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="22f2cc80.gif" border=0 width="556" height="456" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="23033c80.gif" border=0 width="563" height="456" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="23120be0.gif" border=0 width="544" height="446" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="22d60e00.gif" border=0 width="608" height="480" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">peau d'orange<IMG SRC="2326efd0.gif" border=0 width="622" height="253" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">way of the peau dorange formation every thing is in the understanding the anatomy</B></div> <div> <B><IMG SRC="2335e0b0.jpg" border=0 width="350" height="267" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="2342c470.jpg" border=0 width="300" height="327" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="23512460.jpg" border=0 width="274" height="326" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="236991b0.jpg" border=0 width="409" height="283" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="2378efc0.jpg" border=0 width="398" height="252" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="2385d500.jpg" border=0 width="349" height="336" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="239902f0.jpg" border=0 width="400" height="303" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="23a72100.jpg" border=0 width="370" height="272" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="23b880f0.jpg" border=0 width="392" height="271" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B><IMG SRC="23c58410.jpg" border=0 width="600" height="321" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">before and after treatment</B></div> <bR> <div> <B>II. Diagnosis and evaluation</B></div> <bR> <bR> <div> <B>A. Clinical evalua</B>t<B>ion of a breast mass </B></div> <div> should assess </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">the duration of the lesion,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> associated pain, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">relationship to the menstrual cycle or exogenous</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">hormone use, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">and change in size since discovery. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The presence of nipple discharge and its character</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> bloody </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">or tea-colored, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">unilateral or bilateral,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">spontaneous or expressed) should be assessed.</div> <bR> <bR> <div> <B>B. Menstrual history. </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The date of last menstrual period, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">age of menarche,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">age of menopause </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">or surgical removal of the ovaries, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">regularity of the menstrual cycle,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> previous pregnancies,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> age at first pregnancy, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">lactation history should be determined.</div> <bR> <bR> <div> <B>C. History of previous breast biopsies, </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">breast cancer, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">or cyst aspiration</div> <div> should be investigated. </div> <div> Previous or current hormone replacement therapy</div> <bR> <bR> <bR> <div> <B> Breast Cancer Screening</B></div> <div> and dates and results of previous mammograms should be ascertained.</div> <bR> <bR> <div> <B>D. Family history </B>should document breast cancer in relatives and the age</div> <div> at which family members were diagnosed.</div> <bR> <bR> <bR> <div> <B>III.Physical examination[see self examination on breast exploration]</B></div> <bR> <div> <B>A. </B>The breasts should be inspected for </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">asymmetry,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> deformity, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">skin retraction,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">erythema, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">peau d'orange (indicating breast edema), </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">and nipple retraction,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">discoloration,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> or inversion.</div> <bR> <bR> <div> <B>B. Palpation</B></div> <bR> <div> <B>1. </B>The breasts should be palpated while the patient is sitting and then supine with the ipsilateral arm extended. </div> <div> The entire breast should be palpated systematically.</div> <bR> <bR> <div> <B>2. </B>The mass should be evaluated for </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">size, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">shape, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">texture,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> tenderness,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">and fixation to skin or chest wall. </div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The location of the mass should be documented with a diagram in the chart. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The nipples should be expressed to determine whether discharge can be induced. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Nipple discharge should be evaluated for single or multiple ducts, color, and any associated mass.</div> <bR> <bR> <bR> <div> <B>3. </B>The axillae should be palpated for adenopathy. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Enlarged lymph nodesshould be assessed for </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">size,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> number, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">and fixation. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The supraclavicular and cervical nodes should also be assessed.</div> <bR> <bR> <div> <B>IV.Breast imaging[see in exploration for the details]</B></div> <bR> <div> <B>A. Mammography</B></div> <bR> <div> <B>1. Screening mammography</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> </B>is performed in the asymptomatic patient  and consists of two views.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Patients are not examined by a,mammographer.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Screening mammography reduces mortality from breast cancer and should usually be initiated at age 40.</div> <bR> <bR> <div> <B>2. Diagnostic mammography </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">is performed after a breast mass has been detected.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Patients usually are examined by a mammographer, and films are interpreted immediately and additional views of the lesion are completed.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Mammographic findings predictive of malignancy include spiculated masses with architectural distortion and microcalcifications.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> A normal mammography in the presence of a palpable mass does not exclude malignancy.</div> <bR> <bR> <div> <B>B. Ultrasonography </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">is used as an adjunct to mammography to differentiate solid from cystic masses.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> It is the primary imaging modality in patients younger than 30 years old.</div> <bR> <bR> <bR> <div> <B>V. Methods of breast biopsy</B></div> <bR> <bR> <div> <B>A. Stereotactic core needle biopsy</B>.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Using a computer-driven stereotactic unit,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> the lesion is localized in three dimensions, and an automated biopsy needle obtains samples. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The sensitivity and specificity of this technique are 95-100% and 94-98%, respectively.</div> <bR> <bR> <div> <B>B. Palpable masses. Fine-needle aspiration biopsy (FNAB) </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">has a sensitivity ranging from 90-98%. Nondiagnostic aspirates require surgical biopsy.</div> <bR> <div> <B>1. </B>The skin is prepped with alcohol and the lesion is immobilized with the nonoperating hand. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A 10 mL syringe, with a 18 to 22 gauge needle, is introduced in to the central portion of the mass at a 90? angle.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> When the needle enters the mass, suction is applied by retracting the plunger, and the needle is advanced. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The needle is directed into different areas of the mass while maintaining suction on the syringe.</div> <bR> <bR> <div> <B>2. </B>Suction is slowly released before the needle is withdrawn from the mass. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The contents of the needle are placed onto glass slides for pathologic examination.</div> <bR> <bR> <bR> <bR> <div> <B>Breast Cysts </B></div> <bR> <div> <B>C. Nonpalpable lesions</B></div> <bR> <bR> <div> <B>1. Needle localized biopsy</B></div> <div> <B>a. </B>Under mammographic guidance, a needle and hookwire are placed into the breast parenchyma adjacent to the lesion. </div> <div> The patient is  t aken to the operating room along with mammograms for an  excisional breast biopsy.</div> <bR> <bR> <div> <B>b. </B>The skin and underlying tissues are infiltrated with 1% lidocaine with epinephrine.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> For lesions located within 5 cm of the nipple, a periareolar incision may be used or use a curved incision located over the mass and parallel to the areola. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The skin and subcutaneous fat are incised, then the lesion is palpated and the mass is excised.</div> <bR> <bR> <div> <B>c. </B>After removal of the specimen, a specimen x-ray is performed to confirm that the lesion has been removed.</div> <div>  The specimen can then be sent fresh for pathologic analysis.</div> <bR> <bR> <div> <B>d. </B>The subcutaneous tissues should be closed with a 4-0 chromic catgut suture, and the skin should be closed with 4-0 subcuticular suture.</div> <bR> <bR> <bR> <div> <B>Breast Cysts</B></div> <bR> <bR> <div> <B>I. Clinical evaluation</B></div> <bR> <bR> <div> <B>A. </B>A breast cyst is palpable as a smooth, mobile, well-defined mass.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> If thecyst is tense, the texture may be very f irm, resembling a cancer.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Aspiration will determine whether the lesion is solid or cystic.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Breast cyst fluid may vary from straw-colored to dark green. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cytology is not routinely necessary. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The cyst should be aspirated completely.</div> <bR> <bR> <div> <B>B. </B>If a mass remains after drainage or if the fluid is bloody, excisional biopsy is indicated. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">If no palpable mass is felt after drainage, the patient should be reexamined in 3-4 weeks to determine whether the cy st recurs.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Recurrent cysts can be re-aspirated.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Repeated recurrence of the cyst requires an open biopsy to exclude intracystic tumor.</div> <bR> <bR> <bR> <div> <B>C. Nonpalpable cysts.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> </B>If the cyst wall is seen clearly seen on ultrasound and there is no interior debris or intracystic tumor, these simple cysts do not need to be aspirated. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Any irregularity of the cyst wall or debris within the cyst requires a needle localized biopsy.</div> <bR> <bR> <bR> <div> <B>Fibroadenomas</B></div> <bR> <bR> <div> <B>I. Clinical evaluation</B></div> <bR> <bR> <div> <B>A. </B>Fibroadenomas frequently present in young women as </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">firm,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> smooth,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">lobulated masses that are highly mobile. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">They have a benign appearance on mammography and are solid by ultrasound.</div> <bR> <bR> <div> <B>B. </B>A tissue diagnosis can be obtained by fine needle aspiration biopsy or excisional biopsy.</div> <bR> <bR> <div> <B>II. Management of fibroadenomas</B></div> <bR> <div> <B>A. </B>Fibroadenomas may be followed conservatively after the diagnosis has been made. If the mass grows, it should be excised.</div> <div> <B>B. </B>Large fibroadenomas (>2.5 cm) should usually be excised. Often</div> <bR> <bR> <div> <B> Breast Cancer</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">fibroadenomas will grow in the presence of hormonal stimulation, such as pregnancy.</div> <bR> <div> <B>Breast Cancer</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The initial management of the breast cancer patient consists of assigning a clinical stage based on examination.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The stage may be altered once the final pathology of the tumor has been determined. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Staging of breast cancer is based on the TNM staging system.</div> <bR> <bR> <div> <B>I. Preoperative staging in stage I and II breast cancer.</B></div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> </B>Preoperative workup should include a</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> CBC, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">SMA18, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">and chest x-ray.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> If elevated alkaline phosphatase or hypercalcemia is present, a bone scan should be completed.</div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Abnormal liver function tests should be investigated with a CT scan of the liver.</div> <div> <B>Ameri</B><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>Stages of </U></FONT><FONT SIZE="3" COLOR="#800000" FACE="Arial" ><U>breast cancer</U></FONT><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U>Carcinoma in situ</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U>Stage I</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U>Stage II</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U>Stage III</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U>Stage IV</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U>Inflammatory </U><FONT SIZE="3" COLOR="#800000" FACE="Arial" ><U>breast cancer</U></FONT><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U>Recurrent</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <div>  <A NAME="6"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>STAGE EXPLANATION</div> <bR> <div> <B> <A NAME="7"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B><B>Stages of </B><FONT SIZE="3" COLOR="#800000" FACE="Arial" ><B>breast</B></FONT><B> </B><FONT SIZE="3" COLOR="#800000" FACE="Arial" ><B>cancer</B></FONT> </div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Once <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >cancer</FONT> has been found, more tests will be done to find out if the <FONT SIZE="3" COLOR="#800000" FACE="Arial" >cancer</FONT> has spread from the <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> to other parts of the body.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> This is called <FONT SIZE="3" COLOR="#800000" FACE="Arial" >staging</FONT>. To plan treatment, a doctor needs to know the stage of the disease. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The following stages are used for <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >cancer</FONT>. </div> <bR> <div> <B> <A NAME="8"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B><B>Carcinoma in situ</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">About 15% to 20% of <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >cancer</FONT>s are very early <FONT SIZE="3" COLOR="#800000" FACE="Arial" >cancer</FONT>s. They are sometimes called carcinoma in situ. There are two types of <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >cancer</FONT> in situ.