Download Paget`s disease

BREAST DISEASES
Embryology
• The paired glands normally
develops in the pectoral
region, one gland on each
side.
The paired
mammary gland
embryologically
develops along the
milk line that
extends between
the limb buds from
the axilla to the
inguinal region.
Surgical Anatomy Of Breast
• Mammary tissues
anatomically represent
mature modified sweat
glands.
• The Mammary gland
Lies between the
superficial and deep
layers of the pectoral
fascia of the chest wall.
The breast is
partitioned into 4
quadrants by vertical
and horizontal lines
across the nipple:
• Upper inner quadrant
(UIQ)
• Lower inner quadrant
(LIQ)
• Upper outer quadrant
(UOQ)
• Lower outer quadrant
(LOQ)
• The mature female breast
extends superiorly from the
level of the second or third
rib to the inframammary fold
inferiorly that is located at
the level of the sixth or
seventh rib.
Medialy, the breast extends
from the lateral border of the
sternum to the anterior or
midaxillary line laterally .
The breast frequently extends
into axilla as the axillary tail
of Spence.
• The upper half of the
breast, particularly the
upper outer quadrant,
contains the greater
volume of glandular
tissue than the
remainder of the
breast.
The Breast Are Composed Of
Three tissue types
• Glandular epithelium.
• Milk producing tissue.
• Fibrous stroma and
supporting structures.
• Adipose tissue.
Glandular epithelium
The breast is composed of 15 to 20 lobes
, which are each composed of several
lobules.
The lobule
Is the basic structural unit of the
mammary gland.
The number and size of the lobules vary
from 20 to over 40 lobules empty via
ductules into a lactiferous duct.
there are 15–20 lactiferous duct.
each lactiferous duct is lined with a
spiral arrangement of contractile
myoepithelial cells and is provided with
a terminal ampulla, a reservoir for milk
or abnormal discharges.
Blood Supply of the Breast
Arterial
• It is supplied by the axillary artery via
the lateral thoracic and
thoracoacromial branches.
• The internal mammary artery via its
perforating branches.
• Adjacent intercostal arteries.
Venous
• It tends to follow the arterial supply;
axillary, internal mammary, and intercostal
veins.
• The axillary vein is responsible for the
majority of venous drainage
Nerve Supply
• The breast is supplied by 4 main nerves:
•
•
•
•
Long thoracic nerve
Thoracodorsal nerve
Medial and lateral pectoral nerves
Intercostobrachial nerve
Lymphatic's
• The lymphatic's of the breast
drain predominantly into the
axillary and internal mammary
lymph nodes.
•
The axillary nodes receive
approximately 85% of the
drainage.
DIAGNOSIS OF BREAST DISEASE
Symptoms of breast disease
•
•
•
•
Mastalgia
Swelling or change in size or shape
Breast lumps
NIPLE (Discharge, Retraction)
HISTORY
• A history and physical examination are
essential for the diagnostic evaluation of a
breast abnormality.
• the history include details about the :
• presenting symptom.
• history of previous breast disease.
• risk factors for breast cancer
• a menstrual history.
questions focused on the presenting
symptom, whether it be
• a mass,
• nipple discharge,
• palpable adenopathy,
• pain,
• abnormal imaging.
Examination
• The physical examination should be performed with respect for
patient privacy and comfort without compromising the
complete evaluation.
• The examination begins with inspection.
The breasts are visually observed and compared , any obvious
masses, asymmetries, and skin changes.
The nipples are inspected for the presence of retraction,
inversion, or excoriation.
• Palpation the breast is examined
•
patient upright with arms relaxed and supine with the
ipsilateral arm raised above the head.
• Finally the regional nodes should follow to include the
axillary, infraclavicular, supraclavicular, and cervical nodes.
• If a mass is identified, it should be measured, and its
location,mobility, and character should be documented in the
medical record.
• True masses will persist throughout the menstrual cycle.
• Diagnosis should not be delayed.
• In patients who present with nipple discharge, the nipple
discharge is often elicited during palpation of the breast.
• The character, color, and location of the discharging duct or
ducts should be documented.
• If the discharge is not grossly bloody, a Hem occult test may
be used to detect occult blood.
Pathologic discharge:
• unilateral,
• uniduct,
• spontaneous, and/or bloody discharge, should be evaluated
with surgical duct excision.
