There are many patients with breast cancer in outpatient clinics, most of them are in the early to middle stage, but some are in the middle to late stage, with large lumps or multiple lymph node metastases at the time of diagnosis. Most of them are women with low education, lack of knowledge about breast cancer protection and no awareness of breast self-examination. The breast gland is located on the surface of the body and it is easy to detect abnormalities and is an organ for early detection of cancer compared to internal tumors. The first key to early detection is women’s self-examination of the breast. Therefore, modern women, both young and old, should learn to do breast self-examination regularly and go to the hospital in time if there is any problem.
Firstly, in the method of breast cancer self-examination (I will list it in the attached article, which is available online and in related books), you should use your fingers to press and touch the lump when you palpate it, but not to grab and pinch it with your fingers, otherwise you will easily take the normal breast gland as a lump and cause unnecessary panic. Secondly, there are many causes of breast lumps, and there are other benign diseases besides cancer. For most people, they are not doctors after all, so they cannot diagnose themselves against books, and should seek medical consultation with a specialist.
In foreign countries, there are also mammography screening, breast cancer related genetic testing and other means, which are conducive to early detection of breast cancer, but do not meet the reality of our national conditions. However, for those who are at high risk of developing breast cancer, if conditions allow, screening in this area is not a method of early detection.
Attachment: Talking about breast hyperplasia (This is a transcript of a radio lecture given previously, which is attached here for reference.)
Host: Many women have lobular hyperplasia, would Dr. Zhang please talk to our listeners about it?
Dr. Zhang: Lobular hyperplasia is a relatively old name for a disease that is now called mastocytosis in general textbooks. The typical manifestations are single or multiple large or small bumps, lumps, or lamellar thickening in one or both breasts, accompanied by periodic breast pain, and the size of the pain and lumps are mostly related to emotions and the menstrual cycle, i.e. breast pain before menstruation, or increased pain and lump size, and decreased pain and lump size after menstruation, and not relieved by themselves for more than 3 months. This disease is very common in adult women (women of childbearing age).
Structurally, the female breast is divided into 15 to 25 lobes of connective tissue. For example, the mammary gland is like a half orange cut in the middle, and the orange is cut one flap at a time, which is equivalent to a lobe in the mammary gland. Each lobe of the mammary gland is divided into several lobules, each of which is composed of a number of vesicles and intralobular ducts. The intralobular ducts open into the interlobular ducts, which then converge into the common ducts, also known as milk ducts, which open into the nipples. The lobules and lobules are separated and filled with connective tissue and fat. Since mastocytosis is primarily a hyperplasia of the intralobular ducts and alveoli, it used to be called lobular hyperplasia. So what used to be called lobular hyperplasia is now collectively referred to as mastocytosis.
Moderator: How does mastocytosis occur?
Dr. Zhang: As you know, the female sex organs are regulated by sex hormones in the body, and the secretion of sex hormones has its cyclical changes, and the most obvious response to this change in the body is the phenomenon of menstruation in women. In adult women, the endometrium is constantly proliferating under the action of estrogen, progesterone and pituitary hormones, and secretes glycogen to prepare for the fertilized egg to come to term. Like the endometrium, the mammary glands are also regulated by sex hormones in the body and undergo cyclic changes every month, but they are not as pronounced as the endometrium.
In normal women, after ovulation, the ovarian corpus luteum begins to secrete a large amount of luteinizing hormone, and the combined effect of estrogen, luteinizing hormone and pituitary hormone results in epithelial hyperplasia of the breast ducts and hyperplasia of the lobular glandular follicles. If conception occurs, this hyperplasia will continue in preparation for future lactation. If conception does not occur, the ductal epithelium and lobular alveoli will shrink during this period due to the atrophy of the corpus luteum and the decrease in luteinizing hormone secretion, resulting in a reduction in the size of the lobules and alveoli of the breast and the so-called retrogressive changes. As a result, discomfort in the breast area can be felt before menstruation, with swelling, larger, tense and firm breasts, and even varying degrees of pain and tenderness, even with lumps to the touch. After the menstrual period, there is a rejuvenation change in the breast, the breast becomes smaller and softer, the pain and tenderness disappears, and the lumps also or disappear. This is a normal physiological phenomenon. Patients with mastocytosis have an imbalance between the ratio of estrogen and progesterone in the body, with a relative excess of estrogen and a relative excess of progesterone, or abnormal hormone receptors, resulting in excessive hyperplasia and incomplete rejuvenation of the epithelium and lobular alveoli of the breast ducts. After a long time, there is also hyperplasia of fibrous tissue, or cystic changes in the hyperplastic ducts and alveoli, which is called mastocytosis. It manifests as premenstrual breast pain, and large and small bumps (nodules), or lamellar thickening, or lumps can be felt in the breast, which can be relieved after menstruation.