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> One type is ductal carcinoma in situ (DCIS; also known as intraductal carcinoma); the other type is lobular carcinoma in situ (LCIS). LCIS is not <FONT SIZE="3" COLOR="#800000" FACE="Arial" >cancer</FONT>, but for the purpose of classifying the disease, it is called <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >cancer</FONT> in situ, carcinoma in situ, or stage 0 <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >cancer</FONT>. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Sometimes LCIS is found when a biopsy is done for another lump or abnormality found on the mammogram.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Patients with this condition have a 25% chance of developing <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >cancer</FONT> in either <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> in the next 25 years. </div> <bR> <div> <B> <A NAME="9"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B><B>Stage I</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The <FONT SIZE="3" COLOR="#800000" FACE="Arial" >cancer</FONT> is no larger than 2 centimeters (about 1 inch) and has not spread outside the <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT>. </div> <bR> <div> <B> <A NAME="10"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B><B>Stage II</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Any of the following may be true: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The <FONT SIZE="3" COLOR="#800000" FACE="Arial" >cancer</FONT> is no larger than 2 centimeters but has spread to the lymph</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">nodes under the arm (the axillary lymph nodes). </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The <FONT SIZE="3" COLOR="#800000" FACE="Arial" >cancer</FONT> is between 2 and 5 centimeters (from 1 to 2 inches). The <FONT SIZE="3" COLOR="#800000" FACE="Arial" >cancer</FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">may or may not have spread to the lymph nodes under the arm. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The <FONT SIZE="3" COLOR="#800000" FACE="Arial" >cancer</FONT> is larger than 5 centimeters (larger than 2 inches) but has</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">not spread to the lymph nodes under the arm. </div> <bR> <div> <B> <A NAME="11"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B><B>Stage III</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Stage III is divided into stages IIIA and IIIB. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Stage IIIA is defined by either of the following: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The <FONT SIZE="3" COLOR="#800000" FACE="Arial" >cancer</FONT> is smaller than 5 centimeters and has spread to the lymph nodes</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">under the arm, and the lymph nodes are attached to each other or to</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">other structures. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The <FONT SIZE="3" COLOR="#800000" FACE="Arial" >cancer</FONT> is larger than 5 centimeters and has spread to the lymph</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">nodes under the arm. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Stage IIIB is defined by either of the following: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The <FONT SIZE="3" COLOR="#800000" FACE="Arial" >cancer</FONT> has spread to tissues near the <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> (skin or chest wall,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">including the ribs and the muscles in the chest). </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The <FONT SIZE="3" COLOR="#800000" FACE="Arial" >cancer</FONT> has spread to lymph nodes inside the chest wall along the <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">bone. </div> <bR> <div> <B> <A NAME="12"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B><B>Stage IV</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The <FONT SIZE="3" COLOR="#800000" FACE="Arial" >cancer</FONT> has spread to other organs of the body, most often the bones, lungs, liver, or brain.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Or, tumor has spread locally to the skin and lymph nodes inside the neck, near the collarbone. </div> <bR> <div> <B> <A NAME="13"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B><B>Inflammatory </B><FONT SIZE="3" COLOR="#800000" FACE="Arial" ><B>breast</B></FONT><B> </B><FONT SIZE="3" COLOR="#800000" FACE="Arial" ><B>cancer</B></FONT> </div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Inflammatory <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >cancer</FONT> is a special class of <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >cancer</FONT> that is rare. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> looks as if it is inflamed because of its red appearance and warmth.