Gynecology EXIMIUS

Breast Diseases
Kathy B. Izon-Carag, MD, FPOGS
2021
OBJECTIVES
▪ Identify risk factors during history taking
▪ Perform Clinical Breast Examination
▪ Offer instructions on Self Breast Awareness
▪ Evaluate palpable breast masses
▪ Encourage screening mammography
▪ Adequate referral

ANATOMY & EMBRYOLOGY

▪ Utero: bilateral epithelial mammary ridges
▪ Ducts & acini – ectoderm
▪ Supporting tissue - mesoderm
▪ Puberty: ductal tissue and secretory lobules
▪ Large modified sebaceous glands contained within the
superficial fascia of anterior chest wall
▪ 20% glandular tissue
▪ 80% fat and connective tissue
▪ Average weight: 200-300g
▪ Axillary Tail of Spence 12-20 lobes

▪ NAMED AFTER James Spence, a Scottish surgeon 10-100 lobules

▪ Superolateal quadrant is prolonged towards the axilla
along the lower edge of pectoralis major, from which it alveoli (acini)
projects a little terminal ducts
▪ May extend through the deep fascia up to the apex of the
axilla lactiferous ducts
▪ Can be sometimes mistaken for an enlarged lymph node
lactiferous sinuses
(anterior/pectoral)
▪ Montgomery glands nipple
▪ Cooper’s ligaments
▪ Lymphatic System
▪ complex
▪ 75% into regional nodes in axilla -- drain towards the most
adjacent
▪ group of nodes
▪ other metastatic routes:
- internal mammary vessels
- intercostal glands
- subpectoral areas
- subdiaphragmatic areas

TRANSCRIBERS Antonio, Cabaro, Cachero, Suguitan 1

 Gynecology EXIMIUS
Breast Diseases
Kathy B. Izon-Carag, MD, FPOGS
2021
Follicular Phase Luteal Phase
Menses Proliferative Phase Secretory Phase
breast tenderness and
fullness - 25 to 30mL
increase in volume
Fincrease in blood flow
Fvascular engorgement
Fwater retention
- enlargement of
- parenchymal proliferation of ducts
lumina of ducts
- Decreased ductal and acinar cell - Increased ductal and
activity alveolar cell activity
- smaller ducts - alveolar cells è BREAST TISSUE
secretory cells ▪ AMASTIA
@ The breast is made-up of milk-producing glands, lobules, that are ▪ POLYMASTIA
surrounded by a layer of fat. The breast contains no muscle tissue. ▪ ASYMMETRIC DEVELOPMENT benign, normal variation
The breasts are supported and attached to the chest wall by ▪ HYPERTROPHY
ligaments. The breast tissue rests on the muscle of the chest, the ▪ TUBEROUS/TUBULAR BREAST
pectoralis major. Hormones that cause changes in the breast ▪ unilateral or bilateral
during the menstrual cycle are estrogen, progesterone, and
▪ occur in both sexes
prolactin. The hormones also cause breast tissue to develop,
▪ development during puberty is stymied
enlarge, and produce milk.
▪ transverse breast diameter is narrowed
▪ Three major hormones affect the breast ▪ base is constricted (glandular hypoplasia)
▪ Estrogen ▪ Treatment: breast augmentation
▪ Progesterone
▪ Prolactin
▪ undergoes normal maturation changes
▪ gradual increase in fibrous tissue around the lobules
▪ menopause: glandular tissue è fatty tissue
▪ Lobular tissue
- 20s and 30s: gradual increase in nodularity
- after pregnancy and lactation: decrease in size from
prepregnancy state
▪ POLAND SYNDROME
CONGENITAL DEVELOPMENTAL ▪ unilateral hypoplasia of chest muscles and breast tissue
BREAST ANOMALIES ▪ 1:20,000 to 30,000
NIPPLE
▪ ATHELIA
▪ CONGENITAL NIPPLE INVERSION
▪ 2% of women
▪ Etiology:
- Shortening of breast ducts
- Intrauterine development of fibrous bands
▪ Treatment: surgical

