breast- introduction, benign diseases and carcinoma breast

BREAST

INTRODUCTION

AN OVRVIEWDr.B.Selvaraj MS;Mch;FICS;

Professor of Surgery

Melaka Manipal Medical college

Melaka 75150 Malaysia

Must To Know Core ClinicalProblems

BREAST

▪ Surgical Anatomy

▪ Surgical Physiology

▪ Symptomatology

▪ Approach to a patient with breast pathology

▪ Investigations

ANATOMY✓ Breast consists of glandular tissue, ducts,

supporting muscular tissue, fat, blood vessels,

nerves, and lymphatic vessels.

✓ Glandular tissue consists of 15 to 25 lobes,

each of which drains into a separate excretory

duct that terminates in the nipple

✓ Each lobe is subdivided into 50 to 75 lobules,

which drain into a duct that empties into the

excretory duct of the lobe

✓ Each duct dilates as it enters the base of the

nipple to form a milk sinus. This serves as a

reservoir for milk during lactation

✓ Cooper ligaments are the fibrous connections

between the inner side of the breast skin and

the pectoral muscles.

ANATOMY

PHYSIOLOGY✓ At birth, branching system of ducts

emptying into a developed nipple

✓ At puberty, glandular tissue begins to

develop beneath the areola.

✓ Major physiologic change related to the

menstrual cycle is engorgement

✓ With pregnancy, neuroendocrine control of

the breasts starts. Suckling produces nerve

impulses that travel to the hypothalamus.

✓ The hypothalamus anterior pituitary to

secrete prolactin, glandular tissue to

produce milk.

✓ The hypothalamus also posterior pituitary

to produce oxytocin, muscle cells

surrounding the glandular tissue to contract

and force the milk into the ductular system.

Breast- Symptoms

▪ Lump or lumpiness

▪ Mastalgia or Mastodynia- Cyclic or Noncyclic

▪ Nipple Discharge

Breast- Symptoms

▪ Lump or lumpiness

▪ Benign or Malignant

▪ Triple assessment

Breast- Symptoms

▪ Mastalgia or Mastodynia

▪ Cyclical usually associated with menstrual cycle and pain more during 3 to 5 days before menstruation Ex: fibrocystic disease

▪ Breast is subjected to the influence of Estrogen and progesterone hormones every month

▪ Noncyclical mastalgia due to inflammatory lesions like mastitis and breast abscess or chestwall problem like costochondritis

Breast- Symptoms ▪ Nipple Discharge

▪ Colour

-Blood Ductal papilloma &Ductal carcinoma

-PurulentBreast abscess

-Greenish Fibroadenosis & Ductectasia

-Milky Galactocele, Prolactenemia

▪ Spontaneous

▪ Segmental expression

Breast-Investigations

• Staging Investigations

• Xray Chest

• Abdominal Ultrasound/ CT abdomen

• Radionucleide Bone Scan

• CT Brain

• PET Scan

• Radiological Investigations

• Ultrasonography

• Mammography

• Pathological Investigations

• Fine Needle Aspiration Cytology FNAC

• Core Needle Biopsy Trucut Biopsy

• Needle Localisation Biopsy

• Stereotactic Biopsy

• Open Biopsy Incisional& Excisional

• Sentinel node Biopsy

BREAST

Benign Breast Diseases

AN OVRVIEWDr.B.Selvaraj MS;Mch;FICS;

Professor of Surgery

Melaka Manipal Medical college


SYMPTOMS

Causes for Symptoms

Classification of BBD

BBD-Benign Breast Diseases ✓Amastia & Athelia

✓Mastalgia- Fibrocystic disease

✓Fibroadenoma & Breast Cysts

✓Fat Necrosis

✓Duct Ectasia

✓Phyllodes tumor

✓Galactocele

✓Mastitis & Breast Abscess

✓Mondor’s disease

✓ Breast is host to a spectrum

of benign and malignant

diseases.

✓ Benign breast conditions are

universal phenomena among

women.

✓ It accounts for 80% of clinical

presentation related to the

breast.

