Breast Pathology and Surgeries

Breast lesions can be Benign or Malignant;

When deciding to operate, consider indication (local, systemic symptoms, malignancy or cosmetic) against
1) associated risks due to comorbidities etc. and 2) whether the patient’s condition is better left alone.

 ¼ of women have a breast clinical referral in their life-time – very common

o 90% have clinical breast presentations benign
o Mostly minor aberrations of normal development (ANDI); consider managing their
symptoms here
o Also consider however:
 Could it be cancer?
 Is there a risk of developing cancer? E.g. is this benign process a risk for malignancy

Reasons for presentation include:

 Lump
 Mastalgia: Breast pain is common in pre-menstrual women.
 Nipple changes
o Discharge
o Retraction/distortion
o Eczema
 Skin change
o Contour
o Colour
o Dimpling
 Family history

BENIGN LESIONS

Benign breast lesions are inclusive of:

Non- Fibrocystic disease: Painful breasts, with focal areas of nodularity or cysts in the upper
proliferative outer quadrant:
disease  Additional features
o Frequently bilateral
o Mobile
o Varies with the menstrual cycle
o Nipple discharge (straw-like, brown or green
 Treatment:
o Evaluation of breast mass (US + mammogram) and reassuring the patient
– triple assessment
o Analgesia (ibuprofen, ASSA)
o Severe symptoms (OCP, Danazol, bromocriptine)
Proliferative Fibroadenoma (localised ANDI rather than a tumour)
disease  Most common breast tumour in women <30. Comprised of fibroid and epithelial
w/out atypia components.
 Clinical features:
 o Firm, discrete, rubbery nodule
o Well circumscribed, mobile
o Non-tender
o Hormone dependent
 Undergo involution in peri-menopause – but can persist into old
age, undergoing dystrophic calcification.
o Needle aspiration: No yield, unlike cysts.
 Diagnosis:
o Triple assessment incl. core biopsy; US + FNA are insufficient to
distinguish it from a Phyllodes tumour (biopsy is to confirm diagnosis)
 Management:
o Generally conservative, w/ serial observation:
 Review at 3 months after diagnosis (USS and Biopsy)
 If stable, review again at 12 months:
 If stable, D/C from clinic
 If growth, refer for surgical opinion
o Consider excision if: (Consider lesion and patient factors)
 Size >2-3cm and/or growing on serial US (q6mo x 2 years is the
usual follow up) – as aforementioned point.
 Triple test is discordant
 If symptomatic
 Patient request
 Formed after age of 35
 Patient preference
 Features of core biopsy suggesting Phylodes tumour
 Prognosis:
o Increased risk if atypical cells + Family Hx of Brest Cancer. Otherwise,
doesn’t increase risk of breast cancer.
o Regress spontaneously in 85-90%
 DDx:
o Phyllodes tumour: Malignant types are sarcomatous; however, most are
low-grade, benign ones.

Intraductal papilloma
 Solitary intra-ductal benign polyp
 Clinical features:
o May present as nipple discharge (most common cause of spontaneous,
unilateral, bloody nipple discharge = pathologic discharge)
o Breast mass
o Nodule on U/S
 Treatment: Surgical excision of involved duct to ensure no atypia (central ductal
excision)
 Prognosis: Can harbour areas of atypia, DCIS

Usual Ductal Hyperplasia (Proliferative subtype, fibrocystic disease)

 Increased number of cells within the ductal space

 Clinical features:
o Incidental finding on biopsy of mammographic abnormalities, or breast
masses.
 Action: Empirically none; but often if suspicious mass, will remove anyway.
  Prognosis: Generally low risk; slightly increased if moderate or florid hyperplasia.

Sclerosing adenosis (continuation of the proliferative subtype, fibrocystic disease)

 Lobular lesion with increased fibrous tissue, glandular cells
 Clinical features: Mass (can mimic cancer) or mammographic abnormality
 Treatment: Nil required – however, remove for safety and analysis anyway.
 Prognosis: Low risk.

Atypical  Can involve ducts (ductal hyperplasia with atypia) or lobules (lobular hyperplasia
hyperplasia with atypia) i.e. continuation of proliferative lesions aforementioned.
 Cells lose apical-basal orientation
 Prognosis: Increased risk of breast cancer
 Diagnosis: Core or excisional biopsy (Schimmer: Guide wire with wide excision)
 Treatment: Complete resection, risk modification (avoid exogenous hormones)
and close follow-up.
Other lesions  Fat necrosis: Uncommon, result of trauma (may be minor, positive history in
only 50%) or after breast surgery (e.g. reduction)
o Clinical: Firm, ill-defined mass with skin, nipple retraction +/- tenderness
o Regresses spontaneously, but complete imaging + biopsy necessary to
rule out malignancy
 Granulomatous Mastitis
 Diabetic fibrous mastopathy – T1 diabetic girl with scary breast lumps looking
like cancer.
o Have to work up, to exclude cancer.
 Mammary duct ectasia: Obstruction of subareolar duct leading to duct dilation,
inflammation and fibrosis.
o Clinical features: May present with nipple discharge, bluish mass under
nipple and local pain. RFs include:
 Prior pregnancy, breastfeeding but not for extended period of
time, multi-paraous women.
o Risk of secondary infection (abscess, mastitis)
o Resolves spontaneously within weeks, years – however, central duct
excision is available.
 Abscess: Lactational vs periductal/subareolar
o Clinical features: Unilateral, localised pain, tenderness, erythema,
subareolar mass, with nipple discharge, inversion
 Rule OUT inflammatory carcinoma
o Treatment: Initially broad spectrum antibiotics and incision and drainage,
if persistent total duct excision.
 If mass does not resolve, US to assess for presence of abscess,
core biopsy to exclude cancer, consider MRI

