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PGY 101: Chapter 74
Breast
Breast Cancer in the US
• Breast Cancer is estimated to affect over 230,000
women annually in the US
• Based on SEER Database rates from 2009-2011, the
cumulative lifetime risk of an average woman in the
general US population is 12.3%
• Estimated 15,480 new cases of female breast cancer
in Florida
Breast Cancer in the US
• Greatest risk in the 5th and 6th decade of life
Median Age
at Diagnosis
61
Breast Cancer in the US
• Early Detection
through screening
• Advances in
Systemic Therapy
• Patient Education
Percent surviving
5 years
89.2%
• Personalized Care
Breast Cancer
5 yr Relative Survival (%)
100
80
60
40
20
0
5 yr Relative
Survival (%)
Localized
Regional
Distant
98.6
84.4
24.3
SEER Cancer Statistics 2014
What is Breast Cancer?
Breast Cancer Risk
Non-Modifiable
Modifiable
Being a Woman
Getting Older
Family History of Cancer
Menstruating Early
Late Menopause
Never Having Children
Older Age at First Birth
History of Radiation
Dense Breasts
History of Breast Biopsy
History of Abnormal Biopsy
Hormone Therapy
Obesity
Unhealthy Diet
Sedentary Lifestyle
Drinking Alcohol
Lack of Screening
Education,
Awareness,
Action
Hereditary Breast Cancer
Family History
• History of Breast Cancer in First degree relatives increase
an individuals risk of breast cancer
• 2-fold increased risk in women whose sisters or mothers have
had breast cancer
Stratton MR. Nat Genet. 2008;40:17
Genetics
• Approximately 5-10% of all
breast cancer
• Known inherited
alterations in genes that
lead to an increased risk of
developing breast cancer
• Lead to a 10- to 20 – fold
increased lifetime risk of
developing breast cancer as
well as many associated
cancers
• Ovarian, Pancreas,
Prostate, Melanoma,
Thyroid, Colon
• Cancers occur at younger
ages
Inherited Gene Alterations
• BR (Breast) CA (Cancer) Susceptibility genes (BRCA 1 & BRCA 2)
• Approximately 80% of all hereditary breast cancers
• Cumulative lifetime risk of Breast Cancer:
• BRCA 1 – 65-87%
• BRCA 2 – 45-55%
• Cumulative lifetime risk of Ovarian Cancer:
• BRCA 1 – 39-51%
• BRCA 2 – 11-35%
What if a Woman has a strong Family
History but Negative for BRCA?
Risk Calculators
Screening
• Mammography remains the only study
proven to detect early breast cancer and
decrease breast cancer related deaths
• Breast cancer mortality reduction up
to 40%
• Screening detected cancers
• Smaller in size
• Less likely to have lymph nodes
involved
• Less likely to receive chemotherapy
American Cancer Society
Recommendations
• Yearly mammograms are recommended starting at age 40 and
continuing for as long as a woman is in good health
• Clinical breast exam (CBE) about every 3 years for women in their 20s
and 30s and every year for women 40 and over
• Women should know how their breasts normally look and feel and
report any breast change promptly to their health care provider
• Breast self-exam (BSE) is an option for women starting in their 20s
Recommendations vary
based on risk
Screening
• General Population – Baseline mammogram between
35-40 and annual mammography starting at age 40.
