Читать книгу Prevent, Survive, Thrive - John G. West - Страница 19
ОглавлениеIAM FREQUENTLY ASKED by my patients, “What is a breast lump?” The confusion is understandable, since by nature breasts are lumpy. In general, we think of a breast lump as a localized prominence in the breast that stands out from normal, surrounding tissue.
Fortunately, most lumps are easy for the patient to detect. Nodules that are smooth, round, and movable are typically benign. Malignant masses are usually hard, irregular, and, in more advanced cases, fixed in place. For these women, the issue is mainly making an accurate diagnosis.
However, distinguishing the more subtle lumps from normal breast tissue can be challenging even for an experienced physician, who may be convinced that the questionable area is simply a variation of the normal breast pattern. Unfortunately, many physicians don’t understand that any new focal “area of concern” in the breast merits attention. If a woman can point to a specific area where she perceives a change, a directed ultrasound is indicated.
If the ultrasound is not definitive, a focused mammogram should be performed for women in their thirties. Although we do not advise screening mammograms for this age group, diagnostic mammograms to evaluate new symptoms are perfectly safe. In women forty and over, we opt for a diagnostic mammogram with magnification and compression views to the area. If it has been six months or more since the patient’s most recent mammogram, regular whole breast views should be included in the diagnostic workup.
If a lump can be visualized on the ultrasound or mammogram, a core needle biopsy is next. For patients in which the evaluation is completely normal, it is important for the physician to understand the need for close follow-up.
For certain malignancies, such as lobular cancer (also known as “the Devil’s Cancer”—see chapter ten), a subtle clinical finding may be the only indicator of a developing problem. For this reason we follow up on such patients with additional physical examination at two-, four-, and six-month intervals. A menstruating woman is advised to return five to ten days after the onset of her period. This approach has proven to be effective in avoiding a delayed diagnosis and has been much appreciated by my patients.
For some women a more aggressive approach is indicated. In patients forty and over who have persistent focal symptoms despite a negative workup, a diagnostic MRI should be considered as an additional option. For those in whom the MRI is normal, the likelihood of a hidden cancer is remote.
With all the advances in imaging technology, it is now rare to do an open surgical biopsy to make the diagnosis of a “hidden” breast cancer.
MAKING THE DIAGNOSIS—AS IT WAS YEARS AGO
Incredible progress has been made—not just in detecting breast cancers at an early stage, but also in how we go about making the diagnosis. Years ago when I was in residency training, we did a “traditional” one-step approach: The patient with a lump would sign a consent form allowing the surgeon to do a mastectomy if the pathologist determined during surgery that the area of concern was cancer. We told our patient that if the lump proved to be benign, she would wake up with a small Band-Aid–like dressing. If, instead, it was cancer, she would find a large dressing with drainage tubes coming out of her chest.
Understandably, this was a hard concept to explain to a young woman who almost certainly did not have cancer. One case stands out as a reminder of just how frustrating this was in “the old days.”
THE PATIENT WHO WAS SCARED AWAY
Monique was a twenty-one-year-old foreign exchange student I met during my surgical residency. She showed up at our clinic with a small mass in her left breast. She was alone and clearly apprehensive about being in a breast clinic in a foreign country. Even worse, a young and relatively inexperienced surgical resident was seeing her.
After introducing myself and asking a few questions, I did a careful exam. She had a marble-sized lump in the center of her left breast that was smooth, round, and very movable. I could tell with almost complete certainty that it was not cancer. I also knew in my heart that having her sign a consent form for mastectomy was the wrong thing to do.
At the time I was just a junior surgical resident. Before discussing options with the patient, I asked the chief of surgery for permission to remove the lump without having her sign the standard consent form.
His response sent chills down my spine: “That is not the way we do it here.” His tone clearly implied that if I wanted to continue my residency training, I had no choice but to have her sign the consent form.
I went back to the exam room feeling anything but comfortable. Monique appeared to be so vulnerable. I tried to explain to her that in the United States we require a woman to sign a consent form for a possible mastectomy before taking her to surgery to remove a breast mass. I emphasized the probability that her lump being cancer was probably one in a million.
As soon as I mentioned the word “mastectomy,” her mind seemed to go blank. I could tell she was not listening to anything else I said. Tears welled in her eyes. She simply turned and walked away. I never saw her again.