INVESTIGATION
Mammography
Ultrasound
Magnetic resonance imaging (MRI)
Computed tomography
Needle biopsy\cytology
Mammography
X-rays taken by placing the breast
in direct contact with ultrasensitive
film.
The dose of radiation is
approximately 0.1 cGy and,
therefore, mammography is a very
safe investigation.
The sensitivity of this investigation
increases with age as the breast
becomes less dense.
• Mammography is the most sensitive and specific imaging test
currently available.
• In total, 5% of breast cancers are missed by mammographic
screening programmes.
• Thus, a normal mammogram does not exclude the presence of
carcinoma.
• Digital mammography is being introduced, which allows
manipulation of the images and computer-aided diagnosis.
• Screening mammography
is used to detect cancer in asymptomatic women when
cancer is not suspected.
• Diagnostic mammography
is used to evaluate the breasts of patients with breast
symptoms or complaints, such as nipple discharge or a
palpable mass or patients who have had breast cancer
treated with breast conservation therapy.
• Ultrasound
• Ultrasound initially used to differentiate solid masses from
cystic masses, but it has become an important adjunct to
mammography and is an excellent method for guiding some
interventional procedures.
• Ultrasound is not a breast screening tool and remains
operator dependent.
• MRI BREAST
• (MRI) is being used with increasing frequency for the
screening and diagnosis of breast cancer.
•
While mammography remains the “gold standard,” MRI is
emerging as an important modality for evaluating breast
diseases.
• MRI has several advantages, There is no ionizing radiation to
the patient with MRI.
• MRI is not limited by breast density and is an excellent tool
for the screening of young women with increased risk for
inherited breast cancer.
• Disadvantages of MRI are cost, limited availability.
• Patients with MRI-incompatible implantable devices, metallic
clips, or prostheses cannot undergo MRI.
Computed tomography
• appears to be the best way to image internal mammary
nodes and to evaluate the chest and axilla after
mastectomy.
• Needle biopsy/cytology
• Fine-Needle Aspiration Cytology
• Core-Needle (Cutting-Needle) Biopsy
Image-Guided
• Stereotactic
• Ultrasound-Guided
• Fine-needle aspiration cytology (FNAC) is the least invasive
technique of obtaining a cell diagnosis and is rapid and very
accurate if both operator and cytologist are experienced.
• The diagnostic accuracy of FNA biopsy of breast masses
approximates 80%,
False-negative results occur in approximately 15% of cases
and the False-positive result is rare.
When the specimen is properly prepared and
reviewed by an experienced cytopathologist, the
false-negtive a lesion that is suspicious clinically or
by imaging must be further investigated with
surgical excision.
Triple assessment
• any patient who presents with a breast lump or other
symptoms suspicious of carcinoma,
• the diagnosis should be made by a combination of
clinical assessment, radiological imaging and a tissue
sample taken for either cytological or histological
analysis, the so called triple assessment.
• The combinations should exceed 99.9%.
Diseases Of The Nipple
•
•
•
•
•
•
•
Nipple retraction.
Cracked nipple.
Papilloma of the nipple.
Retention cyst of a gland of Montgomery.
Eczema.
Paget’s disease.
Discharges from the nipple.
Nipple retraction
occur at puberty or later in life.
•
pubertal retraction, known as simple nipple inversion, is of
unknown aetiology.
• In 25% of cases it is bilateral.
• It may cause problems with breast-feeding and infection can
occur, especially during lactation, because of retention of
secretions.
• Recent retraction of the nipple may be of considerable
pathological significance.
•
A slit-like retraction of the nipple may be caused by ductectasia
and chronic periductal mastitis , but
•
circumferential retraction, with or without an underlying lump,
may well indicate an underlying carcinoma
Cracked nipple
• This occur during lactation and it’s the cause of acute
mastitis.
• If the nipple becomes cracked during lactation, it should be
rested for 24–48 hours and the breast should be emptied
with a breast pump.
•
Feeding should be resumed as soon as possible.
Papilloma of the nipple
• Papilloma of the nipple has the same features as any
cutaneous papilloma and should be excised with a tiny disc
of skin.
•
Alternatively, the base may be tied with a ligature and the
papilloma will spontaneously fall off.
Retention cyst of a gland of Montgomery
• These glands, situated in the areola, secrete sebum and
if they become blocked a sebaceous cyst forms.
Eczema
• Eczema of the nipples is a rare condition
and is often bilateral; it is usually
associated with eczema elsewhere on the
body.
• It is treated with 0.5% hydrocortisone (not
a stronger steroid preparation).
