Download BREAST DISEASES

BREAST
DISEASES
1 Historical Perspective
Ancient Egyptian references to both benign breast
diseases
and breast cancer in 1600 BC.
In 1894, Halsted described the radical mastectomy
A better understanding of breast physiology and endocrinology
----the use of systemic chemotherapy and hormonal agents
Discovery of the BRCA-1 gene responsible for many instances of
familial breast cancer
2 CHANGES IN BREAST CANCER SURGERY, 1972–1986
3 Anatomy
On pectoral fascia and musculature of the chest wall
Over upper anterior rib cage 2nd or 3rd to 6th
Fat surrounding
Skin envelope
Axillary tail of Spencer
Relation to pectoralis major muscle
Lymph
Pectoralis major → axillary → subclavicular → supra-clavicular
Medial portion → intercostal lymphatic duct →para-mediastinum
Subcutaneous lymphatic communication left→right
Lymphatic plexus on the rectal sheath
→falciform ligament→liver
Some important structures
Intercostobrachial nerve
a sensory nerve supplying the underarm skin
Long thoracic nerve of Bell
a motor nerve to the serratus anterior and subscapularis muscles
Thoracodorsal nerve
a motor nerve to the latissimus dorsi adjacent to its accompanying
artery and veins.
Physiology
Anterior pituitary hormones (prolactin)
Adrenal corticoid hormones (Estrogen)
Sexual hormones (Progesterone)
Insulin
Thyroid hormone
Examination
Inspection
Overall inspection
symmetry, size, shape, skin color, venous pattern, lump, local
dimpling
Nipple
excoriation, inversion, discharge, edema
and redness
Skin
redness, edema, Peau d’orange or pig-skin
Palpation
Gentle palpation, quadrant by quadrant
Mass: number, size, consistency and mobility
Lymph node:
Central,pectoral,subscapular ,subclavicular and supra-clavicular
group
Character of the discharge is significant
Milky, serous, or green-brown discharge are almost always benign
in origin
Bloody discharge most often results from an intra-ductal papilloma,
it may mark an underlying cancer
Imaging Study
Mammography
Thermography
Ultrasound
Ductogram
Magnetic Resonance (MR)
Positron Emission Tomography (PET)
Evaluation of Breast Masses
Biopsy
FNA(0.7-0.9mm)
Open biopsy
Nipple discharge
Serous,colorless
normal menstrual cycle, intraductal papilloma or early
pregnancy
Bloody intraductal papilloma or ductal ca.
Yellowish galactocele or cystic hyperplasia
Ductogram
4 Acute Mastitis
1) Cause
Lactic stasis
Bacterial invasion
(Staphylococcus aureus)
2)Manifestation
Swelling pain
Painful mass with reddish skin
General features:
Chill, fever, ipsilateral LN enlargement, bacteriaemia
Abscess formation
3)Treatment
General
Thermo therapy:
25% Magnesium sulfate
Antibiotic therapy:
Local and general administration
Drainage:
Prevention
5 Cystic Hyperplasia
1) Cause
Hormonal imbalance
Excessive estrogen production and deficient corpus luteinum
activity
2)Clinical manifestation
Pain or lump, nipple discharge (15%)
Bilateral invlvement
Inseparable from other grandular tissue
Tense cyst no fluctuant
Tenderness
Cyst may appear rapidly and then maintain their size or
shrink after next menstraual flow
Most painful in pre-menstraual period: mastodynia
3)Diagnosis
Pain or lump
FNA
Management
Hormonal therapy
FNA, open biopsy, mastectomy
6 Fibroadenoma
1) Cause
Estrogen may play an important role in its pathogenesis.
2) Manifestation
Lump or mass
Freely moveable, smooth, lobulated and independent from
surroundings without fixation regardless the size.
3) Treatment
Excision continued growth and need to be certain of the
diagnosis
4)Mammographic appearance of a degenerating firoadenoma
displaying a characteristic pattern of dense, popcorn-like
calcification
Histological appearance of a typical firoadenoma
7 Intraductal papilloma
Woman of 40-50 years old.
