Health Tips: Diagnosis of Breast Cancer

Here's Easy Inc Magazine 'Health Tips' segment bringing you certain awareness about your health, we are all prone to ill health, the type of illness depending on environment and lifestyle, The different health issues people are facing,  their symptoms, diagnosis and possible treatment.

We also added advantage to this segment by providing solutions to these typical health problems by making available medical professionals to attend to patient's health needs.

We have on this edition of Ei Magazine Health Tip Dr. Tanimomo, he will be discussing  extensively diagnosis of breast cancer.

Ei: What is breast cancer, please give us a brief introduction?

Dr Tanimomo: My name is Dr Tanimomo I'm a resident in the department of anatomic pathology, Ekiti State University Teaching Hospital. The diagnosis of breast cancer can only be made by Doctors, I will be talking briefly about breast masses, they are in different categories,  they can either  be benign or malignant, Breast masses are mostly seen in women across all the age groups, it can also be seen men but it's rare, breast masses seen in women of reproductive age group  are mostly  benign meaning, not life threatening though it could be malignant in some, meaning life-threatening which if nothing is done the patient can eventually, loose his or her life due to the masses.  However, when a lump/ breast mass is seen in males, it is malignant until otherwise proven.

Fig.1; Left breast mass

We normally tell patients especially women; adults and adolescents as the case may be when having their bath every day to raise their hand at the back of their head and examine their breasts,  So anytime a lump or mass is detected in their breasts, they should report themselves to the Hospital.  The first point of call is to see the Doctors at the general outpatient department (GOPD) or Surgical Out Patient Department (SOPD) of the hospital.

Ei: Please describe how the breast is examined?

Dr Tanimomo: when examining the left breast,  put the left hand at the back of your head and place your right palm on the left breast moving it round in a circular clockwise motion and for the right breast,  put the right hand at the back of the head and place the left hand on the right breast moving to round in a circular clockwise motion, once a mass is detected patient is advised to present at the hospital,  either at the GOPD or SOPD, the essence is for the mass to be examined and direct the patient as appropriate, after the patient has been seen at the GOPD or SOPD the patient is hereby referred to the pathologist for further evaluation. In which case Fine Needle Aspiration Cytology (FNAC) is requested for. 

Talking about FNAC,  once the patient is seen at our department, the patient  is re-examined by the pathologist based on the background information given, we look at the mass to know the extent, size, shape, location, edge(s), consistency, mobility, whether there's differential warmth or not, attachment; whether attached to the skin and wheher there are some other things like axillary lymphadenopathy. The  patient is asked to  lie down or sit as the case may be, After locating the mass we clean with methylated spirit and cotton wool  preferably we use 23g needle and 20mls syringe, we stick in the  needle and we try to shed the cells, withdraw and put the aspirate on glass slide place and make a smear, after processing such air-drying or fixing in alcohol before staining with either H & E or pap stain we look at the aspirate under the microscope and report, after reporting we determine whether the mass is benign or malignant and advise the patient as appropriate. 

Ei: Talking about breast examination and patients visiting the hospital,  how confidential are these patients treated, like a patient requested for HIV test you know would have reservations and may not want people to know why he/she has come to the hospital to avoid stigmatization...

Dr.  Tanimomo: It is confidential now.

 Ei: ...also considering the females as the gender mostly involved how well is their privacy protected, we have heard cases of some doctors violating patients during examination how well are these patients protected so they don't fall into wrong hands?

Dr Tanimomo: Well as far as I know Patients are well protected if the patients go through the due process, before examination the patient goes through the GOPD and there's usually someone there to check the Doctor. Even at our clinic there is usually  someone with the doctor, like  a chaperone. 

Even if the patient doesn't go through the due process the patient privacy is protected.

Ei: Are you are saying  a patient should expect at least two people while she's examined?  If not should complain? 

Dr Tanimomo: Yes,  the Doctor could be a female and even if the doctor is not a female if the patient is not comfortable can raise an objection but there's always someone with the Doctor, like a chaperone, mostly females that help out when the need arises. So the patient is well protected and should be rest assured that her privacy would not be tampered with.

Ei: we have talked about the symptoms and examination, let's talk of the diagnosis, we started  with FNAC, after the  aspirate  is collected and smear is made and viewed under microscope what do you expect to see before you can say the mass is benign or malignant?

