CBE FOR THE MAMMOGRAPHER - Part 2: Interpretation and Follow-up

Well, it is well into Autumn here but the weather is holding pretty well so far. No snow yet right in Toronto but the surrounding northern 'burbs have got some already. Thanksgiving is coming up for my US colleagues so a very happy TGing to y'all.


November's techtalk continues with our skills regarding patient assessment in the form of CBE. Enjoy and pass it on. Remember, don't fear new skills and responsibilities, embrace them. Knowledge is power!


Keep in touch,
Anne

OBJECTIVES:
With the constant changing of the expectations of DI personnel our scope of practice changes year on year, full patient assessment now often comes into our scope of practice. With that in mind, the mammographers responsibilities in regards to Clinical Breast exam broaden somewhat.

I will present recommendations in three areas, the clinical breast examination itself, interpretation/ report/follow-up, and overcoming barriers to performance. Some recommendations can be implemented immediately within clinical settings, and clinicians are encouraged to lead this effort. Others will require partnerships between the clinical community and health care organizations to establish systems, increase awareness, and gather necessary information to achieve outcomes.

CLINICAL BREAST EXAMINATION 
The premise underlying CBE is that visually inspecting and palpating of the breast and surrounding tissue can detect breast abnormalities. CBE is considered to include a continuum of integrally related components, from the examination itself, to interpretation and reporting of findings, to patient follow up. The recommendations for performance in this article represent general standards that can be immediately disseminated and adopted based on current evidence. 

Neither CBE nor mammography is a substitute for the other as an independent examination for detecting breast abnormalities. When a suspicious mass is found on CBE, it must be evaluated and explained even if mammography examination does not show an abnormality.

Interpretation and Reporting Overview:

1. Reporting should consist of a summary of the relevant portions of a patient’s history and a description of whether the CBE is interpreted as normal/negative or abnormal. If abnormal, include a description of the visual and palpable findings, including changes in the appearance of skin or nipples, the presence of nipple discharge, the presence of breast masses or palpable asymmetries, and the presence of palpable lymph nodes.  

Lead responsibility for implementation: clinicians and health care organizations. 

2. Develop a consistent, standardized lexicon of terms and format for documenting the interpretation and reporting of specific CBE findings.

Lead responsibility for implementation: health care organizations.


The primary function of CBE is to identify abnormalities that warrant further evaluation; CBE alone is not capable of accurately distinguishing benign from malignant status. Interpreting the visual and tactile observations of CBE is complex. A variety of patient characteristics can influence interpretation, including age, parity, tissue density and nodularity, menopausal status, phase of the ovarian cycle, and health history. For example, bloody nipple discharge during the last trimester of pregnancy or the first 3 months of lactation may be considered a normal physiologic change, but it would be interpreted quite differently in a woman who was not pregnant or lactating. Similarly, skin erythema or lymphedema would not necessarily be cause for further evaluation in a woman having recently undergone radiation therapy of the breast but would certainly require follow up in a woman without such a history. A more common and difficult challenge involves breast lumpiness or nodularity, which varies considerably among women and over time for the same woman. For example, increased nodularity might be normal during the luteal phase of the menstrual cycle, but at other times it might be cause for further examination. 

As with the performance of CBE, no standard system exists for interpreting or reporting CBE findings. Little standardized terminology exists for describing findings such as degree of nodularity; thickening versus a mass; dimpling of skin; or the size, mobility, shape, or consistency of an abnormality. Thus, even if CBE was performed uniformly to its highest potential sensitivity and specificity, differences in interpretation and how findings are reported limit its potential benefits in guiding further evaluation and permitting earlier treatment of breast cancer. Efforts to improve the interpretation of mammography reporting and subsequent associated management recommendations have resulted in improvements in accuracy and consistency in those areas, but several studies demonstrate the importance of continued system refinement and training. 

