breast diseases new
TRANSCRIPT
-
7/29/2019 Breast Diseases new
1/22
GYNECOLOGY BREAST DISEASES Page 1
BREAST DISEASESChristiana P. Calagui-Damaso, M.D. FPSMS
ANATOMY
Breastsarelarge, modified sebaceous glands contained within thesuperficial fascia of the anterior chest wall
Axillary tail of Spence A lateral projection of glandular tissue extends from the
upper, outer portion of the breast toward the axilla
200 to 300g average weight of the adult breast during themenstruating years
mature breast consists of approximately 20% glandular tissue and80% fat and connective tissue
The periphery of breast tissue is predominantly fat, and the centralarea contains more glandular tissue
glandular portion of the breast is comprised of 12 to 15 independent ductal systems that each drain about40 lobules
Each lobule consists of 10 to 100 milk-producing acini that drain into small terminal ducts Terminal ducts drain into larger collecting ducts that merge into even larger ducts, which exhibit a
saccular dilation just below the nipple called a lactiferous sinus
12 to 20 lobes arranged in radial fashion from the nipple Each lobe is triangular and has one central excretory duct that opens to the exterior at the nipple Milk originates in the secretory cells of the alveoli
It is subsequently transported by the branching collecting ducts of the lobules into the lactiferoussinuses and terminally into the excretory ducts of each
respective lobe of the breast
Lobules 10 and 100, in each lobe of the breast ductal tissue surrounded by fibrous tissue Terminal ductules (TD) surround the central ductule (ID) EF, extralobularfibrocollagenous tissue
Montgomery glands are accessory glands located around the periphery of the
areola
Because they are structurally intermediate between true mammary and sebaceous glands, theycan secrete milk
Fibrous septa, Cooper's ligaments, extend from the skin to the underlying pectoralis fascia They are believed to offer support to the breast Invasion of these ligaments by malignant cells produces skin retraction, which is a sign of
advanced breast carcinoma
lymphatic distribution 75% of the lymphatic drainage goes to regional nodes in
the axilla
o axilla contains 30 and 60 nodeso axillary lymph nodes include the pectoral (chest),
subscapular (under the scapula), and humeral
(humerus-bone area) lymph-node groups, which
drain to the central axillary lymph nodes and to
the apical axillary lymph nodes
http://en.wikipedia.org/wiki/Axillary_lymph_nodeshttp://en.wikipedia.org/wiki/Axillary_lymph_nodeshttp://en.wikipedia.org/wiki/Axillary_lymph_nodes -
7/29/2019 Breast Diseases new
2/22
GYNECOLOGY BREAST DISEASES Page 2
25% of the lymph travels to the parasternal nodes (beside thesternum bone), to the other breast, and to the abdominal
lymph nodes
o Mediastinum intercostal glands subpectoral andsubdiaphragmatic areas
Lymph drainage usually flows toward the most adjacent group ofnodes This represents the basis for sentinel node mapping in breast
cancer
breast cancer spreads in an orderly fashion within the axillarylymph node basin based on the anatomic relationship
between the primary tumor and its associated regional (sentinel) nodes
Development and Physiology
Fetal development the primordial breast arises from the basal layer of the epidermis
Before puberty the breast is a rudimentary bud comprised of a few branching ducts capped with alveolar buds,
end buds, or small lobules
At puberty - between the ages of 10 and 13 years ovarian estrogen and progesterone cooperate to direct organized communication between
breast epithelial cells and mesenchymal cells, resulting in extensive branching of the ductal
system and development of lobules
Final differentiation of the breast is mediated by progesterone and prolactin and is not completed untilthe first full-term pregnancy
Reproductive years - terminal ducts near the acini and the acini themselves are most sensitive to ovarianhormones and prolactin
Luteal phase of the menstrual cycle Breast epithelial cells proliferate when estrogen and progesterone levels are increased, and then
undergo programmed cell death at the end of the luteal phase, when levels of these hormones
decline This effect is mediated by paracrine signaling induced by estrogen receptor activation and is
associated with an increase in the water content of the extracellular matrix
o This is often recognized as breast fullness and tenderness the week preceding menseso Premenstrual breast symptoms are produced by an increase in blood flow, vascular