Paget’s disease
• Paget’s disease of the nipple must be distinguished from
eczema.
• Paget’s disease is caused by malignant cells in the
subdermal layer.
•
Eczema tends to occur in younger people who have signs
of eczema elsewhere.
Discharges from the nipple
• Discharge can occur from one lactiferous ducts or more.
Physiologic
•
•
•
•
Bilateral
Involves multiple ducts
Heme (-)
Non-spontaneous
• Pathologic
•
•
•
•
Unilateral
persistent and spontaneous
Heme (+)
not associated with nursing& Requires
further evaluation.
• Most common cause intraductal
papilloma
Workup
•
•
•
•
•
Exam
Labs- Prolactin, Heme
Mammogram
Cytologic evaluation of discharge
Ductography
• Galactorrhea
• Bilateral, milky discharge.
• Obtain prolactin levels, if highly elevated, suspect
pituitary adenoma as one of causes.
Bloody nipple discharge
• Most common cause is intraductal papilloma
• Cancer present 10% of cases .
• Management depends on:
• the presence of a lump (which should always be given
priority in diagnosis and treatment).
• the presence of blood in the discharge from multiple duct
or discharge from a single duct.
• Mammography is useful to exclude an underlying impalpable
mass.
• Cytology may reveal malignant cells.
Treatment
• Treatment must firstly be to exclude a carcinoma by cytology.
• Simple reassurance of the patient,
• if the discharge is proving intolerable, an operation to remove
the affected duct or ducts can be performed.
Intraductal papilloma
•
•
•
•
Benign epithelial tumors arising in ducts of breast.
Main cause of bloody nipple discharge.
Usually women age (40-45).
Size (2-5 ) mm, usually not palpable, nearly always
situated within 4–5 cm of the nipple orifice.
• Present with spontaneous, bloody, serous or cloudy
nipple discharge.
Management
• excisional biopsy
When the duct of origin of nipple bleeding is uncertain or
when there is bleeding or discharge from multiple ducts, the
entire major duct system can be excised for histological
examination without sacrifice of the breast form.
BENIGN BREAST DISEASE
• The most common cause of breast problems.
• 30% of women will suffer from a benign breast disorder
requiring treatment .
•
The most common symptoms are pain, lumpiness or a lump.
• The aim of treatment is to exclude cancer and, once this
has been done, to treat any remaining symptoms.
BENIGN BREAST DISEASE
•
•
•
•
•
•
Congenital disorders.
Infectious and inflammatory.
Fibrocystic Disease
Mastalgia.
Benign mass.
Injury.
Congenital abnormalities
Amazia
• Congenital absence of the breast may occur
on one or both sides.
• It is sometimes associated with absence of
the sternal portion of the pectoralis major
(Poland’s syndrome).
• It is more common in males.
Polymazia
• Accessory breasts recorded in
the axilla (the most frequent
site), groin, buttock and thigh.
• They have been know to function
during lactation.
In approximately 1% of
the female population,
supernumerary breasts
(polymastia) or nipples
(polythelia) may develop.
Diffuse hypertrophy
• occurs in girls at puberty (benign virginal hypertrophy) and less
often, during the first pregnancy.
• The breasts enlarges and may reach the knees when the
patient is sitting, The condition is rarely unilateral.
• This caused by an alteration in the normal sensitivity of the
breast to oestrogenic hormones and some success in treating
it with anti-oestrogens has been reported.
• Treatment by reduction mammoplasty.
Infectious
Mastitis
• Generalized cellulitis of the
breast.
• Ascending infection
subareolar ducts
• commonly occurs during
lactation
Aetiology
• Lactational mastitis in most
cases are caused by
Staphylococcus aureus or
Streptococcus spp .
• The intermediary is usually the infant; after the second day
of life, 50% of infants harbour staphylococci in the
nasopharynx.
• Although ascending infection from a cracked nipple
may initiate the mastitis.
Clinical features
The affected breast, or more usually a segment of it,
presents the classical signs of acute inflammation.
focal tenderness with erythema and warmth of overlapping
skin.
Early on this is a generalized cellulites but later an abscess
will form.
• The presence of pus confirmed with needle aspiration.
•
the pus sent for bacteriological culture.
• When in doubt an ultrasound scan may clearly define an
area suitable for drainage.
Treatment
• During the cellulitic stage the patient
should be treated with an appropriate
antibiotic, for example flucloxacillin or coamoxiclav.
