objectives: anatomy of the breast approach to a patient with breast lump common breast problems...

Objectives: Anatomy of the breastApproach to a patient with breast lump Common breast problems (benign &

malignant)Approach to a patient with nipple discharge

Modified sweat gland Extends from 2nd-6th rib & from sternal edge-midaxillary line.

Positioned over the muscles of the chest wall (the pectoralis major, serratus anterior, external oblique, and rectus abdominus fascia)

Attached to the chest wall by fibrous strands called Cooper’s ligaments ( suspensory ligament) which extend from the deep fascia beneath the breast and attach to the dermis of the skin.

Carcinoma invading these ligaments may result in skin

dimpling

The breast is composed of glandular ducts and lobules, connective tissue, and fat.

The nipple and areola are separate structures. The unique anatomy explains why 18% of malignant cancers are found in the subareolar region

most breast cancer is thought to originate in the terminal ductal lobular unit (TDLU) functional secretory unit.

Half of this glandular tissue is located in the upper outer quadrant; therefore, nearly one half of all breast cancers occur in this area.

Most major venous pathways lead to the pulmonary capillary network (why lung

metastases are common) or the vertebral veins (skeletal metastases).

Interlobular lymphatic vessels sub areolar plexus (sappey’s plexus) (75%) of the drainage to the axillary lymph nodes.

Medial aspect of the breast internal mammery lymph nodes or the axillary lymph nodes.

History :Personal:AgegenderAnalysis of C/CSOCRATES1- Pain2- Lump3- nipple discharge4- abnormal appearancePrevious Hx of breast problemAssociated symptomsConstitutional symptomsChronic illnesses Family Hx:

Cont’ HistoryDDx:Hx of trauma to the breastAny medications ask about the risk factors of breast cancer :- Radiation exposure- Menstrual hx: Early menarcheLate menopauseand late pregnancy.Lactation Metastasis Hx - General malaise, weight loss - Recent backache, Bone ache - Jaundice - Mental changes - Dyspnoea, pleuritic pain - Nodules in the skin

Examination Examination: (A) Local Ex: - Position - Inspection - Palpation: (Feel, press, percussion, move, …. and surrounding

tissues) - Lump: “4S”, “2T”, edge and composition - L.N. Axillary and supraclavicular

(B) General Ex: Abdomen, lumbar spine … Points in Examination: Look for - Firm mass of variable shape and size - Fifty percent of masses found in the upper outer quadrant of the

breast - May have associated pain with palpation, but most are painless - Nipple discharge or inversion - Skin retraction or tethering - Axillary lymphadenopathy - Inflammatory changes of the skin (e.g. peau d'orange)

DDx:Swelling of the whole breast: Bilateral - pregnancy, lactation - Idiopathic hypertrophy - Drug induced (e.g. cimetidine)

Unilateral - Enlargement in the newborn - Puberty

DDx: of localized swellingPainless lump Painful lump- Cyst- Carcinoma- Fibroadenosis (chronic mastitis)- Fibroadenoma - Fat necrosis

- Cyst- Breast abscess- Fibroadenosis-Periductal mastitis-Carcinoma (rare)

special type of X-ray imaging used to create detailed images of the breast.

The initial investigation for symptomatic breast in women older than 35 years.

95% accurate ( 5% - 10% ) false – ve.2 views of each breast is taken as standard mammography: - 45° oblique. Mediolateral (MLO) - Craniocaudal position (CC) Additional views are obtained to clarify questionable lesion:-latero-medial (LM) -medio-lateral (ML) views-exaggerated CC views-magnification views-spot compression views-others Unreliable:because of high dense glandular tissuebelow the age of 35 years.Lactating lady .

