Porth's Essentials of Pathophysiology, 4e

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Disorders of the Female Genitourinary System

C h a p t e r 4 0

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FIGURE 40-19. Carcinoma of the breast. (A) Mammogram. An irregularly shaped, dense mass (arrows) is seen in this otherwise fatty breast. (B) Mastectomy specimen.The irregular white, firm mass in the center is surrounded by fatty tissue. (FromThor AD, Osunkoya AO.The breast. In: Rubin R, Strayer DS, eds. Rubin’s Pathology: Clinicopathologic Foundations of Medicine. 5th ed. Philadelphia, PA: Wolters Kluwer Health | Lippincott Williams &Wilkins; 2008:851.)

use of mammography enables additional definition of the clinically suspect area (e.g., appearance, character, calcification). Placement of a wire marker under radio- graphic guidance can ensure accurate surgical biopsy of nonpalpable suspect areas. Ultrasonography is useful as a diagnostic adjunct to differentiate cystic from solid tis- sue in women with nonspecific thickening. Fine needle aspiration is a simple in-office procedure that can be performed repeatedly in multiple sites and with minimal discomfort. It can be accomplished by stabilizing a palpable mass between two fingers or in conjunction with handheld sonography to define cystic masses or fibrocystic changes and to provide specimens for cytologic examination. Fine needle aspiration can identify the presence of malignant cells, but it cannot differentiate in situ from infiltrating cancers. Stereotactic needle biopsy is an outpatient procedure done with the guidance of a mammography machine. After the lesion is localized radiologically, a large-bore needle is mechanically thrust quickly into the area, removing a core of tissue. Cells are available for histologic evalua- tion with 96% accuracy in detecting cancer. This pro- cedure is less costly than excisional biopsy. Excisional biopsy to remove the entire lump provides the only definitive diagnosis of breast cancer, and often is thera- peutic without additional surgery. Magnetic resonance imaging, positron emission tomography (PET), and computer-based or digital mammography are available as additional diagnostic modalities for breast cancer,

and may be recommended to supplement conventional mammography in women with radiographically dense breasts or a strong family history of cancer, or who are known carriers of BRCA1 or BRCA2 . 58 Tumors are classified histologically according to tis- sue characteristics and staged clinically according to tumor size, nodal involvement, and presence of metas- tasis. It is recommended that estrogen and progesterone receptor analysis be performed on surgical specimens. Information about the presence or absence of estrogen and progesterone receptors can be used in predicting tumor responsiveness to hormonal manipulation. High levels of both receptors improve the prognosis and increase the likelihood of remission. Treatment The treatment methods for breast cancer include sur- gery, chemotherapy, radiation therapy, and hormonal manipulation. Radical mastectomy (i.e., removal of the entire breast, underlying muscles, and all axil- lary nodes) rarely is used today as a primary surgical therapy unless breast cancer is advanced at the time of diagnosis. 61,62 Modified surgical techniques (i.e., mastec- tomy plus axillary dissection or lumpectomy for breast conservation) accompanied by chemotherapy or radia- tion therapy have achieved outcomes comparable with those obtained with radical surgical methods and con- stitute the preferred treatment methods.