Moderator: Dr. Zhang, according to what you just said, mastocytosis seems to be related to hormonal changes.
Dr. Zhang: The cause of mastocytosis is mainly due to endocrine hormone imbalance, which has been agreed upon by the academic community. However, there is no unified and clear understanding of which hormones are imbalanced under what circumstances. The classical theory is that the balance between estrogen and progesterone is imbalanced, which is manifested by the decrease of progesterone secretion during the luteal phase and the relative increase of estrogen, resulting in the long-term stimulation of breast tissue by estrogen and the lack of regulation and protection by progesterone, resulting in the transition of hyperplasia and incomplete restoration of breast ducts and lobules during the menstrual cycle, which leads to the occurrence of mastoproliferative disease. In recent years, many scholars believe that elevated prolactin is also an important factor in causing mastocytosis. In addition, some studies have shown that hormone receptors also play an important role in the pathogenesis of mastocytosis.
So what exactly causes endocrine hormone disorders? It is generally believed that a variety of factors such as neurological, immune and trace elements can cause imbalance of various endocrine hormones in the body. The external environment, work and living conditions, interpersonal relationships, and neuropsychological factors caused by various stresses can all change the internal environment of the human body, thus affecting the function of the endocrine system and causing abnormal secretion of one or several hormones. For example, in a state of chronic stress and anxiety, opioid tension increases, the neurotransmitter-mediated environment is altered, and estrogen/dopamine disharmony occurs, which leads to increased secretion of prolactin, which may cause or aggravate mastocytosis.
In Chinese medicine, mastopathy belongs to the category of “breast fetish”. Chinese medicine believes that the breast is most closely related to the liver and kidney meridians, followed by the two chakras. Liver depression and qi stagnation and internal injury to the emotions have an important impact on the pathogenesis of breast fetish. The depression and stagnation of qi and blood flow in the breast and stomach, and the blockage of the breast meridians, causes pain in the breast; the liver and qi are incompatible with the stomach, the spleen is not healthy, phlegm and turbidity are generated, and the stagnation of qi and blood stasis is accompanied by phlegm and nuclei, which stay in the breast through the meridians, so there are lumps in the breast. Liver and kidney deficiency and dysregulation of the flushing is also an important cause of mastitis. The kidneys are the basis of the five organs, the kidneys produce Tiankui, and Tiankui stimulates the ramification, which starts from the uterus and connects to the breasts, and the qi and blood of the ramification, up to the breast and down to the menstruation. If the Kidney Qi is insufficient, the Qi and blood will be stagnant and accumulate in the breasts and uterus, or the breasts will be painful and lumpy, or the menstruation will be disordered.
Moderator: What are the diagnostic criteria for mastopathy?
Moderator: The diagnostic criteria for this disease are broadly as follows.
(1) Clinically, there are single or multiple lumps in one or both breasts, mostly accompanied by periodic breast pain, and mostly related to emotions and menstrual cycle, generally the symptoms are aggravated about a week before menstruation, and the lumps and pain are significantly reduced after menstruation, and cannot be relieved by themselves for 3 consecutive months
(2) Exclude physiological breast pain, such as premenstrual mild breast swelling, adolescent breast pain and breast pain without lumps only.
(3) Single or multiple irregular nodules of different sizes, tough, mostly located in the upper outer quadrant of the breast, with no adhesions between the nodules and the surrounding tissues, can be pushed, often with mild tenderness, and small axillary lymph nodes can be detected on clinical physical examination.
(4) Use mammography or dry plate photography, ultrasound, thermography and other auxiliary detection means, and perform lump needle aspiration cytology and local biopsy when necessary to exclude other benign and malignant breast diseases such as breast cancer and breast fibroadenoma.
Moderator: How to perform breast self-examination, please give us an introduction
Dr. Zhang: Breast self-examination for women includes two aspects.
1. Visual examination: exposing the breasts and self-observation in the mirror. The observation includes.
(1) Breast shape: you need to check whether the appearance, size and position of the breast are symmetrical.