An important byproduct of standardizing interpretation and reporting is the potential to provide data for more accurate estimates of sensitivity and specificity in clinical practice settings. Estimates of false-positive and false-negative results based on reporting and medical records data could be used to provide feedback to health care professionals to improve their proficiency. 

Information about the number of cancers first identified by CBE, particularly as a function of age and other population characteristics, could help clarify the role of CBE as a component of early detection and the use of this examination in relationship to other screening modalities.

Interpretation:
Interpretation involves three elements:

• Identification of visual and palpable characteristics of the breasts and lymph nodes
• Accurate assignment of specific, common, descriptive terminology to each characteristic
• Determination of appropriate follow-up actions for identified finding

The interpretation and reporting elements described below provide a general framework for identifying all relevant features of a proficient CBE, describing visual and physical findings, and reporting these findings and follow-up recommendations. This framework is general, representing an important initial step in the process of developing a standardized lexicon and patient follow up, as well as a reporting format for CBE. The role of CBE is to identify and appropriately describe visual and palpable findings; determination of benign or malignant status can be established only through further evaluation. Examiners are encouraged to adopt and begin implementing this framework for CBE interpretation and reporting. Development and implementation of a detailed system, as well as analysis of reporting data, must be undertaken as a partnership between clinicians and health care organizations.


The results of CBE can be interpreted in two ways:

• Normal/Negative: No abnormalities on visual inspection or palpation.
• Abnormal: Asymmetrical finding on either visual inspection or palpation that warrants further evaluation and possible referral. Findings will reflect a continuum of possible outcomes, from probably benign to highly suspicious of cancer. Determination of benign or malignant status, however, can be established only through further evaluation.

Reporting:
Reporting should include a description of all findings in specific and precise language, regardless of interpretation. In the case of a negative interpretation, description of findings provides a baseline for interpreting future results from visual inspection and palpation. In the case of an abnormal interpretation, a description provides an important guide for follow-up examination.

Reporting should follow the same sequence as the examination itself. The following outline directs providers’ attention to those aspects of the exam that represent unique patient characteristics or abnormalities. To the extent possible, electronic reporting should be encouraged to provide compatibility with existing medical records systems and more efficient analysis of reporting trends.


 Normal/Negative CBE: Normal Breast Characteristics
Clinical history – describe:

• Breast screening practices
• Breast changes
• Risk factors for breast cancer
• Hormonal factors at time of examination (e.g., time in menstrual cycle, pregnancy, breast feeding, hormonal contraceptives, hormone therapy)

Visual inspection – describe:

• Scarring.
• Symmetry of breast shape and appearance of skin and nipple-areolar complex.
• Palpation of lymph node – describe results with respect to:
• Infra- and supraclavicular nodes
• Axillary nodes

Breast palpation – describe results with respect to:

• Nodularity
• Normal nodularity should not be described as a fibrocystic condition
• Normal cyclic breast tenderness should not be described as a pathologic condition

• Symmetry.
• Tenderness (focal versus generalized and constant versus intermittent)

Abnormal CBE: Abnormal Breast Characteristics

Clinical history – describe:

• Breast screening practices
• Breast changes
• Risk factors for breast cancer
• Hormonal factors at time of examination (e.g., time in menstrual cycle, pregnancy, breast feeding, hormonal contraceptives, hormone therapy)

Visual inspection – describe:

• Contour (skin retraction, dimpling)
• Color (erythema)
• Texture (skin thickening or lymphedema)
• Skin retraction or dimpling
• Nipple scaling or retraction
• Nipple inversion (age of onset during adulthood)
• Location of abnormal findings or mass according to a clock face as the examiner faces the patient, clearly indicating whether the abnormality is in the right or left breast
• Size/extent of abnormal finding or mass

Palpation – for each palpable abnormality (including breast tissue and infraclavicular, supraclavicular, and axillary lymph nodes), describe:

• Three-dimensional dominant mass or two-dimensional thickening
• Location in three dimensions (subcutaneous, midlevel, next to chest wall, and according to a clock face as the examiner faces the patient)

• Size
• Shape (round, oblong, irregular, lobular [having one to four rounded or curved extensions from a central mass]).
• Mobility (mobile, fixed to skin or chest wall).
• Consistency (soft, similar to surrounding breast tissue, hard).
• External texture (smooth, irregular [having bumps distributed over the external surface of the mass]).

