Breast diseases

Ionut Negoi, MD PhD,

Assistant Professor of Surgery,
University of Medicine and Pharmacy Carol Davila Bucharest
Emergency Hospital of Bucharest
OBJECTIVES

Develop an approach to the diagnosis &

treatment of common breast problems:
Mastodynia
Breast Mass
Nipple Discharge
Abnormal Mammogram
OBJECTIVES

Discuss Treatment Options for Men and

Women with Breast Carcinoma

Discuss Breast Cancer Risk Assessment and

Prevention Strategies
Surgical Consult

Majority of surgical consultation for Breast

complaints ultimately prove to have a benign
origin.
Surgeon’s role in management of Breast
Disease includes:
Assessment of Breast Cancer Risk
Breast Cancer Screening
Providing Specific Diagnosis
Treatment/Management
Embriology

• Develops from
Ectoderm Milk Streak
Anatomy
Anatomy

Lobules and Ducts

 The glandular tissue consists
of 15 to 20 lobules (clusters of
milk forming glands, or acini)
that enter into branching and
interconnected ducts.
 The ducts widen beneath the
nipple as lactiferous sinuses
and then empty via nipple
openings.
Anatomy
ANATOMY
Arteries
1. Internal Mammary Artery
2. Intercostal arteries
3. Axillary Artery
Veins
1. Internal Mammary
2. Intercostal
3. Axillary Veins
Lymphatic Drainage
1. 97% to Axillary Nodes
2. Internal Mammary and Supraclavicular nodes
 Anatomy
• Three LNs Levels:
Level I – Lateral to Pm
Level II – Deep to Pm
Level III – Medial Pm
Rotter’s – Between PM
& Pm
Anatomy
 Anatomy

• Nerves
 Long Thoracic Nerve
 Serratus Anterior
m.
 Winged Scapula
 Thoracodorsal Nerve
 Latissimus Dorsi
 Intercostobrachial
Nerve
Evaluation: History
Risk Factors Protective factors
BRCA1 and BRCA2 Breastfeeding
1˚ relative with breast or ovarian cancer Parity
Personal history of breast disease Recreational exercise
Age > 70 yrs Postmenopause BMI < 23
Age at menarche < 12 yrs Oophorectomy at < 35 yrs
Nulliparous or age at first birth > 30 yrs Aspirin
Never breastfed
Age at menopause > 55 yrs
Use of OCP’s
HRT (estrogen + progestin)
Radiation exposure to chest
EtOH
Clinical Exam Components

Inspection/ Upright
Palpation
Supine arm overhead
-radial or circular
-Nipple-areolar complex
Axillary palpation
Supraclavicular palpation
Inspection
Skin Dimpling
Peau d‘orange
 Palpation

Position the patient in Use pads of the index,

third, and fourth Make three circles with the
the direction of palpation finger pads, increasing the
for the CBE. fingers (inset) make
small circular motions level of pressure
(subcutaneous, mid-level,
and down to the chest
wall) with each circle
Palpation
Palpation
BREAST SELF-EXAM
How patients present ?

• Pain

• Discharge

• Mass
OBJECTIVES

Develop an approach to the diagnosis & treatment of

common breast problems:

 Mastodynia

 Nipple Discharge

 Breast Mass

 Abnormal Mammogram
Mastalgia
CYCLIC NONCYCLIC
Most common Less common
Worse Premenstrual Unrelated to cycles
Usually Bilateral Unilateral or Bilateral
Premenopausal Pre or
> UOQ / diffusely postmenopausal
tender Localized or diffuse
Probably hormonal ? Less likely hormonal
? Etiology Underlying Pathology
Mastalgia – EVALUATION

History
Physical Examination
Risk Factor Analysis
> 35 yrs. Include Mammogram*
R/O other treatable etiologies
**Localized new pain in PoMP female
MUST R/O MALIGNANCY
Mastalgia - TREATMENT

NO STRONG EBM DIRECTIVES*

Reassurance & Re-evaluation
Attempted Strategies
 Mechanical Support Bra
 Elimination of methylxanthines
 Vitamins (E, A, B complex)
 Anti-inflammatories
 Primrose Oil
 Hormone manipulation ( OCP’s, Danazol)
Breast inflammation

