Diseases of Breast (New)

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Breast diseases

Prof. Tawfik Abuzalout


MD(AB), MD(LB), MRCS(Eng), AFSA(Fr)
EATS Member
Introduction
Patients with breast problems make up 15 - 20%

of new referral to general surgical out patient

clinics

Breast problems are nightmares for the women


Breast Evaluation
Triple Assessment

Clinical , Radiological, Cytological/Histological

assessment

A - Self breast examination (SBE)

A monthly SBE, ideally just after menses

B - Examination by doctor every 6 months


C - Mammography
Annually start at 40 years of age
1- Breast architecture
2- Asymmetry
3- Skin thickening
4- Irregular masses
5- Architectural distortion
6- Clustered plemorphic microcalcification*
D - Ultrasound

1. Solid or cystic

2. Echogenecity

3. Site and size

4. Axillary LN

5. Guide biobsy
E- MRI

1 . Questionable lesions on a mammogram

2 . Occult breast cancer that present with nodal

disease

3. Distinguish scar from recurrence in woman who

had previous BCS for Ca

4. Women with implants


F- Biopsy

1- Fine-needle aspiration (FNA)

- Aspirate any palpable mass, cystic or solid

- False negative rate (10%) & can’t distinguish

invasive Ca from insitu disease


2- Core needle biopsy : false negative is (< 1%) *

3- Incisional biopsy: If core needle biobsy is

equivocal

4- Excisional biopsy if previous biopsies

inadequate or lesion very small


5- Nonpalpable mammographic abnormalities

(a) Needle-guided biopsy - Excising the lesion after

the radiologist places a localizing wire in the breast

(b) Stereotactic or mammotome biopsy - use

computed mammographic equipment to employ a

fine needle or core needle accurately to sample

nonpalpable lesions .
BENIGN BREST DISEASES
A - Infectious & inflammatory breast disease
1. Cellulitis (Mastitis )
- Common during lactation, bacteria enter through the
nipple (staph Or strept)

- Treatment is a 10 -14 day course of antibiotics to cover


staph & strept
2. Abscess
- Collection of purulent fluid within breast parenchyma
- Treated by surgical drainage or aspiration.
Breast abscess
3. Achronic subareolar abscess

- A sinus tract to the areola develops.

- Treatment - complete excision of the sinus tract .

4. Mondor’s disease

- Phlebitis of the thoraco - epigastric vein

- Apalpable, visible, tender cord runs along

the upper quadrants of the breast

- Treatment - usually self-limited or NSAIDS


B - Benign lesions of the breast

1. fibrocystic breasts

- Affecting middle aged women

- Diffuse thickening with multiple cysts

- Menstrual relations of pain

- Treated by FU & NSAIDS


 2. fibroadenoma

- Well defined tumor of the breast.

- Consists of fibrous stromal tissue with an

epithelial component .

- Common in younger women (15 -20 yrs)

- Mobile & well defined.

- Treatment - Close follow-up or excision


3- Phyllodes tumors

- Previously called cystosarcomaphyllodes

- Treatment : wide local excision (small & benign) or

simple mastectomy (massive , recurrent*& malignant)

4- Sclerosing adenosis

Proliferation of acini in the lobules .


Phyllodes Tu. In 28 yr woman
5 - Epithelial hyperplasia
Can involves ducts or lobules, Moderate ductal
hyperplasia is associated with 1.5 - 3 times higher
incidence of breast cancer
6 - Atypical hyperplasia
Has 3 - 6 times* higher the risk of breast cancer
7- Fat necrosis
Associated with trauma*or radiation therapy to the
breast, may simulate* cancer with a mass or skin
retraction ( biopsy is diagnostic)
8 - Nodularity

May or may not be associated with pain,

Any dominant mass must be biopsied to exclude malignancy

9 - Mammary duct ectasia

Dilation of the subareolar ducts, Palpable retroareolar mass

nipple discharge or slit retraction

Treatment 1- Antbiotics ( Augmentine )

2- Excision of the area .


10 – Cysts*
Diagnosis is made by uss and needle aspiration
a. Color
1. Simple cyst has clear or green fluid & is benign
2. Bloody cyst is a concern for malignancy
3. Milk-filled cyst ( galactocele) is benign
b. Cyst resolution
1. Complete resolution, Perform follow-up
for cysts recurrence.
2. Incomplete resolution or residual mass, Excise
C - Nipple discharge

1. Pathologic nipple discharge

Persistent & spontaneous, requires further evaluation.