Screening :-Baseline mammogram for women ages 35-39

years.-Mammogram every 1-2 years for women ages 40-50 years.-every year once they reach 50 years of age .diagnostic: Metastatic adenocarcinoma without known

primary.Nipple discharge without palpable mass. Follow up

Benign Malignant

Shape Round, uniform density, large, coarse

Linear, branching, pleomorphic, casting

Margins Circumscribed massSmoothly marginated

Spiculation

Content Fat-containing lesion Architectural distortion with no history of prior surgery

Calcification (very important read about the difference between benign & malignant)

Microcalcifications :Widely scattered

Microcalcifications (<0.5 mm) :Tightly clustered

Long axis Long axis of the lesion is along the normal tissue planes

Lesion is taller than it is wide

Homogenicity

Homogeneous internal echotexture

Heterogenous

Echogenecity

Hyperechogenicity Decreased hyperechogenicity,

Marked acoustical shadowing

- The most useful study in younger women < 35 years with palpable breast mass.

- Effective for lesions > 0.5cm.- Easily distinguishes cystic from a solid mass.

Cystic: well defined, round, echo-free lesion with posterior enhancement.

Solid: has echo within it & posterior enhancement.

the introduction of Doppler enable definition of characteristic blood flow patterns. This can aid in separating benign and malignant lesions and distinguishing lymph node metastases from normal or reactive lymph nodes.

Fibroadenoma Cyst

Useful but expensive.Usually used in screening of familial cases of

breast cancer rather than X-ray which could be potentially harmful.

Distinguish scar from recurrence in women who have had previous breast conservative therapy for cancer (although it is not accurate within 9 months of radiotherapy because of abnormal enhancement).

The gold standard for imaging the breasts of women with implant.

CT is primarily used to evaluate for extramammary involvement of the tumor.

Indications: Establish cytological diagnosis.Advantages:

Minimally invasive office procedure that is well tolerated by the patient.

Often allows for a single trip to operating room.Specimen can be processed and interpreted rapidly.

Disadvantages: 1- False (+) rate for cancer varies from 0%-1% on an

institutional basis.2- Significant false (-) rate ( >20%) for cancer because of

small sampling size .

Non palpable mass : stereotactic , Ultrasonographic or MRI- guided

Indications: Establish histological diagnosis for < 3 cm mass.

Advantages: -Minimally invasive, low-morbidity office procedure-False (+) rate for cancer is 0.

Disadvantages: -Rare complications of hematoma and pneumothorax.-Significant false (-) rate (>20%)for cancer because of

small sampling size.

Non palpable mass : stereotactic (visualization by mammogram , Ultra-sonographic or MRI- guided CNB well tolerated & False (-) rate for cancer is approximately 1%.

Indications: Establish histological diagnosis for a large mass (>3cm) when FNA and CNB are non-diagnostic.

Advantages: -Performed under local anaesthesia.-False (+) rate for cancer is 0.-False (-) rate for cancer is close to 0.

Disadvantages: -Substantially higher cost than FNA or CNB.-Open Surgical procedure with associated risks of

bleeding and wound infection.

Indications: Establish definitive histological diagnosis for a small (<3cm) mass when FNA and CNB are non-diagnostic.

Advantages: Can be therapeutic as well as diagnostic for benign mass

and for malignant mass excised with negative microscopic margins.

False (+) and false (-) rates for cancer are 0.Performed under local anaesthesia.

Disadvantages: Open Surgical procedure with risks of bleeding and

wound infection.Substantially higher cost than other biopsy procedures.

Indications: Establish definitive histological diagnosis for a non-palpable but visualized abnormality.

Advantages: -Therapeutic as well as diagnostic for benign masses and

for malignant masses excised with negative margins.-False (+) rate for cancer is 0.-False (-) rate is 0 if visualized abnormality is completely

excised.Disadvantages:

Open procedure that requires radiological localization before surgical excision.

Occasional (1%) failure to excise abnormality. May require relocalization and reoperation.

Cosmetic deformity may result.

Ultrasound-Guided Breast Biopsy

Fibrocystic disease: the most common breast mass in women.