BBD- Amastia & Athelia✓Breast tissue with or without a nipple or

just nipple and areola alone can occur any where along the milk line

✓The milk line extends from the axilla to groin

✓ Total lack of breast tissue( amastia) or of nipple (athlelia) is unusual

✓supernumerary nipples -polythelia & breast- polymasita are quite common

✓Unilateral amastia is often associated with absence of the pectoral musclesPoland’s syndrome

POLAND’S SYNDROME

BBD-Fibrocystic Disease ✓Breast is a dynamic organ undergoing periods of development and

involution throughout a woman’s reproductive life.

✓Affects premenopausal women and is characterized by cyst formation, hyperplasia of duct epithelium (epitheliosis), enlargement of lobules (adenosis) and fibrosis, which may vary in extent and degree in any one breast.

✓This condition is the result of abnormal response to hormonal changes and can be associated with menstrual irregularities.

✓Ill–defined area of induration or firm swelling, often painful prior to menstruation. (cyclical mastalgia)

BBD-Fibrocystic Disease ✓1. Cyst formation

✓2. Epitheliosis—Hyperplasia of duct epithelium

✓3.Adenosis—Proliferation of lobular epithelium

✓4. Fibrosis—It represents involutional change

Fibrocystic Disease- Treatment

✓Reassurance, simple analgesia and a supportive bra often help.

✓Gamma-lineolic acid(evening primerose oil) 3 to 4 Gm/day for 3to4 months

✓Occasionally Danazol- anti gonadotrophin, Tamoxifen- anti estrogen or Bromocriptine- prolactin inhibitor are required

✓Danazol 200- 300 mgm/day reduced to 100mgm/day from day 14 to 28 days of menstruation

✓Mammography and ultrasonography typically show normal breast tissue.

✓Despite negative imaging studies, a biopsy should be performed to r/o malignancy

Fibroadenoma✓Fibroadenoma is a benign tumor of breast consisting of glandular and

connective tissue elements.

✓Commonest benign breast tumor. The typical patient is 15 to 35 yrs

✓Well-circumscribed, solid masses represent hyperplastic lobules.

✓Smooth, encapsulated mass that is freely mobile- “breast mouse”-rubbery in consistency and non-tender.

✓USG shows a mass with smooth margins; Trucut biopsy confirms the diagnosis

✓Fibroadenomas >2cms size or those with inconclusive biopsy should be excised

Fibroadenoma

Fibroadenoma

USG Breast:

Hypoechoic lesion

Smooth partially

lobulated margin

Mammogram:

Popcorn

Calcification in

Involuting

Fibroadenoma

BREAST CYSTS

✓Commonly occurs between age 30 to 50

✓Is due to non-integrated involution of stroma & epithelium

✓Appearance: blue-domed cyst (single/ multiple; unilateral/ bilateral)

✓Treatment:

✓Fluid aspiration (greenish-yellow; can be sent fluid cytology)

✓Hemorrhagic fluid and recurrent cysts can be excised for histological exam to r/o Carcinoma

PHYLLODES TUMOR ✓Other names: cystosarcoma phyllodes,

serocystic disease of Brodie

✓Usually occurs in age > 40

✓Presentation: Very large, firm, mobile, non-tender lump with uneven lobulated surface.

✓Wide variation in appearance (from benign to potentially malignant)

✓Treatment: enucleation/ wide excision/ mastectomy

✓Rarely becomes sarcoma

LEAF LIKE

DUCT ECTASIA ✓Is a peri-ductal inflammation with duct

dilation

✓Presentations: MARD (mass, abscess, retraction, discharge)

✓Subareolar mass

✓Slit-like nipple retraction

✓Brown/ green/ blood-stained nipple discharge

✓Abscess & fistula just below & around areola

✓Treatment: Hadfield’s operation, wide excision of all affected ducts, shave off below nipple

DUCTAL PAPILLOMA ✓This benign lesions of the lactiferous duct wall

occur centrally beneath the areola In 75% of cases.

✓They most commonly produce a bloody nipple discharge, some times associated with pain

✓They are solitary proliferation of ductal epithelium

✓Intraductal papillomas should be treated by excision of a duct as a wedge resection.

✓Treatment: simple excision (microdochectomy)

FAT NECROSIS ✓Occurs following blunt injury to breast (may be

acute/ chronic), usually in obese, middle-aged females

✓Painless, firm, fixed mass with ill-defined margins

✓May even have skin tethering & nipple retraction

✓This condition is also difficult to clinically distinguish from Ca (hence, FNAC/ core biopsy is needed)

✓Treatment: Surgical excision, the excised mass is an infiltrative yellowish white mass

GALACTOCELE ✓Is a solitary sub-areolar cyst filled with

milk during lactation.