• Nipple discharge.
• Spontaneous
• Color.
• Number of involved ducts.
• Right or left breast or both.

Follow Up:
The final but equally important component of the CBE is follow up; different types of findings will require different follow-up actions, but appropriate follow up is essential. Adopt a standardized approach to follow up that provides continuous care to the patient until an appropriate resolution of findings is reached. This approach should make use of all appropriate follow-up options, ensure appropriate timing of subsequent actions, involve communication and coordination with other providers, and include proper documentation and tracking.


Follow Up for Normal/Negative CBE
In the case of a normal/negative CBE, a repeat CBE at the next screening interval or preventive health examination is the appropriate follow up. Descriptive findings from the normal/negative CBE should serve as the baseline for the next interval CBE


Follow Up for Abnormal CBE
In the case of an abnormal CBE, the provider should not discount an abnormal CBE because of a negative mammogram or other imaging examination. 

Providers must follow up all conflicting or abnormal findings to satisfactory resolution using the actions outlined below.

• All referrals must ensure that a copy of the CBE report is provided to specialists performing follow-up imaging to assist in examination and interpretation
• One or more of the following follow-up options are available
• Repeat CBE.
• Medical management of probably benign condition
• Referral to a breast specialist
• Imaging (ultrasound, mammography, and magnetic resonance imaging)
• Aspiration
• Biopsy (percutaneous or excisional)

Follow-up Timing

The timing of follow-up actions must be appropriate to the findings and should be designed to minimize patient burden and psychological stress. For women aged 40 and older, a repeat CBE in the case of negative findings will likely occur as part of the woman’s regular preventive health care. Among women aged 40 and younger with a negative CBE, this interval may be longer. In the case of abnormal findings, follow up should take place at a shorter interval, at least within 6 months and usually within a shorter time frame.

Coordination of Follow-up
If follow up is necessary, examiners may need to work with other care providers, including radiologists, oncologists, surgeons, and other breast health specialists. Clear communication about follow up and effective coordination of any follow-up actions are essential.


Tracking to Ensure That Follow Up Has Occurred
Appropriate tracking must be in place to ensure that follow up has occurred. This involves making adequate documentation, reminders to resolve outstanding issues or patient questions, having a system for patient callback and reminders, and taking actions to obtain patient feedback.


SUMMARY:
As laws change, medical teams form and shift, multi disciplinary education becomes normal and hybrid and fusion imaging becomes standard practice our responsibilities as clinicians expand and evolve. As professionals we are expected to rise to the challenges presented to us.
With education, practice and experience we can embrace these new proficiencies and continue to serve our patients with skill and renewed efficacy. Knowledge is power!

CLINICAL BREAST EXAMINATION FOR THE MAMMOGRAPHER; Part 1: The Exa

Happy Thanksgiving to all my Canadian readers. Up here in the great white north, we are all getting ready to over-stuff ourselves on overstuffed fowl and pumpkin pie dripping with whipped cream. I, for one, am thankful that I only do that once a year (maybe twice if you count Xmas). I am comatose for 3days after "the meal".


The laws they are a-changing for the allied health care professionals. Our practice is expanding and therefore the things we did informally now have to gain some structure. October`s techtalk is the first in a 3part series regarding our approach to patient assessment dealing with clinical breast exam. The first part deals with `how`, the subsequent parts deal with education, reporting, barriers and responsibilities.


Enjoy and pass it on, knowledge is power. 


Anne 

OBJECTIVES:


With the imminent signing into law of bill 172, full patient assessment comes into our scope of practice. With that in mind, the mammographers responsibilities in regards to Clinical Breast Exam broaden somewhat.


