Download Breast Cancer

Breast Diseases
Professor Hassan Nasrat
Chairman
Department of Obstetrics and Gynecology
Faculty of Medicine
King Abudluziz University
• Why Gynecologist should know about
breast diseases
• Anatomy of the Breast
• Common Breast Diseases
• Breast Cancer: Epidemiology,Risk factors
and screening
• Approach to women with common breast
problem
Why Gynecologist need to study Breast Disorders?
For many women gynecologists are their primary
health care physicians.
increased awareness among women concerned
about their own risk of developing breast cancer
Desire to take hormonal therapy such
contraceptive pills or hormonal replacement.
as
Anatomy of the Breast
The breast is subcutaneous gland (tubulo - alveolar gland).
glandular tissue (20%), stroma f adipose and fibrous connective tissue (80%).
The alveoli:
Are the basic unit of the breast Each alveolus (0.2 mm in
diameter).
Lobule:
Each contain 10-100. alveoli.
Lobes:
Each contain 20-40 lobule
All are drained by a single lactiferous duct that opens at the nipple. they
form the lactiferous sinuses (small reservoirs of milk)
(Cooper's ligament): Separate the lobes, it extends from the skin to the
underlying pectoralis fascia.
The alveoli (the basic unit) each 0.2 mm in diameter
It is arranged in lobuli (10-100 alveoli per lobule)
Twenty to 40 lobules form lobes
each lobe is drained
by a single
lactiferous duct
The lactiferous
duct converges
towards the
areola to form
the lactiferous
sinuses
Each lobe is separated by (Cooper's ligament) that extends from the skin
to the underlying pectoralis fascia.
The areola; is a specialized pigmented skin that surrounds
the nipple; it contains sweat glands and sebaceous glands
(glands of Montgomery) that hypertrophy during pregnancy.
It lubricates and protects the nipple during lactation.
The innervation of the nipple and areola mediate the
neurohumoral reflexes responsible for the removal of milk
from the gland and the release of prolactin.
Lymphatic drainage of the breast: Approximately 75% of the
lymphatic drainage goes to the regional axillary lymph
nodes.
The alveoli
Lobule
Lobes
Anatomy of breast.
- Accessory breasts or nipple can occur along the breast
lines which run from the axilla to the groin. { supernumerary
nipples (polythelia)}
- Underdevelopment of one breast in relation to the other is
a common anomaly in approximately 3-5% of population.
Breast tissue, the glandular and non-glandular elements
are sensitive to the cyclic hormonal changes of menstrual
cycles
Extensive polythelia along milk line
The Breast and The Menstrual cycle
Estrogen
During the follicular phase
Progesterone
During the luteal phase
parenchymal proliferation
of the ductal system
dilatation of the ductal
system and differentiation
of the alveolar cells into
secretory cells
• Women often experience breast tenderness and fullness during the
premenstrual period.
• There is an actual increase in the volume of the breast by 25-30 ml
as measured by water displacement technique, due to increased
blood flow, vascular engorgement and water retention.
Systematic approach to evaluation of breast problems
History :
The duration of symptom.
Whether there has been any change
If it is unilateral or bilateral, multiple or single.
Relation to menstruation
The patient background risk factors: most
importantly age, family history of breast cancer, hormonal
therapy...Etc.
Examination:
Systematic and careful examination is essential and presents
a good opportunity for patient education on the proper
method of self examination
Common benign breast diseases
Fibrocystic changes:
Fibroadenoma:
Phyllodes Tumour:
Mastitis:
Superficial thrombophlebitis (Monro's disease):
Chronic Periareolar Abscess:
Fibrocystic changes:
Is commonly observed throughout women reproductive life
with increasing frequency from teenage to the
premenopausal period.
Incidence: Approximately 10% of women under the age of 20
and up to 60-70% in the premenopausal years.
- Is an exaggeration of the normal physiologic response of
breast tissue to the cyclical levels of ovarian hormones.
- Usually not associated with increased risk of breast cancer
unless there is epithelial cell turnover.
It is unusual after the menopause unless associated with
exogenous hormones.
Fibrocystic changes - Histologically :
• Stroma: Fibrosis
• Alveoli: non proliferative cystic changes
• Ducts: proliferative changes including hyperplastic ductal
epithelium,
adenosis and occasional papilloma formation.
The nature and type of predominate change correlates with age:
In the Twenties: more intense proliferation of the stroma (fibrosis). May
lead to fibroadenoma or juvenile hypertrophy may result.
During the Thirties: both the glandular tissue and stroma respond to
the cyclic changes of hormones. If excessive proliferation and
hyperplasia of ducts, ductules and alveolar cells occurs, it results in
cyclic pain and nodularity.