6%-8% malignant tendency.
Forming from the epithelial linings of the main ducts.
Nodule at the areola margin.
Pressure at that point reproduces the bloody discharge.
Surgical excision (involved duct or radical resection if it is
proved malignant by frozen section)
8 Breast Cancer
1)Etiology
Estrogen as an important factor in pathogenesis of the breast
cancer has been confirmed.
Estron(E1) and estradiol (E2)
carcinogenic
Estriol (E3)
non-carcinogenic
Other various factors
Cumulative risk of developing invasive beast cancer after a
biopsy for benign breast disease.
Women with proliferative disease with atypia are at significantly
increased risk for developing invasive breast cancer
Age-specific incidence curves for breast cancer
The curve rises sharply after 30 years of age and continues to
climb thereafter
Demographic factor
Age more than 30 yrs
Female gender (130:1 female/male ratio)
Greatly increased risk
Known carrier of breast cancer susceptibility gene
Strong family history—2 or more first-degree relatives with
bilateral or premenopausal breast cancer
Atypical ductal or lobular hyperplasia or lobular carcinoma in situ
Ductal carcinoma in situ, risk limited to ipslateral breast
Moderately increased risk
Family history—1 or more first-degree relatives with not bilateral
or premenopausal breast cancer
Menstrual history—menarche before age of 12 yrs
Parity—nulliparity or first live birth after age of 30 yrs
Radiation– exposure o low-dose ionizing radiation in childhood or
aldolescence
Previous breast cancer—low-grade, node-negative, or
receptor-positive, lobular history
Other cancers—colon or endometrial cancer
Diet—high-fat or high-calorie diet
2)Pathological procedure
Tumor size
Hormone receptor status
Status of excision margins
Histologic type
Pathological classification
Type 1 Non-metastasizing
Inarticulate carcinoma
Type 2 Rarely metastasizing
1.Pure extracellular mucinous or colloid Ca.
2.Medullary Ca. with lymphocyte infiltration
3.Well-differentiated adenocarcinomas
Type 3 Moderately metastasizing
1. Adenocarcinoma
2.Intraductal Ca.with stromal invasion
3.Any other Ca. not specifically classified in
other groups
Type 4 Highly metastasizing
1.Undifferentiated Ca.
2.Any tumor that definitely invades blood vessels
Breast cancer dissemination is not orderly and predictable but
capricious
Hematogenous spread is the primary mode of metastasis
Blood-borne spread may occur in the absence of node
involvement
Hematogenous metastasis can occur at any time
Regional lymph node metastases are a marker of tumor
dissemination and not necessarily an intermediate step in the
process of distant metastasis
3) Metastasis
Metastasis routes:
Direct invasion
Skin, fascia, muscle
Lymphatic metastasis of 4 routes
Distant metastasizes
Lung, bone, liver, adrenal glands, brain, ovarian
Lymphatic metastasis
Pectoralis major LN→ipslateral axillary LN→subclavicular
→supra-clavicular →thoracic duct →venous stream
Internal mammary nodes (para-sternal)→supra-clavicular lN
Clinical manifestation
Early manifestation is solid, painless mass, which is hard, not
smooth, unmovable, usually found accidentally.
Rapidly developing carcinoma invades surrounding tissue,
changes the contour of the breast:
Skin traction
Nipple traction
Peau d’orange or pig-skin
Chest wall fixation.
Inflammatory Carcinoma
An acute onset of redness, pain and swelling of the breast due
to lymphatic blockade and lymphangitis.
Skin,surface veins and the axiallary nodes are involved.
Poor prognosis and treatment is usually inadequate to control
the disease.
Paget’s Disease
An unique form of breast cancer
Weeping eczematous lesion of the nipple followed a
sub-areolar mass develop beneath the nipple in most cases.
Skin is merely involved and the prognosis is better.