engorgement, and water retention
o 25 to 30 mL - average increase in volume of the premenstrual breasts Follicular phase
there is parenchymal proliferation of the ducts During the luteal phase
there is dilation of the ductal system and differentiation of the alveolar cells into secretory cells Menstruation begins
there is a regression of cellular activity in the alveoli and the ducts become smaller At menopause
ovarian estrogen production ceases breast lobules involute, and the collagenous stroma is replaced by fat Because estrogen receptor expression is negatively regulated by estrogen, there is an increase in
estrogen receptor expression after menopause
-
7/29/2019 Breast Diseases new
3/22
GYNECOLOGY BREAST DISEASES Page 3
Breast Anomalies 1% to 2% of women of European descent and 5% to 6% of Asian women Accessory breasts or nipples
o can occur along the breast or milk lines, which run from the axilla to the groin Supernumerary nipples (polythelia) or breasts (polymastia
Massive hypertrophy of the breasts at puberty (virginal hypertrophy) rare occurrence that has a deeply disturbing effect on a teenager's self-image
EVALUATION OF BREAST DISEASES
Detection
1. History Evaluation of a new breast symptom begins with assessment of symptoms based on a thorough
clinical history
Include questions regarding current symptoms, duration of the condition, fluctuation of the signs andsymptoms, and factors that aggravate or relieve the symptom
Assessment of breast problems should focus on the following points: Nipple discharge
o Characteristics of discharge (spontaneous or nonspontaneous, appearance, unilateral orbilateral, single or multiple duct involvement)
Breast mass (size and change in size, density, or texture) Breast pain (cyclic versus continuous) Association of symptoms with menstrual cycle Change in breast shape, size, or texture Previous breast biopsies
Patient should be questioned about the following risk factors for breast cancero Sexo Increasing age (approximately 50% of breast cancers occurafter age 65)o Age of menarche less than 12 yearso Nulliparity or first pregnancy at greater than 30 years of ageo Late menopause (older than 55 years of age)o Family history of breast cancer (especially premenopausal or bilateral disease)o Number of first-degree relatives with breast cancer and their ages when diagnosedo Family history of male breast cancero Inherited conditions associated with a high risk for breast cancer, including BRCA1 and BRCA2
genes, Li-Fraumeni syndrome, Cowden's disease, ataxia telangiectasia syndrome, and Peutz-
Jeghers syndrome
o Other malignancies (ovary, colon, and prostate)o Pathology of previous breast biopsy showing atypia or lobular or ductal carcinoma in situo Hormone therapyo Alcohol consumptiono Postmenopausal weight gaino Personal history of breast cancer
Breast cancer risk can be determined by the Gail Risk assessment model calculates risk based on patient race, age, age of menarche, age of first live birth, number of first -
degree relatives with breast cancer, number of previous breast biopsies, and presence of atypia
on the biopsy
-
7/29/2019 Breast Diseases new
4/22
GYNECOLOGY BREAST DISEASES Page 4
2. Physical Examination Breast tumors, particularly cancerous ones, usually are asymptomatic and are discovered only by
physical examination or screening mammography
premenstrual phase - most women have increased innocuous nodularity and mild engorgement ofthe breast
a. Inspection performed initially while the patient is seated comfortably with her arms relaxed at her sides Pay attention to the following signs
for symmetry contour edema Discharge or secretions alterations of the nipple
o retractiono eczema on one side
skin modifications or appearanceo redness or erythemao retraction of the skino bulge of the breasto orange skino Skin dimpling
Secretion Tumor infiltrating the skin
Retraction of skin
-
7/29/2019 Breast Diseases new
5/22
GYNECOLOGY BREAST DISEASES Page 5
Inflammation /Redness/Erythema Bulge of the breast
eczema on one side Retraction of nipple
b. Palpation While the patient is seated, each breast should be palpated methodically palpate the breast in enlarging concentric circles until the entire breast has been covered Palpation should use the pads of the first three fingers placed together, exerting firm but gentle
pressure
Pendulous breast can be palpated by placing one hand between the breast and the chest wall and gently palpatingthe breast between both examining hands.