Mastitis
Breast Abscess
Duct Ectasia
Mondor’s Disease
Local Skin Conditions
Trauma +/- Fat necrosis
Breast Inflammation
MASTITIS

PUERPERAL NONPUERPERAL
Lactation related Non-lactational
Unilateral or bilateral Usually unilateral
Nipple micro-trauma ? Nipple trauma vs.
Bacterial:* duct obstruction
Staph.Aureus
Strep.sp., E.Coli Periductal Mastitis
Non-resolving localized Localized to nipple-
fluctuance = abscess areolar complex +
tender mass
 MASTITIS

 Presentation
 Usually seen in breastfeeding mothers
 Unilateral, swollen, wedge-shaped area of
breast
 Pain, redness, induration (hardening)
 Systemic symptoms (high fever, malaise,
chills)

 Treatment
 Rest, fluids
 Dicloxicllin 500mg QID x 10-14d
 Continue frequent breast feeding
MASTITIS vs. Inflammatory breast cancer

 Peau d’orange-dimpling of involved skin due to retraction

caused by lymphatic involvement and obstruction
 Associated erythema
 Cellulitis may mimic inflammatory carcinoma
MASTITIS - TREATMENT

PUERPERAL NONPUERPERAL
Antibiotics Antibiotic Trial
Continued feeding Periductal may
to empty breast require excision
Pain control If no response MUST
Mechanical support R/O Inflammatory
BCA*
Abscess requires
drainage
Breast Abscess

• Drainage of an abscess throught an incision located in

the sulcus
Fat Necrosis

 Caused by trauma
 Tender, firm mass with indistinct borders
 May appear suspicious on physical exam
 Benign breast calcification seen on mammography

Fat necrosis Densely calcified 3-cm area of

manifesting as a fat necrosis 2 years after blunt
spiculated mass trauma to the breast.
FIBROCYSTIC CONDITIONS

Most common benign breast condition

Incidence greatest in reproductive years
Pathogenesis is uncertain : possibly hormone
imbalance btw. estrogen & progesterone
Symptoms decrease after menopause unless
HRT
FIBROCYSTIC CONDITIONS

NON-PROLIFERATIVE PROLIFERATIVE
Micro/macro cysts Intraductal papilloma
Duct Ectasia Florid Sclerosing Adenosis
Papillary Apocrine Epithelial Hyperplasia
Mastitis Ductal
Lobular
Fibrosis
Atypical
Metaplasia
Mild Sclerosing Adenosis
Fibrocystic Disease
 Premenopausal women
 Premenstrual breast swelling/tenderness
 Nodules/masses/lumps related to dense breast tissue or
cysts

 Fibrous  Cystically dilated ducts

tissue  + Calcifications
 + Ductal hyperplasia
Fibrocystic Disease - SIGNS & SYMPTOMS

Pain & Tenderness : Bilateral, premenstrual dull

heavy breast engorgement

Nodularity: localized or generalized, unilateral

or bilateral

Fluctuating size

Nipple discharge on occasion

Fibrocystic Disease - DIAGNOSIS

History & Physical Exam

Risk Analysis
Identification of persistent
dominant mass
Mammogram / Ultrasound
Fibrocystic Disease - TREATMENT

Reassurance & Follow-up plans

Support Bra
Aspiration of Macrocysts
Medications
 Vitamin E
 Primrose Oil
 Hormonal (Danazol, OCP’s Tamoxifen)
 Elimination of Methylxanthines?
Fibrocystic Disease - RELATIVE RISKS

Non-proliferative Minimal

Proliferative without atypia Moderate

Proliferative with atypia High

OBJECTIVES

Develop an approach to the diagnosis & treatment of

common breast problems:

 Mastodynia

 Nipple Discharge

 Breast Mass

 Abnormal Mammogram
NIPPLE DISCHARGE
PHYSIOLOGIC PATHOLOGIC
Bilateral Unilateral
Compression Spontaneous
Multi-colored Bloody
Multiductal Single duct
Lactational or not Nonlactational
Often resolves Persistent
*Associated with mass or
abnormal mammo/US
NIPPLE DISCHARGE - PATHOPHYSIOLOGY

