ARTICLES

CONTROVERSIES IN MANAGEMENT OF BREAST DISORDERS

Dr. RAVI KANT
MS, DNB, MNAMS, FACS, FICS, FAIS
Professor of Surgery
Maulana Azad Medical Collage New Delhi

TERMINOLOGY OF BENIGN BREAST LUMPS:

The benign breast disease is under a banner of ANDI-Abnormalities of Normal development and involution. Thus, the framework provided by the Hughes and colleagues is an essential factor in understanding the syndrome complex of SOLID benign breast diseases¹

INVESTIGATIONS:

The triage of investigations mandated is USG (Ultrasonography), Mammography, and FNA (Fine Needle Cytology). Mammography is not advised below 30 years²

On ultrasound, the cystic diseases are Bloodgood's disease (Single blue domed cyst) or Schimmelbusch's disease (Multiple Cystic disease)³.

The sensitivity of breast FNA on palpable mass is 80 to 90 % (mean 90%). The specificity and predictive value of breast FNA is close to 100% as false positive results are exceptionally rare. The efficacy of the test ranges from 84% to 99.5%.^4-8

PALPABLE BREAST LUMPS: RESULTS OFTRAIGE OF INVESTIGATIONS 9

In clinically palpable breast lumps, comfT1ents on axillary lymph nodes are 30% erroneous as being either false positive or false negative¹⁰

IMPALABLE BREASTTUMOUR:

In impalapable mammographically detected breast lessions, Needle core biopsy is more accu rate than stereotactically guided/ directed FNA. Large needle biopsy has a false negative rate of upto 20%.^11-13

Needle localisation in bi-planer view, (needle guided into the lession) followed by biopsy may be ideal in such a situation. 11% of patient undergoing screening will require such a procedure^II-13

SURGERY IN BBD

More often than not nurgery is not recommended in BBD (including Fibroadenoma). Fibroadenoma tend to regress with time. More than 25% resolve within two years.14-15 Cant et al demonstrated a probability of 0.46 for resolution after 5 years15. Sansbury reported 32% resolution at 2 years.16In Oxford, over 90% patients are treated conservatively as compared top South Africa where only 21 % patients are treated conservatively. This depends upon counselling, facilities and aptitude of surgeon^17-18

SURGERY IN BREAST LUMP SHOULD BE DEFERRED IF:

1. Size is less than 3 cm.

2. FNA is benign on two separate events.

3. No abnormal mammographic (iv1x) pattern.

4. Absence of localised soft tissue density on MX.

5. Absence of localised soft tissue density which changes on successive Mx.

6.Absence of localised soft tissue density with ill defined borders on Mx.

7.Absence of localised focus of microcalcification with stellate distortion of stroma on Mx.

NEWER SURGICAL MODALITIES FOR BDD:

vInterstitial laser Hyperthermia as described by Bina Ravi, Som and Ravi Kant 21 1ooks like an interesting alternative, as it avoids scar.

INCIDENCE OF MALIGNANCY IN BBD: 22,23,28

Non proliferative benign breast diseases (e.g. Adenosis, Cysts, Duct ectasis, Fibroadenoma, Mastitis, Fibrosis, Mild hyoperplasis, Mataplasia- apocrine or squamous) have no increased risk of developing malignancy.

Proliferative diseases like moderate hyperplasia, papiloma with fibroadenosis core has 1 .9 relative risk of developing malignancy. Atypical hyperplasia has a 4.4 relative risk of developing malignancy.

Proliferative disorders, e.g., atypical hyperplasia associatged with family history of breast cancer has a 11.0 relative risk of developing malignancy.

Cystic disease of breast has 2.5 to 7.5 times risk of developing cancer. Incidence is nearly 8 times higher if Epitheliosis is present. The risk appears to be greater in younger ,women Under the age 45 the risk is 6.8 as compared to 3.3 ;n women aged 40-49 yea's 3.34 in 50-54 age group and 1.99 in women over 54 yea's of age The risk is higher in first year after aspiration (8.07) but remains higher after even 5 years (3.08). The risk is irrespective of type and number of the cyst²⁸

SURGERY IN BBD:

Appropriate incision under direct vision or via a laparoscope 9 from an areolar incision should be used and subdermal thinning should be avoided.

LACTATIONAL ABSCESS:24-28

Breast abscess -lactational as well as non lactational abscess do not need general anaesthesia and disfiguring scars any more. If skin overlying breast is normal then repeated USG guided aspirations coupled with broad spectrum antiobiotic will produce satisfactory result. If overlying ,breast is thinned or dead then a very small incision under cover of topical anaesthesia cream or spray will give a good result. The days of disfiguring surgery (under general anaesthesia) are over. Patients should be encouraged to continue breast feeding as this reduces engorgement and pain. Unit or individuals unable or unwilling to carry out such a treatment should hand over these patients to those who are willing to provide this improved service. The age of open surgery for this condition should have vanished.