The axillary and supraclavicular areas should be palpated for enlarged lymph nodes The entire axilla, the upper outer quadrant of the breast, and the axillary tail of Spence are palpated
for possible masses
PLATEAU SIGN
retraction of the skin is invisible unless you move or shift the skinbetween the fingers of both hands
While the patient is supine with one arm over her head, theipsilateral breast is again methodically palpated from the clavicle
to the costal margin
If the breast is largeo a pillow or towel should be placed beneath the scapula to
elevate the side being examined
o otherwise, the breast tends to fall to the side, makingpalpation of the lateral hemisphere more difficult
Major features to be identified Temperature texture and thickness of skin
-
7/29/2019 Breast Diseases new
6/22
GYNECOLOGY BREAST DISEASES Page 6
generalized or focal tenderness Nodularity density asymmetry dominant masses nipple discharge mobility
Premenopausal patients nodular breast parenchyma
Breast cancer mass nontender, firm mass with irregular margins A cancerous mass feels distinctly different from the surrounding nodularity A malignant mass may be fixed to the skin or to the underlying fascia
Breast Self-examination
Increases breast health awareness It helps promote early detection of cancer and may improve the survival rates for patients with breast
carcinoma
Most breast cancers are detected by women themselves (48%), followed by breast imaging (41%),and by physician clinical examination in only 11%
Essential components of breast examination Positions Palpation Pads of fingers for palpation Pressure Perimeter Pattern of search Patient education
It is helpful for all women to examine their breasts at the same time each month to develop a routine Premenopausal women
should examine their breasts monthly 7 to 10 days after the onset of the menstrual cycle For postmenopausal women selection of a specific calendar date is a helpful way to remember to perform a monthly BSE Use the pads of her second, third, and fourth fingers to palpate the contralateral breast Using the pads of her fingers, in a massaging motion with firm pressure, she should examine the
entire breast and surrounding chest wall in a systematic fashion
One of the easier techniques to follow is to palpate the breasts in a clockwise fashion beginning atthe nipple and gradually circumscribing larger circles
-
7/29/2019 Breast Diseases new
7/22
GYNECOLOGY BREAST DISEASES Page 7
3. Breast Imaginga. Mammography
screen-film mammography best method for imaging of the breast
Advantages of digital mammography lower radiation exposure ability to manipulate a computerized image for optimal viewing access to distance consultations through telemammography
Slow-growing breast cancers can be identified by mammography at least 2 years before the massreaches a size detectable by palpation
Mammography is the only reproducible method of detecting nonpalpable breast cancer Most practical method of detecting breast carcinoma at an early and highly curable stage, ideally
discovering an occult cancer (
-
7/29/2019 Breast Diseases new
8/22
GYNECOLOGY BREAST DISEASES Page 8
Mass margin Shape of mass Density of mass Associated findings Special cases
Malignancy clusters of fine calcifications spiculations poorly defined multinodular masses with irregular contours
Mammograhic Screening Recommendaions of the American Cancer Society
Mammograhic screening at age 40o 24% reduction in mortality in screened populations
For women in their 20s and 30so clinical breast examination is suggested at least every 3 years, and preferably
annually
For women older than age 40 years, annual clinical breast examination For older women, recommendations for mammographic screening may be
individualized based on the presence of any comorbidities
Recommendaions of the American Geriatrics Society annual or at least biennial mammography for women up to age 75 years after 75 years, every 2 to 3 years if the woman has a life expectancy of more than 4
years
For high-risk women, consideration can be given to earlier initiation of screening (5 to10 years earlier than the age of the index case) and shorter intervals between screening
Normal mammogram Breast Tumor
-
7/29/2019 Breast Diseases new
9/22
GYNECOLOGY BREAST DISEASES Page 9
b. Digital Radiography X-ray photons are detected after passing through the breast tissue and the radiographic image is
recorded electronically in a digital format and stored in a computer
Advantages compared with conventional mammography Image acquisition, display, and storage are much faster image manipulation through adjustments in contrast, brightness, and electronic
magnification of selected regions enables radiologists to obtain superior views Helpful in screening women with very dense breasts and breast implants
Disadvantages high cost of the equipment the limited image storage capacity the reduced spatial resolution due in part to inadequate resolution of current monitors