BENIGN BREAST PROBLEM

▪ COMMON BREAST SYMPTOMS
▪ Breast pain
- Comparatively late symptom of cancer
- Coincident with menstrual changes
▪ Nipple discharge - less frequent sign of cancer
▪ Breast mass - dependent on age
▪ ACCESSORY NIPPLE/BREAST ▪ Mastitis
▪ supernumerary nipple (polythelia) or supernumerary
breast (polymastia) FIBROCYSTIC CHANGES
▪ along breast ▪ most common of all benign breast conditions
▪ milk lines that run from axilla to groin ▪ fibrocystic disease, misnomer
▪ common anomalies ▪ spectrum of change throughout woman’s reproductive age
▪ occur in European (1-2%) and Asian (5-6%) descent ▪ most common in ages 20 to 50 y/o
▪ unilateral or bilateral ▪ classic sx: cyclic bilateral breast pain
▪ Treatment: management of irritation ▪ difficult to localize
▪ severe when cyst undergoes rapid expansion

TRANSCRIBERS Antonio, Cabaro, Cachero, Suguitan 2

 Gynecology EXIMIUS
Breast Diseases
Kathy B. Izon-Carag, MD, FPOGS
2021
▪ Pathophysiology MASTALGIA/BREAST PAIN
▪ cyst formation ▪ occur in >2/3 of women
▪ epithelial and fibrous proliferation ▪ most common in perimenopausal years
▪ varying degrees of fluid retention ▪ cyclic - Diffuse & bilateral FIBROCYSTIC CHANGE
▪ Differential diagnosis ▪ non-cyclic – localized CYST
▪ referred pain from dorsal radiculitis ▪ Diagnostic
▪ inflammation of costal chondral junction ▪ Mammography
▪ Physical exam ▪ UTZ
▪ excessive nodularity ▪ Hcg
▪ ill-defined thickness or areas of “palpable lumpiness” ▪ Prolactin
▪ rubbery ▪ Differential diagnosis
▪ balloon filled with water in larger cysts ▪ chest wall pain
▪ Histologic variants ▪ radicular pain
▪ cyst ▪ costochondritis
▪ adenosis ▪ mastitis
▪ fibrosis ▪ pregnancy-related pain
▪ duct ectasia ▪ prolactinoma
▪ apocrine metaplasia with atypia ▪ Treatment
▪ intraductal epithelial hyperplasia with atypia ▪ directed on the cause
▪ papillomatosis ▪ NSAIDS

MEDICATIONS ASSOCIATED WITH MASTALGIA

THREE STAGES OF FIBROCYSTIC CHANGES

MAZOPLASIA ADENOSIS CYSTIC
Age 20 y/o 30 y/o 40 y/o
Description PAIN on UOQ of $Premenstrual simple cysts
breast pain no breast pains
2-10mm nodules *cysts tender to
palpation

Histology Intense Marked Proliferation MASTITIS AND INFLAMMATORY DISEASE

proliferation of proliferation and and hyperplasia ▪ infection of ductal system or
stroma hyperplasia of of lobular
smaller sebaceous glands
ducts ductal and acini
epithelium
▪ most commonly related to
Staphylococcus aureus
▪ Treatment
▪ Management ▪ Empiric
▪ Depends on age and severity of symptoms ▪ MRSA
▪ exclude malignancy - Quinine
▪ initial treatment - sulfamethoxazole (trimethoprim)
- sports bra ▪ Puerpearal: cephalosporin
- avoidance of coffee, tea, chocolate, cola drinks ▪ Non-puerperal: dependent on cause
▪ Medical - Syphilis
- OCP - atypical bacterial and fungal
- Bromocriptine - TB
- cyclic progestins - nipple piercing
- Tamoxifen - IGLM
- Danazol
- GnRH

TRANSCRIBERS Antonio, Cabaro, Cachero, Suguitan 3

 Gynecology EXIMIUS
Breast Diseases
Kathy B. Izon-Carag, MD, FPOGS
2021
NIPPLE DISCHARGE
▪ 7% of physician visits for breast complaints
▪ spontaneous or elicited
▪ from multiple ducts: galactorrhea
▪ unilateral & involves few ducts: pathologic
▪ stimulated or compressed
▪ ¾ of women up to 2yrs after breastfeeding
▪ ½ of premenopausal women
▪ Physiologic: bilateral, from multiple ducts

