follow up of abnormal clinical and imaging findings of the breast

129 Pages·2009·2.86 MB·English

FOLLOW UP OF ABNORMAL CLINICAL AND IMAGING FINDINGS
OF THE BREAST: FIVE SELF-STUDY MODULES FOR PRIMARY
CARE CLINICIANS
A uthors: Helen J. Barr, MD; Mary S. Dolan, MD, FACOG; Captain Joseph M. Kaczmarczyk, DO, MPH; Mary F. Mitchell, BA; Judy A. Hannan,
RN, MPH; Captain Herschel W. Lawson, MD, FACOG; Captain Susan Lockhart, PhD, MPH, BA
Lead Writer: Nancy Dunn, RN, MS, President, PRO-Health Inc., Salem, Oregon
Editors: Darlene Foschini-Field, PhD, Contributing Editor
Peggy Keen, PhD, Editor, Medscape Women's Health
Ursula K. Snyder, PhD, Contributing Editor
The reviewers for this program can be found in the acknowledgment section
Acknowledgments | Preface & Overview | Glossary | Resource Links
The 5 self-directed, interactive training modules included in this activity are designed to enhance clinical skills in the examination of the breast.
These modules were developed by the Centers for Disease Control and Prevention Division of Cancer Prevention and Control (CDC) and
endorsed by the American College of Obstetricians and Gynecologists (ACOG) and acknowledged by the Food and Drug Administration (FDA).
The modules were edited and certified for CME credit by Medscape.

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CME/CE Activities
 CME/CE Breast Anatomy, Physiology, and Pathology
Understanding breast anatomy, physiology, and pathology is essential for follow-up of abnormal findings.
 CME/CE Health History and Clinical Breast Examination
Assessing clinical history and performing a thorough clinical breast examination are essential to managing risk and preventing a
delayed diagnosis of breast cancer.
 CME/CE Workup of Abnormal Clinical Findings
Assessing and documenting clinical findings that are suspicious for cancer are essential for timely and appropriate follow-up.
The primary care clinician must also correlate the clinical findings with imaging findings to determine the appropriate plan of
action to prevent a delayed diagnosis of breast cancer.
 CME/CE Follow-up of Abnormal Clinical Findings - Biopsy Methods
Understanding breast imaging findings is essential for correlation with clinical findings and subsequent plan of action to prevent
a delay of diagnosis of breast cancer.
 CME/CE Risk Management
Primary care clinicians can help ensure that women receive timely and appropriate follow-up by practicing risk management
strategies developed from common causes of delay of diagnosis of breast cancer.

Legal Disclaimer: The findings and conclusions in these modules are those of the authors and do not necessarily represent the views of the
Centers for Disease Control and Prevention.

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Breast Cancer Module I:

Breast Anatomy,
Physiology, and
Pathology
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Breast Cancer Module I: Breast Anatomy, Physiology, and Pathology

Authors: Helen J. Barr, MD; Mary S. Dolan, MD, FACOG; Captain Joseph M. Kaczmarczyk, DO, MPH; Mary F. Mitchell, BA;
Judy A. Hannan, RN, MPH; Captain Herschel W. Lawson, MD, FACOG; Captain Susan Lockhart, PhD, MPH, BA
Lead Writer: Nancy Dunn, RN, MS, President, PRO-Health Inc., Salem, Oregon
CME/CE Released: 05/31/2007; Valid for credit through 05/31/2008
Target Audience
This activity is intended for primary care providers who perform screening and clinical breast exams.
Goal
The goal of this activity is to enable primary care providers to better understand the anatomy, physiology, and pathology of the
breast.
Learning Objectives
Upon completion of this activity, participants will be able to:
Identify the normal anatomy and physiology of the breast
Distinguish abnormal clinical and pathology findings of the breast
Define the major types of benign and malignant breast lesions and their prognostic significance
Credits Available
Physicians - maximum of 1.0 AMA PRA Category 1 Credit(s)™
Nurses - 1.0 nursing (0 contact hours are in the area of pharmacology)
All other healthcare professionals completing continuing education credit for this activity will be issued a certificate of
participation.

Physicians should only claim credit commensurate with the extent of their participation in the activity.
Accreditation Statements
For Physicians

Medscape, LLC is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing
medical education for physicians.
Medscape, LLC designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™ . Physicians
should only claim credit commensurate with the extent of their participation in the activity.
Contact This Provider
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For Nurses
This Activity is sponsored by Medscape Continuing Education Provider Unit.

Medscape is an approved provider of continuing nursing education by the New York State Nurses Association, an accredited
approver by the American Nurses Credentialing Center's Commission on Accreditation.
Approved for 1.0 contact hour(s) of continuing nursing education for RNs and NPs; none of these credits is in the area of
pharmacology.
Contact This Provider
For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For
technical assistance, contact [email protected]
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There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and
acceptance of continuing education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits
that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during
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The material presented here does not necessarily reflect the views of Medscape or companies that support educational programming on
www.medscape.com. These materials may discuss therapeutic products that have not been approved by the US Food and Drug Administration and off-
label uses of approved products. A qualified healthcare professional should be consulted before using any therapeutic product discussed. Readers
should verify all information and data before treating patients or employing any therapies described in this educational activity.
Module I Objectives
Understanding breast anatomy, physiology and pathology is essential for follow-up of abnormal breast cancer screening
findings. At the completion of this module, the clinician will be able to:
Identify the normal anatomy and physiology of the breast;
Distinguish abnormal clinical and pathology findings of the breast; and
Define the major types of benign and malignant breast lesions and their prognostic significance.