c. Computed Tomography Has limited value when compared with mammography because of higher radiation dose and
longer study times
Excellent for studying the most medial and lateral aspects of the breast It is sometimes used for preoperative wire location of a mass that is difficult to localize by
mammography
d. Magnetic Resonance Imaging Not be used in screening because of higher cost but as a diagnostic test Proven effective in detecting new tumors in patients with previous lumpectomy because it can
accurately distinguish between scar tissue and cancerous lesions
Indications Stage tumor to rule out multicentric disease Differentiate postoperative scar from recurrence after breast-conserving surgery Find a lesion seen in only one view of mammogram Evaluate positive axillary nodes in the presence of negative mammogram and clinical breast
examination results
Rule out silicone implant rupture Assess focal assymetry
e. Ultrasonography complementary procedure to other imaging techniques in the diagnosis of breast disease,
particularly in differentiating cystic from solid masses
It should not be used as a screening test except for women with very dense breasts whocannot be adequately screened with mammography
Advantages of ultrasound ability to produce images of breast tissue on multiple occasions without harmful effects It is most useful in evaluating solitary masses greater than 1 cm in diameter
greatest limitation of ultrasonography The limited spatial resolution Microcalcifications are not visualized because resolution of less than 2 mm is difficult with
ultrasound
Indications for breast ultrasonography Characterization:
o Palpable abnormalityo Ambiguous mammographic findingso Silicone leako Mass in woman younger than 30 years, lactating, or pregnant
Guidance for interventional procedureso guide for needle aspiration, needle core biopsy, and in localization procedures
-
7/29/2019 Breast Diseases new
10/22
GYNECOLOGY BREAST DISEASES Page 10
o also used to localize tumorsintraoperatively without a guide wire with excellentsuccess rates
Possible role for additional imaging in high-risk individuals Differentiate a cystic breast mass from a solid mass
o most important use of ultrasoundo 96% to 100% accuracy rate
f. Mammoscintigraphy (Scintimammography) Radionuclide imaging test for the detection of breast cancer High diagnostic accuracy for the detection of breast cancer in all women, including women who
may be unsuitable for conventional mammography
Breast Tissue Evaluation: Histology and Cytology
30% of lesions suspected to be cancer prove on biopsy to be benign 15% of lesions believed to be benign prove to be malignant Dominant masses or suspicious nonpalpable mammographic findings must be evaluated by biopsy An apparently fibrocystic lesion that does not completely resolve within several menstrual cycles should
be sampled for biopsy
Any mass in a postmenopausal woman who is not taking estrogen therapy should be presumed to bemalignant
Algorithm for management of breast masses in postmenopausal women
Palpable mass
Not clinically
malignant
Mammography
FNAC or Core
Needle Biopsy
Preoperative
evaluation and
counselling
Definitive Procedure
Excisional Biopsy
Mammography
Not obviously
malignant
-
7/29/2019 Breast Diseases new
11/22
GYNECOLOGY BREAST DISEASES Page 11
Algorithm for management of breast masses in premenopausal women
Palpable mass
Mammogram
Ultrasound
FNAC or Core
Needle Biopsy
Appears malignantcystic
Solid but not
suggestive of
malignancy
Excise or re-examine
after next menses or
1-2 months
persistence
excision
aspirate
Nonbody fluid
resolves
reexamine
recurrence
excisionRoutine follow up
No recurrence
excision
resolution
Clinically malignant
mammogram
Definitive procedure
Preoperative
evaluation andcounselling
Not clinically
malignant
Routine follow up
-
7/29/2019 Breast Diseases new
12/22
GYNECOLOGY BREAST DISEASES Page 12
1. Fine-needle Aspiration The color of the fluid obtained via aspiration varies from clear to
grossly bloody
A biopsy should be performed on cysts that recur within 2 weeks orthat necessitate more than one repeat aspiration
sensitivity of FNA for palpable masses is approximately 90% false-negative rate that varies from 0.7% to 22%
2. Biopsy Core Needle or Open Biopsy Indications for tissue biopsy
bloody discharge from the nipple a persistent three-dimensional mass suggestive mammography Nipple retraction or elevation skin changes, such as erythema, induration, or edema
BENIGN BREAST CONDITIONS
Three life cycles reflect different reproductive phases in a woman's life and are associated with uniquebreast manifestations
During the early reproductive period (15-25 years), lobule and stromal formation occurso fibroadenoma (mass) and juvenile hypertrophy (excessive breast development)
During the mature reproductive period (25-40 years), cyclic hormonal changes affect glandulartissue and stroma
o cyclic mastalgia and generalized nodularity involution of lobules and ducts or turnover of epithelia, which occurs during ages 35 to 55 years