(2) Skin surface of the breast: the color of the breast skin and the presence of edema, rash, ulceration, superficial venous anger, skin folds and orange peel-like changes should be checked.
(3) Nipple areola condition: the nipple should be checked for deformity, elevation, retraction, depression, erosion and desquamation; the areola should be checked for abnormal color and eczema-like changes.
The size, position and shape of normal bilateral breasts should generally be symmetrical, but there are a few asymmetrical ones, such as large on one side and small on the other, but this often starts from the developmental period, and if it is formed within a short period of time, it suggests the possible existence of lesions. The appearance may show a limited bulge if there is a larger lump in the breast.
When a tumor invades Cooper’s ligament deep in the breast causing it to contract, it may produce skin depressions, folds or skin contractions in that corresponding area. The skin depression can be observed in a seated position with arms crossed behind the neck or with the upper body bent forward, or with the whole breast elevated with the hands, which may be easier to observe. Unilateral superficial venous dilatation of the breast should also be taken seriously, as it is often a sign of breast cancer or breast sarcoma. Pregnancy, breastfeeding, or compression of the jugular vein (e.g., in the case of retrosternal goiter) can also cause superficial breast vein dilation, but in these cases the superficial breast veins are often bilateral.
The nipple of a normal breast is bilaterally symmetrical and oriented anteriorly and slightly inferiorly. Three types of nipple abnormalities are often present: nipples are oblique or at different heights. When there is cancer or chronic inflammation near the nipple, the nipple may be skewed toward the lesion, for example, if there is cancer above the nipple, it is pulled upward and shows bilateral nipple height discrepancies. Inverted nipples. If the cancerous tumor is located deep in the nipple, the nipple can be pulled inward. Of course, nipple invagination can also be caused by dysplasia and improper bra usage. However, this condition is formed gradually from the time of development, not within a short period of time. Third, nipple erosion and flaking, eczema around the areola. As long as the woman is not breastfeeding, if the nipple is erosive and flaky and eczema appears around the areola, it may be a manifestation of eczema-like cancer, i.e. Paget’s disease. If the woman is a new mother and is breastfeeding, that is a different story. Nipple erosion and rupture can also occur because the baby bites the nipple while sucking.
The redness and swelling of the skin of the breast should be considered as septic inflammation of the breast first, but extensive redness, congestion and edema of the skin should be alerted to the possibility of a specific type of breast cancer, i.e. inflammatory breast cancer. Cancer cells invading the superficial lymphatic vessels of the breast and causing cancerous embolism can lead to lymphedema and “orange peel-like” changes of the breast skin.
2.Palpation
The purpose of palpation is to find out whether there is a lump in the breast and the nature of the lump. The lymph nodes in the area are not enlarged. Women in the self-examination can take a sitting or standing position, can also take a lying position, look for the inner half of the breast arm up, look for the outer half of the upper arm down at the side. The correct palpation technique is to use the palm of the hand on the breast in the inner upper, outer upper (including the tail), outer lower, inner lower, central (nipple, areola) in order to gently palpate the breast. Do not grasp the breast with your fingers to avoid mistaking the normal glandular tissue for a breast lump. Small lumps in the central region are not easy to find, so use your left hand to hold the breast up and use your right hand to look for them, so they are easier to find. Lower breast lumps are often concealed by sagging breasts; they can be detected by lifting the breast or lying down and raising the arm. If you find a lump in your breast or if you have doubts, you should go to the hospital for further examination.
Moderator: Can mastocytosis become breast cancer?
According to epidemiological data, the incidence of breast cancer is 3-5 times higher in women with mastocytosis than in women without mastocytosis (reports vary, but the main one closely related to breast cancer is cystic hyperplasia). This means that if 10 out of 100,000 people without hyperplasia get breast cancer, then 30-50 out of 100,000 people with hyperplasia will get breast cancer. This shows that people with mastocytosis have a higher risk of breast cancer than people without mastocytosis. Here we must understand correctly, and we can also see from the data cited above, that not most patients with mastocytosis will become breast cancer, but just have a higher chance.
Moderator: Mastoproliferative disease, breast fibroids and breast cancer are all manifested as breast lumps, how can we differentiate between them?
Dr. Zhang: Patients with mastoproliferative disease who have atypical clinical manifestations or no obvious premenstrual breast swelling and pain but only breast lumps, especially unilateral single, hard lumps, should be differentiated from breast fibroadenoma and breast cancer.