DIFFERENT KINDS OF BREAST LUMPS
Most breast lumps will prove to be benign. The younger the woman, the more likely it will not be cancer. However, new nodules in women over forty should be managed with the assumption that they are cancer until proven otherwise. Breast lumps can be divided into two basic categories: cystic and solid.
Breast Cysts
Breast cysts are fluid-filled sacs found mostly in women between the ages of forty and fifty, though they do appear in all age groups. Most cysts do not form lumps and are only detected on breast imaging. Except for the rare cyst that does not have typically benign features on imaging, the majority can be ignored if they do not form a lump.
Of those that can be felt by the patient, most are easily managed and present no risk. One of the truly rewarding events in my practice occurs when a patient has an obvious tender mass, which on ultrasound proves to be smooth, round, and fluid-filled, but, when the mass is aspirated with a needle under ultrasound guidance, the lump completely disappears—along with the woman’s fears. These are among the most appreciative patients in my practice.
In rare instances, the cyst is not smooth and round but has some irregular features. These cysts require clinical judgment, but if there is any concern about the possibility of malignancy, a core needle biopsy (see chapter seven) must be done to remove the entire cyst wall.
In other cases, the cyst will recur following repeated aspirations, and a core needle biopsy should also be done to remove the recurrent cyst.
Open biopsy for a cyst without some kind of tissue diagnosis is no longer a common procedure. If surgical removal is advised in the absence of a previous core biopsy, a second opinion should be obtained.
Solid Breast Lumps
Fibroadenoma: Benign
As previously noted, benign breast lumps are usually smooth, round, and mobile. As with any lump, the ultrasound exam is key to making an accurate diagnosis. The most common benign solid breast mass is the fibroadenoma. How we treat women with this suspected condition illustrates our general approach to breast lumps that are thought to be benign.
Young women with breast lumps often show up in my office with a bored expression and an anxious mother. The daughters seem to know intuitively that the overwhelming probability is that their lump is not cancer. Thank God for moms, though, because despite the odds, sometimes a lump in a young woman will be malignant—as was the case of Michelle in chapter one who was only twenty-one when she discovered her lump.
However, in most cases, my young patients felt their nodule by chance as opposed to discovering it in their monthly self-exam. Usually the patient was aware of the problem weeks before telling her mom, hoping it would just go away.
On physical examination, the lump typically meets all the criteria for being benign—and the ultrasound shows a round or oval mass with smooth edges. The inside is gray to white in contrast to the interior of a cyst, which is black.
A small fibroadenoma can be safely observed as long as the patient is willing to come back at regular intervals or return immediately if there are signs of growth. When there is doubt about the diagnosis, or the family is anxious, an ultrasound-guided core needle biopsy (see chapter seven) typically confirms the diagnosis.
Once a benign diagnosis has been established, the pressure is off. Elective surgical removal can be performed if desired. Knowing that the spot is benign allows the surgeon to remove it with a small cosmetic incision on the border of the areola (the pigmented tissue surrounding the nipple), in the armpit, or in the skin fold below the breast (inframammary fold). There is no need to do the incision directly over the mass if a benign diagnosis has been established.
Cystosarcoma Phyllodes (CSP): Low-Grade Malignancy
Phyllodes tumors of the breast are unusual. Though considered malignant, they are curable in most cases. On examination they can look much like a fibroadenoma, which is one reason we prefer to do a core needle biopsy before removing a suspected fibroadenoma. The one clue that a lump may be a phyllodes tumor is rapid growth. When a patient notes that her lump has increased in size over the past several months, a phyllodes tumor should be suspected.
Again, a core needle biopsy makes the diagnosis. These tumors require complete surgical excision, which includes a thin rim of normal breast tissue. Failure to completely remove the tumors sets the stage for recurrence, so doing the surgery right the first time is the key to success. It takes a surgeon who is experienced in dealing with challenging breast problems to deal with cases of CSP.
If a cystosarcoma phyllodes proves to be malignant, patients are typically referred to both a medical and a radiation oncologist, although chemotherapy is not usually given and radiation is of limited benefit. Wide removal with the rim of normal breast tissue is the treatment of choice.