o macrocysts (lumps)o sclerosing lesions (mammographic abnormalities)o Those associated with ductal involution - duct dilation (nipple discharge) and periductal
fibrosis (nipple retraction)
o those with epithelial turnover are mild hyperplasia (pathologic description)1. Fibrocystic Change
most common lesion of the breast refers to a histologic picture of fibrosis, cyst formation, and epithelial hyperplasia Cysts arise from the breast lobules and are an aberration of normal breast involution common in women ages of 20 and 50 (35 to 55 years of age) but rare in postmenopausal women not
taking hormone therapy
it is present bilaterally, increased in the perimenopausal age group, and responsive to endocrinetherapy
believed to be an exaggeration of the normal physiologic response of breast tissue to the cyclic levelsof ovarian hormones
imbalance of the ratio of estrogen to progesterone secondary to increased daily prolactin production Women with fibrocystic changes have
enhanced prolactin production in response to thyroid-releasing hormone
Signs and Symptoms - more prevalent during the premen-strual phase of the cycle cyclic bilateral breast pain classic symptom
pain is most frequently located in the upper, outer quadrants of the breasts. Often thepain radiates to the shoulders and upper arms
increased engorgement and density of the breasts excessive nodularity rapid change and fluctuation in the size of cystic areas increased tenderness
-
7/29/2019 Breast Diseases new
13/22
GYNECOLOGY BREAST DISEASES Page 13
occasionally spontaneous nipple discharge Differential diagnosis of breast pain
Referred pain from a dorsal radiculitis Inflammation of the costal chondral junction (Tietze's syndrome)
Physical Examination Excessive nodularity of fibrocystic changes is similar to palpating the surface of a plateful of
peas Multiple solid areas are described as ill-defined thicknesses or areas of palpable lumpiness
that are rubbery in consistency and may seem more two-dimensional than the three-
dimensional mass usually associated with a carcinoma
The larger cysts have a consistency similar to a balloon filled with water Clinical Stages
a. mazoplasia (mastoplasia) first stage occurs in women in their 20s Breast pain is noted primarily in the upper, outer quadrants of the breast The indurated axillary tail is in the most tender area of the breast There is intense proliferation of the stroma
b. Adenosis second stage women in their 30s breast pain and tenderness are premenstrual but less severe Multiple small breast nodules vary from 2 to 10 mm in diameter marked proliferation and hyperplasia of ducts, ductules, and alveolar cells
c. Cysticphase - third stage
women in their 40s There is no severe breast pain unless a cyst increases rapidly in size woman experiences a sudden pain with point tenderness and discovers a lump Cysts are tender to palpation and vary from microscopic to 5 cm in diameter fluid aspirated from a large cyst is straw-colored, dark brown, or green
Diagnostic Tests Characteristic findings on ultrasonography
o Mass with thin wallso Smooth round shapeo Absence of internal echoeso Posterior acoustic enhancement
If these imaging criteria are not met, a tissue diagnosis of the mass usually requires a FNA, FNAC,or EB
Fine needle aspiration Benign cyst fluid - straw colored to dark green to brownish
Fibrocystic change is not associated with an increased risk of breast cancer unless there is histologicevidence of epithelial proliferative changes, with or without atypia
If there is a persistent dominant mass or any uncertainty in the examination, a biopsy of the areashould be performed to rule out a malignancy
Management patient wearing a support bra, which provides adequate support for the breasts both night
and day
Diuretics during the premenstrual phase occasionally relieve breast discomfort Oral contraceptives or supplemental progestins administered during the secretory phase of
the cycle
Danazol drug of choice for severe symptoms 100, 200, and 400 mg daily continuously for 46 months should not continue more than 6 months because side effects are common
Bromocriptine or Tamoxifen Patients who do not respond to danazol
-
7/29/2019 Breast Diseases new
14/22
GYNECOLOGY BREAST DISEASES Page 14
Bromocriptine - an inhibitor of prolactin given continuously of 5 mg daily
Tamoxifen - a synthetic antiestrogen 70% relief of breast symptoms when prescribed for fibrocystic changes
2. Fibroadenomas firm, rubbery, freely mobile, solid, usually solitary breast masses second most common type of benign breast disease adolescents and women in their 20s Usually discovered accidentally while bathing Do not change in size with the menstrual cycle, and they do not produce breast pain or tenderness 30% will disappear and 10% to 12% become smaller average fibroadenoma is 2.5 cm in diameter responsive to estrogen stimulation not associated with an increased risk for breast cancer Sonography - differentiating a solid from a cystic mass FNAB Open biopsy or surgical removal