• Feeding from the affected side may
continue if the patient can manage and
recommend breast pump as an
alternative..
• Support of the breast, and analgesia will
help to relieve pain.
Breast Abscess
• Treated by surgical drainage
Chronic intramammary abscess
• A chronic intramammary abscess, which may follow
inadequate drainage or inprpoer antibiotic treatment, is often
a very difficult condition to diagnose.
• When encapsulated amass will form within a thick wall of
fibrous tissue the condition cannot be distinguished from a
carcinoma without the histological evidence from a biopsy.
Antibioma:
• This is a large, sterile, brawny oedematous swelling that
takes many weeks to resolve, may form If antibiotic is
used in the presence of undrained pus.
Mondor’s disease
•
•
•
•
Phlebitis of the thoracoepigastric vein
Palpable, visible, tender cord
Ultrasound may be helpful in confirming this diagnosis.
Treatment self-limited, can use anti-inflammatories if
necessary
Tuberculosis Of The Breast
• Rare, usually associated with active
pulmonary tuberculosis or tuberculous
cervical adenitis.
• Tuberculosis of the breast, presents with
multiple chronic abscesses and sinuses
and a typical bluish, appearance of the
surrounding skin.
• Diagnosis
• rests on bacteriological and histological examination.
•
Treatment :
• anti-tuberculous chemotherapy.
• Healing is usual, but delayed, and mastectomy restricted
to patients with persistent residual infection.
Inflammatory
Ductectasia / periductal mastitis
• This is a dilatation of the breast ducts, which is often
associated with periductal inflammation.
• The underlying cause is unknown, although the disease is
common in smokers.
• Generally found in older women 5th and 6th decades .
• The dilated lacteferouse ducts,
filled with a stagnating brown
or green secretion.
Clinical features
• This secretion may discharge,
Nipple discharge (of any
colour) , thick, cheesy nipple
discharge.
• These fluids then set up an irritant reaction
in surrounding tissue leading to periductal
mastitis or even abscess and fistula
formation.
In some cases, a chronic indurated mass forms
beneath the areola, which mimics a carcinoma.
• Fibrosis eventually develops, which may
cause slit-like nipple retraction.
Treatment
• In the case of a mass or nipple retraction, a carcinoma
must be excluded by obtaining a mammogram and
negative cytology or histology, If any suspicion remains the
mass should be excised.
• Antibiotic therapy may be tried, the most appropriate
agents being co-amoxiclav or flucloxacillin and
metronidazole.
•
surgery is often the only option likely to bring about cure
of this difficult condition; this consists of excision of all of the
major ducts (Hadfield’s operation).
Fibrocystic Disease
• Fibrocystic changes affect 50-80% of all
menstruating women.
• Age 30-50, 10% < 21Y.
• Exaggerated response from hormones
and growth factors usually prior to
menstrual cycle.
Pathology
• The disease consists essentially of four features that may
vary in extent and degree in any one breast.
Cyst formation:
Cysts are almost inevitable and very variable in size.
Fibrosis:
Fat and elastic tissues disappear and are replaced with
dense white fibrous trabeculae.
Hyperplasia:
of epithelium in the lining of the ducts and acini may occur,
with or without atypia.
Papillomatosis:
The epithelial hyperplasia may be so extensive that it results
in papillomatous overgrowth within the ducts.
Usually diagnosed 20 to 40 years
Present as pain and tenderness, palpable lumps, nipple
discharge.
Often multifocal and bilateral , general “lumpiness”
• A solitary cyst or small collection of cysts can be aspirated. If
they resolve completely no further treatment is required.
•
However, 30% will recur and require reaspiration.
• If there is a residual lump or if the fluid is blood-stained, a core
biopsy or local excision for histological diagnosis is advisable,
which is also the case if the cyst reforms repeatedly.
•
This will exclude cystadenocarcinoma, which is more common
in elderly women.
Mastalgia
Breast pain is the most common breast symptoms .
Classified as:
• Cyclical mastalgia.
• Non-cyclical mastalgia.
• Extra mammary (non breast) pain.
It can be severe enough to interfere with usual daily
activities.
• Cyclical mastalgia has a clear relationship to the menstrual
cycle, due to hormonal changes during luteal phase.
• Dull, diffuse and bilateral
• Non-cyclical mastalgia may be constant or intermittent but
is not associated with the menstrual cycle and often occurs
after menopause.