In the Forties: the lobules and ducts involutes and there is no severe
pain unless a cyst increase rapidly in size giving point tenderness and
lumps. Periductal mastitis and duct ectasia may develop at this stage.
Virginal hypertrophy, age 13.
symptoms and signs of fibrocystic changes
- Symptoms: cyclic premenstrual breast pain, commonly
bilateral and mostly located in the upper outer quadrant of
the breast.
- Signs: tenderness and ill-defined thickness "palpable
lumpiness or nodularity " that are rubbery in consistency.
Larger cysts, if present, are felt as balloon filled with water.
- Investigations: rarely required
Fibrocystic Changes The etiologic factors
Unknown
Hormonal: No hormonal abnormalities have
been found, though the possibility of imbalance of
estrogen and progesterone hormones as well as
abnormal prolactin secretion have been suggested.
Dietary factors: excessive consumption of
methylxanthines containing foods (coffee, tea,
chocolate and cola drinks)
Fibrocystic Changes - The management
Reassurance:
Non pharmacological treatment:
Breast Support, reduction of consumption of compounds that contain
methylxanthines and tobacco, evening primrose oil administration, γlinolenic acid a polyunsaturated fatty acid to replenish fatty acid deficiency.
Pharmacologic treatments:
- Diuretics for 2-3 days in the premenstrual days.
- Low estrogen contraceptive pills.
- Progesterone administration: during the secretory phase.
- Anti prolactin e.g. Bromocriptine (5 mg /day)
-Tamoxifen. (antiestrogen competes with estrogen for the estrogen
receptors in the breast)
- Gonadotrophin releasing hormone (Gn-RH) analogs:
- Danazol: 100-400 mg/day continuously
Surgical intervention: e.g. if a dominant mass, a cyst. More major surgery
for cases of intractable pain or if biopsy showed a precancerous lesion.
Fibroadenoma
 The second most common benign breast lesion.
 It affects women in their early twenties.
 Is an aberrant growth of normal tissue rather than neoplasm.
Clinically
it is usually discovered accidentally as painless solid mass which is
mobile, non tender and rubbery in consistency.
Investigations:
Ultrasound examination may be required in some cases to differentiate
between a cyst and fibroadenoma.
Enormously enlarged right breast due to the presence of a giant fibroadenoma
Treatment:
• Excision biopsy especially if it increases in size
and in women above thirties years of age.
• conservative treatment and assurance In young
girls (<25 years) is appropriate.
The frequency of carcinoma within a fibroadenoma
is very low, with only 119 reported cases
(Yoshida 1985). Approximately 30 % of
fibroadenoma regresses spontaneously and in
10-20% it decrease in size.
Fat Necrosis
- clinically can be confused with breast carcinoma.
- It usually follows trauma but the incident can not often be
recalled by the patient.
- Is felt as a tender, firm, irregular mass that may be
associated with area of ecchymosis and even skin
retraction.
- The diagnosis is determined after excision biopsy.
Phyllodes Tumour
• Is a Fibroepithelial breast tumour seen more frequently during the
premenopausal age.
• Histologically it has similarity to fibroadenomas but with distinct
connective tissue hypercellularity with different type of connective
tissue elements, pleomorphism and higher level of mitotic activity
(Azzopard 1979).
• The lesion is most frequently benign, in the same time it is the most
frequent cause of breast sarcoma.
•
There have been reports of cases with benign histologic
characteristics demonstrating unexpected metastases leading to
subsequent patient demise. The lesion is treated by total excision
with wide margin of healthy breast tissue.
Mastitis
• Is the most common inflammatory condition of the
breasts. It is seen most commonly, but not always,
among nursing mothers.
• The causative organisms are Staphylococcus aureus
and Streptococcus species.
• Clinically: fever, erythema, induration and tenderness. If
neglected it may progress to form a breast abscess.
• Treatment with broad spectrum antibiotics
• lactation may continue from the unaffected breast while
expressing the affected one in order to prevent milk
engorgement.
Superficial thrombophlebitis (Monor's disease):
• This is an uncommon
(Haagensen et all 1986).
inflammatory
condition
• It presents as acute pain or erythema in the upper lateral
portion of the breast usually caused by an inflammation
of the superficial veins.
• It may be associated with pregnancy, breast trauma, or
surgical plastic breast procedures.
• The treatment is conservative with symptomatic
treatment similar to superficial thrombophlebitis in any
other location.
Chronic Periareolar Abscess
• Is an uncommon condition. More commonly seen in
premenopausal women.