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The skin may show signs of ridges and wheals or it may have a pitted appearance. Inflammatory <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >cancer</FONT> tends to spread quickly. </div> <bR> <div> <B> <A NAME="14"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B><B>Recurrent</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Recurrent disease means that the <FONT SIZE="3" COLOR="#800000" FACE="Arial" >cancer</FONT> has come back (recurred) after it has been treated. It may come back in the <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT>, in the soft tissues of the chest (the chest wall), or in another part of the body. </div> <bR> <div> <B>c</B><FONT SIZE="3" COLOR="#800080" FACE="Arial" ><B>Stages</B></FONT><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> Stage 1 </div> <div> Tumor <=2 cm with no lymph node metastasis </div> <div> Stage 2 </div> <div> Tumor >2 cm or positive lymph nodes </div> <div> Stage 3 </div> <div> <FONT SIZE="3" COLOR="#000000" FACE="Arial" >Locally advanced </FONT><U>Breast</U><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U> </U></FONT><U>Cancer</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > (Skin or Chest wall) </FONT></div> <div> Stage 4 </div> <div> <FONT SIZE="3" COLOR="#000000" FACE="Arial" >Metestatic </FONT><U>Breast</U><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U> </U></FONT><U>Cancer</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > (Lung, Liver, Bones, Brain) </FONT></div> <div> <B>Prognosis</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> Stage 1: </div> <div> Five year survival: 90% </div> <div> Stage 2 </div> <div> Five year survival: <60% </div> <div> Seven Year survival </div> <div> One to three Nodes Positive: 60% </div> <div> Over 3 Nodes Positive: 38% </div> <div> <B>an Joint Committee on Cancer TNM staging for breast cancer</B></div> <div> <B>Methods</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> Axillary Node dissection </div> <div> Conventional <FONT SIZE="3" COLOR="#800000" FACE="Arial" >staging</FONT> procedure </div> <div> Complications </div> <div> Numbness in axillae </div> <div> Hand and arm <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>Lymphedema</U></FONT> (may be severe) </div> <div> <U>Sentinel Node </U><FONT SIZE="3" COLOR="#800000" FACE="Arial" ><U>Breast</U></FONT><U> Biopsy</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <div> <B>Major Risk Factors</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> Female Gender: 75% have no other known risk factors </div> <div> Age related <FONT SIZE="3" COLOR="#800000" FACE="Arial" ><U>Breast</U></FONT><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U> </U></FONT><FONT SIZE="3" COLOR="#800000" FACE="Arial" ><U>Cancer</U></FONT> <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>Incidence</U></FONT> in women </div> <div> Age 25 years = 1:19608 risk </div> <div> Age 30 years = 1:2525 risk </div> <div> Age 35 years = 1:622 risk </div> <div> Age 40 years = 1:217 risk </div> <div> Age 45 years = 1:93 risk </div> <div> Age 50 years = 1:50 risk </div> <div> Age 55 years = 1:33 risk </div> <div> Age 60 years = 1:24 risk </div> <div> Age 65 years = 1:17 risk </div> <div> Age 70 years = 1:14 risk </div> <div> Age 75 years = 1:11 risk </div> <div> Age 80 years = 1:10 risk </div> <div> Age 85 years = 1:9 risk </div> <div> Lifetime = 1:8 risk </div> <bR> <bR> <bR> <div> <B>Other Risk Factors</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <FONT SIZE="3" COLOR="#000000" FACE="Arial" >History of </FONT><U>Breast</U><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U> </U></FONT><U>Cancer</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> Personal History </div> <div> Inversely related to Age </div> <div> Risk: 0.5% - 1% per year for at least 15 years </div> <div> Family History relative risk </div> <div> First Degree relative: 2.3 relative risk </div> <div> Unilateral/Postmenopause: 1.2 relative risk </div> <div> Unilateral/Premenopause: 1.8 relative risk </div> <div> Bilateral/Postmenopause: 4.0 relative risk </div> <div> Bilateral/Premenopause: 8.8 relative risk </div> <div> Second Degree relative: 1.5 relative risk </div> <div> Mother and Sister affected: 14.0 relative risk </div> <div> References </div> <div> <I>Sattin (1985) JAMA 253 </I></div> <bR> <div> <I>Parity </I></div> <div> <I>Age at first birth </I></div> <div> <I>Age at first birth <20 years: 1.0 relative risk </I></div> <div> <I>Age at first birth 20-24 years: 1.2 relative risk </I></div> <div> <I>Age at first birth 25-29 years: 1.6 relative risk </I></div> <div> <I>Age at first birth 30-35 years: 1.9 relative risk </I></div> <div> <I>Age at first birth >35 years: 2.4 relative risk </I></div> <div> <I>Nulliparous: 2.0 relative risk </I></div> <div> <I>Hyperplasia on </I><FONT SIZE="3" COLOR="#800000" FACE="Arial" ><I>Breast</I></FONT><I> Biopsy </I></div> <div> <I>Fibrocystic </I><FONT SIZE="3" COLOR="#800000" FACE="Arial" ><I>breast</I></FONT><I> changes: No increased risk </I></div> <div> <I>Hyperplasia </I></div> <div> <I>No atypia: 2.0 relative risk </I></div> <div> <I>Atypia (4% </I><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><I><U>Incidence</U></I></FONT><I>): 5.0 relative risk </I></div> <bR> <bR> <div> <I><B>Special Topics</B></I><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><I> </I></FONT></div> <div> <I><U>Estrogen Replacement</U></I><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><I> Therapy (>5 years of use) </I></FONT></div> <div> <I>Risk increased by 40% (1.4 relative risk) </I></div> <div> <I>Alcohol may increase risk (limit to 1 drink/month) </I></div> <div> <I>Reference </I></div> <div> <I>Colditz (1995) New Eng J Med 332:1589-93</I><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><I> </I></FONT></div> <div> <I><U>Oral Contraceptive</U></I><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><I>s </I></FONT></div> <div> <FONT SIZE="3" COLOR="#000000" FACE="Arial" ><I>No (or minimal) increased </I></FONT><I><U>Breast</U></I><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><I><U> </U></I></FONT><I><U>Cancer</U></I><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><I> risk </I></FONT></div> <div> <I>Reference </I></div> <div> <I>Swanson (1992) J Amer Med Women's Assoc 47:140-8</I><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><I> </I></FONT></div> <div> <I>Elective Abortion </I></div> <div> <FONT SIZE="3" COLOR="#000000" FACE="Arial" ><I>No