Download Breast Disease

The Breast
Basic Science Conference
Cindy M Deutmeyer
MUSC Department of Surgery
May 25th, 2010
Anatomy
Develop along paired mammary ridges
Primary bud  15-20 secondary buds
epithelial cords
Major (lactiferous) ducts empty into
shallow mammary pit  mesenchyme
proliferates  elevation above skin
nipple
4% Inverted nipples (pit not elevated
above skin)
Puberty: Estrogen & Progesterone
proliferation of epithelial &
connective tissue elements
Polymastia: accessory breast
Amastia: absence of breast
Poland’s Sx: hypoplasia or absence of
breast w/rib, chest wall, & upper
extremity defects
Polythelia: accessory nipples (1%)
Anatomy
3 tissue types: fatty,
fibrous, glandular
15-20 lobes composed of
several Lobules
Each lobe drains into
Lactiferous Duct/Sinus,
and eventually nipple
Cooper’s suspensory
ligaments: fibrous
connective tissue bands,
perpendicular to dermis,
structural support
Breast Boundaries
Superior
Clavicle, 2nd rib
Inferior
Inframammary Fold, 6th rib
Medial
Sternum (lateral border)
Lateral
Anterior axillary line,
Latissimus dorsi
Posterior
Pectoral fascia
* Axillary tail of Spence
Blood Supply & Lymphatics
Internal Mammary a. perforators
Intercostal a.
Axillary a. branches
* Lateral thoracic
* Highest thoracic
Thoracoacromial a. branches
3 principal groups of veins
* Internal thoracic v. perforators
* Intercostal v. perforators
* Axillary v. tributaries
Batson’s plexus: surrounds vertebral column
6 axillary lymph node groups
Receive 75% lymph drainage
3 axillary lymph node levels
* Level I: lateral to Pec minor
* Level II: deep to Pec minor
* Level III: medial to Pec minor
Cases
Case 1: Breast Pain
35 y.o. G1P1 presents with complaints of pain in breasts.
Pain is bilateral, diffuse. Feels swollen.
POBHx- SVD x 1
PGYNHx- regular menses
PMHx/PSHx- negative
MEDS- none
FHx- noncontributory
Breast Pain
Differential diagnosis
Fibrocystic changes
Mastalgia/mastodynia
Cyst
Duct obstruction
Inflammation/infection- mastitis
Trauma
Breast Pain
Fibrocystic change
Most common of benign breast conditions
Replaces “fibrocystic disease”
Multiple tender breast masses
May be cyclic in nature
May be exaggerated response to hormones
Usually present as cyclic, bilateral pain and breast
engorgement
Pain diffuse, often radiates to shoulders or upper arms
Prominent thickened plaques of breast tissue, often in
upper outer quadrants
Breast Pain
Fibrocystic change
Management
Fine-needle aspirationdiagnostic & therapeutic
Ultrasound w/needle biopsy if
bloody fluid, residual mass,
cyst recurrence
Restrict caffeine, foods
containing methylxanthines
OCPs
Pain medications- ibuprofen,
salicylates, acetaminophen
Diuretics
Danazol
Bromocriptine
Breast Pain
Infection/inflammation
Presents with pain, erythema,
fever
Lactational mastitisOccurs postpartum, Staph
aureus or MRSA colonization
Management- ultrasound,
antibiotics (PCN), continue
breast feeding or pumping (if
not MRSA); incision and
drainage of abscess if virulent
strain/nosocomial
Nonlactational abscessCan be due to fistula,
tuberculosis, fungi, carcinoma
Mammo & Ultrasound req
Zuska’s Dz: recurrent
retroareolar infections
Case 2: Nipple Discharge
35 y.o. G1P1 presents with complaints of spontaneous
nipple discharge.