• It presents as recurring tender erythematous nodule that
develop just at the edge of the areola.
• Due to chronic ductal infection secondary to obstruction
of the duct by keratin and other ductal debris.
• It is treated by expression but may require incision
draining to prevent recurrence.
Breast Cancer
• is the most common malignant neoplasm in women and
comprises 18% of all female cancers
•
The incidence is increasing particularly among women
aged 50-64.
• One in eight women will develop breast cancer during her
lifetime.
• Gynecologist should be able to provide basic counsel to
women about screening and prevention methods for
breast cancer also advise regarding potential risks of
hormonal therapy e.g. HRT, or contraceptive pills in
relation to the development of breast cancer.
By age 25
1 in 19,608
30
1 in 2525
35
1 in 622
40
1 in 217
45
1 in 93
50
1 in 50
55
1 in 33
60
1 in 24
65
1 in 17
70
1 in 14
75
1 in 11
80
1 in 10
85
1 in 9
Ever
1 in 8
Data from National Cancer Institute. Painter K: Factoring
in cost of mammograms, USA Today,, Dec. 5, 1996.
Risk By Age: A Woman's Risk of Developing Breast Cancer
Risk factors for breast Cancer:
• Reproductive factors
(Age at Menarche and Menopause, Age at
first pregnancy)
• Particular histological diagnosis of
breast biopsies:
namely atypical hyperplasia, lobular
carcinoma in situ
• Family history
• Particular life style factors
Risk factor
High Risk Feature
Relative Risk
Menarche onset
<12 yr old
1.3
Menopause onset
>55 yr old
1.5
Age at birth of Nulliparous or >30
first child
1.9
Benign
disease
breast Any
benign
breast
condition
Proliferative disease
Atypical Hyperplasia
1.5
Family history of Mother affected
breast cancer
Two
first
degree
relatives
1.7
5.0
2.0
4.0
Obesity
90th percentile
1.7
Alcohol use
Moderate drinker
1.7
HRT
Current use, age 50-59
1.5
Genetic risk of breast:
• Approximately 5-10% of breast cancers occur in
families in which there are many women with the
disease.
• Two highly penetrance breast-ovarian cancer genes
have been identified BRCA1 and BRCA2, Both are
tumour suppressor genes inherited as an autosomal
dominant
• It can be transmitted through either sex and that
some family members may transmit the abnormal
gene without developing the cancer themselves.
• Together they account for about 5% to 7% of all
cases of breast and ovarian cancer and for 50% to
70% of hereditary cases of breast cancer.
• Breast and ovarian cancer when linked to BRCA1 and
BRCA2 mutation it tends to strikes early in
• Inheritance of BRCA1 and BRCA2 mutation increase
women lifetime risk of developing breast cancer between
50% and 85% (a seven fold increase).
• In addition BRAC1 mutation increases the risk of ovarian
cancer by as much as 28 fold, from 1.8% to 50% by the
age 70
• Screening for breast cancer:
Aim: To decrease mortality by detecting
the disease at an early stage.
Methods:
Monthly Breast Self Examination
Mammographic Examination.
Mammography being performed with appropriate
compression applied.
Normal mammogram and the process of aging.
(A) the normal breast parenchyma is seen as ill-defined white densities located
predominantly behind the nipple. In young women, the breast tissue can be
extremely dense with only a small amount of interspersed fat, making tumors hard to
see.
(B) mammogram on the same patient several years later shows fatty replacement
of most of the breast tissue.
An ultrasound examination of a young woman with a palpable lesion
shows an echo-free simple cyst.
Preventive measure for women at genetic risk of breast
and ovarian cancer:
• Surveillance:
intensive surveillance program. In addition chang
in life still e.g. cessation of smoking, alcohol
drinking and encourage exercise
• Medical prophylaxis: e.g. OCP, Tamoxifen
• Prophylactic surgery: Prophylactic oophorectomy:
Common Presentation of Breast Problems
• Breast pain or mastalgia.
• Breast lumps.
• Nipple discharge.
• Presentation due to cosmetic complains
e.g. too small or too large breasts…etc.
Breast Pain “Mastalgia”
• Is defined as pain originating in the breasts. It
may be localized in the breast or in a severe
case may radiate to the axillae.
• Should be differentiated from premenstrual
breast discomfort which is not uncommon
symptoms. But moderate to severe mastalgia
estimated to occur in 11 % of cases.
• Sometimes the symptoms are severe and can
disturb daily activities, sex life and even sleep.
Etiology of breast pain
• In the majority of cases no apparent cause
can be found.
• Important causes to exclude are pain
originating from costochondritis junction.
• mastitis or breast abscess.