(1) Mastocytosis and fibroadenoma: Both of them can be seen as breast lumps, single or multiple, with firm texture. Most of the breast lumps in mastoproliferative disease are bilateral and multiple, with different sizes, nodular, lumpy or granular, generally soft, or hard and firm, occasionally unilateral and solitary, but mostly accompanied by premenstrual breast swelling and pain when touched, and the size and nature of the breast lumps may change periodically with menstruation, and the age of onset is mostly young and middle-aged; most of the breast lumps in mammary fibroadenoma are unilateral and solitary. Most breast lumps are round or ovoid, with clear borders, high mobility, and generally firm texture, but there are also multiple cases, but there is usually no breast swelling and pain, or only mild menstrual breast discomfort, no tenderness, and the size and nature of breast lumps do not change with menstrual cycle. In addition, on mammograms, breast fibroadenomas often appear as round or ovoid shadows with a characteristic ring-shaped transparent halo, which can be an important basis for differential diagnosis.
(2) Mastoproliferative disease and breast cancer: Both of them can be seen as breast lumps. However, breast lumps in mastoproliferative disease are generally soft or moderately hard in texture, mostly bilateral, varying in size, and may be nodular, lumpy or granular, movable, and not adherent to skin and surrounding tissues. The lumps are mostly unilateral and solitary, and can be round, oval or irregular in shape, and can grow to a large size, with poor mobility and easy adhesion to skin and surrounding tissues. In addition, on the mammogram of breast, breast cancer often appears as lump shadow, tiny calcified dots, abnormal vascular shadow and burr, which can also help in the diagnosis. Mass needle aspiration of breast cancer can find heterotypic cells. The final diagnosis needs to be based on histopathological examination results.
Moderator: How is mastopathy treated?
Dr. Zhang: As mentioned above, mastopathy is the result of endocrine disorder in women. Therefore, it is ideal to regulate endocrine secretion and restore it to normal. In the early stage, it can be treated with medication, which is effective in both Chinese and Western medicine, and the common Western medicine is estrogen receptor antagonist, such as triamcinolone (tamoxifen). In contrast, Chinese medicine is available in the form of tonics and has good efficacy, especially for those who also have irregular menstruation, and has the advantage of commonly used methods such as dredging the liver and Qi, activating blood stasis, resolving phlegm and dispersing knots, tonifying the kidneys and regulating menstruation, etc. Specific medications need to be prescribed after the examination and diagnosis. If the hyperplasia has become cystic, the efficacy of drugs is poor. If the nodules of hyperplasia have changed insignificantly, you can also skip the medication and observe them with regular checkups and surgery if necessary.
Moderator: Under what circumstances should surgical treatment be performed?
Dr. Zhang: Mastoproliferative disease is a benign hyperplastic lesion of the breast, and conservative treatment is generally advocated. However, as mentioned earlier, due to its relationship with the development of breast cancer, there is a certain clinical rate of malignant transformation, so patients are recommended to receive surgical treatment from a specialist when mastoproliferative disease has some of the following conditions
(1) The lesion is confined to one quadrant of the unilateral breast, especially in the outer upper quadrant of the breast, and the lump is large in size and hard in texture, and the effect of conservative treatment is not obvious.
(2) Those who are over 35 years old, have a family history of maternal breast cancer, and have a nodular breast lump that has not shrunk significantly with various treatments.
(3) Those with existing hyperplastic breast lumps that increase rapidly within a short period of time.
(4) In the process of observation and treatment of the original hyperplasia of the breast, the symptoms and signs have recently increased, and the results of imaging examinations such as mammography and needle aspiration cytology examination have progressed compared with the previous examination, suggesting the possibility of malignant transformation.
(5) Post-menopausal elderly women with newly developed “breast hyperplasia”, such as breast pain, glandular thickening, etc.
(6) Patients with breast hyperplasia who have been confirmed by needle aspiration cytology or biopsy to have active proliferation of breast epithelial cells, or even to have heterotypic changes, should undergo excision of the hyperplastic mass or simple mastectomy and, if necessary, intraoperative frozen section pathological examination.
In principle, during the treatment of patients with mastocytosis, the patient’s condition should be closely observed. Even if the condition has improved significantly and the patient can stop taking medication, the patient should be instructed to undergo follow-up or review for about 3 to 6 months, and thereafter, the patient can be reviewed every six months to a year, and timely surgery can be given if changes are found. Only in this way can we ensure the monitoring of those who may develop malignant changes.