2. Galactorrhea

Bilateral, milky nipple discharge occurs

Prolactin level is obtained, if elevated, pituitary

adenoma should be suspected.


3. Bloody nipple discharge

- Most common cause of bloody nipple discharge is

an intraductal papilloma*

- Cancer is present in up to 10% of such cases.

4. Greenish yellowish disharge

- Usually due to ductectasia*

- Associated with slit nipple


Evaluation & treatment

1. Cytological examination to rule out malignancy*

2. culture sensitivity

3. Mammogram to rule out an associated mass

4. Duct excision
D - Mastalgia refers to breast pain.

1- cyclic pain

This pain correlates with the menstrual cycle, usually

worst just before the menses

Treatment is with danazol , bromocriptine, ammalinoliec

acid (80mg t.d.s), tamoxifen (10mg O.D)

2- Noncyclic pain has no such pattern


Treatment

1 - Reassurance & explanation

2 - Dietary modification - Refrain from drinking caffeine,

soft drinks, fatty food, stop smoking & regular exercise

3 - Wear a supportive bra .

4 - Simple analgesia (NSAIDS or paracetamol)

5 - Persistent localized painful area ( L.A / steroid injection)


3 - Chest wall pain musculoskeletal pain, osteochondritis,

thrombophlebitis of chest wall veins, intra-abdominal

(GBS) or intra-thoracic (cardiac, plural ) pain may all

presents as breast pain.

4 - Cancer must be excluded as a cause through an

examination, mammogram & ultrasound.


MALIGNANT DISEASES OF

THE BREAST
A - Epidemiology of breast cancer :

It is most common Cancer in women & common

cause of death in middle aged women

A bout 1 woman in 8 will develop the disease & 1 in 18

will die from it .

The incidence of Ca. breast increased steadily in the last


B - Risk factors

1. Family history 2—3 times higher risk .

. 1st degree relatives ( mother, daughter, sister)

- Premenopausal have 3 times higher risk .

- B/L ca. breast have a 5 times higher risk.

- B/L premenopausal ca. breast have a risk that is 8 times

. Hereditary breast cancer (HBC)

1. BRCA1 – Increases risk of ca.breast (80%) & ca.ovary

(60%).
2. BRCA-2 Increases risk of ca. breast 60% &ovary 40%

2- Hormonal factors

- Age at menarche ( younger age increase the risk)

- Age at menopause ( menop At age 55y doubles

the risk compared at age of 45y ).

- Number of pregnancies (higher is protective ).

- Age at 1st pregnancy ( > 30yr double the risk

compared to < 20yr at 1st pregnancy ).


- Breast feeding is protective .

- O.C.P ( high estrogen pills, use before age of 20y, use for

10y or more increase risk )

- Hormonal replacement therapy (HRT) .

- Oophorectomy in premenp. woman Greatly reduces the

risk of Ca. breast .


3.A typical hyperplasia 3 - 6 times higher risk.

4. prior contralateral breast

- Previous adenocarcinoma double the risk .

- Previous lobular carcinoma occurs in 25- 50% .

5. High socioeconomic status. (late menarche &

late1st pregnancy).

6. Individuals of western hemisphere extraction


7. a nulliparous woman’s 2 – 3 times risk

8. Diet - Fat, salt, red meat, alcohol & obesity

9. Age - Risk increases with age , median age for ca.

breast is 60y .

10 . Radiation - Doubles the risk.


factor High risk Low risk
Relative risk > 4 times
- Age old young
- H/O ca. in one breast yes no
- F/O premen B/L Ca. breast yes no

Relative risk 2 – 4 times


- Any 1st degr. Relative with Ca. yes no
breast
- H/O primary Ca. ovary or yes no
endomet.
- Age at 1st pregnancy. > 30y < 20y
- Oophorectomy No yes
- Body habits, post-menop. obese thin
- Country of birth North America & Eur Asia. Africa
- Socioecon Class upper lower
- H/O fibrocystic disease yes no
Relative risk 1- 2 times
- Marital status single married
- Place of residence urban rural
- Race white black
- Age at menarche early late
- Age at menopause. late early
C - Symptoms

1. lumps

2. pain

3. Skin changes - peau d’orange ,nipple retraction, skin

ulceration & fixation to chest wall

4. Metastatic disease - May be the initial symptom

- Axillary nodes - 2% of patient with breast Ca.present

with axillary node enlargement but no palpable primary

breast tumor .
Peau d’orange of the Breast
Slit-like retraction of duct- Circumferential retraction of
ectasia Ca. Breast
- Distant organs - brain, lungs, liver & musculoskeletal

Asymptomatic patients : high risk patients (family or

personal H/O Ca- breast) should followed by SBE,

mammography & physical examination.