• Start 10 years younger then your youngest 1st
degree relative diagnosed with breast cancer
• High Risk Population – Annual mammography and
MRI starting at the age of 30
• BRCA 1 or 2 carriers
• 1st degree relative of BRCA carriers but untested
• Lifetime risk of 20-25% based on family risk assessment models
• History of chest wall radiation
Screening
Diagnostic Imaging
• Addition of Spot Magnification Mammographic
Views, Breast Ultrasound, and or MRI
Mag Views
Ultrasound
MRI
1
2
3
4
5
Biopsy for Diagnosis
Stereotactic
Ultrasound
MRI
Cancer Staging
• Stage
• Tumor Size
• Lymph Node Involvement
• Spread to other Organs
• Tumor Proteins
• ER
• PR
• Her2 Neu
Size
Nodes
Metastasis
Tumor Marker
Profile: ER/PR/Her
2 status
Breast Cancer Treatment
Cure
Breast
• Surgical Oncologists
• Radiation Oncologists
• Plastic/Reconstructive
Surgeons
Whole Body
• Medical Oncologists
• Anti-Estrogen Therapy
• Chemotherapy
• Targeted Therapy
Surgical Treatment
Breast Tissue
Breast
Saving
Mastectomy
Lymph Nodes
Dr. William S. Halsted
(1852-1922)
Halstedian Principle:
“Cancer spreads in an orderly,
slow, and localized manner,
contiguous with its site of
origin”
The Complete Operation
Skin Envelope
NAC
Breast Tissue
Pectoralis Major
and Minor
Axillary Levels I-III
“The result of operations for the cure of cancer of the breast performed at the Johns Hopkins Hospital from June 1889 to 1894”
Radical Mastectomy
Surgical Evolution
Radical Mastectomy
Modified Radical Mastectomy
Skin Sparing Mastectomy
Nipple Sparing Mastectomy
Partial Mastectomy
No difference
in Survival
NASBP B06 Breast Conservation
Fisher B, Anderson S, Bryant J et al. N Engl J Med. 2002;347:1233-1241.
NSABP B06 Breast Conservation
Fisher B, Anderson S, Bryant J et al. N Engl J Med. 2002;347:1233-1241.
Breast Conservation
Candidacy
•
•
•
•
•
Focality of Disease
Tumor Location
PMH/Genetic
Prior Radiation
Cosmetic Outcome
Reconstructive Surgery
Reconstructive Surgery
Women’s Health and Cancer Rights
Act of 1998
Mandated that all health plans include breast and nipple
reconstruction as well as contralateral breast symmetry
procedures to all mastectomy patients
Surgical Evolution
Levels I, II, III
Levels I, II
Sentinel Lymph Node
Biopsy
Sentinel Lymph Node Biopsy
Giuliano AE. Ann Surg. 1994;220:391-401
Sentinel Lymph Node Biopsy
Penile Squamous Cell Cancer
Cabanas
1977
Melanoma
Morton
Breast Cancer
Giuliano
1992
1994
Cabanas RM. Cancer. 1977;39:456-466.
Morton DL. Surg Oncol Clin North Am. 1992;1:247-259
Giuliano AE. Ann Surg. 1994;220:391-401
Study
Year
(n)
Giuliano
1994
174
Identification Accuracy
78.0
95.6
Negative Sensitivity
Predictive
Value
93.5
93.7
False
Negative
Rate
4.3
Sentinel lymph node biopsy is an accurate method of axillary
lymph node staging in women with early stage clinically node
negative breast cancer
Giuliano AE. Ann Surg. 1994;220:391-401
Randomized Controlled Trials
Study
Year
(n)
Identification Accuracy
Rate (%)
(%)
Negative Sensitivity
Predictive
(%)
Value (%)
False
Negative
Rate (%)
Veronesi
2003
516
99
96.9
95.4
91.2
8.8
Krag
Zavagno
2007
2008
5536
749
97.2
95
97.1
94.4
96.1
92.3
90.2
83.3
9.8
16.7
Veronesi U. N Engl J Med. 2003;349:546-553
Krag DN. Lancet Oncol. 2007;8:881-888
Zavagno G. Ann Surg. 2008;247:207-213
Randomized Controlled Trials
Study
Year
(n)
Local
Regional
Overall
Survival
Disease Free
Survival
ALND SLNB ALND SLNB ALND SLNB ALND SLNB
Veronesi
2010
516
1.5
1.5
0
0.7
89.7
93.5
88.8
89.9
Krag
2010
5536
1.9
1.7
0.3
0.5
91.8
90.3
82.4
81.5
Zavagno
2008
749
0.8
3.4
0
1.1
95.5
94.8
89.9
87.6
Veronesi U. Ann Surg. 2010;251:595-600
Krag DN. Lancet Oncol. 2010;11:927-933
Zavagno G. Ann Surg. 2008;247:207-213
ACOSOG Z0011
Clinical T1-T2, N0, M0
undergoing BCT + XRT
(n=856)
Patient with ≤ 2 SLNB
+ ALND
(n=420)
No ALND
(n=436)
Endpoints:
Locoregional Recurrence
Overall Survival
Giuliano AE, McCall L, Beitsch et al. Ann Surg. 2010;252:426-32
ACOSOG Z0011
92.5%
91.8%
83.9%
82.2%
Giuliano AE, Hunt K, Ballman KV et al. JAMA. 2011;305:569-575.
