ABC OF BREAST DISEASES Third Edition Edited by J MICHAEL DIXON Consultant surgeon and senior lecturer in surgery, Edinburgh Breast Unit, Western General Hospital, Edinburgh Blackwell Publishing 0727918281_01_pretoc.qxd 10/12/05 9:48 Page i © 1995, 2000 BMJ Books © 2006 by Blackwell Publishing Ltd BMJ Books is an imprint of the BMJ Publishing Group Limited, used under licence Blackwell Publishing, Inc., 350 Main Street, Malden, Massachusetts 02148-5020, USA Blackwell Publishing Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK Blackwell Publishing Asia Pty Ltd, 550 Swanston Street, Carlton, Victoria 3053, Australia The right of the Author to be identified as the Author of this Work has been asserted in accordance with the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher. First published 1995 Second edition 2000 Third edition 2006 Library of Congress Cataloging-in-Publication Data ABC of breast diseases/edited by J. Michael Dixon.—3rd ed. p. ; cm. Includes bibliographical references and index. ISBN-13: 978-0-7279-1828-4 ISBN-10: 0-7279-1828-1 1. Breast—Diseases—Treatment. 2. Breast—Cancer—Treatment. I. Dixon, J. M. (J. Michael) [DNLM: 1. Breast Diseases. 2. Breast Neoplasms. WP 840 A134 2006] RG491A232 2006 616.99�449—dc22 2005020705 ISBN-13: 978 0 7279 1828 4 ISBN-10: 0 7279 1828 1 A catalogue record for this title is available from the British Library The cover shows a coloured mammogram of an abscess of the areola of a woman’s breast seen from the side. With permission from CRNI/Science Photo Library Set in 9/11 pt New Baskerville by Newgen Imaging Systems (P) Ltd, Chennai, India Printed and bound in India by Replika Press Pvt. Ltd, Harayana Commissioning Editor: Eleanor Lines Development Editors: Sally Carter, Nick Morgan Production Controller: Debbie Wyer For further information on Blackwell Publishing, visit our website: http://www.blackwellpublishing.com The publisher’s policy is to use permanent paper from mills that operate a sustainable forestry policy, and which has been manufactured from pulp processed using acid-free and elementary chlorine-free practices. Furthermore, the publisher ensures that the text paper and cover board used have met acceptable environmental accreditation standards. 0727918281_01_pretoc.qxd 10/12/05 9:48 Page ii iii Contents Contributors iv Preface v 1 Symptoms, assessment, and guidelines for referral 1 JM Dixon, J Thomas 2 Congenital problems and aberrations of normal development and involution 8 JM Dixon, J Thomas 3 Mastalgia 15 J Iddon 4 Breast infection 19 JM Dixon 5 Breast cancer—epidemiology, risk factors, and genetics 24 K McPherson, CM Steel, JM Dixon 6 Screening for breast cancer 30 ARM Wilson, RD Macmillan, J Patnick 7 Breast cancer 36 JRC Sainsbury, GM Ross, J Thomas 8 Management of regional nodes in breast cancer 42 NJ Bundred, A Rodger, JM Dixon 9 Breast cancer: treatment of elderly patients and uncommon conditions 48 JM Dixon, JRC Sainsbury, A Rodger 10 Role of systemic treatment of primary operable breast cancer 54 IE Smith, S Chua 11 Locally advanced breast cancer 65 A Rodger, RCF Leonard, JM Dixon 12 Metastatic breast cancer 70 RCF Leonard, A Rodger, JM Dixon 13 Prognostic factors 77 AM Thompson, SE Pinder 14 Clinical trials of management of early breast cancer 81 JR Yarnold 15 Psychological aspects 87 P Maguire, P Hopwood 16 Carcinoma in situ and patients at high risk of breast cancer 92 DL Page, NJ Bundred, CM Steel 17 Breast reconstruction 100 JM Dixon, JD Watson, JRC Sainsbury, EM Weiler-Mithoff Index 107 0727918281_02_toc.qxd 10/12/05 19:16 Page iii iv NJ Bundred Professor of surgical oncology, department of surgery, South Manchester University Hospital, Manchester S Chua Oncology research fellow, Royal Marsden Hospital, London JM Dixon Consultant surgeon and senior lecturer in surgery, Edinburgh Breast Unit, Western General Hospital, Edinburgh P Hopwood Consultant and honorary senior lecturer in psychiatry and psycho-oncology, Christie Hospital NHS Trust, Manchester J Iddon Specialist registrar, North West Region, University Hospital of South Manchester RCF Leonard Professor of medical oncology, South West Wales Cancer Institute, Singleton Hospital, Swansea RD Macmillan Consultant surgeon, Nottingham Breast Institute, Nottingham City Hospital, Nottingham P Maguire Professor of Psychiatric Oncology, Cancer Research UK Psychological Medicine Group, Christie Hospital NHS Trust, Manchester K McPherson Visiting professor of public health epidemiology, Nuffield Department of Obstetrics and Gynaecology Research Institute, Churchill