• Extramammary pain arises from the chest wall or other
sources and its interpreted as a cause within the breast.
• The risk of cancer with breast pain as her only symptom is
extremely low.
• Cancer must be excluded through examination, mammogram,
and ultrasound if the pain is localized.
• After clinical evaluation, most patients with breast pain
respond by reassurance and simple pharmacological
measures.
Treatment of mastalgia
Cyclical mastalgia
•
Firm reassurance that the symptoms are not associated with
cancer will help the majority of women.
• appropriate fitting supportive bra should be worn throughout
the day and a soft bra worn at night.
• Avoiding caffeine drinks is said to help.
• The medications danazol, tamoxifen, and bromocriptine are
effective; however, the serious adverse effects of these
medications limit their use to selected patients with severe,
sustained breast pain.
Non-cyclical mastalgia
• It is important to exclude extramammary causes such as
chest wall pain.
• This is common in postmenopausal women who are not on
HRT and the neck and shoulders are common sites of
referred pain.
• Treatment may be with non-steroidal analgesics or by
injection with local anaesthetic on a ‘trigger spot’.
Benign masses
Galactocele
•
rare, presents as a solitary, subareolar cyst and usually
follows lactation.
•
Milk-filled cyst & in longstanding cases its walls tend to
calcify.
• Firm, tender mass.
• Diagnostic aspiration often curative.
Fibroadenoma
• These tumor are benign, mobile (breast mouse) , most
common tumor in women younger than age 30 years.
• They arise from hyperplasia of a single lobule Composed
of both stromal and epithelial elements and usually grow
up to 2–3 cm in size, They are surrounded by a well
marked capsule.
• Can be diagnosed by FNA ,Otherwise Dx by excision.
Giant fibroadenomas occasionally occur during puberty.
They are over 5 cm in diameter and are often rapidly
growing but, in other respects, are similar to smaller
fibroadenomas and can be enucleated through a
submammary incision.
Phyllodes tumour
• These are benign tumours.
• previously known as serocystic disease of Brodie or
cystosarcoma phyllodes,
• occur in women over the age of 40 years but can appear in
younger women.
• They are large, sometimes massive, tumour .
• Malignant potential.
• These may metastasise via the blood stream
• Occasionally, ulceration of overlying skin occurs because of
pressure necrosis.
• Despite their size they remain mobile on the chest wall.
• They tend to recur locally .
Lipoma
• Nontender
• No associated skin or nipple changes
• Usually postmenopausal women
• Management- biopsy or excision
Injuries of the breast
Haematoma
• Haematoma, particularly a resolving
haematoma, gives rise to a lump,
which, in the absence of overlying
bruising, is difficult to diagnose
correctly unless it is biopsied.
Fat Necrosis
• Traumatic fat necrosis may be acute or chronic and usually
occurs in middle-aged women.
• Following a blow a lump, often painless, appears.
• This may mimic a carcinoma, displaying skin tethering and
nipple retraction, and biopsy is required for diagnosis.
• A history of trauma is not diagnostic as this may merely
have drawn the patient’s attention to a pre-existing lump.
CARCINOMA OF THE BREAST
• Breast cancer is the most common cause of
death in middle-aged women in western
countries.
Breast cancer is second only to lung
cancer as a cause of cancer deaths in
women.
One out of 8 women will be diagnosed
with breast cancer.
Breast Cancer Facts
2nd leading cause of death

2nd most common cancer

Incidence increases with
age

All women are at risk

Risk factors
• Age
• Gender
• Genetic
• Diet
• Endocrine
• Previous radiation
• Age Carcinoma of the breast is extremely rare
below the age of 20 years but, thereafter, the
incidence steadily rises so that by the age of 90
years nearly 20% of women are affected.
• Gender Less than 0.5% of patients with breast
cancer are male.
• Genetic It occurs more commonly in women with
a family history of breast cancer than in the
general population
• Diet breast cancer commonly affects women in
the ‘developed’ world, dietary factors may play a
part in its causation, A high intake of alcohol is
associated with an increased risk of developing
breast cancer.
Endocrine
• common in nulliparous women.
• breast feeding appears to be protective.
• Also protective is having a first child at an early age,
especially if associated with late menarche and early
menopause.
• It is known that in postmenopausal women, breast cancer
is more common in the obese,This is thought to be
because of an increased conversion of steroid hormones
to oestradiol in the body fat.
• Recent studies clarified the role of exogenous hormones,
in particular the oral contraceptive pill and HRT, in the
development of breast cancer.