I will present recommendations in three areas, the clinical breast examination itself, interpretation/ reporting/follow-up, and overcoming barriers to performance. Some recommendations can be implemented immediately within clinical settings, and mammographers are encouraged to lead this effort. Others will require partnerships between the clinical community and health care organizations to establish systems, increase awareness, and gather necessary information to achieve outcomes.


CLINICAL BREAST EXAMINATION 


The premise underlying CBE is that visually inspecting and palpating of the breast and surrounding tissue can detect breast abnormalities. CBE is considered to include a continuum of integrally related components, from the examination itself, to interpretation and reporting of findings, to patient follow up. The recommendations for performance in this article represent general standards that can be immediately disseminated and adopted based on current evidence.


Neither CBE nor mammography is a substitute for the other as an independent examination for detecting breast abnormalities. When a suspicious mass is found on CBE, it must be evaluated and explained even if mammography examination does not show an abnormality.


The Examination: 

A. Adopt standards for CBE that include a stepwise progression of elements consisting of clinical history, visual inspection, and palpation.

Lead responsibility for implementation: clinicians.

B. Encourage widespread dissemination of standards for CBE.

Lead responsibility for implementation: health care organizations.

Studies have assessed the influence of test characteristics (such as search pattern, palpation, pressures, duration), patient characteristics (such as tissue density, and nodularity), and tumor characteristics (such as size, depth, mobility) on the CBE’s sensitivity and specificity. CBE techniques have been described and illustrated in several recent reviews; figures from one of several reviews are used to illustrate the recommendations presented here. These studies provide some basis for recommendations concerning the specific way CBE is performed. Not all aspects of visual inspection and palpation have been studied in controlled settings, however, and thus the following recommendations rely in part on the clinical expertise and the premise that visual inspection and palpation of every area of the breast and surrounding tissue will lead to identification of more breast masses.

FIGURE 1 Position of Patient and Direction of Palpation for the CBE. The top figure shows the lateral portion of the breast, and the bottom picture shows the medial portion of the breast. Arrows indicate the vertical strip pattern of examination. 

FIGURE 2 Palpation Techniques. Pads of the index, third, and fourth fingers (inset) make small circular motions, as if tracking the outer edge of a dime.

FIGURE 3 Levels of Pressure for Palpation of Breast Tissue Shown in a Cross-sectional View of the Right Breast. The examiner should make three circles with the finger pads, increasing the level of pressure (subcutaneous, mid-level, and down to the chest wall) with each circle. 

Clinical History:
A clinical history that identifies the patient’s personal and family health history is useful in assessing risk of breast cancer. Some women will not report symptoms until asked, and a clinical history provides an important opportunity to seek out this information. This health history can direct attention to potentially relevant symptoms and provides important context for interpreting findings. The clinical guidelines and policy statements of many organizations concerning the performance of screening CBE emphasize the importance of a woman’s individual risk for breast cancer. Furthermore, information on clinical history can help guide follow up. The clinical history also provides an opportunity for the health care provider to explain the benefits and limitations of the examination, its elements, the time involved, and the related events that occur after the examination (interpretation, reporting, and follow up).


The clinical history should: 

• Identify screening practices for breast health, when they were performed, and results. These practices include breast self-examination (BSE), prior CBE, and prior screening and diagnostic mammograms.
• Ask about any breast changes and how they were identified. This includes changes in appearance of skin or nipples, presence of lumps, pain (focal versus general and constant versus cyclic), itching, or staining of garments or bed sheets that would indicate spontaneous nipple discharge.
• Assess risk by asking about age and personal history, including benign breast disease, biopsy, cancer, cosmetic or other breast surgery, history of hormonal therapy, and/or oral contraceptive use, obstetric history, family history, and health promotion habits (e.g., exercise, nutrition).