▪ Range in color
▪ milky
▪ green
▪ brown
▪ clear – Intraductal papilloma FIBROEPITHELIAL TUMORS
▪ bloody – Fibrocystic changes FIBROADENOMA
▪ Diagnosis ▪ Most common benign neoplasm of breast
▪ PE ▪ Adolescents to 20s
▪ mammography ▪ Symptom: painless breast mass noted on SBE or upon bathing
▪ ductography ▪ Mass is slow in growth, painless, freely mobile, firm, solid
▪ 2.5cm in diameter
INTRADUCTAL PAPILLOMA ▪ No change in size during menstrual cycle
▪ Small papillomas of glandular tissue of milk duct ▪ 30% will disappear
▪ Most common in perimenopausal age ▪ 10-12% will regress
▪ 75% located beneath areola ▪ 2x risk for invasive breast cancer
▪ Classic symptom: unilateral spontaneous bloody discharge ▪ Physical exam
from one or a few ducts ▪ single or multiple
▪ Discharge ▪ firm, freely mobile
▪ spontaneous ▪ nontender breast mass
▪ intermittent ▪ Diagnostic
▪ watery, serous, serosanguinous ▪ Breast UTZ – to differentiate solid from cystic mass
▪ few drops to several mL of fluid ▪ Core needle biopsy – cause is not established
▪ Physical exam ▪ Excision biopsy
▪ difficult to palpate - complex cysts, any cyst with solid areas
▪ 1-3mm in diameter - rapidly increasing breast mass
▪ circumferentially put radial pressure on different areas of ▪ Three parameters
areola ▪ Clinical Exam
▪ Differential diagnosis - Single Duct Carcinoma ▪ Imaging
▪ Diagnostic ▪ Core Needle Biopsy
▪ Mammogram ▪ Treatment
▪ Ductography ▪ Excision under local anesthesia
▪ Treatment - excision biopsy of duct and small amt of surrounding ▪ Conservative
tissue - small fibroadenomas in <35y/o
- ff-up every 6 months x 2yrs
▪ Alternative treatment - UTZ guided high intensity focused
ultrasound or cryoablataion
▪ Post-op
- annual mammography
- 20% risk of recurrence

TRANSCRIBERS Antonio, Cabaro, Cachero, Suguitan 4

 Gynecology EXIMIUS
Breast Diseases
Kathy B. Izon-Carag, MD, FPOGS
2021
BREAST CARCINOMA
▪ Most common malignancy of women
▪ One of 2 leading causes of all cancer deaths
▪ Generally, presents in two ways:
▪ Notable mass
▪ Mass on screening evaluation
- Self-breast examination
- Clinical breast Examination
- Imaging
PHYLLODES TUMOR/CRYSTOSARCOMA PHYLLODES
▪ Rare, 2.5% of fibroepithelial tumors
EPIDEMIOLOGY AND RISK ASSESSMENT
▪ With hypercellularity of connective tissue
▪ help identify factors that through exposure or inheritance place
▪ Histologically - stromal elements dominate and invade the ducts
a woman at risk for a greater chance of cellular change
in “leafy” projection
▪ Relative risk - risk compared with subjects in a control group
▪ Commonly seen in ages 40s to 50s
who are not exposed
▪ Types
▪ Major risk – increase RR >2x normal
▪ Benign
▪ Minor risk
▪ Borderline
▪ malignant
RISK FACTORS FOR BREAST CANCER
▪ mass is locally aggressive and grow rapidly
▪ <25% metastasize
▪ Treatment: excision with wide margin of normal tissue

MYOFIBROBLASTOMA
▪ Rare neoplasm of stromal elements
▪ Benign disease
▪ Treatment: EXCISION BIOPSY