increased risk of </I></FONT><I><U>Breast</U></I><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><I><U> </U></I></FONT><I><U>Cancer</U></I><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><I> </I></FONT></div> <div> <I>Reference </I></div> <div> <I>Melbye (1997) JAMA 336:81-5</I><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><I> </I></FONT></div> <div> <I><U>Lactation</U></I><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><I> </I></FONT></div> <div> <I>Risk decreases with 2 years of cummulative </I><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><I><U>Lactation</U></I></FONT><I> </I></div> <div> <I>Affects premenopausal risk (not postmenopausal risk) </I></div> <div> <I>Reference </I></div> <div> <I>Newcomb (1994) N Eng J Med 338: 81-7</I><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><I> </I></FONT></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Definitions for classifying the Primary Tumor <B>(T)</B> are the same for clinical and pathologic <FONT SIZE="3" COLOR="#800000" FACE="Arial" >staging</FONT>. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">All measurements refer to the tumor's greatest dimension, and the "cm" in the measurements refers to centimeters. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">For reference: 1 inch = 2.54 cm. </div> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="635" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="79"><div> TX</div> </tD> <tD VALIGN=CENTER WIDTH="541"><div> Primary tumor cannot be assessed</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="79"><div> T0</div> </tD> <tD VALIGN=CENTER WIDTH="541"><div> No evidence of primary tumor</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 38 WIDTH="79"><div> Tis</div> </tD> <tD VALIGN=CENTER WIDTH="541"><div> Carcinoma <I>in situ</I>, intraductal carcinoma (DCIS), lobular carcinoma in situ (LCIS), or Paget's disease of the nipple with no tumor</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="79"><div> T1</div> </tD> <tD VALIGN=CENTER WIDTH="541"><div> Tumor 2 cm (centimeters) or less</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="79"><div> T1a</div> </tD> <tD VALIGN=CENTER WIDTH="541"><div> 0.5 cm or less</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="79"><div> T1b</div> </tD> <tD VALIGN=CENTER WIDTH="541"><div> More than 0.5 cm but not more than 1 cm</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="79"><div> T1c</div> </tD> <tD VALIGN=CENTER WIDTH="541"><div> More than 1 cm but not more than 2 cm</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="79"><div> T2</div> </tD> <tD VALIGN=CENTER WIDTH="541"><div> Tumor more than 2 cm but not more than 5 cm</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="79"><div> T3</div> </tD> <tD VALIGN=CENTER WIDTH="541"><div> Tumor more than 5 cm</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="79"><div> T4</div> </tD> <tD VALIGN=CENTER><NOBR><div> Tumor of any size with direct extension to chest wall or skin</div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="79"><div> T4a</div> </tD> <tD VALIGN=CENTER WIDTH="541"><div> Extension to chest wall</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 38 WIDTH="79"><div> T4b</div> </tD> <tD VALIGN=CENTER WIDTH="541"><div> Edema (including peau d'orange) or ulceration of the skin of the <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> or satellite skin nodules confined to the same <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="79"><div> T4c</div> </tD> <tD VALIGN=CENTER WIDTH="541"><div> Both T4a and T4b</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="79"><div> T4d</div> </tD> <tD VALIGN=CENTER WIDTH="541"><div> Inflammatory carcinoma</div> </tD> </tR> </TABLE></div> <div> Definitions for classifying the Regional Lymph Nodes <B>(N)</B> </div> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="635" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER HEIGHT= 19 ><NOBR><div> NX </div> </NOBR></tD> <tD VALIGN=CENTER><NOBR><div> Regional lymph nodes cannot be assessed (e.g., previously removed)</div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 ><NOBR><div> N0 </div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="598"><div> No regional lymph node metastasis</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 ><NOBR><div> N1 </div> </NOBR></tD> <tD VALIGN=CENTER><NOBR><div> Metastasis to movable axillary lymph node(s) on the same side</div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 38 ><NOBR><div> N2 </div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="598"><div> Metastasis to axillary lymph node(s) on the same side fixed to one another or other structures</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 ><NOBR><div> N3 </div> </NOBR></tD> <tD VALIGN=CENTER><NOBR><div> Metastasis to internal mammary lymph node(s) on the same side</div> </NOBR></tD> </tR> </TABLE></div> <div> Definitions for classifying the Distant Metastasis <B>(M)</B> </div> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="635" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER HEIGHT= 19 ><NOBR><div> MX </div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="599"><div> Presence of distant metastasis cannot be assessed</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 ><NOBR><div> M0 </div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="599"><div> No distant metastasis</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 38 ><NOBR><div> M1 </div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="599"><div> Distant metastasis (includes metastasis to lymph node(s) on the same side, but above the collar