3. CystosarcomaPhyllodes fibroepithelial breast tumors hypercellularity of the connective tissue rare - represent only 2.5% of fibroepithelialtumors and 1% of breast malignancies They are the most frequent breast sarcoma Rapidly growing tumors Most common in the fifth decade of life Rarely bilateral and usually appear as isolated masses that are difficult to distinguish clinically from a
fibroadenoma
Patients often relate a long history of a previously stable nodule that suddenly increases in size Reported sizes range from 1.0 to 50 cm
Factors that are considered in recommending excision include older age new mass in a well-screened individual rapid growth size greater than 2.5 to 3 cm suspicious FNAC or CB mammographic or ultrasonographic features that demonstrate lobulation and intramural
cysts
Treatment - wide local excision, attempting to obtain a 1- to 2-cm margin Prognosis
benign phyllodestumors can recur locally in up to 10% of patients Malignant phyllodestumors tend to recur locally and occasionally may metastasize to the lung,
although brain, pelvic, and bone metastases also may occur
Borderline tumor Malignanttumor
-
7/29/2019 Breast Diseases new
15/22
GYNECOLOGY BREAST DISEASES Page 15
4. Intraductal Papilloma spontaneous bloody discharge from one nipple - classical symptom
discharge from the nipple is spontaneous and intermittent watery, serous, or serosanguineous When the discharge comes from a single duct, the differential diagnosis involves both intraductal
papilloma and carcinoma
If multiple ducts are involved, the diagnosis of carcinoma is more likely perimenopausal age group 75% of intraductalpapillomas are located beneath the areola difficult to palpate because they are small and soft Treatment - excisional biopsy of the involved duct and a small amount of surrounding tissue
5. Nipple Discharge complaint of 10% to 15% of women with benign breast disease spontaneous nipple discharge is infrequently found to be associated with carcinoma, ranging from 4%
to 10%
Nonneoplastic processes galactorrhea physiologic changes resulting from mechanical manipulation parous condition periductal mastitis subareolar abscess fibrocystic change mammary duct ectasia
Neoplastic causes in nonlactating women solitary intraductal papilloma carcinoma papillomatosis squamous metaplasia adenosis
Characteristics of the discharge to be evaluated Nature of discharge (serous, bloody, or milky) Association with a mass Unilateral or bilateral Single or multiple ducts Discharge that is spontaneous (persistent or intermittent) or expressed by pressure at a
single site or on entire breast
Relation to menses Premenopausal or postmenopausal Hormonal medication (contraceptive pills or estrogen)
Chronic unilateral nipple discharge, especially if it is bloody, is an indication for resection of theinvolved ducts
Treatment surgical excision
o periareolar incision adjacent to the trigger point, the pressure point that elicits nippledischarge
6. Fat Necrosis Rare but clinically important because it produces a mass, often accompanied by skin or nipple
retraction, which is indistinguishable from carcinoma
-
7/29/2019 Breast Diseases new
16/22
GYNECOLOGY BREAST DISEASES Page 16
firm, tender, indurated, ill-defined mass that may have an area of surrounding ecchymosis Sometimes the area of fat necrosis liquefies and becomes cystic in consistency needle-core excisional biopsy of the entire mass to rule out carcinoma
7. Breast Abscess Lactational Abscesses
Staphylococcus aureus mastitis is diagnosed, manual pressure, antibiotics, and continued breastfeeding are
recommended
dicloxacillin 250 mg four times daily, or oxacillin, 500 mg four times daily for 7 to 10 days If the lesion progresses to a localized mass with local and systemic signs of infection, an abscess is
present
It should be drained, and breastfeeding should be discontinued Nonlactational Abscess
Staphylococcus epidermidis Staphylococcus aureus Proteus mirabilis Pseudomonas aeruginosa sterile abscess
If these infections recur after multiple aspirations, incision and drainage followed by excision of theinvolved lactiferous duct or ducts at the base of the nipple may be necessary during a quiescent
interval
BREAST CARCINOMA
Epidemiology
Established and Probable Risk Factors for Breast Cancer
Risk Factor ComparisonCategory Risk Category
Typical
RelativeRisk
Family history of breast cancer - 5% to 10%
- BRCA1 (chromosome 17q21) and BRCA2 No first-degreerelatives affected Mother affectedbefore the age of60
2.0
Mother affected
after the age of 60
1.4
Two first-degree
relatives affected
46
Age at menarche - There is no clear association between
the risk of breast cancer and menstrual irregularity and the
duration of menses
16 yr 11 yr 1.3
12 yr 1.3
13 yr 1.3
14 yr 1.3
15 yr 1.1
-
7/29/2019 Breast Diseases new
17/22
GYNECOLOGY BREAST DISEASES Page 17
Age at birth of 1st child
If a woman's first term birth occurs before age 20, she has 50% less
risk than a nulliparous woman.