Visual Inspection:


Once the clinical history has been completed, the patient’s breasts should be visually inspected. To minimize awkwardness and potential misunderstandings, clinician should inform women in advance that a visual inspection will be performed and describe what is being assessed during this part of the examination. The patient should sit with her hands pushing tightly on her hips. This position contracts the pectoralis major muscles and enhances identification of asymmetries. Although adding multiple positions (e.g., hands over head and hands at sides) may further assist identification of asymmetries, it does not add substantively to the single position recommended and may reduce time devoted to palpation. When conducting the visual inspection, the provider must view the breasts from all sides and should:

• Assess symmetry in breast shape or contour (subtle changes or differences)
• Assess skin changes, particularly any skin erythema, retraction or dimpling, and nipple changes.
• Physical signs associated with advanced breast cancer have been summarized using the acronym BREAST:

1. Breast mass
2. Retraction
3. Edema
4. Axillary mass
5. Scaly nipple
6. Tender breast

If the clinician is seeing the patient on a regular basis, visual inspection allows the monitoring of changes in appearance over time when observations are compared with previously documented examination. Visual inspection takes only a short amount of time, with the remainder of the examination spent predominately on palpation.

Palpation:
Following the visual inspection, the examiner palpates each breast and nearby lymph nodes. To minimize awkwardness and the potential for misunderstanding, providers should inform women in advance that palpation will be performed and describe what is being assessed during this part of the examination. Palpation provides an opportunity for discussion of the normal variability of breast characteristics and the importance of women becoming familiar with the characteristics of their own breasts. Thoroughness is essential; palpation must examine all breast tissue as well as nearby lymph nodes. Appropriate palpation includes five key characteristics:

1. Position: Patients should be sitting for palpation of the axillary, supraclavicular, and infraclavicular lymph nodes. Patients should be lying down for breast palpation, with their ipsilateral hand overhead to flatten the breast tissue on the chest wall, thereby reducing the thickness of the breast tissue being palpated (Figure 1, pg 2). If this maneuver does not result in a relatively even distribution of breast tissue, the breast should be further centralized by placing a small pillow under the shoulder/lower back on the side of the breast being examined. The tissue being examined needs to be as thin as possible over the chest wall. The examiner must be able to see the full palpation area.
2. Perimeter: All breast tissue falls within a pentagon shape (as opposed to the traditional perception of the breast as a conical structure). The examiner should use the following landmarks to cover all of this area: down the midaxillary line, across the inframammary ridge at the fifth/sixth rib, up the lateral edge of the sternum, across the clavicle, and back to the midaxilla.
3. Pattern of search: The full extent of breast tissue should be searched using a "vertical strip" pattern (Figure 1, pg 2). (A systematic analysis demonstrated the superiority of the vertical strip search pattern over concentric circle and radial spoke patterns in thoroughness of coverage, as performed by women trained in BSE to examine themselves.) The search should be initiated at the axilla. If a mastectomy has been performed, the chest wall, skin, and incision should be included.
4. Palpation: The examiner should use the finger pads of the middle three fingers to palpate one breast at a time (Figure 2, pg 2). Palpate with overlapping dime-sized circular motions. Tissue at and beneath the nipple should be palpated, not squeezed. Squeezing often results in discharge as well as discomfort. Only spontaneous discharge warrants further evaluation. Breast tissue in the upper outer quadrant and under the areola and nipple should be thoroughly searched, as these are the two most common sites for cancer to arise.
5. Pressure: As each area of tissue is examined, three levels of pressure should be applied in sequence: light, medium, and deep, corresponding to subcutaneous, mid-level, and down to the chest wall (Figure 3, pg 2). Adapt the palpation to the size, shape, and consistency of tissue, and accommodate pressure to other factors such as breast size and the presence of breast implants. Providers sometimes lack confidence performing CBE in women with breast implants; implants correctly placed are located behind the tissue of the breast. Therefore, the steps for CBE are exactly the same as in women without implants.