Next Steps for Possibly Malignant Solid Lumps
Solid lumps that are clinically suspicious are common in our practice. They are typically hard, non-mobile, and painless. After a careful exam of the breast and armpit, an ultrasound is ordered, along with a diagnostic mammogram.
FIBROCYSTIC DISEASE: NOT A DISEASE
During the early years of my practice we did not have ultrasound, and mammography was in its infancy. Core needle biopsies were primitive and clumsy and used sparingly, primarily to diagnose larger breast cancers.
The vast majority of biopsies in the early 1970s were still being done by surgically removing the entire breast mass. The most common diagnosis of a surgically removed breast lump was “fibrocystic disease.”
Back then we did not have the tools to evaluate the nature of a lump without doing an open biopsy. The decision to do such a biopsy was based primarily on whether or not we could feel a distinct mass. An anxious patient would often prompt us to be more aggressive about surgical removal.
All of the removed lumps were sent to the pathologist. In many cases the pathologist gave us a specific diagnosis, such as fibroadenoma or invasive breast cancer. However, it happened frequently that a specific diagnosis could not be made. Rather than calling the excised material normal breast tissue, it was commonly referred to as fibrocystic disease—when in fact it was just a variant of normal breast tissue.
We now substitute the term “fibrocystic changes” to imply a benign condition noted on core needle biopsy. Once the biopsy establishes the diagnosis of a fibrocystic condition, an open biopsy can usually be avoided.
The next step, once again, is a core needle biopsy using an ultrasound for guidance. Several samples are taken and a small titanium tissue marker is placed in the center of the mass. The “cores” are sent to pathology for analysis.
The challenge with suspicious breast lumps is making the diagnosis without delay. All too often in my practice I see a patient who has detected a small lump in her breast and her physician told her not to worry. The following is a list of common statements by physicians that should be ignored by patients:
• You’re too young to get breast cancer.
• Don’t worry; it doesn’t run in your family.
• Your mammogram was normal, so it can’t be cancer.
• It’s just hormonal changes, or it’s just fibrocystic disease.
• Breast cancer doesn’t cause breast pain.
• You need an open biopsy to make the diagnosis.
Women who suspect a breast lump must be on guard. This is a classic situation in which the woman must be better informed than the average physician, who often doesn’t have the time or experience to properly address her concerns.
When a woman suspects a lump, she must tell her physician that she insists on a directed ultrasound and a diagnostic mammogram if needed. If there are abnormal findings, she must demand a core biopsy. If the workup is negative, she should require follow-up visits two, four, and six months after the ultrasound. If there are still questions, she must insist on referral to a breast surgeon.
MAKING A DIAGNOSIS UNDER REAL-LIFE CONDITIONS
Janine found a small nodular prominence in her left breast. She was twenty-eight at the time and was planning her wedding.
On exam, I could feel her lump and it had all the features of a fibroadenoma. The ultrasound appearance was consistent with that diagnosis. She was in a rush and did not have time for a fine needle biopsy.
I explained that the overwhelming odds were that it was a fibroadenoma and could be safely followed. She promised to see me again soon after returning from her honeymoon.
One month later our reminder system indicated that she had not made a follow-up appointment. Our office made a call. I saw her the following day. On exam, her lump seemed slightly more prominent. A biopsy showed an infiltrating ductal cancer. She elected to have both breasts removed and immediate reconstruction. In addition, two of her lymph nodes were positive for metastatic breast cancer—meaning the original cancer had spread.
Janine underwent a course of chemotherapy and tolerated it quite well. One day during chemo she appeared in my office wearing a shocking pink wig. When I think back on Janine’s case, a picture of the two of us comes to mind: Janine, with her bald head, and me wearing her flamboyant pink wig.
She is now a twenty-year survivor. She serves as an excellent reminder of how important it is to detect breast cancer early in young women. A longer delay in her case could have led to a less joyous outcome.
WHAT I’D TELL MY DAUGHTER
• Most breast lumps in young women are not cancer.
• Persistent breast lumps require a physician exam.
• Ultrasound should be performed on new breast lumps in young women. Diagnostic mammograms should be done in addition to ultrasound in women forty and older.
• Core needle biopsy is the procedure of choice for making the diagnosis of a solid lump.