If the first full-term pregnancy occurs after age 35, the risk is 1.5
times greater than for women who have their first baby before age
26
It was believed that nursing an infant offered a protective effect for
the future development of breast neoplasia
related to the intensity and duration of exposure to unopposed
endogenous estrogen
Before 20 yr 2024 yr 1.3
2529 yr 1.6
30 yr 1.9
Nulliparous 1.9
Age at menopause - After menopause the incidence of breast
carcinoma increases directly with a woman's age
-twofold increased risk for women who menstruated for 40 years or
longer
- Bilateral oophorectomy before age 35, without hormonalreplacement, reduces the risk of breast carcinoma by 70%
4554 yr After 55 yr 1.5
Before 45 yr 0.7
Oophorectomy
before 35 yr
0.4
Benign breast disease No biopsy or
aspiration
Any benign disease 1.5
Proliferation only 2.0
Atypical hyperplasia 4.0
Radiation - Ionizing radiation is a definite risk factor because of the
long-accepted relationship between radiation and malignant
transformation
No special
exposure
Atomic bomb (100
rad)
3.0
Repeated
fluoroscopy
1.5
2.0
Obesity - increased amount of peripheral conversion ofandrostenedione to estrone and decreased levels of sex hormone-
binding globulin
10th percentile 90th percentile:
Age, 3049 yr 0.8
Age, 50 yr 1.2
Height 10th percentile 90th percentile:
Age, 3049 yr 1.3
Age, 50 yr 1.4
Oral contraceptive use - no consensus on the association of
exogenous estrogen administration
Never used Current use 1.5
Past use[*]
1.0
Postmenopausal estrogen-replacement therapy - no consensus on
the association of exogenous estrogen administration
Never used Current use all ages 1.4
Age,
-
7/29/2019 Breast Diseases new
18/22
GYNECOLOGY BREAST DISEASES Page 18
Detection and Diagnosis
use of screening tests in asymptomatic women at periodic intervals to discover breast malignancies Physical examination
detects 10% to 20% of cancers not seen radiographically 10% to 50% of cancers detected mammographically are not palpable
Breast cancer most commonly arises in the upper outer quadrant, where there is proportionally morebreast tissue
Masses are easier to palpate in older women with fatty breasts than in younger women with dense,nodular breasts
When a dominant breast mass is identified, the presence of a carcinoma must be considered biopsy should be performed to establish a tissue diagnosis
About 30% to 40% of lesions believed clinically to be malignant will be benign on histologic examinationPrevention
lifestyle modifications associated with good general health weight control, avoidance of smoking, decreased alcohol consumption, and exercise
tamoxifen had a significant decrease in the incidence of contralateral breast cancers
Surgical prophylaxisClassification
classic sign solitary, solid, three-dimensional, dominant breast mass borders of the mass are usually indistinct, which makes it difficult to define precisely the size of
the mass
mass is not freely mobile Far-advanced local disease
produces changes in the skin and nipples of the breast, includ-ing retraction, dimpling,induration, edema (peaud'orange), ulceration, and signs of inflammation
Simplified Classification of Breast Carcinoma
Type of Carcinoma Percentage of All Cases Diagnosed
Ductal Carcinoma
- in situ
- infiltrating
5
80
Lobular Carcinoma
- In situ
- Infiltrating
- Inflammatory carcinoma
- Paget's disease
3
9
2
1
Intraductalcarcinomain situ
the cellular abnormalities are limited to the ductal epithelium and have not penetrated the basemembrane
It is most commonly discovered in perimenopausal and postmenopausal women. not usually detected by palpation because the disease does not produce a definitive mass Mammography sometimes demonstrates the fine stippling of microcalcifications. The histologic diagnosis includes a heterogeneous group of tumors with varying malignant potential
-
7/29/2019 Breast Diseases new
19/22
GYNECOLOGY BREAST DISEASES Page 19
Lobular carcinoma in situ
considered to be a marker for an increased breast cancer risk It does not have the same malignant potential as intraductal carcinoma in situ has a much greater tendency to be bilateral and to present as multifocal disease
Infiltrating ductal carcinoma
most common breast malignancy Histologically, nonuniform malignant epithelial cells of varying sizes and shapes infiltrate the surrounding
tissue
Infiltrating lobular carcinomas
characterized by the uniformity of the small, round neoplastic cells the malignant epithelial cells infiltrate the stroma in a singlefile fashion tends to have a multicentric origin in the same breast and tends to involve both breasts more often than
infiltrating ductal carcinoma
Histologic subdivisions small cell round cell signet cell carcinomas
Inflammatory carcinomas