Dr Tanimomo: Thats why the procedure is called fine needle aspirate cytology (FNAC) , it is not the definitive diagnosis but it's the quickest way of making an assessment of the patient  to determine whether the lesion (breast mass) is benign or malignant, the essence of fnac is getting the cells from the patient, just some minute aspects,  look at the cells under the microscope,  the nature of the cells,  if they are benign there are certain things we would see like staghorn cells,  in benign lesions the epithelial cells are monomorphic, the same shape and size,  they may be in clusters or sheets (they may be together or they may be separate), that makes it a benign lesion. But if it is malignant the cells are pleomorphic,  the sizes are variable and scattered they may be in sheaths or in clusters, they of different sizes or shapes, hyperchromatic they are deeply stained unlike the benign which is uniformly stained. These are the distinguishing features  between the benign and malignant lesions . Benign cells are uniform, they may be in sheets, clusters or singly arranged, they are monomorphic the nucleus is uniformly stained as well, that's why they are described as staghorn cells but in malignant  lesions the cells are pleomorphic and hyper-chromatic and high nuclear cytoplasmic ratio.

We have several  classifications for breast examinations and diagnosis.

C1: this is when the breast is normal

C2: this is when the lesion is benign i.e when the epithelial  cells are not injurious or life threatening to the patient .However, the mass( masses) should be removed surgically.

C3: means when the breast mass has suspicious looking cells on the slides and patient will still require a tissue biopsy to confirm diagnosis.

C4: the  breast mass is suspicious for malignancy, diagnosis is established with tissue biopsy.

C5: the breast mass is malignant.

So based on this we now request for tissue biopsy, that is the definitive diagnosis. We have 2  biopsies,  the incisional and excisional.

Incisional biopsy just a part of the mass is removed, the patient is asked to do incisional biopsy if you are suspecting a malignancy, so the malignancy is not spread to other parts of the body (i.e to prevent metastasis),  or excisional removal of the whole mass in benign cases which might be the treatment.

Fig. 2; Right breast mass recurrence following an incisional biopsy.

Ei : we thank you for the thorough briefing on breast masses, so when is a patient said to have breast cancer, is it when the breast mass is malignant?

Dr. Tanimomo: Yes.

Ei: How do you identify a breast  cancer patient

Incisional biopsy just a part of the mass is removed, the patient is asked to do incisional biopsy if you are suspecting a malignancy, so the malignancy is not spread to other parts of the body (i.e to prevent metastasis),  or excisional removal of the whole mass in benign cases which might be the treatment.

Fig. 2; Right breast mass recurrence following an incisional biopsy.

Ei : we thank you for the thorough briefing on breast masses, so when is a patient said to have breast cancer, is it when the breast mass is malignant?

Dr. Tanimomo: Yes.

Ei: How do you identify a breast  cancer patient

Dr Tanimomo: There are ways the patient presents clinically that one may be thinking of breast cancer ; 

(i)  If the patient comes complaining of huge breast mass that is attached to the skin of the breast and attached to the underlying tissue on examination

(ii) the age is important,  Cancer of the breast can present at any age. We've had a 15year old with breast cancer, But most cases of breast lumps in the reproductive age group( 35years and below) are benign. But they should still present in the hospital to rule out malignancy.

(iii) Positive family  history, if the patient family member has had breast cancer 

(iv) Use of hormonal therapies  e.g progesterone in use of contraceptives especially  hormonal birth control pills and implants 

(v) clinically looking at the patient, the patient may present with weight loss 

( vi) There's usually swelling in the armpit called axillary lymphnode enlargement, 

(vii) the patient may present with Ulcer of the breast,  i.e  wound around the breast 

(viii) Purulent discharge from the  breast mass 

(ix) nipple retraction,  there could be bloody discharge from the nipple,  the nipple can even fall off., and other constitutional symptoms, weight loss,  like easy satiety, weakness or easy fatiguability,  present with pain in the breast (mastalgia), palpable masses and nipple discharge, in addition to what we av said earlier, these are essentially the clinical features.

Fig.3; Right breast mass suspicious for malignancy.

Ei: People are of the opinion that breast cancer is terminal,  at what stage is it terminal.

Dr Tanimomo:, Whether the disease is terminal or not as I said depend on the stage at which the patient is presenting, that's why we are saying every woman or lady should examine their breasts, for the clinical presentations: the patient may present with what we call peau d'orange, that's when the cancer cells have penetrated the skin, something that looks like the back of an orange, peau d'orange is a French word meaning back of an orange,  you would see holes on the skin on the breast, there can be abdominal tenderness or swelling if the cancer cells have metastasised to the liver, the patient can present with edema when there's fluid accumulation, edema of the hands and edema of the legs those are the end stage symptoms.