ACOSOG Z0011
Local Recurrence
Regional Recurrence
SLNB + ALND
SLNB
3.6
0.5
1.8
0.9
Giuliano AE, McCall L, Beitsch et al. Ann Surg. 2010;252:426-32
ACOSOG Z0011
• At 6.3 year follow-up, women with clinically
node-negative early stage breast cancer with <
3 positive sentinel nodes, who underwent
breast conservation surgery demonstrated:
– No Benefit in Locoregional control following ALND
– No Benefit in Overall or Disease-free survival
following ALND
Breast Cancer Treatment
Cure
Breast
• Surgical Oncologists
• Radiation Oncologists
• Plastic/Reconstructive
Surgeons
Whole Body
• Medical Oncologists
• Anti-Estrogen Therapy
• Chemotherapy
• Targeted Therapy
Adjuvant Therapy
Radiation Therapy
• Whole Breast Radiation
•
All Breast Conservation
•
Locally Advanced Mastectomy
•
Nodal Disease
•
Close Margins
•
Inflammatory
• Partial Breast Radiation
•
Selected Early Stage
Additional Therapy
Systemic Therapy
• Chemotherapy
• Endocrine Therapy
• Tamoxifen
• Aromatase Inhibitors
• Targeted Therapy
Clinical Stage
Biology of the Tumor
Tumor Marker Profile
Oncotype
Adjuvant Therapy
Systemic Therapy
• Endocrine Therapy (Anti Estrogen Therapy)
•
Any ER or PR + patient > 1%
•
Premenopausal/DCIS: Tamoxifen, Postmenopausal: Aromatase Inhibitors
• Chemotherapy
•
ER/PR/Her2 negative
•
Any Her2 +
•
+/- ER/PR + Her2 negative
•
Node + disease
• Targeted Therapy: Herceptin
•
Her 2 +
Genomic Profiling of Tumors
Oncotype DX
Clinical Practice Guidelines
NCCN Guidelines
Consider use in >0.5cm, HR+, HER 2 – negative disease, pT1-3 and
pN0 or pN1mic
ASCO Guidelines
Newly diagnosed patients with node-negative, ER+ breast cancer who
will receive tamoxifen
Oncotype DX
16 Cancer Genes
5 Reference Genes
Proliferation
Invasion
HER 2
Reference
Ki-67
STK15
Survivin
Cyclin B1
MYBL2
Stromelysin 3
Cathepsin L2
GRB7
HER2
Ki-67
GAPDH
RPLPO
GUS
TFRC
Estrogen
Other
ER
PR
Bcl-2
SCUBE2
GSTM1
CD68
BAG1
Paik S et al. NEJM. 2004;351:2817
NSABP B-14: Recurrence Score as Predictor of 10 yr
Distant Recurrence (n=675)
RS <18
RS18-30
RS>30
Paik S et al. NEJM. 2004;351:2817
Oncotype DX
10-yr Rate of Distant
Recurrence
95% CI
6.8%
(4-9.6%)
14.3%
(8-20.3%)
30.5%
(23.6-37.4%)
Paik S et al. NEJM. 2004;351:2817
Women with Node-negative,
HR+ Breast Cancer
Oncotype DX
Low RS
Endocrine
Intermediate RS
Endocrine
Endocrine
+ chemo
High RS
Endocrine
+ chemo
Treatment Algorithm
• Classic Treatment Design:
– Surgery  +/- Chemo  +/- XRT  +/- Endocrine
• Neoadjuvant therapy:
– Chemo  Surgery  +/- XRT  +/- Endocrine
• Inflammatory Breast Cancer:
– Chemo  +/- Surgery, XRT, Endocrine
Neoadjuvant Chemotherapy
Surgical:
• Treat locally advanced cancers
• Convert mastectomy candidates into breast
conservation candidates
• Improve cosmesis in patients undergoing breast
conservation
Medical:
• Use primary tumor and nodal response to tailor
locoregional and systemic therapy
• Identify better predictors of complete response
Pre- Neoadjuvant