✓ Formed by obstruction to a duct in the puerperium . The milk retained proximal to the obstruction eventually becomes cheese-like

✓Appears as a painless lump weeks –months after cessation of breast feeding

✓Complication Infection

✓Treatment Aspiration or Surgical Excision

CHRONIC MASTITIS

✓Chronic intramammary abscess: Pus encapsulated by thick-walled fibrous tissues. Difficult to clinically distinguish from Ca.

✓TB breast: Presents with multiple chronic abscesses & sinuses. A/w active pulmonary TB/ cervical adenitis. Bacteriological & pathological confirmation are required. Treatment: anti-TB drugs

✓Chronic granulomatous mastitis, Actinomycosisbreast

ACUTE MASTITISBREAST ABSCESS

✓Is usually due to Staph Aureus & a/w lactation

✓Breast mastitis is an infection that commonly affects women who are breast-feeding (especially during the first two months after childbirth) but can occur in all women at any time

✓ Sore & cracked/ inverted nipple is the route of infection, the usual mode of infection is via the nipple, the infection being carried by suckling infant’s nasopharynx.

✓ Part or all of the breast is intensely: painful, hot, tender, red, and swollen

✓The breasts are growing more tender, and the fever is becoming more pronounced.


✓Ultrasound: used to localize the abscess

✓FNAC: used to exclude underlying carcinoma especially in chronic Breast abscess where the abscess become encapsulated with a thick fibrous capsule & the condition can’t be distinguished from a carcinoma without a biopsy.

✓Needle Aspiration: to confirm presence of pus.

✓Mammogram: to exclude underlying carcinoma.


✓ MANAGEMENT:

✓ Simple Needle Aspiration: using a wide bore needle under local anesthesia.

✓Guided drainage: under image control with radiological or ultrasound techniques a tube drain can be inserted & left until the cavity has collapsed.

✓Surgical drainage: it is the most certain method, not only can all loculi be reached, but also dead tissue can be removed. The cavity is then dressed regularly & left open to heal by secondary intention.

MONDOR’S DISEASE

✓Superficial thrombophelebitis of vein over breast & chest– thoracoepigastricartery

✓Thrombosed subcutaneous cord attached to skin

✓Self limiting condition

✓Treatment is restricted arm movement

BENIGN BREAST DISEASES

✓Benign breast disorders & diseases are common

✓The aetiopathogenesis is complex and not fully understood

✓Lump and pain are the most common complaints

✓Evaluation is done by Triple assessment

✓Histological risk factors for future malignancy are relative and not absolute risk factors

✓Treatment is based on the natural history of clinical problems

✓Treatment must be tailored to individual needs

BENIGN BREAST DISEASES

EMQ

CARCINOMA BREAST

AN OVERVIEW

AN OVRVIEWDr.B.Selvaraj MS;Mch;FICS;Professor of Surgery

Melaka Manipal Medical College


OBJECTIVES

• Etiopathogenesis

• Types & Clinical features

• Investigations

• Staging

• Treatment of EBC, LABC&ABC

• Prognosis and Followup

EtiopathogenesisIncidence of Sporadic, Familial, and Hereditary Breast

Cancer

Sporadic breast cancer 65–75%

Familial breast cancer 20–30%

Hereditary breast cancer 5–10%

BRCA1 a 45%

BRCA2 35%

p53 a (Li-Fraumeni syndrome) 1%

STK11/LKB1a (Peutz-Jeghers syndrome) <1%

PTENa (Cowden disease) <1%

MSH2/MLH1a (Muir-Torre syndrome) <1%

ATMa (Ataxia-telangiectasia) <1%

Unknown 20%

Risk FactorsMajor factors

Gender

Age

Previous breast cancer

Family history and genetic predisposition (BRCA 1 or 2 mutations)

Intermediate factorsAlcohol and diet

Endocrine factors:

Early menarche

Late menopause

Hormone replacement therapy

Nulliparity and elderly primi

Irradiation

Benign proliferative breast disease (e.g. multiple papillomatosis)Smoking & OCPs not a risk factor