Previous radiation
• women who have been treated with radiotherapy
as part of the management of Hodgkin’s disease, in
which significant doses of radiation to the breast
are received.
• The risk appears about a 10 years after treatment
and is higher if radiotherapy occurred during
breast development.
Signs and Symptoms
Early breast cancer
may not have symptoms.
Most common:
lump or
thickening in
breast. Often
painless
Discharge
or
bleeding
Change in size
or contours of
breast
109
Redness or pitting
of skin over the
breast, like the
skin of an orange
Change in color
or appearance
of areola
Symptoms of breast cancer
– Asymptomatic
Why we advise yearly mammogram after age 40
– Lumps
Presenting symptom in 85% of patients with carcinoma
– Pain
Must completely evaluate to rule out carcinoma
– Metastatic disease
Axillary nodes
Distant organ symptoms, such as neurological
Signs of breast cancer
• Most breast cancers will present as a hard
lump, which may be associated with
indrawing of the nipple.
• As the disease advances locally there may be
skin involvement with peau d’orange.
• Although any portion of the breast, including
the axillary tail, may be involved, breast
cancer is found most frequently in the upper
outer quadrant .
• As the disease advances locally there may be
ulceration and fixation to the chest wall ,
described as cancer-en-cuirasse.
• 5% of breast cancers in the UK will present with
either locally advanced disease or symptoms of
metastatic disease.
• This figure is much higher in the developing
world.
• These patients must then undergo a staging
evaluation(metastatic workup) , which include:
– a careful clinical examination, chest radiograph,
computerised tomography (CT) of the chest and
abdomen and pelvis and an isotope bone scan .
• Why we do this metastatic work up
This important for both prognosis and treatment; a
patient with widespread visceral metastases may obtain
an increased length and quality of survival from systemic
hormone therapy or chemotherapy but is unlikely to
benefit from surgery as she will die from her metastases
before local disease becomes a problem.
patients with relatively small tumours (< 5 cm in
diameter) confined to the breast and ipsilateral
lymph nodes rarely need staging beyond a good
clinical examination as the pick-up rate for
distant metastases is so low.
A chest radiograph, full blood count and liver
function tests are all that are recommended for
screening of patients with early-stage breast
cancer.
The spread of breast cancer
Local spread
• The tumour increases in size and invades other
portions of the breast.
• It involve the skin and penetrate the pectoral
muscles and chest wall if diagnosed late.
Lymphatic metastasis
• occurs primarily to the axillary and the internal
mammary lymph nodes.
• Involvement of supraclavicular nodes and
contralateral lymph nodes represents advanced
disease.
Spread by the blood stream
• By this route bone metastases occur, In order of
frequency the lumbar vertebrae, femur, thoracic
vertebrae, ribs and skull and these deposits are
generally osteolytic.
• Metastases occur in the liver, lungs and brain and,
the adrenal glands and ovaries.
Pathology
• Breast cancer may arise from the epithelium of the
duct system anywhere from the nipple end of the
major lactiferous ducts to the terminal duct unit,
which is in the breast lobule.
• Cancer cells are in situ or invasive depending on
whether or not they invade through the basement
membrane.
• The disease may be in situ, an increasingly
common finding with the progress of breast
cancer screening, or invasive cancer.
• The degree of differentiation of the tumour is
usually described using three grades:
• well differentiated,
• moderately differentiated
• poorly differentiated.
Grading system based on the scoring of three
individual factors (nuclear pleomorphism,
tubule formation and mitotic rate) is used,
with grade III cancers roughly equating to the
poorly differentiated group.
Classifications
I. Non-invasive breast cancers •
II. Invasive breast cancers •
I. Non-invasive breast cancers
– 10% of all types of breast cancer
– Good prognosis
– Ductal carcinoma in situ, lubular carcinoma in situ,
and paget’s disease
Ductal Carcinoma in Situ
•
•
•
•
Seen as microcalcifications on mammogram
Confined to ductal cells.
No invasion of the underlying basement membrane.
Chance of recurrence 25-50% in 5 years.
Rx
– Wide excision alone suitable and the margins are
clear.
– Wide local excision and radiation reduce local
recurrence to 2%
– Node dissection not necessary (nodal disease < 1%)
– Mastectomy an option if there is a substantial risk of
local/regional recurrence
Lobular Carcinoma in Situ
• Not detectable on mammography
– Most commonly found incidentally
• Risk of invasive breast cancer in 20 years is 15-20%
bilaterally
Rx
– Careful follow-up
– Bilateral masectomy may be considered if other risk
factors are present such as family history or prior
breast cancer, and also dependent on patient
preference.