So for lumps, consider benign causes, chronic mastitis (granulomatous, T1DM, fat
necrosis), infections and malignancy + Other skin lump causes.
Aberrance of Aberrations of normal development, cyclical change and involution. Disease is reserved
Normal for severe disorders.
Development
(ANDI)
Conditions
and risk of
breast cancer

MALIGNANT LESIONS
Breast Cancer
Epidemiology  Leading cancer diagnosis in women
 2nd leading cause of cancer mortality in women
 1/8 life-time risk in Canada for women; 1/30 die from breast cancer.
Anatomy Lies within the superficial pectoral fascia, each consisting of 15-20 lobules, with a
lactiferous duct opening onto the areola. Ligaments extend from deep pectoral fascia to
the superficial dermal fascia (suspensory/Cooper’s ligaments), frequently extending to
axillary tail of spence.

Breast Anatomy: Is compromised of a number of tissues, each with its own pathologies:
 Skin:
o Eczema or Paget’s disease of the nipple
o Naevi/Melanoma
 Fat
 Muscles
 Stroma, and epithelium of gland

 Divided into 4 quadrants:

o Upper inner quadrant
o Upper OUTER QUADRANT
o Lower OUTER QUADRANT
o Lower INNER QUADRANT
 Blood supply: (Venous follows arterial)
o Arterial
 Axillary artery via lateral thoracic and thoracoacromial branches
 Internal mammary: Via perforating branches and adjacent
intercostal arteries (coming off the aorta)
o Venous: Axillary, intercostal and internal mammary veins; this is
responsible for metastases to the spine
 Lymphatics:
o Axillary nodes (Note – if level 2 axillary dissection done and shows cancer
in the nodes  Use chemotherapy next. Level 3 dissections are only ever
done with melanoma)
 Level I: Lateral to pectoralis minor
 Level II: Deep to pectoralis minor
 Level III: Medial to pectoralis minor

o Rotter’s noes: Between pectoralis major and pectoralis minor muscles.

o Lymphatic drainage from nipple, areola and lobules into sub-araeolar
lymphatic plexus
o There is quadrant wise drainage:
 Lateral quadrants: Axillary nodes and supraclavicular through
pectoral through the pectoral, interpectoral (Rotter’s) and
deltopectoral
  Medial quadrants: Parasternal nodes
 Lower quadrants: Inferior phrenic (abdominal) nodes
 Nerves in the region:
o Long thoracic nerve – serratus anterior; if damaged, lose winging of
scapula
o Thoracodorsal nerve: lattisimus dorsi; if damaged, cannot push oneself up
from sitting position
o Medial and lateral pectoral nerves: Pectoralis major and minor; weakness
of muscles if damaged
o Intercostobrachial nerve; Crosses axilla transversely, supplying inner
aspect of arm. Area of anaesthesia on inner aspect of arm.
Pathology Review Pathology Notes (T5W4)

- Most commonly, infiltrating ductal carcinoma; cells invade stroma and have
various histological forms: NOS, comedo (cribriform), medullary, colloid, ?
mucoidpapillary, tubular – 80% of cases
o Originates from ductal epithelium and infiltrates supporting stroma.
Characteristics: hard, scirrhous, infiltrating tentacles. Gritty on cross-
section.
o Precursor lesion: DCIS (proliferation of malignant ductal cells within
breast ducts, often multifocal). Requires screening with increased
frequency.
 80% non-palpable; detected by screening mammogram
 Risk of Invasive ductal carcinoma of 35% at 10 years in the same
breast
 Treatment:
 Lumpectomy w/ wide excision margins + radiation (5-10%
risk of invasive cancer)
 Mastectomy: If large area of disease, high grade or
multifocal (risk of invasive cancer reduced to 1%)
 Possibly Tamoxifen as an adjuvant treatment
 99% 5 year survival
- Lobular carcinoma: 10% of cases. High likelihood of being bilateral; ill-defined
thickening of the breast. Lacks micro-calcifications and is often multi-centric.
Takes longer to detect on imaging as it spreads out in india-file (single file, rather
than chunks)
o If the patient clinically has a large lump appear immediately, consider
this.
o Originates from lobular epithelium
o 20% bilateral (i.e. more than infiltrating ductal carcinoma)
o Does not form micro-calcifications, harder to detect mammographically –
may be more visible on MRI. As such, will be detected later and thus has
a worse prognosis due to increased spread.
o Precursor lesion: LCIS (Neoplastic cells completely contained within
the breast lobule. Requires screening with increased frequency.
 No palpable mass, no mammographic findings (since very fine),
usually incidental finding for another indication
 Risk factor for invasive carcinoma: 1% per year.
 Treatment:
 If diagnosed with core biopsy; excisional biopsy necessary
to rule out malignancy.
  If diagnosed on excisional biopsy, wide excision not
needed since LCIS is often multi-centric and not managed
as a precursor legion.
 Clinical follow up and surveillance
 Consider chemoprevention (e.g. Tamoxifen).
The following are variations of IDC or ILC:
- Paget’s disease of nipple: Underlying LCIS or ductal carcinoma extending into
skin (1-3% of cancers). Invades the nipple with scaling, eczematous lesion.
o Tx: Modified radical mastectomy.
- Inflammatory carcinoma 1-4%): Ductal carcinoma that invades the dermal
lymphatics.
o The most invasive form of breast cancer
o Clinical features: Erythema, skin oedema, warm, swollen, tender breast
+/- lump.
o Peau d’orange indicates advanced disease (IIb-IV)
- Medullary: May have erythema, peau d’orange and nipple retraction. Most
deadly type of cancer. (A type of IDC)
o Tx: Chemotherapy followed by surgery and/or radiation, depending on
response to chemotherapy.
The remaining two are their own variants:
- Sarcomas (rare)
o Most common Phyllodes tumour – a variant of fibroadenoma with a
potential for malignancy
o Can also be angiosarcomas after radiation.
- Lymphoma: Rare