D - Noninvasive breast cancer :

Constitutes 10% of all types of Ca. breast & carry

good prognosis

1. Ductal Ca. in situ (DCIS)

- DCIS is confined to ductal cells

- No invasion of the underling basement membrane

- Risk of invasive cancer within 20y is 40%.


- Classified into:
Comedo DCIS - High grade cytology, extensive necrosis,
& branched calcification
Noncomedo DCIS - Low grade cytology, lack of necrosis,
calcification is incosistent .
- The chance of recurrence within 5y is 25-50%, of these
recurrence 50% is invasive .
- Treatment:
1. Mastectomy for extensive DCIS > 4cm or affecting more
than 1 quadrant.
2. Wide local excision & radiation
2- lobular Ca in-situ (LCIS)

- Commonly found incidentally

- Risk of invasive Ca. within 20y is 15 - 20% B/L

- Treatment involves careful follow-up, because the

lesion considered to be a marker for increase future

risk of invasive Ca. in both breasts

- B/L mastectomy may be considered if other risk factors

are present ( F/H , other hormone sensitive Tu, prior

Ca. breast )
3- Paget’s disease

- Uncommon lesion involves the nipple areola complex .

- Histologically vacuolated cells (paget’s cells) are

seen in the epidermis of the nipple areola complex &

results in eczematous dermatitis of

the nipple .

- May be associated with an invasive component

in the underlying ducts


- Mammography should be performed to look for amass

- Treated by Mastectomy or local excision + radiotherapy

- Prognosis is that 80% have a 10-year survival (if no

masses is present & axillary nodes are not involved).


Paget’s disease of the nipple
E - Invasive Ca. breast

1. Favorable histologic types (85% 5yr survival rate )

a. Tubular carcinoma ( grade 1 intraductal )

b. Colloid or mucinous carcinoma .

c. Papillary carcinoma .
2. Less favorable lesions

a. Medullary cancer – Well circumscribed & Lymphocytic

infiltration

b. Invasive lobular cancer - Higher incidence of bilaterality

c. Invasive ductal cancer - Most common type

d. Invasive ductal lesion – with poor nuclear grade,

vascular & lymphatic invasion have a poorer prognosis


3. Least favorable histologic type

Inflammatory breast cancer - ( 5 year survival rate 30%)

- Tumor plugged sub dermal lymphatics

- Local inflammatory signs

- Localized warmth

- Swelling

- Pain
Inflammatory Ca. of Rt breast
Screening
- Performed by mammography.

- Two view (craniocaudal & oblique ) and double reading

- Performed every year starting of age 40 yr

- Screen detected Ca are smaller, better differentiated &

node negative

- Reduce mortality from Ca- breast by 40%


F - Staging & prognosis :
Guides treatment & predicts survival
1. Tumor size (T)
Poor prognostic factors includes :
1- Edema or ulceration of the surrounding skin
2- Tu Fixed to the chest wall or overlying skin
3- Satellite skin nodules
4- Dermal lymphatic invasion (peau d’orange )
5- Skin retraction & dimpling (cooper’s ligament)
6- Inner lower quadrant involvement
2. Axillary node status (N)

- Best source of predicting survival

poor prognostic features :

1 - More than 10 nodes

2 - Capsular invasion .

3 - Extra nodal spread .

4 - Edema of the arm

5 - Hard matted.
3. Metastasis (M)

Sites - Lung, Liver, Bone, Brain, Adrenal

1- Mammogram - determine both additional foci in

the involved breast & the presence of metastatic

or synchronous disease.

2- Chest radiograph - detects pulmonary parynchymal

or bone metastasis
3. USS Abdomen – detects liver mets

4. CT Chest, Abdomen & Pelvis

5. CT Brain - if neurological signs present

6. Bone scan - if bone pain or node + or stage 3

7. PET scan

8. LFT – Alkaline phosphatase


4.Estrogen & Progesterone receptors
Positive (+) receptor - good response to hormonal
treatment & better survival
5. HER-2/neu
Over expression is bad prognosis, but respond to
trasuzumab
5. DNA content analysis
Diploid tumors have normal DNA tumors & better
prognosis
Aneuploid tumors have abnormal DNA content &

worse prognosis .

