Metastasis

• 
  
  Bone (80%)
• 
  
  Lung (25%)
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  Liver (20%)
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  Brain (15%)
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  Other organs which include the bone marrow, brain, ovaries, spinal cord, eye (20%)
  
  

  Breast cancer
  Screening

  
  

  Breast self examination

  The American Cancer Society (ACS) recommends that:
  
  
  • Beginning in their 20s, women should be told about the benefits and limitations of breast self-examination (BSE).

  Benefits:

  • There is no data to suggest that breast self examination reduces the risk of mortality from cancer.
  • 
    
    Women who performed breast self-examination were found to be more likely to have smaller tumors and less likely to have axillary node metastases than those who did not.
  A major problem with breast self-examination as a screening technique is that it is rarely performed well.
  
  

  Clinical breast examination

  The ACS recommends clinical breast examination for women:
  
  
  • 
    
    Between ages 20 and 39 - every 3 years
  • 
    
    Beginning at age 40 -  every year
  The clinical examination should include inspection and palpation of the breast and regional lymph nodes. If the clinician detects an abnormality, the patient should then undergo diagnostic imaging rather than screening.

  Benefits:

  • There is no data to suggest that clinical breast examination reduces the risk of mortality from cancer.
  • Approximately 20% of breast cancers are detected by clinical breast examination.

  Mammography

  Screening mammography is performed in the asymptomatic patient to detect an occult breast cancer. Currently, the American Cancer Society recommends:
  • 
    
    Beginning at age 40 years - annual mammography and examination by a physician

  Benefits:

  • 
    
    Mammography has a sensitivity and specificity of 90% if there is a palpable mass.
  • 
    
    In impalpable cases the sensitivity and specificity are reduced to 50%.
  • 
    
    It detects the majority of cases an average of 2 years prior to any perceptible clinical signs or symptoms.
  • 
    
    Multiple prospective randomized controlled trials have demonstrated that mammography canreduce the mortality from breast cancer by 24% in women aged 50-74.
  This, however, does not apply to younger women, particularly those aged younger than 40 years. In addition, the sensitivity of mammography is decreased significantly in young patients with dense breast tissue and possibly with augmentation prosthesis. Mammography seldom is recommended in patients younger than 30 years. Exceptions to this rule would be young women with extensive family histories for breast cancer.
  
  

  Mammographic findings & suggestive lesions

  1. Breast masses: Stellate shape, irregular or spiculated margins suggest cancer.
  2. Evaluating the breast for calcifications: Pleomorphic calcifications less than 0.5 mm (microcalcifications).
  3. Architectural distortion and asymmetry suggest cancer.
  4. Skin thickening
  5. Nipple changes
  6. Axillary adenopathy

  BI-RADS

  The American College of Radiology established the standard for classification of radiographic abnormalities, known as the Breast Imaging Reporting and Data System
  (BI-RADS), as follows:

  BI-RAD Class	Description	Recommendation
  0	Incomplete examination	Usually requiring further imaging or evaluation
  I	Normal	Follow-up study in 1 year
  II	Benign	Follow-up study in 1 year
  III	Likely to be benign	Follow-up mammogram in 6 months
  IV	Suspicious	Consider biopsy
  V	Highly suspicious for malignancy	Biopsy recommended

  Ultrasound

  As an adjunct to mammography, ultrasonography (US) can be particularly useful in younger patients or women with fibrocystic change and should be the initial investigation for palpable lesions in women younger than 35 years. Its main use remains in distinguishing solid from cystic lesions. In the workup of nonpalpable lesions, US can be used to guide a needle biopsy or to place a localizing wire to direct an excisional biopsy.

  Benefits

  • 
    
    In palpable masses it sensitivity and specificity are about 95%.

  Magnetic Resonance Imaging (MRI)

  MRI is a particularly useful modality for detailing architectural abnormalities in the breast and can help detect lesions as small as 2-3 mm. MRI should be used in scarred breasts, implants, multifocal lesions, and for borderline lesions planned for breast conservation.

  Benefits

  • 
    
    Has a sensitivity approaching 100% but its specificity is only 50%.

  Scintigraphy

  The label typically used is technetium Tc 99m Sestamibi, a compound that concentrates in mitochondria and whose efflux is related to expression of the multidrug resistance protein. Therefore, the size of the signal distinguishes the high metabolic rate of a malignant tumor and may help predict resistance to chemotherapy.
  Scintimammography is less sensitive than MRI for lesions smaller than 1 cm, is more specific for palpable lesions and is useful for detecting axillary involvement. It can also be useful in cases with impalpable masses due to its high specificity in this setting.

  Benefits

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    Has a sensitivity and specificity of 90% in detection of impalpable masses.

  Positron emission tomography (PET)

  PET is the most sensitive and specific of all the imaging modalities for breast disease. However, it is also one of the most expensive and least widely available. PET is useful in axillary assessment, scarred breasts, and multifocal lesions.

  Benefits

  • 
    
    Has a sensitivity of 95% and specificity of 100%.
    
    

    Breast cancer
    Diagnosis

    
    

    	Breast Cancer

    FNAC (Fine needle aspiration cytology)

    Benefits:

    • FNAC (Fine needle aspiration cytology) from breast mass: sensitivity 95% & specificity 98%.
    However, it should not be used for diagnosing lymph node metastasis (only excisional biopsy). One drawback of FNAC is that it cannot differentiate between invasive and insitu cancers as only cells are seen and the architecture cannot be evaluated as in biopsies. Aspiration of a simple benign breast cyst should yield non-bloody fluid and result in complete resolution of the lesion.
    
    

    Ultrasound /  stereotactic core biopsy

    This technique is helpful in cases where there are findings in the mammography. A wire or needle guided lumpectomy can follow this procedure.
    
    

    Benefits

    • 
      
      Wide-bore needle biopsy is less sensitive but more specific when compared to FNAC (specificity 100%)

    Excisional biopsy

    An excisional biopsy, in which the entire breast mass is removed, definitively establishes the diagnosis. When the mass is extremely large, an incisional biopsy (which entails removal of only a portion of the mass) may be more appropriate.
    
    
    • Specificity of 100%.

    Ductal lavage

    Ductal lavage is currently being developed and analyzed as a minimally invasive tool to identify cellular atypia within breast ducts in women who are already at high risk for developing breast cancer. Preliminary results indicate that this method has a low sensitivity and specificity(Journal of the National Cancer Institute 2004;96:1488-1489,1510-1517)