Fibroadenoma: the most common benign tumor.Fat necrosis AbscessCyst Others : - Intraductal papilloma - Ductal/ lobular Hyperplasia - Ductectasia - Lipoma - Granulomatous mastitis

Note :1- in general, Mass: cystic or solid, Tumor: solid2- the difference between fibrocystic changes and fibroadenoma is that in fibrocystic changes u cant define a mass while fibroadenoam is a mass

Benign changes - Age: 30 – menopause (and after if HRT used) - C./F. : Breast pain, swelling, with focal area of

nodularity, freq. bilateral, mobile and varies with menstrual cycle…

- No increase risk of breast cancer but makes evaluation of mammographic malignant changes more difficult.

- Treatment: If >40 y : mammography every 3 years analgesia, OCP or danazol for sever symptoms.

- Most common benign breast tumor in women < 30y - No malignant potential except if sclerosing adenosis present. - C./F. nodules: smooth, rubbery, discrete, well-circumscibed, non-tender,

mobile, hormone dependent .- Unlike cysts, needle aspiration yield no fluid Investigations: - Mammogram - US - FNA to R/O solid lesion Rx: - Generally conservative – serial observation -Excision if mass rapidly growing, if >5cm in size or if Pt. wants , equivocal

result , if the pt has no access for follow up, if there is family history of cancer.

Rare type of fibroadenoma. typically large, fast growing masses that form

from the periductal stromal cells of the breast.most common between the ages of 40 and 50, prior to the

menopause.Although it is mostly benign , It can recur after excision .The malignant form (10%) can metastasizehematogenously most commonly to the lungs .The common treatment for phyllodes is wide local excision.

- Result of trauma (may be minor, +ve trauma Hx in only 50%)

- Firm, ill-defined mass with skin or nipple retraction +/- tenderness

- Regress spontaneously, but complete excisional biopsy to rule out carcinoma .

- It resembles cancer clinically & radiologically. The only way to differentiate is by biopsy.

- Unilateral localized pain and erythema. - R/O inflammatory carcinoma, as indicated - Staphylococcus aureus are the most common

organisms .

C\F :Fluid-filled sacs that often feel like soft grapes. Can sometimes be tender, especially just before the menstrual period.

- Cysts may be drained in the clinic.Rx: - If the fluid removed is clear or greenish, and the lump disappears completely after it is

drained, no further treatment is needed. -If the fluid is bloody, it is sent to the lab to look for

cancer cells. If the lump doesn't disappear, or recurs, it is usually removed surgically.

is a cystic tumor containing milk or a milky substance that is usually located in the mammary glands.

Galactoceles are benign and are not a cause for concern.It is caused by a protein plug that blocks off the outlet. Once

lactation has ended the cyst will resolve on its own without intervention.

A galactocele does not cause infection as the milk within is sterile and has no outlet for which to become contaminated.

Attempts to drain the cyst are unsuccessful because the protein plug remains intact and milk production continues.

Granulomatous mastitis:Characteristic for granulomatous mastitis are multinucleated

giant cells and epithelioid histiocytes around lobules. Often minor ductal and periductal inflammation is present. The lesion is in some cases very difficult to distinguish from breast cancer.

most often completely aseptic but infectious causes must be considered as well.

C\F:distinct firm mass mostly in the subareolar region.PREDISPOSING FACTORS: -2 years and up to 6 years after pregnancy, usual age range is 17

to 42 years. -Use of hormonal contraceptives, prolactin raising medications

and hyperprolactinemia .

Epidemiology:

The 2nd leading cause of cancer mortality in women (1st?)

- Lifetime risk : 11-13%

Risk factors of breast cancer: - 99% female - 80% >40 y.o. - Prior Hx of BC, prior breast biopsy.1st degree relative with BC( incr. risk if

premenopausal ) risk in (HYPERESTROGENEMIA STATE):- early menarche <12y - late menopause>55y - 1st pregnancy >30y, - nulliparity- OCP- HRT for 5y - risk with lactation, early menopause, early childbirth - Radiation exposure - Hx of specific benign breast disease ( Atypical

hyperplsia 4x )

Types and presentation :

1- Non- invasive: a) Ductal carcinoma in situ (DCIS) - Completely contained within breast ducts - 80% non-palpable, detected by screening

mammogram

b) Lobular carcinoma in situ (LCIS) -Completely contained within breast lobule -No palpable mass, no mammographic findings,

usually incidental finding on breast biopsy.