Hospital, Oxford DL Page Professor in the department of pathology, Vanderbilt University Medical Center, Nashville, Tennessee, USA J Patnick Director of NHS Cancer Screening Programmes, The Manor House, Sheffield SE Pinder Consultant breast pathologist, department of histopathology, Addenbrooke’s NHS Trust, Cambridge A Rodger Medical director, Beatson Oncology Centre, Western Infirmary, Glasgow GM Ross Consultant clinical oncologist, Royal Marsden Hospital, London JRC Sainsbury Senior lecturer in surgery, Royal Free and University College Medical School, University College London IE Smith Professor of cancer medicine, Royal Marsden Hospital, London CM Steel Professor in medical science, University of St Andrew’s, Bute Medical School, St Andrew’s, Fife J Thomas Consultant pathologist, Western General Hospital, Edinburgh AM Thompson Professor of surgical oncology and honorary consultant surgeon, Ninewells Hospital and Medical School, University of Dundee, Dundee JD Watson Consultant plastic surgeon, St John’s Hospital at Howden, West Lothian EM Weiler-Mithoff Consultant plastic and reconstructive surgeon, Canniesburn unit, Glasgow Royal Infirmary, Glasgow ARM Wilson Clinical director, Nottingham Breast Institute, Nottingham City Hospital, Nottingham JR Yarnold Consultant clinical oncologist, Royal Marsden NHS Trust, Surrey Contributors 0727918281_03_posttoc.qxd 10/12/05 9:49 Page iv v The aim of the third edition of the ABC of Breast Diseases is to provide an up to date, concise, well illustrated, and evidence based text that will meet the dual challenges of managing the increasing numbers of women who attend breast clinics and the increasing numbers of women who are diagnosed with breast cancer. This edition contains many new illustrations and diagrams. The chapters on screening, adjuvant therapy, clinical trials, and prognostic factors have been completely rewritten, and all other chapters have been extensively revised. The topics of adjuvant therapy and metastatic breast cancer have been extended to cover the explosion of results gained from the many multinational breast cancer trials which have reported since the last edition of this ABC was published. New authors have added their work to that of those who have already contributed to the success of the book. Thanks to Jan Mauritzen my PA who has coordinated the many revisions, to Eleanor Lines. Commissioning Editor, ABC series, to Sally Carter, Development Editor, BMJ editorial and Nick Morgan, Senior Development Editor at Blackwell Publishing who converted the authors’ words and pictures into the book that is before you. Such a comprehensive review has been time consuming. I continue to be grateful for the support of my colleagues in the Edinburgh Breast Unit, and to my family Pam, Oliver, and Jonathan. I also thank the many patients who agreed to be photographed for this book, but more importantly, for the inspiration they provide in how they cope, not only with their disease but with all that we do to them. The care provided for patients with breast cancer is better coordinated and more truly multidisciplinary than that for any other cancer. This is a testimony to those multidisciplinary teams that treat breast cancer, and to the many groups and individual women who have demanded access to good quality care for all. As a clinician I hope that the knowledge and understanding gained through research will continue to result in improved treatments. Many challenges remain in the field of breast diseases, and there is much we do not know. This book is our effort to inform you of everything that we think we know and understand about breast diseases and its management. J Michael Dixon Edinburgh 2005 Preface 0727918281_03_posttoc.qxd 10/12/05 9:49 Page v 0727918281_03_posttoc.qxd 10/12/05 9:49 Page vi 1 1 Symptoms, assessment, and guidelines for referral JM Dixon, J Thomas One woman in four is referred to a breast clinic at some time in her life. A breast lump, which may be painful, and breast pain constitute over 80% of the breast problems that require hospital referral, and breast problems constitute up to a quarter of all women in the general surgical workload. For patients presenting with a breast lump, the general practitioner should determine whether the lump is discrete or if there is nodularity whether this is asymmetrical or is part of generalised nodularity. A discrete lump stands out from the adjoining breast tissue, has definable borders, and is measurable. Localised nodularity is more ill defined, often bilateral, and