The duration of the examination is intentionally not specified, for several reasons. First, while thoroughness is related to time spent performing CBE; performance time can decrease with increased proficiency. Additionally, a variety of patient factors, such as breast size, tenderness, lumpiness, body weight, and risk factors, can influence the time required to perform a proficient CBE. Therefore specifying a uniform time frame would be misleading more often than not and would inappropriately shift the focus of performance away from proficiency and thoroughness.


SUMMARY:


As laws change, medical teams form and shift, multi disciplinary education becomes normal and hybrid and fusion imaging becomes standard practice our responsibilities as clinicians expand and evolve. As professionals we are expected to rise to the challenges presented to us.


With education, practice and experience we can embrace these new proficiencies and continue to serve our patients with skill and renewed efficacy. Knowledge is power!

Uncommon Breast Cancers Part Three: MEDULLARY ARCINOMA OF THE BREAST; Teasing Fact from Fiction

September is here and the long, lazy summer has come to an end. We all hate to see it go but there is always something kind of nice about the coming of Autumn, the start of the school year and the retrieval of our favourite woolly sweater. This month's techtalk is a continuation of the series on rare and difficult to diagnose breast cancers. Enjoy it and please pass it on.

Keep in touch,
Anne

OBJECTIVES:
Medullary carcinoma of the breast is a rare subtype of invasive ductal carcinoma (cancer that begins in the milk duct and spreads beyond it), accounting for about 1-2% of all cases of breast cancer. It is called “medullary” carcinoma because the tumour is a soft, fleshy mass that resembles a part of the brain called the medulla.

Medullary Carcinoma:

This special type of infiltrating breast cancer has a rather well-defined boundary between tumour tissue and normal tissue. It also has some other special features, including the large size of the cancer cells and the presence of immune system cells at the edges of the tumour.
Medullary carcinoma accounts for about 1-2% of breast cancers. The outlook (prognosis) for this kind of breast cancer is generally better than for the more common types of invasive breast cancer. Most cancer specialists think that true medullary cancer is very rare, and that cancers that are called medullary cancer should be treated as the usual invasive ductal breast cancer.
Medullary carcinoma can occur at any age, but it usually affects women in their late 40s and early 50s. Medullary carcinoma is more common in women who have a BRCA1 mutation. Studies have shown that medullary carcinoma is also more common in Japan than in North America.
Medullary carcinoma cells are usually high-grade in their appearance and low-grade in their behavior. In other words, they look like aggressive, highly abnormal cancer cells, but they don’t act like them. Medullary carcinoma doesn’t grow quickly and usually doesn’t spread outside the breast to the lymph nodes. For this reason, it’s typically easier to treat than other types of breast cancer.

Diagnosis:
Like other types of breast cancer, medullary carcinoma may not cause any symptoms at first. Over time, a lump can form, and unlike most invasive ductal carcinomas the mass is often soft and fleshy or somewhat spongy to the touch. Most medullary carcinomas are small — less than 2 cm in size. Medullary carcinoma may be the cause of pain, swelling, redness, or tenderness in the breast. Because of the soft homogeneous mass medullary Ca is not always easy to detect with either BSE or CBE.
Tests that obtain images of the tissue inside the breast, such as mammography and ultrasound, can help identify a medullary carcinoma. On these tests, medullary carcinoma appears as a small, well-defined mass. However, because of its well defined, smooth, well circumscribed nature, mammography alone is not always reliable at determining medullary carcinomas as a malignant process.

Diagnosing medullary carcinoma usually involves a combination of steps:

• A physical examination of the breasts. The mass created, although soft and homogenous, may be detected and dealt with.
• A mammogram to triangulate and examine any existing mass and check for evidence of cancer in other areas of the breast.
• Ultrasound to obtain additional images of the mass and check for other areas of cancer.

Biopsy, either surgical or large core, is the key to accurate diagnosis of medullary Ca, because imaging tests alone have difficulty differentiating between medullary carcinoma, benign processes and other types of breast cancer.