2- invasive:

Infiltrating ductal carcinoma (most common 80%):

hard ,scirrhousthe most common type ,infiltrating tentacles

Papillary ,medullary ,mucinouse ,tubular cancers Generally better prognosis. Invasive lobular carcinoma (8-15%): -20% bilatral -Dose not form microcalcification , harder to detect

mammographically .Paget’s disease (1-3%): Ductal carcinoma that invades nipple with

scaling ,eczematous lesion .

Inflammatory carcinoma (1-4%)Ductal carcinoma that invades dermal lymphatics Most aggressive form of breast cancer Erythema , skin edema ,warm, swollon ,tender +-

lump Male breast cancer (<1%) Most commonly infiltrating ductal carcinoma Often diagnosed at later stages Sarcoma Rare ,most commonly cystosarcoma phyllodes , a

variant of fibroadenoma Lymphoma –rare

1-TNM Classification2-Clinical staging

Primary tumor (T):

TIS –carcinoma in situ T0- no primary tumour located

T1- tumour less than 2 cmT2- tumour 2-5 cm T3- tumour greater than 5cmT4 – extension to chest wall

Regional lymph nodes (N):N0-no nodal involvement N1-mobile ipsilateral axillary nodes

N2-fixed ipsilateral axillary nodes N3 - ipsilateral supraclavicular nodes

Metastasis (M):

M0: No distant spread. M1: Spread to distant organs is present. (The most common sites are bone,

lung, brain, and liver.)

Clinical staging

AJCC stage groupings

Stage T N M Survival (5 year)

O In situ None None 99%

I Less 2cm None None 94%

II A Less 2cm Mobile ipsilatral None 85%

IIB 2-5 cm or more 5 cm

None or mobile ipsilatral None

None None

70%

IIIA Any size Fixed ipsilatral or internal mammary

None 52%

IIIB Skin /chest wall invasion

Any None 48%

IIIC Any size Ipsilatral infraclavicular /internal mammary plus axillary node ;ipsilatral supraclavicular nodes =axillary nodes

None 33%

IV Any Any Distant 18%

Primary: Surgical 1- Breast – conserving surgery (BCS)-

lumpectomy with wide local excision

-for stage I and II

-Combined with radiation-axillary lymph node dissection (ALND) :For staging of nodes and reduced recurrance in

axilla Complication of ALND :Arm lymphedema (10%-15%),decreased arm

sensation ,shoulder pain .

BCS not appropriate if:Factors present that increase risk of local

recurrance : extensive malignant –type calcification on mammogram , multifocal primary tumuor .

Contraindication to radiation therapy( pregnancy, cardiac or skin disease, pnumonitis)

Large tumor size (stage :????3Patient prefers mastectomy .Bad cosmetic result.(In all the previous we do mastectomy)

2- Mastectomy:

- Modified radical mastectomy (MRM)-removes all breast tissue ,nipple –areolar complex ,skin , axillary nodes .

- Simple (total) mastectomy –similar to MRM but axillary nodes not removed .

- Offer breast reconstruction

Adjuvant:

Radiation:Decrease risk of local recurrence and almost

always used before BCS, sometimes after mastectomy .

Axillary nodal radiation may added if nodal involvement .

For high risk of local recurrence , inoperable locally advanced cancer (no clear margins after excision) ,metastases.

In Stage I/II .

Chemotherapy :

Classically CMF ( cyclophosphamide, methotrexate, 5-fluorouracil)

Almost all pt. with stage III disease In stage I at high risk ER (Estrogen receptor ) –ve plus node +ve

/high risk node –ve .ER +ve and young age .Palliation for metastatic disease.( premenopausal pt with +ve or –ve nodes need

chemo, post-menopausal with +ve node need chemo)

Hormonal :Indication :ER +ve (pre-/post-menopausal )plus node +ve

or high risk node –ve .Palliation for metastases .Tamoxifen or aromatase inhibitor (eg. anastrozole) ,

ovarian ablation (GnRH agonist ,oophorectomy ), Progestins (e.g. megestrol acetate ), androgens (fluoxymesterone ).