6. proliferative ability

S - phase fraction, the worse will be the prognosis

7. Other biological markers

Ki-67, Cathepsin,p53
Table- 1 T N M staging .
T Primary Tu size
Tx A primary Tu Can't be assessed
T0 No evidence of primary Tu
Tis Intraductal Ca or lobular Ca in situ, paget’s disease of
nipple with no Tu
T1 Tu 2cm or less in greatest dimension
T1mic - Microinvasion 0.1cm or less in g.d .
T1a > 0.1 and < 0.5cm in g.d
T1b > 0.5cm and < 1cm .. ..
T1c > 1cm and < 2cm .. ..
T2 Tu > 2cm and < 5cm .. ..
T3 Tu > 5cm in g.d .
T4 Tu Of any size with distant extension to
chest wall or skin
T4a - extension to chest wall.
T4b - edema (peau d’orange) or skin
ulceration or satellite skin nodules
T4c - both 4a &4b
T4d - inflammatory Ca
N regional L.N

Nx regional L.N can’t be assessed

N0 no regional L.N metastasis

N1 Met. To movable ipsilateral axillary L.N


N2 Met. To fixed ipsilateral axillary L.N

N3 Met. To ipsilateral internal mammary


or supraclavicular L.N

M distant metastasis
Mx D.M can’t be assessed
M0 No D.M

M1 D.M
Table-2 Breast cancer prognosis based on stage

stage Tu.size L.N status Dist. Met. 5-yr93%


urvival
stage 1 T1 N0 M0 93 %

Stage 2a T1 N1 M0 72%
T2 N0 M0
Stage 2b T2 N1 M0
T1 N2 M0
Stage 3a T2 N2 M0
T3 N1 M0
T3 N2 M0
Stage 3b T4 Any N M0 41%

Stage 4 Any T Any N M1


18%
Treatment of Breast

cancer
I - Surgery (local treatment )

(1) Breast conservation surgery - For patient with

stage 1&2

a. Lumpectomy - Removal of the primary lesion with

clear gross & histological margin


c. Sentinel node biopsy
1. Allows minimal dissection & less morbidity
( lymph edema)
2. Nuclear scanning or vital blue dye is used to
identify the first node drained by the breast
3. The node is then used to determine axillary
disease
4. Done only for clinically negative axillary LNs
d. post-operative radiation therapy
4500 rads for whole breast.
e. Contra indications
1. Large Tu size compared with a small breast size
(Tu > 5cm)
2. Gross, multifocal disease & diffuse malignant
microcalcifications
3. Connective tissue disease (scleroderma)
4. Inability to participate in necessary follow-up
5. Non vailability of radiotherapy
6. Recurrence after BCS
Breast conservation surgery
(2) Modified radical mastectomy

1- Entire breast is removed

2- Axillary contents are removed

3- Pectoralis muscle remains

4- Breast reconstruction often performed

simultaneously ( silicon prosthesis or TRAM )


(3) Simple mastectomy

- Non-invasive cancer is treated.

- All breast tissue is removed .

Special considerations (long thoracic N & thoracodorsal N)


Bilateral Lt. TRAM flap with nipple
silicon prosthesis tattooing
II - Chemotherapy ( systemic treatment )
1- Eradicate risk of occult distant mets
2- 6 month cycles of CMF or CAF with taxol, etc
3- Improvement in both disease free interval & over all
survival of premenopausal women
4- Used to treat recurrent & met. disease

III - Neoadjuvent therapy


1- Chemotherapy for stage 3 pt & inflammatory breast
cancer
2- Hormonal therapy ( Tamoxifen ) for postmenopausal
woman with ER(+)
IV- Radiatiotherapy
- Used for primary & met. disease .
- There is a 1% recurrence rate per year .
- As adjuvant therapy after mastectomy in high risk pt

V- Hormonal therapy
1- Tamoxifen (antiestrogen ) 20 mg /day for 5yrs and

Aromatase inhibitors
2 - As effective as chemotherapy in postmenopausal
pts.
3- Excellent choice in elderly pts who can’t tolerate
chemotherapy
4- Based on ER status of the Tu ( ER+ 65% respond,
ER-ve 5% respond )
5- Decrease the size of the Tu. in ER+ pts. with
recurrent disease
VI – Targeted therapy
A B

Radiotherapy for advanced Ca. Lt breast (A)-before &(B)


After course of radiotherapy .

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