FAT NECROSIS
▪ rare but important cause of breast
mass
▪ usual cause: trauma
▪ Physical exam
▪ firm, tender, indurated, ill-
defined mass that may have an
area of ecchymosis
▪ cystic in consistency
▪ skin retraction
▪ Diagnostic – MAMMOGRAM
▪ fine, stippled calcification
▪ stellate contraction
▪ Treatment: EXCISION BIOPSY

TRANSCRIBERS Antonio, Cabaro, Cachero, Suguitan 5

 Gynecology EXIMIUS
Breast Diseases
Kathy B. Izon-Carag, MD, FPOGS
2021
FACTORS ASSOCIATED WITH A SCREENING AND DIAGNOSTIC MODALITIES
DECREASED RISK FOR BREAST CANCER ▪ Signs and symptoms
▪ Asymptomatic
▪ Breast pain
▪ Nipple discharge
▪ Classic sign
▪ Solitary, solid, three-dimensional, dominant mass
▪ Borders are indistinct
▪ Not freely mobile
▪ Far advanced local disease: changes in skin and nipple
▪ Retraction
▪ Dimpling
▪ Induration
▪ Edema
▪ Ulceration
▪ Utilizes tests in asymptomatic women at periodic intervals
▪ Early diagnosis reduces mortality
▪ Kinetics of growth
RISK LEVELS FOR THE DEVELOPMENT OF BREAST CANCER ▪ Must develop neovascularization to grow beyond 1-2mm
then metastasis
▪ Average breast mass doubles in volume every 100 days in
diameter every 300days
▪ Breast carcinoma grows for 6 to 8 years before reaching
1cm then less than a year reach 2cm
▪ THREE SCREENING MODALITIES
▪ BREAST SELF-EXAMINATION
- No cost
- Convenient
- Mean diameter discovered is 2cm
- Diagnosis is established by biopsy
- Performed a few days after menstruation
- Begin in shower- “wet” technique
- After shower: lie down
- Use pad of 2nd, 3rd, 4th finger

MAJOR INHERITED GENE MUTATION SYNDROMES

ASSOCIATED WITH BREAST CANCER

▪ CLINICAL BREAST EXAMINATION

INDICATORS FOR REFERRAL FOR GENETIC COUNSELING - varies from physician to physician
FOR BRCA GENE TESTING - ability to detect mass directly related to size
• 87% - 1cm
• 33%-0.5cm
• 14%- 0.3cm

- thorough exam takes 3-5minutes

• inspection sitting and supine
• palpation
• Note the site, size, shape, consistency, mobility
of mass tenderness, attached to deep
structures

TRANSCRIBERS Antonio, Cabaro, Cachero, Suguitan 6

 Gynecology EXIMIUS
Breast Diseases
Kathy B. Izon-Carag, MD, FPOGS
2021
- Sitting
• hands above head and then on hips
• inspection
o contour
o symmetry
o vascular pattern
o skin: irritation, retraction, edema
- Supine
• Inspection
o nipple retraction
o discharge
• palpation
o compress areola to identify discharge
o done with hands at sides and above head
o axilla, supraclavicular areas, adjacent
chest wall

- 68% of occult breast carcinomas and 34% of

palpable breast cancers demonstrate calcification
on mammogram
- standardized terminology used to describe
mammographic findings

BI-RAD CLASSIFICATION OF MAMMOGRAPHIC LESIONS

▪ MAMMOGRAPHY
- best method for screening
- most practical method of detecting breast
carcinoma
- most accurate conventional method of detecting
non-palpable breast carcinoma
- not precise in younger woman or women with dense
breasts 2 to fibroglandular tissue
- most sensitive in older women (fatty tissue)
- Screening mammography reduces breast cancer ▪ OTHER MODALITIES
mortality by 33% in women aged 50 to 70years of age ▪ Digital Mammography
- All patients with breast masses or persistent - Technique by which x-ray photons are detected after
spontaneous nipple discharge should have passing thru the breast tissue
mammogram of both breasts prior to biopsy - Radiographic image is recorded electronically in a
- sensitivity decreases with density of breast digital format
- (+) dense breastàDIGITAL MAMMOGRAPHY - More useful than plain mammography in women
- >20% risk of Breast canceràMRI with dense breast and breast implants
- It has two views - Advantages
- breast compression: • Faster image acquisition, display and storage
• holds the breast still to prevent motion artifact • Image manipulation
• decreases the amt of radiation exposure - Disadvantage
• Cost
• Reduced spatial resolution