Mammary Duct Ectasia

Nonpuerperal Mastitis
Galactorrhea
Fibrocystic Condition
Pregnancy Associated discharge
Intraductal Papilloma
Intraductal Carcinoma
NIPPLE DISCHARGE - EVALUATION & TREATMENT

Clinical Examination Reassurance &

Mammography/ US Follow-up plans
Galactography Duct Excision if
Pathologic/
Prolactin Suspicious
Cytology
Normal
Abnormal
Intraductal Papilloma US
OBJECTIVES

Develop an approach to the diagnosis & treatment of

common breast problems:

 Mastodynia

 Nipple Discharge

 Breast Mass

 Abnormal Mammogram
BREAST MASS

True versus Perceived

Dominant
Solid versus Cystic
Imaging features
 BREAST MASSES
REQUIRE A TISSUE
DIAGNOSIS
REGARDLESS OF THE
AGE OF THE PATIENT
BREAST MASSES - ALL TO GET A TISSUE DIAGNOSIS

• WHY?
• CANCER IN YOUNG WOMEN
• UNUSUAL DIAGNOSIS
• LYMPHOMA
• TUBERCULOSIS

• HOW?
• FINE NEEDLE ASPIRATE
• CORE/TRUCUT BIOPSY
• SONAR GUIDED FNA OR CORE
• MAMMOGRAM GUIDED
• HOOK WIRE
• LAST RESORT EXCISIONAL DIAGNOSIS
 95% of all patients should
have the diagnosis made prior
to surgery
 Breast Disease

 Benign  Malignant
 Nonproliferative
 Ductal carcinoma
 Fibrocystic changes
 Lobular carcinoma
 Simple cysts
 Lactational adenoma  Tubular carcinoma
 Fibroadenoma  Mucinous carcinoma
 Hyperplasia without atypia  Micropapillary carcinoma
 Epithelial hyperplasia  Metaplastic carcinoma
 Sclerosing adenosis  Inflammatory carcinoma
 Intraductal papillomas
 Hyperplasia with atypia
 LCIS
 DCIS
DOMINANT BREAST MASSES

Fibroadenoma
Cyst
Fibrocystic mass
Fat necrosis
Carcinoma
Breast mass - EVALUATION & TREATMENT

Clinical Exam Establish Diagnosis

Imaging Studies Follow-up Plan
Mammography Definitive
Ultrasound Management
Risk Analysis Benign
Biopsy Aspirate
FNA Sample
Core Excise
Excisional Malignant
 FIBROADENOMA
Well defined, rubbery mass Well circumscribed mass
Usually solitary and mobile by mammo
Premenopausal Solid mass by US
May involute PoMP Require histologic
May increase w/preg confirmation
Rarely associate Core Biopsy
w/malignancy Excisional Biopsy
Follow-up
Fibroadenoma
 Solitary, firm, rubbery, mobile mass
 Women < 30 yrs
 Slow growing (? hormonally mediated)

Fibroadenoma gross specimen

 Firm, tan, lobulated
 Well circumscribed mass
 Variable size
Fibroadenoma
Fibroadenoma US
Fibroadenoma
CYSTS

Well demarcated, mobile, Well Circumscribed on

firm mammography
Single or multiple Fluid filled by US
Unilateral or bilateral Premenopausal
Tender or asymptomatic Aspirate if symptomatic or
suspicious
Tend to vary with cycles
No Routine Cytology
Commonly 40’s and
Bloody,no-collapse, or
peri-menopausal recurs: excise
Postmenopausal
+/- Aspirate all cysts
Short term follow-up
CYST
CYST
OBJECTIVES

Develop an approach to the diagnosis & treatment of

common breast problems:

 Mastodynia

 Nipple Discharge

 Breast Mass

 Abnormal Mammogram
MAMMOGRAPHY

Screening Mammogram = 2 view, both

breasts CC and MLO

Diagnostic Mammogram= special views,

magnification/ compression, markers
over palpable mass
ABNORMAL MAMMOGRAM

Microcalcifications
Mass
Asymmetric density
Architectural Distortion
Mass + Density + Calcifications
Stellate Lesion
Asymmetric Density
Mass & Distortion
US lesion
 MAMMOGRAPHY - EVALUATION & TREATMENT

Additional views +/- US to Exam – Mammo +

clarify findings Need image guided Biopsy
Patient & Physician Needle localization
notification
Stereotactic
H&P ( does exam correlate
w/ mammo?) If low probability of
suspicious lesion
Biopsy indeterminate or
suspicious findings Short term mammo F/U ~
6mo interval
ACR Standardized Reporting

Category 1-2: negative no further w/u

Category 3: if no palpable abnormality f/u
mammogram in 6 mo
Category 4: Indeterminate, biopsy
recommended
Category 5: Highly suspicious for malignancy
biopsy indicated
Tissue Diagnosis

Image guided
US Directed
Stereotactic (1985)
MRI Directed
Needle localization open biopsy (Surgical)
Core Needle Biopsy
Excisional Biopsy (Surgical)
BIOPSY COMPARISON
FNA CORE EXCISIONAL

Cytology Histopathology Histopathology

Cells only Tissue (Entire lesion)

Sampling error Less sampling error Provides margin

10% False - information

Rapid, easy $ Rapid, painless $$ Requires anesthesia $$$

Image guided Image guided Image guided ?

requires confirmation* requires confirmation* requires confirmation*
US Directed Biopsy
Mammography Directed
Biopsy = Stereotactic
Biopsy
• Mammotome® Vacuum Biopsy System
Stereotactic
Stereotactic biopsy
Open Biopsy
Needle Localization
Open Excisional Biopsy
Specimen Radiograph
WHEN TO REFER?

Dominant Mass

Suspicious Mammogram

Established high risk history or pathology

Need for tissue diagnosis or ancillary studies

Physician or Patient driven

Breast cancer
Incidența cancerului de sân la
nivel global 90
Incidența în România 91
BREAST CARCINOMA

RISK FACTORS
Personal history of BCA
Family History
Genetic Mutations (BRCA1-2, p53)
Early Menarche, Late Menopause, Nulliparity
Late age at first pregnancy
Proliferative breast disease
Other (Hormones, fat, ETOH ?)
Types of Breast Cancer

Non-invasive
In-SITU
Ductal Carcinoma In-Situ (DCIS)
Lobular Carcinoma In-Situ (LCIS)
Invasive
Ductal 70-80%
Lobular 5-10%
Other
DCIS
IDC
DIAGNOSIS

Mass
Skin Changes
Pathologic Nipple Discharge
Abnormal Mammogram
+ Biopsy/ + FNA
Palpable mass
Ulcerated lesion
Neglected Breast Cancer
Nipple retraction
Paget’s Disease
Inflammatory Breast CA
Imaging

Characterize Lesions: size, extent, #, location

Determine operability
Evaluate the opposite breast
Search for distant metastases
Create a reproducible image to gauge response
to treatment
Mammogram
Breast MRI
Lobular Carcinoma
Liver Metastases
PET SCAN / PET-CT SCAN
Metastatic Disease/ PET SCAN
STAGING

• TNM CLASSIFICATION

• A BIOLOGICAL
CLASSIFICATION
Staging and Prognosis
• Primary Tumor
• T1 = Tumor < 2 cm. in greatest dimension
• T2 = Tumor > 2 cm. but < 5 cm.
• T3 = Tumor > 5 cm. in greatest dimension
• T4 = Tumor of any size with direct extension to chest wall or skin
• Regional Lymph Nodes
• N0 = No palpable axillary nodes
• N1 = Metastases to movable axillary nodes
• N2 = Metastases to fixed, matted axillary nodes
• Distant Metastases
• M0 = No distant metastases
• M1 = Distant metastases including ipsilateral supraclavicular nodes
• Clinical Staging and prognosis
• Clinical Stage I T1 N0 M0 Stage Prognosis (5 year surv. Rate)
• Clinical Stage IIA T1 N1 M0 I 93%
• T2 N0 M0 II 72%
• Clinical Stage IIB T2 N1 M0 III 41%
• T3 N0 M0 IV 18%
• Clinical Stage IIIA T1 N2 M0
• T2 N2 M0
• T3 N1 M0
• T3 N2 M0
• Clinical Stage IIIB T4 any N M0
• Clinical Stage IV any T any N M1
TNM (Tumor, Nodes, Metastases)