Right breast, bloody discharge
POBHx- SVD x 1
PGYNHx- benign
PMHx/PSHx- negative
MEDS- OCPs
FHx- noncontributory
Nipple discharge
Differential diagnosis
Breast lesionsintraductal papilloma, ductal ectasia, fibrocystic changes, breast
abscess
Drug inducedphenothiazines, reserpine, methyldopa, imipramine,
amphetamine, OCPs
CNS lesionspituitary adenoma, empty sella, hypothalamic tumor
Medical conditionsCushings, hypothyroid, chronic renal failure
Carcinoma
Idiopathic
Nipple discharge
Workup
Exam
Labs- Prolactin, TSH
Mammogram
Cytologic evaluation of discharge- not very useful
Ductography
Nipple Discharge
Intraductal papilloma
Epithelial tumors arising in ducts of breast
Main cause of nipple discharge in nonpregnant or
nonlactating women
Usually women age 40-45
Benign, extremely small increased cancer risk
Size 2-5 mm, usually not palpable
Present with spontaneous, bloody, serous or cloudy
nipple discharge
Management- excisional biopsy
Nipple Discharge
Ductal ectasia
Second most common cause of nipple discharge
Older patients
Increase in glandular secretion
Discharge thick, gray/black color
Can lead to nipple retraction and breast mass
Management- medical, icepacks, anti-inflammatory
agents, broad spectrum antibiotics, surgery if abscess or
mass present
Nipple discharge
*Bad signs
Serous, serosanguinous, or watery discharge
Associated with mass
Unilateral
Single duct
Positive cytology
Positive mammography
Age >50 yrs old
Case 3: Breast Lump
45 y.o. G2P2 presents with complaints of mass in left
breast. Noticed on self exam.
Breast Lump
History
Length of time present
Presence of pain
Change in size or texture
Relationship to menstrual cycle
Nipple discharge
Family history of breast or ovarian cancer and ages
Age at first live birth, menarche, menopause
Breast Lump
Differential diagnosis
Fibroadenoma
Macrocysts
Galactoceles
Lipoma
Abscess
Rare causes- sclerosing adenosis, cystosarcoma
phyllodes
Malignancy
Breast Lump
Work up
Exam
ImagingDiagnostic mammogram- less sensitive in younger
women due to breast density
Ultrasound- can distinguish cystic lesions from solid
masses (require further evaluation)
Biopsy- GET A TISSUE DIAGNOSIS!!
Fine needle aspiration, Core needle biopsy, Open
biopsy
Breast Mass
Fibroadenoma
Second most common benign breast disease, most
common benign solid tumor
Firm, painless, mobile breast mass, 2-3 cm, commonly in
upper outer quadrants
Usually women aged 20-40
Multiple in 15-20% of patients
Slow growing, do not regress spontaneously
Can be stimulated by exogenous estrogen,
progesterone, lactation, pregnancy
Management- watch & wait, biopsy, or excision
Breast Mass
Macrocysts
Most often women age 35-50
Fluid-filled sac
Often solitary but can be multiple
Can have associated nipple discharge
Aspiration for diagnosis and therapy
Galactocoele
Milk-filled cyst
Usually follows lactation
Firm, tender mass
Usually in upper quadrants
Diagnostic aspiration often curative
Lipoma
Nontender
No associated skin or nipple changes
Usually postmenopausal women
Management- biopsy or excision
Breast cancer
>180,000 new cases per year (estimated from 2008)
80% in women >50 yrs old, 20% in women <50 yrs old
>40,000 deaths per year (estimated from 2008)
Second leading cause of cancer-related death in women
Lifetime risk of breast cancer 12%
One in eight women will develop breast cancer
Increasing incidence but decreasing mortality
Lower incidence in Asian/Pacific Islanders, Hispanic/Latina,
American Indian/Alaska natives
Higher mortality in African Americans (though lower lifetime risk)
Incidence & Mortality lowest in Asia/Africa, underdeveloped nations,
those who have not adopted the Westernized reproductive & dietary
patterns
Breast cancer
Risk factors (21% of cases)
Factor
Relative Risk
+ FHx
Menstrual Hx (menarche <12, >40 yrs total)
OCP use
Estrogen replacement <10 yrs
Pregnancy (1st >35 y.o., nulliparous)
Contralateral breast cancer
Ovarian/uterine cancer
1.2-3.0
1.3-2.0
No effect
No effect
2.0-3.0
5.0
2.0
Breast cancer