TYPESClassification of Primary Breast Cancer

Noninvasive Epithelial Cancers Lobular carcinoma in situ (LCIS)

Ductal carcinoma in situ (DCIS)

Invasive Epithelial Cancers (Percentage of Total) Invasive lobular carcinoma (10%-15%)

Invasive ductal carcinoma

Invasive ductal carcinoma, NOS (50%-70)

Tubular carcinoma (2%-3%)

Mucinous or colloid carcinoma (2%-3%)

Medullary carcinoma (5%)

Invasive cribriform carcinoma (1%-3%)

Invasive papillary carcinoma (1%-2%)

Adenoid cystic carcinoma (1%)

Metaplastic carcinoma (1%)

Clinical Presentation

• Paget’s Disease of the Nipple

• Skin Tethering/dimpling/puckering

• Peau d’Orange

• Skin Ulceration / Fungation

• Visible / Palpable Lump

• Hard Consistency

• Non Tender

• Low mobility

• Axillary Lymphnodes+

• Nipple Retraction

• Nipple Discharge


The location of breast cancer is as

follows:

Upper outer quadrant: 60%

Central area: 12%

Lower outer quadrant: 10%

Upper inner quadrant: 12%

Lower inner quadrant: 6%


Peau d’ orange Appearance


Skin dimpling and puckering are

inspectory findings

Tethering is due to infiltration of Astley

cooper’s ligaments and is confirmed by

palpation


Nipple retraction- Recent,

Unilateral, circumferential

infiltration and fibrosis of

lactiferous ducts


Nipple discharge

suggestive of

malignancy if:

1. Spontaneous

2. Unilateral

3. From single duct

4. Bloody discharge

5. Associated with mass

6. Age > 40 yrs

Skin Ulceration

Paget’s disease of nipple✓Eczema like condition

✓Malignant cells in the subdermal layer

✓Red flat ulcer, nipple erosion

Paget’s disease of nipplePaget’s Disease Eczema of Nipple

Unilateral Bilateral

Itching absent Itching present

Absence of oozing Presence of oozing

Scales & Vesicles absent Scales & Vesicles present

Nipple destroyed Nipple intact

Underlying lump may be present No underlying lump present

Edges are distinct Edges are indistinct

No response to treatment Responds to treatment

Occurs at menopaus( old age) Seen in lactating women( young women)

Investigations

“The choice of initial diagnostic evaluation after the detection of a breast lump should be individualised for each patient according to the age, perceived cancer risk and characteristics of the lesion.”

Investigations- Triple Assessment

Investigations

• Staging Investigations

• Xray Chest

• Abdominal Ultrasound/ CT abdomen

• Radionucleide Bone Scan

• CT Brain

• Radiological Investigations

• Ultrasonography

• Mammography

• Pathological Investigations• Fine Needle Aspiration Cytology

FNAC• Core Needle Biopsy Trucut Biopsy

• Needle Localisation Biopsy

• Stereotactic Biopsy• Open Biopsy Incisional& Excisional

• Sentinel node Biopsy

Investigations- Mammography

• Dense opacity

• Irregular and Ill-defined margins

• Asymmetry

• Clustered pleomorphicmicrocalcification

• Architectural distortion

• Stellate or spiculatedappearance

Investigations- Mammography

Investigations- Ultrasonography

• High frequency 7MHz probe is used although 10 to 13MHz preferable

• Differentiate solid and cystic lesions

• Malignant appearing masses

1.Irregular margins

2.Hypoechoic

3.Posterior acoustic shadow

4.Vertical growth appearance (TALLER than wide)

MASS

SHADOW

Investigations- FNAC

• 1.5 inch 22 gauge needle attached to a 10 ml syringe is used

• With or without image guidance

• FNAC-DISADVANTAGES

1. FALSE NEGATIVE rate high

2. Inadequate specimen

3.Requires skilled cytopathologist

4. Cannot differentiate in situ vsinvasive lesions

Investigations- Trucut Biopsy

Core Needle Biopsy• Done using a 14 gauge needle or Tru cut needle

• ADVANTAGES

1. Lower FALSE negative rates

2. Doesn't need specially trained cytopathologist

3. Adequate samples are obtained

4.Can differentiate in situ vs invasive lesions

5.Can confirm-ER/PR/Her 2 neu status

Investigations-For Nonpalpable

Lump

Image Guided Biopsies

1.USG guided FNAC or core needle biopsy(if mass is visualised)