tends to fluctuate with the menstrual cycle. About 10% of all breast cancers present as asymmetrical nodularity rather than a discrete mass. When the patient is sure there is a localised lump or lumpiness, a single normal clinical examination by a general practitioner is not enough to exclude underlying disease. Reassessment after menstruation or hospital referral should be considered in all such women. Conditions that require hospital referral Lump G Any new discrete lump G New lump in pre-existing nodularity G Asymmetrical nodularity in a postmenopausal woman G Asymmetric nodularity in a premenopausal woman that persists at review after menstruation G Abscess or breast inflammation that does not settle after one course of antibiotics G Cyst persistently refilling or recurrent cyst (if the patient has recurrent multiple cysts and the GP has the necessary skills, then aspiration is acceptable) G Palpable or enlarged axillary mass including an enlarged axillary lymph node Pain G If pain is associated with a lump G Intractable pain that interferes with a patient’s lifestyle or sleep and that has failed to respond to reassurance, simple measures such as wearing a well supporting bra, and common drugs G Unilateral persistent pain in postmenopausal women Nipple discharge G All women aged �50 G Women aged �50 with: Bloodstained discharge Spontaneous single duct discharge Bilateral discharge sufficient to stain clothes Nipple retraction or distortion, nipple eczema Change in skin contour Family history G Request for assessment of a woman with a strong family history of breast cancer (refer to a family cancer genetics clinic where possible) Bathsheba bathing by Rembrandt. Much discussion surrounds the shadowing on her left breast and if this represents an underlying malignancy (with permission of the Bridgeman Art Library) When a patient presents with a breast problem the basic question for the general practitioner is, “Is there a chance that cancer is present, and, if not, can I manage these symptoms myself?” Patients who can be managed, at least initially, by their GP include G Young women with tender, nodular breasts or older women with symmetrical nodularity, provided that they have no localised abnormality G Young women with asymmetrical localised nodularity; these women require assessment after their next menstrual cycle, if nodularity persists hospital referral is then indicated G Women with minor and moderate degrees of breast pain who do not have a discrete palpable lesion G Women aged �50 who have nipple discharge that is small in amount AND is from more than one duct and is intermittent (occurs less than twice per week) and is not bloodstained. These patients should be reviewed in 2–3 weeks and if symptom persists hospital referral is indicated Prevalence (%) of presenting symptoms in patients attending a breast clinic G Breast lump—36% G Strong family history of breast G Painful lump or lumpiness— cancer—3% 33% G Breast distortion—1% G Pain alone—17.5% G Swelling or inflammation—1% G Nipple discharge—5% G Scaling nipple (eczema)—0.5% G Nipple retraction—3% Patient presenting with breast lumps or lumpiness History Patient reports lumpiness or nodularity Asymmetrical nodularity confirmed Patient reports discrete lump Discrete lump confirmed Examination normal Refer Reassure but review after next menstrual cycle Discrete lump identified Examination normal Refer Reassure and advise on continued breast awareness Reassure and advise on continued breast awareness �35 years �34 years and relevant family history <35 years No relevant family history Refer Nodularity gone Nodularity persists Review after next menstrual cycle Refer Management of patient presenting in primary care with a breast lump or localised lumpy area or nodularity 0727918281_04_001.qxd 10/12/05 9:49 Page 1 ABC of Breast Diseases 2 Assessment of symptoms Patient’s history Details of risk factors, including family history and current medication, should be obtained and recorded. Duration of a symptom can be helpful as cancers usually grow slowly but cysts may appear overnight. Clinical examination Inspection should take place in a good light with the patient’s arms by her side, above her head, then pressing on her hips. Skin dimpling or a change in contour is present in up to a quarter of symptomatic patients with breast cancer. Although usually associated with an underlying malignancy, skin dimpling can follow surgery or trauma, be associated with benign conditions, or occur as part of breast involution. Positions