Gross description of Medullary Carcinoma tumours

• Well circumscribed, often large, resembles fibroadenoma but without whorls
• Soft, fleshy, tan-gray
• No desmoplasia, easy to cut, large areas of necrosis and hemorrhage

 Images of Tumours diagnosed as Medullary Ca

Figure1: Sharply defined margin with internal nodularity and bosselated surface.

Figure2: Grey fleshy tumour

Figure3: Well circumscribed

Figure 4: Smooth, well-circumscribed border, homogeneous with no fibrous stroma

Figure 5: smooth 7cm tumour

Microscopic description
When looked at under a microscope, medullary carcinoma has a number of important features that a pathologist looks for:

• A clear, well-defined boundary between tumour tissue and normal breast tissue. Medullary carcinoma pushes against the surrounding healthy tissue, but doesn’t grow into it in the same way invasive ductal carcinoma usually does.
• Large-sized cancer cells with a high-grade appearance, meaning that they look very different from normal, healthy breast cells. However, medullary carcinoma cells do not behave like high-grade cancer cells, which are aggressive and grow and spread quickly. Medullary cancer cells also tend to blend together in a distinctive “sheet like” pattern; it’s hard to see each cell’s individual membrane (outer lining).
• Immune system cells (white blood cells called lymphocytes and plasma cells) at the edges of the tumour. Immune system cells work to fight off diseases and any substances they see as a threat to the body. It’s believed that these cells help keep the medullary carcinoma in check, preventing it from growing and spreading quickly.

If the tumour has all of these features, it is considered to be a “true” medullary carcinoma. Sometimes the tumour has only some of these features but not others, or there may be some invasive ductal carcinoma cells mixed in. In these cases, the tumour is “atypical medullary carcinoma.”

  

High grade tumor cells with syncytial pattern of cells

More distinct cell borders

    

Clusters of sheets of syncytial cells with prominent lymphoplasmacytic infiltrate

Various images of typical medullary Ca

Lymphocytes in micro papillary and medullary carcinomas

In addition, medullary carcinoma cells often express a protein called p53. The pathologist may test for p53 to help decide if the cancer is truly medullary.
There are some other key features of medullary carcinoma:

• Hormone-receptor-negative: Medullary carcinoma usually tests negative for hormone receptors.
• HER2-negative: Medullary carcinoma also usually tests negative for receptors for the protein HER2/neu.

• (1) Indistinct cell borders (syncytial growth) making up 75%+ of tumor with large pleomorphic tumor cells containing large nuclei, prominent nucleoli, numerous mitotic figures; peripheral cells are more eosinophilic
• (2) Prominent lymphoplasmacytic infiltrate at periphery composed of T cells and IgA plasma cells
• (3) Pushing borders / well circumscribed

• Classify as medullary carcinoma if tumor has above three features
• Classify as atypical medullary carcinoma (or infiltrating ductal carcinoma) if tumor has only 2 of 3 features listed above (atypical medullary carcinoma has similar prognosis as ductal carcinoma NOS)

Other features:

• Sparse stroma
• Variable spindle cell or squamous metaplasia, occasional bizarre tumor giant cells and extensive necrosis
• No/minimal glandular differentiation, no intraductal growth or DCIS, no mucin, no calcification

Atypical medullary carcinoma

Figure 1: Atypical tumour invades fat and is not well circumscribed

Figure 2: Typical tumour includes poorly differentiated nuclei, syncytial growth, lymphoplasmacytic infiltrate

Figure 3: Tumour is infiltrative

SUMMARY:
We are the ‘thin pink line’ that stands as a protection against ignorance, a source of pertinent breast health information and as a foundation for the start of treatment or diagnosis. We have the chance to be the voice of reason, to dispel myth and present fact. The more we know about signs and symptoms that affect our patients the better professionals we become.

Power is knowledge; the truth is much less scary than myth, story and insinuation.