Post- Neoadjuvant
pCR
Pre- Neoadjuvant
Post- Neoadjuvant
Loco-Regional Endpoints
• In Breast pCR:
– 25-30% w/ anthracyclines/taxanes
– 40-50% w/ chemo + trastuzamab in HER-2+
– 50-60% w/ chemo + two anti-HER-2 agents
• Axillary pCR:
– 30% w/ anthracyclines
– Up to 40% w/ anthracyclines/taxanes
– > 50% w/ chemo + anti-HER-2 therapies
True or False: 97% of the lymphatic
drainage of the breast drains to the internal
mammary lymph node basin.
True or False: Axillary Node Levels are
based on the pectoralis major muscle
When performing a modified radical
mastectomy, what levels of axillary nodes
are removed?
1.Level I
2.Level II
3.Level III
4.All of the above
5.Only A & B
Which is the only screening modality that
has shown to decrease mortality from
breast cancer in woman over the age of 50?
1.Breast Ultrasound
2.Breast Mammography
3.Breast MRI
4.Breast Thermography
A 24 you woman undergoes a breast
ultrasound for a self-palpated left breast
mass. You order a breast ultrasound which
is demonstrated below. What Bi-Rad
classification is this lesion?
1. Bi-Rads 0
2. Bi-Rads 1
3. Bi-Rads 2
4. Bi-Rads 4
A 63 you woman undergoes a breast
ultrasound for a self-palpated left breast
mass. Her diagnostic breast ultrasound is
demonstrated below. What Bi-Rad
classification is this lesion?
1. Bi-Rads 0
2. Bi-Rads 1
3. Bi-Rads 2
4. Bi-Rads 5
Which Bi-Rads classification recommends 6
month short term follow up imaging?
1. Bi-Rads 0
2. Bi-Rads 2
3. Bi-Rads 3
4. Bi-Rads 4
True or False: Breast cancer affects 1 in 8
women in the United States.
Indications for genetic testing in a patient diagnosed
with breast cancer are?
1. A woman diagnosed prior to the age of 45
2. A woman diagnosed at any age, who has two
family members with breast, ovarian or
pancreatic cancer
3. Any man diagnosed with breast cancer
4. All of the above
True or False: Survival is improved in patients
undergoing mastectomy for a Stage II and Stage III
breast cancer as compared to breast conservation
surgery.
55 yo postmenopausal woman presents to you for a
high risk evaluation. You perform quantitative risk
assessment on her using the GAIL risk assessment
model. Her 5 year risk is 4.2% as compared to 1.8% of
the general population, and her lifetime risk is 42% as
compared to 16% of the general population. Your talk
to her about chemoprevention. Which medications
would you use for chemoprevention?
1. Raloxifene
2. Tamoxifen
3. Exemestane
4. All of the above
5. 1 & 3
True or False: A 48 yo woman presents to your
office for evaluation of newly diagnosed Triple
negative inflammatory breast cancer. You explain
that your treatment algorithm includes modified
radical mastectomy followed by adjuvant
chemotherapy and radiation therapy.
A 72 yo old undergoes her screening mammogram. She
is called back for compression views of her left breast
which is demonstrated below. What is the next step in
management?