Early Stage ( Stage 1-II)

Locally Advanced (Stage III)

Advanced (Stage IV)

Breast Cancer management

• Multimodal Approach
• Surgical
• Radiation therapy
• Chemotherapy
Treatment

• Modalities (palliative vs. curative)

• Surgery
• Local treatment
• Radiation
• Local treatment
• Chemotherapy and hormonal therapy
• Systemic treatment
TREATMENT OPTIONS

IN SITU (NON-INVASIVE)
Local Excision
Partial mastectomy +/- Radiation
Total Mastectomy
Bilateral Mastectomy ?
Sentinel Node sampling ?
Adjuvant therapy / Prophylaxis
TREATMENT OPTIONS

INVASIVE
Partial Mastectomy w/axillary sampling (SLN BX)
& radiation therapy (lumpectomy)
Simple Mastectomy w/axillary sampling (SLN BX)
Modified radical mastectomy
Modified radical mastectomy w/ reconstruction
Neoadjuvant therapy
Adjuvant therapy
http://www.nccn.org/
Key Questions

• When should we operate?

• What operations should we be doing ?
• Should we operate at all?
• What are the complications of surgery?
• Axillary surgery?
• Is there a uniform treatment plan?
 Surgery

• Breast conservation therapy

• Stage I, stage II, and sometime stage III carcinomas
• Lumpectomy, axillary lymphadenectomy, and postoperative radiation therapy
• Contraindications: tumors > 5 cm , gross multifocal disease, and diffuse malignant
microcalcifications
• Local recurrence more than mastectomy so follow up important
• Modified radical mastectomy (most common mastectomy procedure for
invasive breast cancer)
• Entire breast and axillary contents are removed
• Pectoralis muscles remains
• Halsted radical mastectomy
• Removes breast, axillary contents, and pectoralis major muscle
• Cosmetically deforming
• Only indicated when pectoralis muscle involved
• Simple mastectomy
• All breast tissue is removed, axillary contents not removed
• Treatment for non-invasive breast cancer
Breast conserving procedures are being
employed with increasing frequency...

• How strong is the justification for the changes

that have occurred?
• Why have they come about?
• Has science played a role?
• Is this few tampering with tradition?
• Is this consumer pressure?
Breast Conservation

Stage I & II BCA

Margins Negative: no tumor at ink or >
2 mm up to 20 mm
Positive margin predicts residual disease at re-
excision and increased local recurrence risk
Extensive DCIS at margin or invasive lobular
histology increases risk
 IB, 52 ani 123

• Autopalpare, la nivelul cadranului

superointern sân drept
• Formațiune tumorală de 2/3 cm
• Ecografie mamară: leziune BIRADS 5
• Mamografie: BIRADS 5 (risc carcinom
> 95%)
• T2N0M0 – Rezecție chirurgicală
Chirurgie comservatoare a
sânului 124
Limfadenectomia axilară 125
Expunerea venei axilare 126
Piesa de limfadenectomie
axilară: stațiile III, II, I 127
T2N1M0 – Stadiul II A 128

Radiochimoterapie adjuvantă
Hormonoterapie
• Supraviețuirea la 5 ani

93%
Clinical trials testing the
Alternative Hypothesis

• NSABP B-04 trial (Aug 1971) to evaluate

different regimens of surgical a management
for primary breast cancer
• NSABP B-06 trial (1976)
Conclusion

• Local excision with radiation produces equivalent

results, in terms of survival, when compared to
mastectomy (proven by 7 randomised trials)

• Lumpectomy with level 1 & 2 axillary LN

dissection + RXT= total mastectomy + axillary LN
dissection : If tumour is < 4cm and margins are
clear
Conservative treatment of the
axilla