Classification
Ductal carcinoma (>80% of cancers)
In situ: progresses to invasive cancer; cribiform, solid, comedo types;
classified by nuclear grade & necrosis; calcifications on mammo
Medullary carcinoma: soft, hemorrhagic, BRCA1
Colloid/Mucinous carcinoma: elderly, bulky, gelatinous
Tubular: peri- early menopausal, rarely metastasizes
Papillary: 7th decade, nonwhite women, small, rarely metastasize
Inflammatory: dermal lymphatics invaded, erythema & warmth
Paget’s disease: eczematous lesion on nipple, usu assoc w/underlying
malignancy,
Apocrine duct
Breast Cancer
Lobular carcinoma
In situ: only in female breast; calcifications on mammo in
adjacent tissue; 12x more common in white women; not
premalignant lesion, but marker for future development of
invasive cancer
Infiltrative- multifocal, multicentric, bilateral; no distinct mass;
signet-ring cell variant
Rare variants
Juvenile, epidermoid, carcinoid, squamous cell, spindle cell
Sarcoma and carcinosarcoma
Cystosarcoma phyllodes, angiosarcoma, malignant lymphoma
Breast cancer
Symptoms
33% discovered by self-exam
Breast enlargement or asymmetry
Nipple changes, retraction, or discharge
Ulceration or erythema of skin
Axillary mass
Musculoskeletal complaints
Early- mammo abnormality, painless, mobile
tumor
Breast cancer
Screening Mammogram
Annually every year >age 40,
before age 40 in selected
high-risk patients, w/annual
clinical breast exam
Start 5-10 yrs before age of
affected family member
Decreases mortality by up to
33% (not proven in women
age 40-49)
10% False-positive rate
7% False-negative rate
Clustered microcalcifications,
fine/stippled calcium around a
lesion, solid mass, &
asymmetric tissue thickening
are suspicious for cancer
If equivocal findings on
mammo, get ultrasound
Hereditary breast cancers
Hereditary breast cancers 5-10% of breast cancers
Appropriate counseling must be provided to patient and family before testing for BRCA mutations
BRCA1 mutation (Breast & Ovary; some colon & prostate)
AD inheritance, chromosome 17q21, thought to be tumor suppressor gene
lifetime risk of breast cancer 90%, lifetime risk of ovarian cancer 40%
Early age onset breast cancer
Bilateral
Usu invasive ductal CA, poorly differentiated, hormone receptor (-)
BRCA2 mutation (Breast, less Ovary; some GI, Prostate, Melanoma, & Pancreas)
chromosome 13q12, early age of onset, male breast cancer
lifetime risk of breast cancer is 85%, lifetime risk of ovarian cancer 20%
Well differentiated, hormone receptor (+)
Ashkenazi Jews, Icelandic & Finnish populations
Clinical breast exam Q6 mo, w/yearly mammo (MRI) & transvaginal ultrasound w/CA-125
level starting at age 25 (if options below not excercised)
Prophylactic mastectomy after child-bearing
Prophylactic oophorectomy after age 40
Breast Cancer Staging
Clinical staging based on physical exam
Pathological staging more accurate
TNM Staging system
T1:<2cm, T2:>2cm, T3:>5, T4: any size +
involvement of chest wall or skin
N0:0 nodes, N1:movable, N2:fixed,
N3:infraclavicular, supraclavicular, internal
mammary
M0:no mets, M1:mets
Most important predictor of survival is…
Breast Cancer Treatment
In Situ (Stage 0)
LCIS:observation, chemoprevention w/Tamoxifen, &
bilateral total mastectomy
DCIS: >4 cm disease or disease in >1quadrant =
mastectomy
Low-grade DCIS <0.5cm: Needle-localized Lumpectomy
alone if margins are widely free of disease
High-grade DCIS or larger size: Lumpectomy w/Adjuvant
radiation tx, or Mastectomy
Recurrence rate greater (9%) w/Lumpectomy + Rad, but
mortality rate similar to mastectomy
Risk for recurrence increases with: >2.5 cm size,
comedo type, close margins
Breast Cancer Treatment
Early Invasive (Stage I, IIA, or IIB)
Mastectomy with assessment of axillary lymph node status
Breast conserving surgery with assessment of axillary lymph node status +
radiation (standard of care)
Sentinel lymph node bx is now standard care for women with clinically negative
nodes; metastatic disease in an axillary or sentinel lymph node requires full axillary