1. Ultrasound guided percutaneous biopsy
2. Stereotactic percutaneous biopsy
3. Wire localized excisional biopsy
4. Short term follow up diagnostic breast imaging in
6 mo
Your patient undergoes a stereotactic biopsy. Her
pathology demonstrates grade 2 DCIS ER 0%, PR 24%.
The area of calcifications spans 2 cm. What is not a
treatment option for your patient?
1. Surgery
2. Tamoxifen
3. Radiation Therapy
4. Chemotherapy
True or False: Radiation therapy decreases risk of local
recurrence by at least 50%.
True or False: Approximately 20% of all breast cancers
are associated with genetic mutation.
True or False: Male breast cancer is higher in BRCA 1
gene mutation carriers.
A 62 yo woman is diagnosed with a new screen-detected
left breast cancer. On clinical exam her tumor measures
3 cm in size. What is her T stage?
1.
2.
3.
4.
5.
Tis
T1
T2
T3
T4
A 65 yo woman presents with a 6 week history of
eczematoid changes to her right nipple. She has tried
every over the counter moisturizer and lose dose
steroid cream without relief. She states that her recent
mammogram was just prior to the onset of symptoms
which was negative. You punch biopsy the skin and it
is diagnostic for paget cells within the dermis. What is
the next step in management?
1. Central lumpectomy with sentinel lymph node
biopsy
2. Simple mastectomy with sentinel lymph node
biopsy
3. Breast MRI
4. Modified Radical Mastecotmy
Paget’s Disease
• 1-3% of all breast cancers
• Eczematoid changes of the nipple: itching,
erythema, nipple discharge
• Dx: Biopsy demonstrates Paget cells in the
dermis (in-situ disease)
• Typically underlying malignancy therefore get
diagnostic imaging, if negative include MRI
• Tx: Classically mastectomy, but depending inbreast disease central lumpectomy + XRT
A 57 yo woman presents to your office with complaints
of a 1 month history of breast erythema, induration,
and edema. She was prescribed antibiotic therapy by
her PCP which did not help with her symptoms. Due to
persistence in symptoms, her PCP referred her to you
for evaluation. What is pathognomonic for her disease
process?
1.
2.
3.
4.
Dermal lymphatic invasion
Pagetoid cells within the dermis
Lymphovascular invasion
All of the above
What is the mainstay of treatment for the above patient?
1.
2.
3.
4.
Modified Radical mastectomy
Chemotherapy
Radiation therapy
Central lumpectomy
A 62 you woman is recently diagnosed with a screen-detected
right breast invasive ductal carcinoma. She undergoes wire
localized segmental mastectomy with sentinel lymph node
biopsy. Her final pathology demonstrates a 2 cm invasive ductal
carcinoma, ER/PR positive, Her 2 neu negative with clear margins
and negative lymph nodes. What adjuvant therapy does she
need?
1. Chemotherapy because her tumor is > 1 cm in size plus
radiation therapy and an aromatase inhibitor
2. No chemotherapy because her lymph nodes were
negative, therefore only radiation therapy and an
aromatase inhibitor
3. Send an Oncotype score to determine need for
chemotherapy, then proceed with radiation therapy
followed by an aromatase inhibitor
4. Only Tamoxifen
What if the above patient’s Oncotype returned as
12?
1. No chemotherapy, but radiation therapy
followed by an aromatase inhibitor
2. Chemotherapy followed by radiation
therapy and an aromastase inhibitor
3. Radiation therapy alone
4. None of the above
True or False: All woman undergoing breast
conservation therapy who have a positive
sentinel lymph node require completion axillary
dissection.