bone</div> </tD> </tR> </TABLE></div> <div> The various TNM classifications are then used to describe the various Clinincal stages as follows: </div> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="338" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="139"><div> Stage 0 </div> </tD> <tD VALIGN=CENTER WIDTH="75"><div> Tis </div> </tD> <tD VALIGN=CENTER WIDTH="75"><div> N0 </div> </tD> <tD VALIGN=CENTER WIDTH="24"><div> M0</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="139"><div> Stage I </div> </tD> <tD VALIGN=CENTER WIDTH="75"><div> T1 </div> </tD> <tD VALIGN=CENTER WIDTH="75"><div> N0 </div> </tD> <tD VALIGN=CENTER WIDTH="24"><div> M0</div> </tD> </tR> <tR> <tD VALIGN=CENTER ROWSPAN=3 HEIGHT= 19 WIDTH="139"><div> Stage IIA</div> </tD> <tD VALIGN=CENTER WIDTH="75"><div> T0 </div> </tD> <tD VALIGN=CENTER WIDTH="75"><div> N1 </div> </tD> <tD VALIGN=CENTER WIDTH="24"><div> M0</div> </tD> </tR> <tR> <tD VALIGN=CENTER WIDTH="75"><div> T1 </div> </tD> <tD VALIGN=CENTER WIDTH="75"><div> N1 </div> </tD> <tD VALIGN=CENTER WIDTH="24"><div> M0</div> </tD> </tR> <tR> <tD VALIGN=CENTER WIDTH="75"><div> T2 </div> </tD> <tD VALIGN=CENTER WIDTH="75"><div> N0 </div> </tD> <tD VALIGN=CENTER WIDTH="24"><div> M0</div> </tD> </tR> <tR> <tD VALIGN=CENTER ROWSPAN=2 HEIGHT= 19 WIDTH="139"><div> Stage IIB </div> </tD> <tD VALIGN=CENTER WIDTH="75"><div> T2 </div> </tD> <tD VALIGN=CENTER WIDTH="75"><div> N1 </div> </tD> <tD VALIGN=CENTER WIDTH="24"><div> M0</div> </tD> </tR> <tR> <tD VALIGN=CENTER WIDTH="75"><div> T3 </div> </tD> <tD VALIGN=CENTER WIDTH="75"><div> N0 </div> </tD> <tD VALIGN=CENTER WIDTH="24"><div> M0</div> </tD> </tR> <tR> <tD VALIGN=CENTER ROWSPAN=5 HEIGHT= 19 WIDTH="139"><div> Stage IIIA </div> </tD> <tD VALIGN=CENTER WIDTH="75"><div> T0 </div> </tD> <tD VALIGN=CENTER WIDTH="75"><div> N2 </div> </tD> <tD VALIGN=CENTER WIDTH="24"><div> M0</div> </tD> </tR> <tR> <tD VALIGN=CENTER WIDTH="75"><div> T1 </div> </tD> <tD VALIGN=CENTER WIDTH="75"><div> N2 </div> </tD> <tD VALIGN=CENTER WIDTH="24"><div> M0</div> </tD> </tR> <tR> <tD VALIGN=CENTER WIDTH="75"><div> T2 </div> </tD> <tD VALIGN=CENTER WIDTH="75"><div> N2 </div> </tD> <tD VALIGN=CENTER WIDTH="24"><div> M0</div> </tD> </tR> <tR> <tD VALIGN=CENTER WIDTH="75"><div> T3 </div> </tD> <tD VALIGN=CENTER WIDTH="75"><div> N1 </div> </tD> <tD VALIGN=CENTER WIDTH="24"><div> M0</div> </tD> </tR> <tR> <tD VALIGN=CENTER WIDTH="75"><div> T3 </div> </tD> <tD VALIGN=CENTER WIDTH="75"><div> N2 </div> </tD> <tD VALIGN=CENTER WIDTH="24"><div> M0</div> </tD> </tR> <tR> <tD VALIGN=CENTER ROWSPAN=2 HEIGHT= 19 WIDTH="139"><div> Stage IIIB </div> </tD> <tD VALIGN=CENTER WIDTH="75"><div> T4 </div> </tD> <tD VALIGN=CENTER WIDTH="75"><div> Any N </div> </tD> <tD VALIGN=CENTER WIDTH="24"><div> M0</div> </tD> </tR> <tR> <tD VALIGN=CENTER WIDTH="75"><div> Any T </div> </tD> <tD VALIGN=CENTER WIDTH="75"><div> N3 </div> </tD> <tD VALIGN=CENTER WIDTH="24"><div> M0</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="139"><div> Stage IV </div> </tD> <tD VALIGN=CENTER WIDTH="75"><div> Any T </div> </tD> <tD VALIGN=CENTER WIDTH="75"><div> Any N </div> </tD> <tD VALIGN=CENTER WIDTH="24"><div> M1</div> </tD> </tR> </TABLE></div> <bR> <bR> <div> <B>II. Surgical options for stage I and II breast cancer</B></div> <bR> <div> <B>A. Breast conservation therapy (BCT)</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> </B>has been shown to result in survival   and local recurrence rates equivalent to modified radical mastectomy; therefore, breast conservation is the preferred therapy for stage I and II breast cancer. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The technique includes</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> lumpectomy,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> axillary lymph nodedissection, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">and breast irradiation.</div> <bR> <bR> <div> <B>1. Contraindications to BCT</B></div> <div> <B>a. </B>Contraindications to radiotherapy (ie, prior breast irradiation,ongoing pregnancy)</div> <bR> <div> <B>b. </B>Steroid-dependent collagen vascular disease</div> <bR> <div> <B>c. </B>Tumor-breast ratio that would result in an unacceptable cosmetic result (eg, a large tumor in a small breast)</div> <bR> <div> <B>d. </B>Diffuse, malignant microcalcifications on mammography</div> <bR> <div> <B>e. </B>Tumor greater than 5 cm in diameter</div> <bR> <div> <B>2. Lumpectomy technique.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> </B>Incisions should be curvilinear and parallel with the nipple.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> A gross margin of 1 cm should be removed.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The lumpectomy specimen is given immediately to the pathologist for inking and for an assessment of the gross margins.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Subcutaneous tissue is closed, and the skin is approximated with a subcuticular suture.</div> <bR> <bR> <div> <B>3. </B>Follow-up following BCT consists of a physical examination every 3-4 months for the first 3 years,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> every 6 months for the next 2-3 years,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> then yearly. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A SMA18 and CBC are done at each visit and a chest x-ray is done yearly.</div> <bR> <bR> <div> <B>4. </B>A posttreatment mammography of the treated side is done 6 months after the completion of radiotherapy,  then every 6 months for the first 2 years, </div> <div> followed by annual mammograms.  Yearly mammography should be performed on the opposite breast.