Paget’s disease of the nipple
• Uncommon, Usually involves the nipple.
• It is a superficial manifestation of an underlying
breast carcinoma.
• Eczematous dermatitis of the nipple, which persists
despite local treatment.
• The nipple is eroded slowly and eventuall
disappears.
• If left, the underlying carcinoma will sooner or
later become clinically evident.
• Nipple eczema should be biopsied if there is any
doubt about its cause.
• It is associated with an underlying intraductal
carcinoma.
– Mammography should be performed
• About 30% of patients have axillary node
metastasis at diagnosis.
• Mastectomy is the standard care of treatment
– 80% have a 10 year survival rate if there is no mass present and no axillary
nodes are involved.
II. Invasive breast cancers
– Favorable histologic types
– Less favorable types
– Least favorable type
Favorable histologic types
• Tubular carcinoma
• Mucinous (colloid) carcinoma
• Papillary carcinoma
2-3% of all invasive breast cancers .
5 and 10 year survival rates are 73 and 59 %.
Less Favorable Histologic Types
• Invasive ductal carcinoma
– Most common and occurs in 78% of all invasive breast
cancers.
– Metastases to axillary nodes in 60%
– 5 and 10 year survival rates are 54 and 38 %
• Invasive lobular carcinoma
– 9% of all invasive breast cancers
– Metastases to axillary nodes in 60%
– 5 and 10 year survival rates are 50 and 32 %
– Higher incidence of bilaterality
Least favorable type
Inflammatory carcinoma
• 1.5 - 3% of breast cancers
• Characteristic clinical features of erythema, peaud’orange, and skin
ridging with or without a palpable mass.
• Commonly mistaken for cellulitis.
– Will generally fail antibiotics before being diagnosed
• Disease progresses rapidly, and more than 75%
of patients present with palpable axillary
nodes.
• Distant metastatic disease also at much higher
frequency than the more common breast
cancers.
• 30% 5 year survival rate
• Requires chemotherapy treatment immediately
Diagnosis of breast cancer
1. Fine-needle aspiration
Sensitivity is 80-98%, specificity 100%
False negatives are 2-10%.
2. Core-needle biopsy
More tissue, however still possibility of false “negative” and could
represent sampling error.
3. Excisional biopsy
Removal of entire lesion and a margin of normal breast
parenchyma.
Staging, Prognosis, And Treatment
Staging of breast cancer
• The clinical stage of breast cancer is determined
primarily through physical examination of the skin,
breast tissue, and regional lymph nodes (axillary,
supraclavicular, and cervical).
• Mammography, chest radiography, an
intraoperative findings (primary tumor size, chest
wall invasion) also provide necessary staging
information.
• Pathologic stage combines the findings from
pathologic examination of the resected primary
breast cancer and axillary or other regional lymph
nodes.
Classical staging of breast cancer by means of the
TNM (tumour– node–metastasis) .
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)
– Clinical Stage IIA
T1
T2
N1
N0
M0
M0
– Clinical Stage IIB
T2
T3
N1
N0
M0
M0
– Clinical Stage IIIA
T1
T2
T3
T3
N2
N2
N1
N2
M0
M0
M0
M0
– Clinical Stage IIIB
T4 any N M0
– Clinical Stage IV
any T any N M1
Stage
Prognosis (5 year surv. Rate)
–I
93%
– II
72%
– III
41%
– IV
18%
Breast Cancer Treatments Modalities
–Surgery
• Local treatment
–Radiation
• Local treatment
– Chemotherapy and hormonal therapy
• Systemic treatment
Surgery
– Breast conservation surgery (BCS)
• 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 by mamography.
• 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
Sentinel node biopsy
• The sentinel node is defined as the first lymph node
draining the tumour-bearing area of the breast.
• This technique is currently becoming the standard of care
in the management of the axilla in patients with clinically
node-negative disease.
• The sentinel node is localised peroperatively by the
injection of patient blue dye and radioisotope-labelled
albumin in the breast.
• The recommended site of injection is in the subdermal
plexus around the nipple although some still inject on
the axillary side of the cancer.
• The marker passes to the primary node draining the
area and is detected visually and with a hand-held
gamma camera.