Benign Breast Disease
Fibrocystic Changes
• Generic term used to describe symptoms related
to the aberration of normal development and
involution of the breast
• Encompasses:
–
–
–
–
–
Cyclical Change
Cyst formation
Fibroadenoma formation
Duct ectasia
Sclerosing Adenosis
• Benign Nodular breast tissue
Cysts
• Fluid filled round structures
derived from the terminal duct
lobular unit
• Common in Perimenopausal
women
• Fluctuate in relation to the
menstrual cycle and hormonal
milieu
Cysts
• Exam:
– Firm or Rubbery, well defined
• Imaging:
– US (Anechoic)
– Mammography
• Treatment:
– Asymptomatic:Observation
– Symptomatic: Aspiration
– Recurrent or Bloody: Excision
A 21 yo old woman presents for evaluation of a selfpalpated right breast lump. You order an ultrasound which
is demonstrated below. What is the next step in
management?
1. Reassure her that it is benign and tell her to follow as
needed
2. Reassure her that it is benign and have her follow up
in 6 months with repeat ultrasound
3. Explain that it is likely benign however recommend
surgical excisional biopsy
4. Explain that you are concerned that it is malignant
and move forward with an ultrasound guided biopsy
Fibroadenomas
• Fibroepithelial Lesion
• Solid round structures arise
from the epithelium of the
terminal duct lobular unit
• Most common breast mass in
adolescent women
• Occur from teens through 70s
Fibroadenoma
• Exam:
– Painless well circumscribed mass
– 10-20% are multiple or bilateral
• Imaging:
– US (Isoechoic, wider than tall,
gently lobulated/elliptical)
– Mammography
• Treatment:
– Observation
– Surgical
• Giant Juvenile
• Enlarging
• Symptomatic: Painful
Fibroadenoma
A 34 yo uninsured woman presents to your office with a
neglected left breast mass. She cannot fit in the
mammography unit, therefore you order a breast
ultrasound, for which a representative image is
demonstrated below. You order an ultrasound guided
biopsy. Her pathology is also provided. What is her most
likely diagnosis?
1.
2.
3.
4.
Locally advanced Invasive ductal carcinoma
Inflammatory breast cancer
Locally advanced invasive lobular carcinoma
Borderline malignant phyllodes tumor
Phyllodes Tumor
• Fibroepithelial Lesion
• <1% of all breast tumors
• Occurs in wide range of ages: 10-80
• Wide range of biological behavior
– Benign
• – <2, no atypia, no stromal overgrowth, well-circumscribed
– Borderline
• – 2-10, mild atypia, no stromal overgrowth, infiltrative margins
– Malignant
• – >10, marked atypia, presence of stromal overgrowth, infiltrative
margins
Phyllodes Tumor
• Exam:
– Painless firm discrete palpable
mass
– Average size is 4 – 5 cm (1-20 cm
reported)
• Imaging:
– US (Isoechoic, circumscribed,
lobulated, Horizontal striations)
– Mammography (Sharply defined
high density mass)
• Treatment:
– Excision with 1 cm margin
Phyllodes Tumor
Phyllodes Tumor
Leaf-like Architecture
A 50 yo woman undergoes screening
mammogram and is called back for spot
compression views which is demonstrated
below. She is then referred for stereotactic
biopsy which demonstrates a radial scar.
What is your next step in management?
1. Wire localization excisional biopsy
2. Wire localized segmental mastectomy
3. Short term 6 month mammographic
follow up
4. Continued annual surveillance
Sclerosing Lesions
Sclerosing Adenosis
• Benign proliferative disorder
• Not a precursor to breast cancer
• Safely observed unless presence of atypia
Sclerosing Lesions
Radial Scar
• Rosettes or proliferation centers that might give rise to carcinoma
• Often spiculated lesion on mammography
• Found in both benign and malignant breast tissue therefore
thought to be associated with increase risk of subsequent cancer
• Increased cancer with larger lesions and in women with age >50
• Treatment: Excisional biopsy
Mastalgia
• Common complaint
• Typically no histologic difference in women with or without
mastalgia
• Treatment is reassurance – rule out malignancy if age
appropriate
• Evening primrose oil, and vitamin E have been studied in
randomized controlled trials
The most common cause of bloody nipple
discharge is?