4) Diagnosis
Self-examination
60% cancer discovered by patients
Physical examination
Mammography
Asymmetry, skin thicking, irregular masses or architectural
distortions
5) Staging
Primary tumor (p)
TX
Primary tumor cannot be assessed
T0
No evidence of primary tumor
Tis
Carcinoma in situ
T1
Tumor 2 cm or less in greatest dimension
T2
Tumor more than 2 cm but not more than 5 cm in
greatest dimension
T3
Tumor more than 5 cm in greatest dimension
T4
Tumor of any size with direct extension into chest wall
(not including pectoral muscles) or skin edema or skin
ulceration or satellite skin nodules confined to the same
breast or inflammatory carcinoma
Regional Lymph Node Involvement
NX
Regional lymph nodes cannot be assessed
N0
No regional lymph node involvement
N1
Metastasis to movable ipsilateral axillary
lymph node(s)
N2
Metastasis to ipsilateral axillary lymph node(s)
fixed to one another or to other structures
N3
Metastasis to ipsilateral internal mammary
lymph nodes
Distant Metastasis
MX
Presence of distant metastasis cannot
be
assessed
M0
No distant metastasis
M1
Distant metastasis present
Staging
Stage1 T1-T2, N0, M0
Stage2 T1-T2, N1, M0
Stage3 T1-T2, N2-N3, M0 or T3-T4, N0-N3, M0
Stage4 Any combination of TN with M1
Examination
Ultrasound
Solid or cystic
Needle aspiration
Solid or cystic
Cytology
Excision biopsy
Preferred method
Treatment
Surgical procedures
Curative or palliative : Halsted radical mastectomy
En bloc removal of breast, pectoralis muscle and axillary LN
dissection (ALND)
Extended radical mastectomy : Plus mediastinal LNs
(2,3,4 rib cartilage and intra-thoracal A and V, LN)
Modified radical mastectomy
En bloc removal of breast and ALND
Total mastectomy
Breast conservation operation
Lumpectomy, ALND and post-operative irradiation
Breast conservation operation
Factors favoring breat-conserving therapy are as followings:
 Patient preference for breast conservation
 Tumor size and location in breast favorable for good aesthetic
result
 Unifocal tumor
 Small or absent intraductal component of tumor
 Postlumpectomy breast anticipated easy to follow by physical
examination and mammography
 Patient inability to tolerate general anesthesia
Breast Reconstruction Techniques
A: Subpectoral prosthetic implant
B: Pedicle transverse rectus
abdominis myocutaneous
(TRAM) flap
Adjuvant Therapy
Radiotherapy
Pre-or post-operative reduce local recurrence rate and
dissemination at the time of mastectomy
Chemotherapy
Breast cancer is considered relatively sensitive to chemotherapy.
CMF: cyclophosphamide, methotrexate, and 5-fluorouracil
leads to objective responses in more than half of
premenopausal women with metastatic breast cancer.
Other active regimens :
CMFVP: CMF plus vincristine and prednisone
AC: Adriamycin plus cyclophosphamide
CAF:
cyclophosphamide, Adriamycin, and 5-fluorouracil
Numerous studies confirm :
premenopausal, node-positive patients women have both
longer disease-free survival and longer overall survival when
treated with adjuvant CMF or CMFVP after “curative” surgery.
Endocrinotherapy
Both ER and PR at a level of at least 10 fmol/mg have the
highest likelihood of response to hormonal intervention (60% to
70%).
Hormonal interventions may be either ablative or additive.
Ablative measures :oophorectomy or ovarian irradiation,
adrenalectomy or hypophysectomy, and antiestrogenic drugs,
such as tamoxifen.
Additive measures : pharmacologic doses of female sex
hormones, either estrogens or progestins, corticosteroids and
testosterone derivatives
Tamoxifen is by far the most commonly used hormonal
intervention for both adjuvant and advanced disease treatment
because of its ease of administration and minimal toxicity.
9 MALE BREAST DISEASES :Gynecomastia
Gynecomastia is defined as palpable enlargement of the male
breast.
Nonspecific breast enlargement from fat deposition in obese
patients must be differentiated
At the onset of puberty, the estrogen/testosterone ratio may be
high in some males, and this can persist for several years.
Asymptomatic gynecomastia is a surprisingly common finding in
adolescent males, probably because of this relative imbalance.