• Detection (75% -95%)

• False negative rate (0-20%)
• Uncertain: injection site;micromets; FN rate;
clinical practice vs random trials

• Surgical experience and pathological study of

the node
Sentinel Lymph Node Biopsy

Highly accurate 92-100%

Proposed site of first nodal drainage after
breast
May be more than one SLN
Radioactive tracer +/- Blue dye
Pathologic exam multiple slices of fewer nodes
Addition of special stains (IHC) highly
sensitive/individual CA cells
Breast Lymphedema
Lymphedema
Breast conservation Pressure

• Use of pre-operative treatment for

downstaging large breast cancers

• Chemotherapy is the standard

• Tamoxifen for elderly (chemo unfit)

• Pre-operative radiotherapy
Each case as an individual

• Tumour size
• Grade
• Other markers

NOT THE CENTIMETRES OR MILLIMETRES

BUT THE AGE OF THE PATIENT!!!!!!
 Radical Mastectomy

• Radical mastectomy removes the entire breast, the underlying

pectoral muscles, and the contiguous axillary lymph nodes in
continuity.

• Radical mastectomy did not enhance overall survival rates.

• Locally destructive surgery is not justified.

• Nowadays – Modified radical mastectomy –

without resection of pectoral muscles
Incisions
Incisions for skin sparing
mastectomy
Limits of the dissection
Skin flap development
Mobilization of the breast off
the chest wall
 Mobilization of the breast off
the chest wall
• The breast parenchyma
and pectoralis major fascia
are elevated en bloc from
the underlying pectoralis
major muscle in a plane
parallel to the muscle
bundles as they course
from their medial origin
(ribs 2 to 6) to their lateral
insertion on the humerus
 Dissection interpectoral space &
axilla
• Exposure of the
pectoralis minor
muscle and
incision of the
investing fascia
of the axilla.
• Upward
retraction of the
pectoralis major
muscle reveals
the underlying
pectoralis minor
muscle and an
intervening
compartment -
Rotter space.
Pathology Report

Diagnosis: Cancer Type- In-situ/ Invasive

Tumor Size
Tumor Grade
Microscopic features
Receptor Status: ER/PR,
Her2/Neu
Margins
Lymph Node
Prognosis

Predict risk of recurrence

Predict which patients may benefit from treatment
Tumor Size – reflects how long tumor has been there
Tumor grade - suggests aggressiveness
Lymph node + reflects risk of disease spread
Oncotype DX*
Radiation Treatment

Partial Mastectomy (lumpectomy)

Large tumors > 5cm
> 4+ axillary nodes
Goal decrease local recurrence
Breast Brachytherapy
APBI
3-D Conformal
IMRT
RT standard versus stereotaxică 154
Chemotherapy

• Tumours >1,5cm
• All lymph node positive tumours
• All receptor negative tumours
• Tumours with poor prognostic indicators
her2neu, lymph vascular invasion
 Chemotherapy and Hormonal
Therapy
• Chemotherapy
• Eradicates risk of occult distant disease in stage I and stage II
patients.
• All patients with axillary node involvement are candidates along with
patients with negative axillary node involvement who are high risk by
other prognostic indicators.
• Improvement in disease free interval and overall survival

• Hormonal therapy
• Tamoxifen
• Generally taken for five years in patientss with estrogen receptor
positive tumors.
• As effective as chemotherapy in post-menopausal patients with
estrogen receptor positive tumors
Adjuvant Therapy

Neoadjuvant Chemotherapy
Pre-op treatment
Adjuvant Chemotherapy
Adjuvant Hormonal Therapy
Tamoxifen
Aromatase Inhibitors (AI)
Monoclonal Antibodies (Herceptin)
 ADJUVANT THERAPY GUIDELINES
PREMENOPAUSAL Node positive Node negative
Tumor > 1cm

ER Positive Chemotherapy Chemotherapy or

+/- Tamoxifen Tamoxifen <2cm ?
ER Negative Chemotherapy Chemotherapy

Her 2 neu + Chemotherapy + Chemotherapy +

Targeted Therapy Targeted Therapy

POSTMENOPAUSAL Node positive Node negative

ER Positive Tamoxifen or AI +/- Tamoxifen or Aromatase

Chemotherapy Inhibitor
ER Negative Chemotherapy Chemotherapy or, no
tx. ?
Her 2 neu + Chemotherapy + Chemotherapy +
Targeted Therapy Targeted Therapy
Breast Reconstruction
Post-mastectomy

• Mastectomy remains the most common treatment for stage 1 &

2 breast cancer

• Potential for avoiding radiotherapy if do breast recon.