for breast inspection. Skin dimpling in lower part of breast evident only when arms are elevated or pectoral muscles contracted Skin dimpling visible in both breasts due to breast involution Skin dimpling associated with breast infection Breast palpation Skin dimpling (left) and change in breast contour (right) associated with underlying breast carcinoma Skin dimpling after previous breast surgery Breast palpation is performed with the patient lying flat with her arms above her head, and all the breast tissue is examined using the most sensitive part of the hand, the fingertips. It is essential for the woman to have her hands under her head to spread the breast out over the chest wall because it reduces the depth of breast tissue between your hands and the chest wall and makes abnormal areas much easier to detect and define. If an abnormality is identified, it should then be assessed for contour, texture, and any deep fixation by tensing the pectoralis major, which is accomplished by asking the patient to press her hands on her hips. All palpable lesions should be measured with calipers. A clear diagram of any breast abnormalities, including dimensions and the exact position, should be recorded in the medical notes. 0727918281_04_001.qxd 10/12/05 9:50 Page 2 Symptoms, assessment, and guidelines for referral 3 Patients with breast pain should also be examined with the woman lying on each side and the underlying chest wall palpated for areas of tenderness. Much of so called breast pain emanates from the underlying chest wall. Assessment of axillary nodes Once both breasts have been palpated the nodal areas in the axillary and supraclavicular regions are checked. Clinical assessment of axillary nodes is often inaccurate: palpable nodes can be identified in up to 30% of patients with no clinically significant breast or other disease, and up to 40% of patients with breast cancer who have clinically normal axillary nodes actually have axillary nodal metastases. Mammography Mammography requires compression of the breast between two plates and is uncomfortable. Two views—oblique and craniocaudal—are usually obtained. With modern film screens a dose of less than 1.5 mGy is standard. Mammography allows detection of mass lesions, areas of parenchymal distortion, and microcalcifications. Breasts are relatively radiodense, so in younger women aged �35, mammography is of more limited value and should not be performed in younger women unless there is suspicion on clinical examination or on cytology or core biopsy that the patient has a cancer. All patients with breast cancer proved by cytology or biopsy, regardless of age, should undergo mammography before surgery for assessment of the extent of disease. Mammograms showing (left) two mass lesions in left breast, irregular in outline with characteristics of carcinomas, and (right) mass lesion with extensive branching, impalpable microcalcification characteristic of carcinoma in situ Assessment of regional nodes Mammography Ultrasound scans showing clear edges of fibroadenoma (left) and indistinct outline of carcinoma (right) MRI scan showing cancer Ultrasonography High frequency sound waves are beamed through the breast, and reflections are detected and turned into images. Cysts show up as transparent objects, and other benign lesions tend to have well demarcated edges whereas cancers usually have indistinct outlines. Blood flow to lesions can be imaged with colour flow Doppler ultrasound. Malignant lesions tend to have a greater blood flow than benign lesions, but the sensitivity and specificity of colour Doppler is insufficient to accurately differentiate benign from malignant lesions. Ultrasound contrast agents are available, but they are of doubtful value and not often used. Magnetic resonance imaging (MRI) Magnetic resonance imaging is an accurate way of imaging the breast. It has a high sensitivity for breast cancer and is valuable in demonstrating the extent of invasive and non-invasive disease. Ongoing studies are evaluating its role in improving the rate of successful breast conserving procedures. It is useful in the treated, conserved breast to determine whether a mammographic lesion at the site of surgery is due to scar or recurrence. It has been shown to be a valuable screening tool for high risk women between the ages of 35 and 50. MRI is the optimum method for imaging breast implants. It is also of value in assessing early response to neoadjuvant therapy in women with established breast cancer. 0727918281_04_001.qxd 10/12/05 9:50 Page 3