1. Duct ectasia
2. Intraductal papilloma
3. DCIS
4. Invasive ductal carcinoma
A 45 yo woman presents for evaluation of bloody
nipple discharge. She states that it is unilateral, single
duct, and spontaneous. She underwent diagnostic
mammogram last week which was normal. What is
your next step in management?
1. Repeat mammogram
2. Breast MRI
3. Retroareolar ultrasound
4. Ductogram
5. 3&4
Your previous patient undergoes an
ultrasound and ductogram which is
demonstrated below. What is your
diagnosis?
1.
2.
3.
4.
Ductal carcinoma in situ
Invasive ductal carcinoma
Duct ectasia
Intraductal papilloma
Nipple Discharge
• Accounts for 3-8% of all breast clinic referrals
• Typically associated with a benign cause
– 2/3rd of non-lactating women have a small amount of fluid on manual
expression
• Risk of cancer increases with age:
– < 40 – 3%
– 40-60 – 1%
– > 60 – 32%
• Divided into Surgical and Non surgical nipple discharge
– Surgical: Papillomas, DCIS, Cancer
– Nonsurgical: Physiologic, endocrine, pharmacologic, idiopathic
Nipple Discharge
• Exam:
–
–
–
–
Number of ducts
Laterality
Color
Spontaneity
• Imaging:
– Mammo
– Ultrasound (retroareolar)
– Ductogram
• Treatment:
– Duct excision – selected or
terminal duct excision
Ductogram
Duct Ectasia
• Dilation of the subareolar duct in peri and post-menopausal women
• Typically asymptomatic
• May present with cheesy, viscous, toothpaste like discharge or have nipple
retraction
• Observation, unless discharge is persistent or repeated bouts of periductal
mastitis/abscess
Papilloma
•
•
•
•
•
Typically arise from central/subareolar ducts
Most common in women 30 to 50 years of life
50% are single lesions
30% present with bloody nipple discharge
Treatment is surgical excision because of upgrade rates:
– DCIS 10.5%
– ADH 14.5%
Papilloma
Terminal Duct Excision
A 34 yo woman presents for evaluation of a new right
breast mass. She states that it is associated with
fevers, chills, and has been progressively worsening
over the past 24 hours. What is your plan in
treatment?
1. Systemic chemotherapy followed by surgery if
good response
2. Antibiotic therapy and surveillance
3. Ultrasound guided biopsy
4. Incision and drainage with antibiotic therapy
Breast Infection
Lactational
• MCO: Staph Aureus
• First 6 wks or during weaning
• Either from mouth of baby or skin
of nipple
• Related to blockage of lactiferous
ducts  stagnate milk 
bacterial overgrowth
• Diagnosis: Clinical exam and
breast ultrasound
• Tx: Aspiration/Drainage/Abx
Non-lactational (Periductal Infection)
• MCO: Staph Aureus
• Young smokers
• Associated with duct ectasia
• Secretions become stagnate in
dilated ducts  bacterial
overgrowth
• Diagnosis: Clinical exam and breast
ultrasound
• Tx: Aspiration/Drainage/Abx or
Fistulotomy
Which of the below is not an indication for
surgical excision?
1.
2.
3.
4.
Atypical ductal hyperplasia
Radial scar
Flat epithelial atypia
Discordance between pathology and
radiographic imaging
5. Pseudoangiomatous Stromal Hyperplasia
6. All of the above are indications for
excision
Pseudoangiomatous Stromal
Hyperplasia (PASH)
• Myofibroblasts that proliferate in response
to hormonal stimuli
• Affects women from teens to 50s
• Presents as discrete painless mass
• Imaging: focal asymmetry or well
circumscribed mass
• Treatment: Observation (some studies
suggest excision)
• Increase risk of recurrence up to 22%
Fibromatosis
• Desmoid tumor of the breast
• Affects women from teens to 80s
• Typically presents as firm unilateral painless
mass
• Microscopically the tumor is composed of
spindle cells
• Margins are infiltrative and typically invade
around normal structures
• Proper treatment is wide local excision
• The role of adjuvant radiation and chemo is
investigational