• Patients with in situ tumours (DCIS) are significantly more likely

to undergo recon.

• Histological grade was not a significant predictor of use of

recon.

• Patients’ age most important factor

Post-mastectomy recon…

• Post-mastectomy recon. does not interfere with

ability to detect local recurrence

• Does not delay the administration of chemotherapy

• Various options with improved aesthetic outcome

• ? Lack of patient desire or failure of surgeon to

offer recon.
BREAST RECONSTRUCTION

• Initial or delayed
• Implant
• Creation of a pocket beneath pec major and
insertion of a tissue expander followed by a
sialastic implant.
• Autologous tissue
• Use of either a rectus abdominis musculocutaneous
flap or a latissimus dorsi flap
Reconstruction
MALE BREAST CANCER

Risk factors
Excess estrogen exposure
Testicular deficiency
BRCA prone families ?
First Degree relative w/ BCA
Gynecomastia
Other
 MALE BREAST CANCER

Signs & Symptoms Pathology

1=Breast mass (79-98%) Invasive Ductal (84-93%)
2=Axillary nodes(40-50%) Most often high grade
3=Nipple retraction DCIS uncommon
4=Skin fixation LCIS rare
5=Nipple Discharge Sarcomas
Same prognostic indicators **
High proportion are ER +
DIAGNOSIS & TREATMENT

Clinical Exam Based on therapeutic trials

in women*
Index of suspicion *
Modified Radical
Mammogram Mastectomy
Biopsy Adjuvant Therapy
Often present in Hormone manipulation ?
later stage*
Stage per stage survival =
in men & women
DIAGNOSIS

Consultation with a Surgeon or Breast Cancer

Specialist *
History& Physical Examination
Evaluation of Family History and Risk
Review of Imaging
Obtain Tissue Diagnosis (BIOPSY)
Multi-modality Therapy

Local & Regional

Surgery
Radiation

Systemic
Chemotherapy
Hormonal Therapy
Monoclonal antibodies*
BREAST CANCER PREVENTION

Screening
Breast self-exam
Clinical Breast Exam
Mammography
Risk Assessment
Genetic Testing BRCA1/BRCA 2
Tamoxifen / SERM Trials
Risk Factors

Increased
Decreased
Age/ Female
Hormone Replacement Early Pregnancy
Therapy Breast Feeding
Early menarche/late Exercise
menopause
Family History SERMS
Tamoxifen/Raloxifene
Genetics
Obesity
Aromatase Inhibitors
Alcohol Prophylactic Mastectomy
Radiation
SCREENING GUIDELINES
Age < 40
 Clinical breast exam should be part of a periodic health exam, about
every three years for women in their 20s and 30s, and every year for
women 40 and older.

 Women should know how their breasts normally feel and report any
breast changes promptly to their health care providers. Breast self-exam
is an option for women starting in their 20s.

 Women at increased risk (e.g., family history, genetic tendency, past

breast cancer) should talk with their doctors about the benefits and
limitations of starting mammography screening earlier, having additional
tests (i.e., breast ultrasound and MRI), or having more frequent exams.
Age > 40
Yearly mammograms are recommended starting at age 40.
Screening & Prevention

Mammography
*Digital Mammography
Breast Clinical Exam
Breast Self-Exam
CHEMOPREVENTION TRIALS

NSABP-1 Tamoxifen
40 % reduction in invasive BCA
~ 50% reduction in non-invasives
Increased endometrial CA 2.5x
STAR TRIAL Tamoxifen vs Raloxifene
(Evista)