TRANSCRIBERS Antonio, Cabaro, Cachero, Suguitan 7

 Gynecology EXIMIUS
Breast Diseases
Kathy B. Izon-Carag, MD, FPOGS
2021
▪ MRI • Localization issues
- differentiate benign from malignant o UTZ guided
- reduce frequency of breast biopsy in women with o Mammographically guided wire-
dense fibroglandular breast localized excisional biopsy
- Indications § wire is placed percutaneously on
• detects tumors in patients with previous vicinity of lesion
lumpectomy § breast is imaged
• Improve imaging of structures close to chest § lesion is localized using computer-
wall assisted positioning and targeting
• Improve imaging of women with breast device
prosthesis § small nick is made
• Evaluate prosthesis rupture § core needle advanced for biopsy
• Patients with axillary adenopathy without
apparent breast mass
- Disadvantage
• not for mass screening program
• cannot identify microcalcification
• loss of image quality with respiration
• cost
- Women with greater than 20% lifetime risk of
breast cancer should be scheduled for regular MRI

▪ ULTRASOUND - EXCISIONAL BIOPSY

- Complementary procedure to other imaging • open
techniques in detecting breast CA • local anesthesia
- Differentiates cystic from solid mass • 1980’s – biopsy, frozen, definitive surgery
- Not a screening test except for women with very • two-step approach
dense breast - FNA BIOPSY
- Advantages • for cystic mass
• Ability to produce images of breast tissue on • simple office-based procedure
multiple occasions without harmful effects • Procedure
• Most useful in evaluating solitary masses o infiltration with anesthesia
greater than 1cm o breast mass secured with 1 hand
• Used to guide in FNA and Core needle biopsy o introduction of 22G syringe (10 or 20mL)
o aspiration by negative pressure
▪ COMPUTED TOMOGRAPHY o firm pressure after removal of syringe
- Limited value compared to mammogram
- Higher radiation dose and longer study time • Colors of fluid
- Advantages o clear
• Excellent for studying most medial and lateral o yellow, brown, green
aspects of breast • FNA is appropriate for new, well-
• Used for preop wire location of mass that is circumscribed, usually tender masses that are
difficult to localize in mammography thought to be simple (not complex) cysts.
CORE NEEDLE BIOPSY is the procedure of
▪ TISSUE BIOPSY choice for all other findings.
- for tissue diagnosis after imaging has suspicious • note for residual mass or recurrence
findings • (+) recurrence à BIOPSY
- obtains a tissue specimen for histology, genetics, • No further work-up is necessary if aspirated
hormone receptor assessment fluid is clear if no residual mass plapated
- Indication (after procedure and 1month after)
• bloody nipple discharge
• persistent three-dimensional mass
• nipple retraction
• skin changes
- CORE NEEDLE BIOPSY
• For solid or complex cystic mass
• Performed with a 14g to 16g needle
• Sometimes vacuum assisted
• Small amt of specimen sent for
o Hormone receptor
o Gene profiling

TRANSCRIBERS Antonio, Cabaro, Cachero, Suguitan 8

 Gynecology EXIMIUS
Breast Diseases
Kathy B. Izon-Carag, MD, FPOGS
2021
CLASSIFICATION ▪ COLLOID – soft with extensive deposition of extracellular
▪ based on histologic appearance mucin
▪ divided into invasive and in-situ lesions ▪ PAPILLARY – have greater fibrovascular elements

LOBULAR CARCINOMA IN SITU (DCIS)

▪ bilateral and multifocal
▪ not detected by palpation
▪ latent period on developing into CA is longer >20years
▪ Treatment
▪ Excision with negative margins
▪ Radiation to ipsilateral breast
▪ hormone receptor (+): chemoprevention with SERM