• The excised node can be sent for frozen-section
histological analysis
• In patients in whom there is no tumour
involvement of the sentinel node, further axillary
dissection can be avoided.
Radiation
• Utilized for primary and metastatic disease
• Useful in breast conservation therapy to reduce
rate of recurrence.
• Radiate entire breast
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.
– Example treatment is 6 months of
cyclophosphamide, methotrexate or adriamycin, and
flourouracil along with paclitaxel.
• Improvement in disease free interval and overall survival
Hormonal therapy
– Tamoxifen
• Generally taken for five years in patients with estrogen
receptor positive tumors.
• As effective as chemotherapy in post-menopausal patients
with estrogen receptor positive tumors
Treatment of advanced breast cancer
• Breast cancer may present as metastatic disease without
evidence of a primary tumour (occult primary).
• The diagnosis is made by exclusion of another site
for the primary tumour and confirmed by histology with
special immunohistological stains of the metastatic
lesions.
• Management by palliation of symptoms and treatment
of breast cancer by endocrine manipulation with or
without radiotherapy.
Locally advanced inoperable breast cancer
• Locally advanced inoperable breast cancer,
including inflammatory breast cancer, is usually
treated with systemic therapy, either
chemotherapy or hormone therapy.
• Occasionally, ‘toilet mastectomy’ or radiotherapy
is required to control a fungating tumour.
Metastatic carcinoma of the breast
• Metastatic carcinoma require palliative systemic
therapy to alleviate symptoms.
1) Hormonal manipulation: is the first-line treatment because of its minimal side
effects, hormonal therapy like Tamoxifen, It is particularly useful for bony
metastases.
2) Surgery: for ovarian suppression (premenopausal women).
3) Radiotherapy : for bone mets.
4) Cytotoxic therapy : used in younger women, visceral metastases, rapidly growing
tumours.
5) Local treatment : may also prove useful for some metastatic disease such as
radiotherapy for painful bony deposits and internal fixation of pathological
fractures.
Follow-up of breast cancer
• Patients with breast cancer used to be followed for life to
detect recurrence and dissemination.
• It is current practice to arrange yearly or 2-yearly
mammography of the treated and contralateral breast.
• There is currently no routine role for repeated
measurements of tumour markers or imaging other than
mammography if no new symptoms or signs appear .
Screening for breast cancer
• a population screening programme that could detect
tumours before they come to the patient’s notice might
reduce mortality from breast cancer, a number of studies
have shown that breast screening by mammography in
women over the age of 50 years will reduce mortality .
• self examination programmes that have benefit for the
population in terms of earlier detection or decreased
mortality from breast cancer .
Familial breast cancer
• Recent developments in molecular genetics and the identification of
a number of breast cancer predisposition genes (BRCA1, BRCA2 and
p53).
• Those who prove to be ‘gene positive’ have a 50–80% risk of
developing breast cancer, predominantly while premenopausal.
• Many will have option for prophylactic mastectomy.
• This work should be carried out in special centres.
Pregnancy
Breast cancer presenting during pregnancy or lactation tends to be at
a later stage, because the symptoms are masked by the pregnancy;
Treatment : is similar with some precautions:
• Mastectomy is agood option than breast conservening surgery.
• Chemotherapy avoided during the 1st trimester but safe
subsequently.
• Radiotherapy should be avoided during pregnancy.
• Hormonal therapy, which is potentially teratogenic, is not required.
The Male Breast
Gynecomastia
• The most common breast problem in men is
gynecomastia.
• Gynecomastia is a benign hypertrophy of breast tissue.
• The unilateral gynecomastia patient usually presents
with a discoid mass symmetrically placed beneath the
areola, which may be tender to palpation.
– Prepubertal gynecomastia
• Rare, adrenal carcinoma and
testicular tumor can cause this.
– Pubertal gynecomastia
• Occurs in 60-70% of pubertal boys.
– Senescent gynecomastia
• 40% of aging men have this to
some degree.
• Drugs, such as steroids, digitalis,
hormones, spironolactone, and
antidepressants can cause this.
Male breast carcinoma
–
–
–
–
0.7% of all breast cancers
<1% of male cancers
Average age of diagnosis is 63.6 years old
Painless unilateral mass that is usually
subareolar with skin fixation, chest wall
fixation,, and ulceration.
– Mostly ductal carcinoma
– Males generally present at later stage than
woman
• Overall survival worse in men, however when
compared stage for stage the survival rates are
similar.