• The most common cause is fibrocystic
changes
• Cancer is infrequently present with pain.
Pain is usually a late symptom of cancer..
Breast Pain
Non Cyclic Pain
Stretching of Cooper’s ligament
Pressure from Bra
Fat Necrosis
Hydradenitis suppurative
[Focal Mastitis
Periductal Mastitis
Cysts
Mondor’s disease
Cyclic Pain
Hormonal stimulation
Non Breast Pain
Chest wall
Tietze's syndrome
Radicular pain from cervical arthritis
Non Chest Wall Pain
Gallbladder disease
Ischemic heart disease
Management of Mastalgia
• Careful history taking and examination.
• Any risk factors for breast cancer should be identified
• Systemati Physical Breast examination.
• In low risk patients usually no further investigations are required.
• In high-risk women (>40 years)
mammography and ultrasound
• In most of cases management as in fibrocystic changes.
• Patients with a breast lump or who fail to respond to medication or
unilateral persistent pain in post-menopausal women should be
referred for further evaluation
Nipple Discharge
• Spontaneous, persistent discharge in non lactating women can be
due to a variety of causes:
• Although in only approximately 3% nipple discharge is associated
with breast carcinoma each case should be carefully evaluated.
• The main objective is to rule out underlying malignancy. It is to be
noted that the color of the discharge does not differentiate a benign
from a malignant process.
• cytology of the discharge is important it may yield false negative
results in up to 20% of cases.
• Therefore the diagnosis of the underlying cause of nipple discharge
requires careful evaluation, mammographic examination and
eventually excision biopsy.
TABLE 14-1 -- Causes of Single Duct Nipple Discharge in 170
Patients (Nottingham 1988)
Diagnosis
Number (%)
Duct papilloma
77 (45)
Benign disease (for example, duct ectasia)
80 (47)
Cancer in situ
No abnormality
2 (7)
1 (0.6)
From Chetty U: Nipple discharge. In Smallwood JA and Taylor I,
editors: Benign breast disease, Baltimore, 1990, Urban &
Schwarzenberger.
TABLE 14-2 -- Relation Between Nipple Discharge and Diagnosis in 432
Operations from New York Medical College, 1960–1975
Intraduct
al
Fibrocyst
Infect Papillom
ic
Canc
ion
a
Disease
er
Galactorrh
ea
Duct
Ectasia
Milky
2
0
0
0
0
0
Multicolored and
sticky
0
46
0
0
0
0
Purulent
0
0
14
0
0
0
Watery
0
0
0
3
1
5
Serous
0
5
0
79
52
11
Serosanguineous
0
8
0
59
34
14
Sanguineous
0
6
0
45
28
20
_
__
__
___
___
__
2
65
14
186
115
50
Discharge
TOTAL
Reprinted with permission from Pilnik S: J Reprod Med 22:286, 1979.
Nipple Discharge
Presence of Galactorrhea
No Galactorrhea
Hyperprolactinemia
From one duct
Bloody
Serosanguineous
Intraduct papilloma
Ductal carcinoma in situ
Paget’s disease of the breast
From Multiple Ducts
Fibrocystic changes
Ductal ectasia
Breast Lump
• Breast Lump whether discrete or multiple is a
common presentation and perhaps one of the
most worrying for women.
• The DD includes a variety of conditions.
• The objective is to define cases that need further
investigations
Discrete Solitary Lump
Age < 30 yr
Firm
rubbery
Lump
Fibroadeno
ma
Age 30-50 yr
Firm discrete lump
Fibroadenoma, cyst,
fibrocystic changes, ductal
hyperplasia, atypical
ductal hyperplasia,
atypical lobular
hyperplasia
Diffuse Lumps (lumpy breast)
Absence of Discrete lump
Fibrocystic changes
Age >50 yr
Firm discrete
lump
Cyst, Ductal
Carcinoma in
situ, invasive
cancer
Thank you
Lymphatics of breast.
This low-power photomicrograph of a lobule illustrates the centrally located
terminal duct and the peripherally arranged clusters of small glandular
structures grouped within a loose fibrovascular stroma. The stroma exterior to
the lobule and the terminal duct is composed of collagen-rich connective
tissue.
Classic fibroadenoma of the breast.
Breast biopsy from a 38-year-old woman demonstrating characteristic gross
appearance of fibrocystic changes. Note multiple cysts interspersed between the
dense fibrous connective tissue.
Examination of axilla in sitting position during breast examination.
BI-RAD classification of mammographic lesions.
Needle biopsy and aspiration with negative pressure. Needle is rotated,
moved back and forth, and slightly in and out to aspirate representative
specimen.