2. Needle localising biopsy

3. STEREOTACTIC needle biopsy

(when no mass present but micro calcifications seen mammographically)

Investigations-Sentinel Node Biopsy

• LYMPHAZURIN BLUE DYE

• Tch99 SULPHUR COLLOID

• Accuracy 99%

PORTABLEGAMMA CAMERA

Investigations-Sentinel Node Biopsy

INDICATIONS

• High-risk IN SITU cancer, non-palpable breast cancer

• T1 or T2 carcinoma and especially good prognosis tumors (mucinous, papillary and adenoid cystic)

CONTRAINDICATIONS

• Altered drainage of breast.eg-

Augmentation surgery

• Recent mammoplasty and

pregnancy

• Allergy to dye or radiocolloid

• Inflammatory Ca

• Axillary metsAbsolute

Other Investigations

1.CXR-PA VIEW

2.CT CHEST

3.USG – ABDOMEN AND PELVIS

4.SKELETAL SURVEY/ Tc99 BONE SCAN

5.MRI BREAST- Voluminous breast/ Implant rupture

6.PET SCAN- Follow up to detect residual disease

7.Tumor Marker- CA- 15/3

AJCC Staging/TNM Staging

T (Primary Tumor)

Tis Carcinoma in situ (lobular or ductal)

T1 Tumor <2 cm

T2 Tumor >2 cm, <5 cm

T3 Tumor >5 cm

T4 Tumor any size with extension to the chest

wall or skin

N (Nodes)

N0 No regional node involvement

N1 Metastasis to 1-3 axillary nodes

N2 Metastasis to 4-9 axillary nodes

N3 Metastasis to >10 axillary nodes

M (Metastasis)

M0 No distant

metastasis

M1 Distant

metastasis

TNM Staging

▪ Stage 1 and stage 2 – EBC

▪ Stage 3 – LABC

▪ 3a- T3, N 1,2,

▪ 3b- T4, ANY N

▪ 3c- N3, ANY T

▪ Stage 4- ABC

Management –Multimodality

Treatment

▪Surgery

▪Curative

▪Palliative

▪Radiotherapy

▪Chest Wall

▪Axilla

▪Supraclavicular

▪Chemotherapy

▪Hormonal Therapy

Management

•Stage 1 & 2

• Breast conservation

treatment- BCT

✓ Lumpectomy

✓ Wide local excision

✓ Quadrantectomy

✓ Axillary dissection

✓ Radiotherapy

• Modified radical

mastectomy- MRM

EBC•Stage 3

• MRM+Adjuvant RT+

Adjuvant CT +/- HT

• Neoadjuvant CT+MRM+

Adjuvant RT &CT+/- HT

LABC

•Stage 4

•Toilet Mastectomy

• Adjuvant RT & CT +/-

HT

ABC

Management –ECB

RT after BCT

Management –LABC

Classification of LABC

•LABC Operable at Presentation

•T3, N1, M0

•LABC Inoperable at Presentation

•T4, Any N, M0

•Any T, N2 or N3, M0

•Inflammatory Carcinoma of Breast

•T4d, N0, M0

Management –LABC

Treatment of Operable LABC

1. MRM → Adjuvant Radiotherapy (RT) &

Adjuvant Systemic Chemotherapy (CT) +/-

Hormone Therapy (HT)

2. Neoadjuvant CT→ To attempt to Down-Stage

lesions for Breast Conservation Surgery

Tumor Responding → BCS → CT,RT +/- HT

Non-responders → MRM → CT with RT +/- HT

Management –LACB

Treatment of Inoperable LABC

Aim of Treatment: To make the disease operable and

achieve loco – regional control, hence improve patients

quality of life

Neoadjuvant CT → MRM → CT & RT +/- HT

Advantages of Neoadjuvant CT

To make the tumor operable

To assess tumor response to CT

PROGNOSTIC FACTORS

1.Axillary nodal status( most important)