dissection
Contraindications to sentinel node bx: T3/T4, Inflammatory CA, palpable axillary
nodes, pregnancy, DCIS without mastectomy, prior axillary surgery, after neoadjuvant
chemo, prior nononcologic breast surgery
Relative contraindications to breast conserving tx: prior radiation, positive
surgical margins after re-excision, multicentric disease, scleroderma, lupus
Chemo tx: for all node (+), cancers >1cm,and cancers >0.5cm with adverse
prognostic features (BV or lymph invasion, high nuclear or histological grade, HER-2neu amplification, & (-) hormone receptors
Tamoxifen: for hormone receptor (+), >1cm; 5yr tx if premenopausal; 1-2 yr tx then
aromatase inhibitor if menopausal
Herceptin: for HER-2-neu (+) cancers
Breast Cancer Treatment
Advanced Local-Regional (Stage IIIA or IIIB)
No clinically detected distant mets
Neoadjuvant chemo to shrink tumor & allow for breast conservation
tx w/radiation (doxorubicin or taxane regimin
Most get Mastectomy with evaluation of axillary status followed by
radiation, +/- chemo
SLNBx acceptable after neoadjuvant tx if no clinical nodes prior to
chemo (need axillary dissection then)
Distant Metastases (Stage IV)
Tx mostly aimed at enhancing quality of life
Hormonal therapy: bone or soft tissue mets only and receptor (+)
Cytotoxic chemo: hormone receptor (-) or refractory, or symptomatic
visceral mets
Bisphosphonates: bony mets
Radiation Therapy
Can be used for all stages of Breast cancer
Reduces risk of local recurrence
Standard in breast conservation tx
Not needed for low-grade DCIS of the solid,
cribiform, or papillary subtypes that is <0.5 cm &
excised widely w/negative margins
Mastectomy radiation: positive margins, 4 or
more lymph nodes positive (or 3 or more in
premenopausal woman)
Chest wall & supraclavicular lymph nodes are
radiated
Surgical Approach- Breast
Conservation
Resection of primary cancer with a
2mm margin of normal-appearing
tissue + assessment of regional
node status + radiation tx
Segmental mastectomy,
lumpectomy, partial mastectomy,
wide local excision
Use areolar incision when
possible
Should be able to encompass in
mastectomy incision if completion
mastectomy needed
Upper breast lesion: follow lines of
Zahn
Lower breast lesion: radial incision
Oncoplastic techniques if possible
Surgical Approach- Mastectomy
Skin sparing: removes all breast
tissue, NAC, & prev biopsy scars
(recurrence rate 6-8%)
Total (simple): all breast tissue, NAC,
skin
Modified radical: all breast tissue,
NAC, skin & Level I & II axillary lymph
nodes
Halstead radical: same as modified,
with pectoralis major & minor removed
& Level III nodes
Patey modification of MRM: removes
pectoralis minor for dissection of Level
III nodes
Skin flap thickness usu 7-8 mm
Complications: seroma (30%),
hematoma, wound infection, skin flap
necrosis
Lymphedema w/MRM: 10-20% (tx
w/compression sleeve)
Breast Reconstruction
Immediate for prophylactic mastectomy or early
invasive cancer
Delayed for advanced cancer (radiation needed)
Immediate: Expander/Implant, or Autologous
tissue (latissimus dorsi myocutaneous flap;
abdominal TRAM or DIEP flap)
If 2 or less ribs resected, no recon needed (scar
tissue provides stabilization)
Special Situations
Breast CA in Pregnancy: usu present w/advanced disease; MRM in
1st & 2nd trimesters; lumpectomy w/axillary node dissection,radiation
after delivery; chemo acceptable in 2nd & 3rd trimesters only
Male Breast CA: <1% of all breast CA; usu invasive ductal; highest
in Jewish & African-Americans; preceded by gynecomastia in 20%;
similar survival rates as women; tx similar to women
Phyllodes tumor: benign, borderline, or malignant; mammo findings
cannot distinguish type; sharp demarcation from normal breast
tissue; Tx w/lumpectomy or mastectomy; no axillary dissection
needed
Inflammatory Breast CA: induration, erythema, & edema; invasion of
dermal lymphatics classic finding; 75% have palpable lymph
nodes;Tx is neoadjuvant chemo w/MRM, radiation, +/- adjuvant
chemo; poor prognosis