C h a p t e r 4 0
Disorders of the Female Genitourinary System
1045
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.
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.)
A
B