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Breast Anatomy
The breast lies on top of the pectoralis major muscle. Fibrous stroma provides the background architecture of the breast.
Cooper's ligaments are attached to both the fascia of the skin and the pectoralis major muscle. Carcinoma invading these
ligaments may result in skin dimpling which could be subtle or obvious during visual inspection (Figure 1).

Figure 1. Carcinoma may result in skin dimpling.
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Internal Anatomy
Where does breast cancer originate?
The breast is composed of glandular ducts and lobules, connective tissue, and fat, with most of the benign and malignant
pathology arising in the duct and lobular network (Figure 2). Specifically, most breast cancer is thought to originate in the
terminal ductal lobular unit (TDLU).

Figure 2. The breast is composed of glandular ducts and lobules, connective tissue, and fat.
Republished with permission from Hindle, William H. Breast Care: A Clinical Guidebook for Women's Primary Health Care
Providers. New York, NY: Springer-Verlag; 1999.
Half of this glandular tissue is located in the upper
outer quadrant; therefore, nearly one half of all breast
cancers occur in this area.
Glandular tissue and fat vary with a woman's age and weight. Lobes, lobules, and acini serve to produce and secrete milk—the
primary function of the breast mammary glands. Ducts and lactiferous sinuses are tubular connections between the lobes and
nipples to allow milk to exit the breast. The lactiferous sinuses (located beneath the nipple) may contribute to feeling granularity
under the areola on physical examination. The parenchyma of the breast is composed of these ductal/glandular structures.
Adipose tissue is present throughout the breast. A high ratio of ductal/glandular breast tissue to adipose and fibrous tissue
makes detection of abnormalities during clinical breast examination (CBE) and mammography more difficult, especially in
premenopausal women.
All women, regardless of breast size, have the same
number of lobes, approximately 15-25. Six to 10 major
ducts exit the nipple.[1]

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Nipple and Areola
The nipple and areola are separate structures. The unique anatomy explains why 18% of malignant cancers are found in the
subareolar region, a location not easily palpated unless using a technique that permits palpation to the chest wall (Figure 3) (see
Module II).

Figure 3. Subareolar region.
Republished with permission from the professional education unit cancer
detection section, California Department of Health Services.

Supernumerary nipples and/or breasts and inverted nipples are congenital conditions that occur in about 10% of the population.
Supernumerary nipples occur along the milkline and are sometimes mistaken for skin tags or moles (Figure 4). Neoplasms can
occur in supernumerary breasts and should be screened and diagnosed in the same manner as usual breast cancer (CBE,
imaging or minimally invasive biopsy[2]).
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Figure 4. Supernumerary nipples are sometimes mistaken for skin tags or moles.
Graphic republished with permission from Hindle, William H. Breast Care: A Clinical Guidebook for Women's Primary
Health Care Providers. New York, NY: Springer-Verlag; 1999.

Breast cancer can occur anywhere within the breast perimeter, including in supernumerary breast tissue anywhere along the
milkline. Most breast cancers occur in the upper outer quadrant and subareola region because that is where most of the tissue is
located. (Figure 5).
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Figure 5. Upper outer quadrant of the breast.
Republished with permission from the professional education unit cancer detection section, California Department of Health
Services.
Microscopic Anatomy
The distal terminus of the ductal network is the terminal ductal lobular unit (TDLU). Each of the lobes in the breast contains
thousands of TDLUs, which form the functional secretory unit. The secretory units produce milk, which drains via the branching
ducts to their terminus as the ampullae at the surface of the nipple. The TDLU is complex and consists of the extralobular and
intralobular terminal ducts, and the blindly ending lobules (or ductules). An inner layer of secretory cells and an outer layer of
myoepithelial cells which contain contractile fibers that eject the milk into the ducts during lactation surround this inner layer.
Hence the lobules are referred to as acini during pregnancy and lactation.
Lymphatic Drainage and Blood Supply
Most of the lymphatic drainage of the breast is into the axilla, although the lower inner quadrants drain to the infraclavicular and
sometimes to the medial substernal nodes. The lymphatic channels travel through the axilla, along the sternum, and above and
below the clavicle. Arterial blood supply is abundant, while the venous drainage is variable. Most major venous pathways lead to
the pulmonary capillary network (why lung metastases are common) or the vertebral veins (skeletal metastases). Obstruction of
the lymphatic system in the dermis of the skin is a serious sign of inflammatory carcinoma of the breast. Later-stage
presentation will give the skin an orange peel appearance called "peau d'orange."
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