TREATMENT OF MASTALGIA:

Patients need counselling regarding the concept of ANDI, proof of it being benign based on USG, FNA (Mammography being excluded from age less than 30 years).

The need of correct bra size is explained to the patients. It is interesting that only 19% of patients wear correct size of bra.9,29 The patients are advised to wear the bra at night as well.

MEDICATIONS FOR MASTALGIA:

A decision is to be made as to whether the pain is cyclical, non-cyclical or even non-breast (referral from chest wall, muscles, neck shoulder, or Tietze's syndrome can all present as breast pain). Evening Primrose Oil = Gamma Linoleic Acid (response rate 30-70%); it is more useful in women over 40 years of age and has fewer side effects.

Danazol (GLA)- Gonadotrophin release inhibitor has higher response rate but side effects are also higher. Bromocriptine -a long acting dopamine agonist has response reate similar to GLA but with higher side effects. GESTAINOME30 has similar response rate to GLA with fewer side effects; Tamoxifen is also effective but side effects mount to 60% at 6 months. There is no place for use of diuretics or antibiotics. Misc. drugs used are Naferalin, Diosmin, Ru kuai xiao, and Phytoestrogens^9,28,30,31

CURRENT IMAGING MODALITIES:

The current imaging modalities are :-

1. Magnetic resonance (Gadolinium enhanced RODEO = rotating delivery of excitation off-resonance sequence);

2. Mammoscintigraphy by 99mm Tc SESTAMIBI Scanning, 99 mm Tc tetrafosmin scanning;

3. Lymphoscintigraphy and gamms probe for axilla;

4. FDGI FES- PET (Positron Emission Tomography) .

Mammography tends to underestimate tumour size, multifocality, and skips 5-15 % of cancer33,34 USG is of limited value in detection of tumouir less than 1 cm, multifocality and intraductal disease. Mammography and USG are of limited value in assessment of response to chemotherapy and irradiated conserved breast^33,34,35

Magnetic resonance (Gadolinium enhanced RODEO -rotating delivery of excitation off-resonance sequence)

MR IMAGES AND THEIR INTERPRETATION 36

Magnetic resonance (Gadolinium enhanced RODEO=rotating delivery of excitation off- resonance sequence) or MA-CE-AO- DEO has shown sensitivity of 95%. MR is a method of choice in diagnosing muticentricity, as compared to USG and Mammography.34 MR does not under- estimate tumor size in contrast to mammography and USG.35 MA imaging picked up 84% multifocal disease as compared to 44% by mammography, and even less by USG.

MR imaging has a role in diagnosirlg axillary lymph nodes, as it enhances lymph nodes larger than five mm. MR-CE-RODEO is investigation of choice today in dense breast tissue which is significantly depicted by mammography.36 This was proven in a series of 61 patients with breast cancer³⁷

MR-CE-AODEO is investigation of choice in diagnosing local recurrence in a conserved breast.38 MR-CE-AODEO is inv6'stigation of choice in assessment of response to neo-adjuvant chemotherapy, thus allowing patients to be selected for breast conservative therapy. MR is accurate in the pathological determination of residual disease in 97% of cases.39 MA is also presently investigation of choice in evaluating response to Interstitial Laser Photocoagulation of Breast Cancer⁴⁰

MR RODEO is more accurate than mammography and USG in local staging of breast cancer, diagnosis of local recurrence, assessment of response to neo-adjuvant chemotherapy and evaluation of silicon implants.

MAMMOSCINTIGRAPHY by 99mm Tc SETAMIBI SCANNING. 99mm Tc TETRAFOSMIN SCANNING

These investigations have a sensitivity of 97% for T 2 tumors, 95% for T 1 c tumors. However, for T 1 a and T1 b results are only 26% and 56%.41 This has encouraged use of nuclear medicine guided stereotactic prebiopsy localisation of occult breast lesions⁴² And for preoperative and intraoperative localisation of non-palpable tumours⁴³

LYMPHOSCINTIGRAPHY AND GAMMA PROBE FOR AXILLA:

Probe localisation of sentinel lymph node is becoming an integral part in the management of axilla in breast cancer

patients ⁴⁴

Mammoscintigraphy is also useful in detecting multidrug resistance in breast tumours by recognising P- glycoprotein.

FDGI FESI PET (Position Emission Tomography):

FDG-PET has a sensitivity of 70-90% and specificity of 85-95%.45 It has got a good predictive value to response of neo-adjuvant chemotherapy.

Radiolabeled estrogen lignad FES- PET may have a role in detecting EA, PA and Axillary and mediastinal nodes ⁴⁵

FUTURE:

Digital technology coupled with computer assisted substraction will be an additional tool in improving the results of MR-RODEO- CE, Mammoscintigraphy, and FDG-PET. Currently, less than 1 cm tumor cannot be diagnosed my Mammoscintigraphy.

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