</div> <bR> <bR> <div> <B>B. Modified radical mastectomy </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">consists of a total mastectomy and an axillary node dissection. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">In staging axillary lymphadenectomy, levels I and II are removed routinely. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Reconstruction of the breast should be offered to all patients undergoing mastectomy.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Physical examination schedule and blood work are the same as for lumpectomy.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The chest wall should be examined for of recurrence.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Mammography of the opposite breast should continue yearly.</div> <bR> <bR> <div> <B>III.Locally advanced breast cancer (LABC)</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">consists of T3 N0 (stage IIB), IIIA,  and IIIB breast cancer. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">All LABC patients should undergo staging with CBC, SMA18, bone scan, and CT scan of chest and abdomen.</div> <bR> <bR> <div> <B>A. Noninflammatory LABC.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> </B>Multimodality therapy consists of neoadjuvant chemotherapy (ie, given before surgery), </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">modified radical mastectomy, radiotherapy to the chest wall, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">axilla and supraclavicular nodes, and further chemotherapy.</div> <bR> <bR> <div> <B>B. Inflammatory LABC (T4d). </B>Inflammatory breast cancer is characterized by erythema of the skin, skin edema, warmth, tenderness, and an underlying</div> <div> tumor mass.</div> <div>  Treatment requires aggressive multi-modality therapy.</div> <bR> <bR> <div> <B>C. Follow-up. </B>Patients should be followed closely because they are at higher risk of local and distant recurrence.</div> <bR> <bR> <bR> <div> <B>IV.Ductal carcinoma in situ (DClS) </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">consist of Tis, stage 0 lesions. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">These lesions consists of malignant ductal cells that have not penetrated the basement membrane. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">DCIS is a precursor of invasive ductal cancer.</div> <bR> <bR> <div> <B>A. Physical examination </B>is usually normal with DCIS. </div> <div> The most common presentation is suspicious microcalcifications on mammography.</div> <div>  DCIS can cause a nipple discharge or a palpable mass.</div> <bR> <bR> <div> <B>B. Surgical therapy</B></div> <bR> <bR> <div> <B>1. BCT. </B>Lumpectomy and adjuvant radiotherapy are an alternative to mastectomy in well-localized DCIS when negative microscopic margins</div> <div> can be obtained.</div> <bR> <bR> <div> <B>2. Total mastectomy, </B>including removal of the nipple areolar complex and breast tissue, results in survival rates of 98-99%.</div> <div>  An axillary dissection is not done routinely because the chance of nodal involvement is only 1-2%.</div> <bR> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="511" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER BGCOLOR=#00FFFF HEIGHT= 20 WIDTH="248"><div> <B>Free Tissue Flaps</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#00FFFF WIDTH="248"><div> <B>Pedicle Tissue Flaps</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#00FFFF HEIGHT= 57 WIDTH="248"><div> Is cut completely free from its donor site and then moved to a new site near or far.</div> </tD> <tD VALIGN=CENTER BGCOLOR=#00FFFF WIDTH="248"><div> Skin, fat and muscle is cut free from its donor site and moved to near-by area.</div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#00FFFF HEIGHT= 57 WIDTH="248"><div> Blood supply is cut and the arteries and veins are reconnected in the new area.</div> </tD> <tD VALIGN=CENTER BGCOLOR=#00FFFF WIDTH="248"><div> Blood supply is never cut, the flap remains attached to its original site by the blood vessels.</div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#00FFFF HEIGHT= 57 WIDTH="248"><div> Can be moved anywhere on the body that allows re-attachment of the blood supply.</div> </tD> <tD VALIGN=CENTER BGCOLOR=#00FFFF WIDTH="248"><div> Can only be moved as far as the blood supply will allow.</div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#00FFFF HEIGHT= 19 ><NOBR><div> Includes skin, fat, and muscle.</div> </NOBR></tD> <tD VALIGN=CENTER BGCOLOR=#00FFFF><NOBR><div> Includes skin, fat, and muscle.</div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#00FFFF HEIGHT= 57 WIDTH="248"><div> Works very well for <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> reconstruction, can give a very nice result.</div> </tD> <tD VALIGN=CENTER BGCOLOR=#00FFFF WIDTH="248"><div> Works very well for <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> reconstruction, can give a very nice result.</div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#00FFFF HEIGHT= 76 WIDTH="248"><div> Technically a more difficult operation, usually takes longer to perform, only done by surgeons with microvascular training.</div> </tD> <tD VALIGN=CENTER BGCOLOR=#00FFFF WIDTH="248"><div> Not as technically demanding of an operation, can usually be performed a bit quicker.</div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#00FFFF HEIGHT= 57 WIDTH="248"><div> Complications less common, but much more difficult to deal with if they occur.</div> </tD> <tD VALIGN=CENTER BGCOLOR=#00FFFF WIDTH="248"><div> Complication rate is higher, but easier to deal with.</div> </tD> </tR> </TABLE></div> <bR> <bR> </td> </tr></table></body>