2% of breast cancers initially appear to have acute inflammation of the breast with corresponding redness and edema recognized clinically as a rapidly growing, highly malignant carcinoma Infiltration of malignant cells into the lymphatics of the skin produces a clinical picture that simulates a
skin infection
Paget's disease
less than 1% has an innocent appearance and looks like eczema or a dermatitis of the nipple erosion results from invasion of the nipple and surrounding areola by characteristic large cells with
irregular nuclei, called Paget cells produced by an infiltrating ductal carcinoma that invades the epidermis has an excellent prognosis
Breast Cancer in Pregnancy
complicates 1 in 3,000 pregnancies second most common malignancy seen in association with pregnancy Generalized recommendations for treatment
cancers diagnosed during the first or second trimester of pregnancy have been treated withmodified radical mastectomy. Sentinel node biopsy remains a controversial procedure in
pregnancy
Localized tumors found during the third trimester of pregnancy can be managed with breastconservation therapy, with radiation delayed until after delivery, or with modified radical
mastectomy
If the breast cancer is diagnosed during lactation, lactation should be suppressed and the cancershould be treated definitively
Advanced, incurable cancer should be treated with palliative therapy
-
7/29/2019 Breast Diseases new
20/22
GYNECOLOGY BREAST DISEASES Page 20
Treatment of Breast Cancer
four most important variables for treatment selection tumor'ssiz its inherent aggressiveness, as determined by the histology of the initial lesion the presence of positive nodes the receptor status of the tumor
TNM system widely recognized staging system based on both clinical and pathologic criteria
Surgical Therapy radical mastectomy
o standard operation for carcinoma of the breasto designed to control local disease by an extensive en bloc removal of the breast and
underlying pectoralis major and pectoralis minor muscles and complete axillary
dissection
o It is a cosmetically disfiguring operation, leaving a major deformity of the chest wall modified radical mastectomy removes the breast and only the fascia over the pectoralis major muscle. The pectoralis minor
muscle may be removed to facilitate the axillary dissection
Simple mastectomyo removal of the breast without underlying muscle tissue
Stages I and II breast cancero conservative surgery, which preserves the breast, followed by radiation therapy
Medical Therapy Adjuvant systemic chemotherapy decreases the odds of dying from breast cancer during the first
10 years following diagnosis by approximately 25%
Tamoxifen Medroxyprogesterone (Depo-Provera) Androgens danazol gonadotropin hormone-releasing hormone (GH-RH) agonists Combination therapy
o paclitaxel Adriamycin cyclophosphamideo cyclophosphamide (C), methotrexate (M), and 5-fluorouracil (5-FU).
http://localhost/var/www/apps/conversion/tmp/scratch_1/Primary%20Tumor.docxhttp://localhost/var/www/apps/conversion/tmp/scratch_1/Primary%20Tumor.docx -
7/29/2019 Breast Diseases new
21/22
GYNECOLOGY BREAST DISEASES Page 21
Primary Tumor (T)
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis[*]
Carcinoma in situ. Intraductal carcinoma, lobular carcinoma in situ, or Paget's disease of the nipple with no tumor
T1 Tumor is 2.0 cm in greater dimension
T1a Tumor is 0.5 cm in greatest dimension
T1b Tumor is >0.5 cm but not more than 1.0 cm in greatest dimension
T1c Tumor is more than 1.0 cm but not more than 2.0 cm in greatest dimension
T2 Tumor is >2.0 cm but not more than 5.0 cm in greatest dimension
T3 Tumor is >5.0 cm in greatest dimension
T4 Tumor of any size with direct extension to chest wall or skin
T4a Extension to chest wall
T4b Edema (including peau d'orange) or ulceration of the skin of the breast or satellite skin nodules confined to the same breast
T4c Both T4a and T4b above
T4d Inflammatory carcinoma
Regional Lymph Node Involvement (N) (Clinical)
NX Regional lymph nodes cannot be assessed (e.g., previously removed)
N0 No regional lymph node metastasis
N1 Metastasis to movable ipsilateral axillary lymph node(s)
N2 Metastasis to ipsilateral axillary lymph node(s) fixed to one another or the other structures
N3 Metastasis to ipsilateral mammary lymph node(s)
Distant Metastasis (M)
MX Presence of distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis (includes metastasis to ipsilateral supraclavicular lymph node[s])
Stage Grouping
Stage 0 Tis N0 M0
Stage I T1 N0 M0
Stage IIa T0 N1 M0
T1 N1[*]
M0
T2 N0 M0
Stage IIb T2 N1 M0
T3 N0 M0
Stage IIIa T0 N2 M0
T1 N2 M0
T2 N2 M0
T3 N1, N2 M0
Stage IIIb T4 Any N M0
Any T N3 M0
Stage IV Any T Any N M1
-
7/29/2019 Breast Diseases new
22/22
GYNECOLOGY BREAST DISEASES Page 22