LOBULAR CARCINOMA INFILTRATING

▪ 15% of breast carcinoma
▪ characterized by uniformity of small, round, neoplastic cells
▪ malignant cells infiltrate the stroma in single-file fashion
▪ multicentric origin in same breast
▪ Histology
▪ small cell carcinoma
▪ round cell carcinoma
▪ signet-cell carcinoma

INFLAMMATORY CARCINOMA
▪ 2% of breast carcinoma
▪ rapidly growing, highly malignant carcinoma
▪ malignant cells infiltrate lymphatics of skin
▪ no specific histologic type

PAGET’s DISEASE
▪ rare: <1% of breast carcinoma
▪ innocent appearance: eczema-like or dermatitis of nipple
▪ clinical picture: infiltrating ductal CA that invades epidermis
▪ has good prognosis

SIMPLIFIED CLASSIFICATION OF BREAST CARCINOMA

BASED ON HISTOLOGY

INTRADUCTAL CARCINOMA IN SITU (DCIS)

▪ premalignant lesion
▪ cellular abnormalities limited to ductal epithelium
▪ basement membrane not penetrated
▪ most common in peri & postmenopausal women
▪ sx: (-) mass, (+) discharge
▪ Diagnosis
▪ Mammography (fine stippling of microcalcification)
▪ Core Needle Biopsy (UTZ guided)
▪ Treatment
▪ Excision with negative margins TREATMENT
▪ Radiation to ipsilateral breast ▪ Multiple variables considered
▪ hormone receptor (+): Tamoxifen ▪ Stage
▪ DCIS is a marker for significantly increased breast cancer risk ▪ Inherent aggressiveness (histology, receptor status)
with a lifetime risk of 25% ▪ Positive nodes
▪ Uniform histo appearance ▪ Natural history of untreated breast carcinoma
▪ grossly softer, mobile, well-delineated ▪ 20% alive at 5years
▪ smaller ▪ 5% alive at 10years
▪ more optimistic prognosis ▪ Breast carcinoma may recur many years after initial
▪ MEDULLARY – soft with extensive stromal infiltration by diagnosis
lymphocytes and plasma cells ▪ Involves both local (surgical) and systemic therapy (medical)
▪ Three major objectives

TRANSCRIBERS Antonio, Cabaro, Cachero, Suguitan 9

 Gynecology EXIMIUS
Breast Diseases
Kathy B. Izon-Carag, MD, FPOGS
2021
▪ Control of local disease ▪ HER2(Neu) (+)
- Breast conservation with lumpectomy - epithelial growth factor determinant
- Quadrantectomy - gene when overexpressed--- poor prognostic sign
- Trastuzumab (Herceptin)C recombinant
▪ Treatment of distant metastasis - Chemotherapy monoclonal antibody
▪ Improved quality of life for women treated for the • directed against HER2 protein
disease • sensitizes cells to chemotherapy and radiation
- Reconstructive surgery ▪ Adjuvant chemotherapy
- Counseling - cyclophosphamide
- methotrexate
STAGES OF BREAST CANCER - doxorubicin
- 5-FU
- Vinblastine 4-6x
- Paclitaxel 4-5x
Conservative
management

▪ Surgical therapy
▪ Modified Radical Mastectomy
▪ Simple Mastectomy
▪ Lumpectomy with Sentinel node mapping
▪ Medical therapy
▪ adjuvant systemic therapy decreases odds of dying from
Breast CA in 1st 10yrs from diagnosis by 25%
▪ Two major factors predicting likelihood of systemic disease
- diameter of primary tumor
- presence of axillary LN
- <1cm negative
- <10% risk for relapse in 10 years
▪ Estrogen receptor status ER-alpha, ER-beta
- 60% will respond to hormonal therapy
- 10% will respond to hormonal therapy
▪ Hormonal therapy
- ablative surgery
- Tamoxifen
• Oral antiestrogen
• Most frequently used
- Arimidex
• Aromatase inhibitor
• Blocks peripheral conversion of adrenal
androgens to estrone
- DMPA
- Danazol
- GnRH agonists

TRANSCRIBERS Antonio, Cabaro, Cachero, Suguitan 10