Stage 0Ductal Carcinoma In Situ (DCIS)

Ipsilateral total mastectomy. WLE and radiation therapy. No need for axillary node dissection. Overall 5-year survival rate is 95-100%.

Lobular Carcinoma In Situ (LCIS) Bilateral total mastectomy. Tamoxifen 20mg daily for 5 years with close observation. No need for axillary node dissection.

Invasive carcinoma (invasive on biopsy but no mass, no nodes) Modified radical mastectomy. WLE with axillary node dissection and radiation therapy.

Paget’s disease Total mastectomy. Modified radical mastectomy.

Stage I and IIModified radical mastectomy.WLE with axillary node dissection and

radiation therapy.Adjuvant chemotherapy for node-positive or

high risk node-negative patients.Overall 5-year survival rate is 80% for stage I

and 60% for stage II.

Stage III and IVMultimodality therapy.Mastectomy remains the mainstay of surgical

treatment.Overall 5-year survival rate is 20% for stage

III and 0% for stage IV.

Post-Treatment follow up: - Regular visits (3-6 m x 2y) - Annual mammography - Psychosocial support and counseling - Signs of recurrence : (CXR, CT abdomen,

liver enzymes, bone sacan, CT brain, MRI spine….)

Metastasis: - Bone > lungs > pleura > liver > brain - Rx: is palliative – hormonal therapy,

chemotherapy, radiation.

Key points: The most common breast lumps occurring <

35 yrs are fibroadenomas & fibrocystic disease.

The most common breast lumps occurring > 50 yrs are Carcinomas & Cysts.

Pain is more characteristic of infection / inflammation than tumors.

Skin tethering is more characteristic of tumors than benign disease

Multiple lesions are usually benign (cystic or fibrocystic) disease.

Nipple Discharge

Definition: Abnormal nipple discharge is abnormal fluid

leakage from one or both nipples of the breast.

The likelihood of nipple discharge increase with age and number of pregnancies.

Causes:common cause: 1. Duct ectasia (periductal mastitis). 2. Intraduct papilloma (small noncancerous

growth in the breast). Other causes: a) Prolactinoma ( tumor in the brain). b) Breast abscess (most commonly seen in

women during breastfeeding). c) Breast cancer. d) Fibrocystic change in the breast.

DDx of nipple discharge :

Serous Early pregnancyfibroadenosis

MilkyLate pregnancy

LactationPuberty

prolactinoma

Yellow, brown, green

fibroadenosis

Thick and creamy

Duct ectasia

Purulent Retroareolar abscessBreast abscess

TB

BloodyIntraduct. ca

Intraduct. papillomaPaget’s disease

Duct ectasia (periductal mastitis): Etiology: unknown. Pathological feature: Dilated duct → engorged with breast secretion →

infection → retroareolar abscess → fibrosis → nipple retraction.

Clinical features: - Pain: usually cyclical. - Periareolar erythema. - Nipple discharge: thick & creamy or greenish brown. - Periareolar tender mass. - Nipple retraction (when healing occurs by fibrosis).

Investigations: - Mammogram: opaque mass

of dilated ducts & skin indentation.

- Cytology: for discharge. Managements: - Infection: aspiration &

antibiotic. - Abscess: drainage. - Severe discharge or

recurrent sepsis: mammadochectomy (nipple ducts excised through a circumareolar incision preserving the nipple).

Intraduct papilloma Benign. Occurring in middle-aged women. Clinical features: - Bloodstained discharge. - Bleeding from a single duct orifice - (pressure over a certain spot or the palpable mass). - Small mass: NOT usually. Investigation: - Mammogram (exclude carcinoma). - Cytology assessment. Managements: - Duct orifice (bleeding) is identified:

microdochectomy. - If not: excision of the major nipple ducts.

Thank you