2.Tumour size

3.ER/PR Status – Both positive- good prognosis

4.Histological grade of tumour

5.Her 2neu overexpression – aggressive malignancy-

poor prognosis

6.Proliferating rate

1.DNA flow cytometry – aneuploid – poor prognosis

2.S phase fraction – low S phase – good prognosis

PROGNOSTIC FACTORS

5 yr survival – Ca Breast

Stage 1 – 90%

Stage 2 – 70%

Stage 3 – 40 %

Stage 4 – 20 %

NOTTINGHAM PROGNOSTIC INDEX- NPI

The index is calculated using the

formula:

NPI = [0.2 x S] + N + G

Where:

S is the size of the index lesion in

centimetres

N is the node status: 0 nodes = 1, 1-4

nodes = 2, >4 nodes = 3

G is the grade of tumour: Grade I =1,

Grade II =2, Grade III =3

NPI Score Prognosis 5yr survival

2 to 2.4 Excellent 93%

2.4 to 3.4 Good 85%

3.4 to 5.4 Moderate 70%

> 5.4 Poor 50%

Adjuvant Chemotherapy

To deal with occult metastasis

Always use combination

chemotherapy

More effective in pre-menopausal

CT + HT > CT / HT alone

Drugs used:

Cyclophosphamide

Methotrexate

5 – FU

Anthracyclines: Doxorubicin,

Epirubicin

Taxanes: Paclitaxel, Docitaxel

Schedule used commonly:

CAF q21d x 6cycles

Cyclophosphamide:

500mg/m2 D1

5 – FU: 500mg/m2 D1 &

D8

Doxorubicin: 50mg/m2 D1

Regimen of choice: TAC

Good efficacy irrespective

of ER/PR/HER-2 neu

status

Neo Adjuvant Chemotherapy

CT given before Local Control of disease

It does not provide any survival advantage

Helps decide response of tumor to CT

Indications:

1.To downstage Operable LABC for BCT

2.To downstage Inoperable LABC for operability

3.Inflammatory Breast Cancer

4.In EBC, to improve cosmetic appeal after BCS, for large

tumor in small breast

Neo Adjuvant Chemotherapy

▪Usually 2 – 4 cycles are given till maximum shrinkage is

achieved

▪Choice of drugs are the same as for Adjuvant CT – CAF /

TAC

▪If tumor is resistant then non cross resistant drugs can be

used as second line CT

Hormone Therapy

▪ER+/PR+ → 80% chance of

favorably response to HT

▪All (pre/post menopausal)

patients with ER/PR+ LABC

should undergo HT for 5yrs.

▪Can be given in combination

with CT

▪Most commonly used agent →

Tamoxifen

Dose: 20mg/day, Oral for 5 Yrs

Side effects: Hot flushes,

sexual dysfunction, endometrial

cancer, thromboembolism

Raloxifene- drug of choice

Hormone TherapyClass Agents

Selective estrogen receptor

modulators (SERMS)Tamoxifen, Raloxifene,

Toremifene

Aromatase inhibitors Anastrozole, Letrozole,

Exemestane

Pure antiestrogens Fulvestrant

LHRH agonists Goserelin, Leuprolide

Progestational agents Megestrol

Androgens Fluoxymesterone

High-dose estrogens Diethylstilbestrol

Hormone Therapy

Trastuzumab or Herceptin

▪Monoclonal antibody that targets the HER-2 neu oncogene

▪Her 2 neu codes for a growth factor that is overexpressed in

25% to 30% of breast cancers

▪Her 2 neu over-expression indicates aggressive nature of

malignancy.

▪Trastuzumab may be used for Her 2 neu positive tumours in

adjuvant or neo adjuvant setting

Radiotherapy

Indications for PMRT(Post Mastectomy Radio

Therapy) :

1. >4 Positive axillary nodes

2. Tumour size > 5 cm

3. Positive surgical margins

4. As a part of LABC PROTOCOL

Followup▪ Monthly self examination of the breast

▪ Regular physical examination following mastectomy is necessary

▪ Every 4 months for years 1 and 2,

▪ Every 6 months for years 3 through 5,

▪ Every 12 months thereafter

▪ Contralateral mammogram yearly

▪ Routine bone scans, skeletal surveys, CT of abdomen and brain-

Not necessary, Yield is low

Treatment AlgorithmEarly Breast Carcinoma

Treatment AlgorithmAdvanced Breast Carcinoma

breast- introduction, benign diseases and carcinoma breast

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