R/Fs for cancers include

1. Age
2. Gender
3. FmHx
a. Age of onset
b. Bilaterality
c. Ovarian cancer
4. PHx
a. Previous Breast or related cancers?
b. Past breast biopsy? What does the biopsy say
c. Consider medications
5. DCIS
6. Radiation: Radiation therapy for lymphoma at a young age
7. Oestrogen exposure

Other questions to consider include:

- Duration of symptoms (including cyclical nature)

 Risk factors include:

 Gender (99% female)

 Age (80% > 40 years of age); don’t screen beyond 74 as it’s no longer economical
and they’re more likely to die of other things.
 Personal history of breast cancer and/or prior breast history (regardless of
pathology)
o 2x in the elderly
o 8x in <45 year olds
 Family history of breast cancer (greater risk if relative was first degree and pre-
menopausal)
o BRCA1, BRCA2: 9x more likely
o Cancer families: Up to 50%
o First degree relatives: 2-3x risk (dependent upon age)
 OB-GYN history
o Nulliparity, first pregnancy, >30 years, menarche <12 years, menopause
>55 years (+ post-menopausal obesity)
o High fat, low fibre diet, smoking, alcohol
o Decreased risk with lactation, early menopause, early childbirth
 High breast density
 Radiation exposure (e.g. mantle radiation for Hodgkin’s disease)
 >5 years HRT use, >10 years OCP use
 Alcohol use, obesity, sedentary lifestyle

Male Breast Cancer:

 Most commonly invasive ductal carcinoma – often diagnosed at later ages

 Stage-for-stage similar prognosis to breast cancer in females
 Consider genetic test: Most often hormone receptor positive

Investigations Screening:

 Populations at-risk (women aged >50)

o Target 50-74 years
o BreastScreen Australia provides free screening mammograms every 2
years from 40; high risk features include:
 Mass that is poorly defined, speculated border
 Microcalcifications
 Architectural distortion
 Interval mammographic changes
 High risk groups (younger women with significant genetic risk)
 o MRI – NOTE: Can also be used when US, Biopsy are negative, to reassure
a nervous patient.

Pros of Screening Cons of screening

 Characteristic of screen-detected  Psychological morbidity induced
cancer: by breast screening
o Smaller  Risk of mammogram – radiation
o DCIS exposure
o Low grade  Unnecessary biopsies
o NOS  Limitation of MMG in dense
o LN negative (60 to 80%, vs breasts
40-50%)  MMG sensitivity: 68%, specificity:
75%

If screening returns positive, or there is a clinical suspicion of Breast cancer, consider:

Triple Investigation:
- History + Exam
o Other indications include 1) Well women check or 2) Any symptomatic
woman (or man)
o Limitations:
 Misses lesions <1cm
 Low specificity: Other causes for thickenings or lumps e.g. cysts
- Mammogram: Much lower rates of lymph node invasion, compared with
clinically identified types (if multiple slices put together, called Tomosynthesis).
Be sure to compare with mammograms 2 or 4 years ago.
o Stellate, speculated mass with associated micro-calcifications
o Dusty calcification, radial scar
o Indications:
 Screening 50-75 year old women (>40 yo woman)
 Any symptomatic patient >35yo; selectively in women <35
o If any abnormal results, recalled to assessment clinic, where the
remainder of the triple assessment occurs (OPD)
- US in younger persons in whom the breast is more dense
o US: Can distinguish between cystic, solid. In future, will be a cup over the
breast which ultrasounds the entire breast. Can be done every 6 months.
 Indications:
 First line in women <35yo; any symptomatic person >35
 In addition to MMG for screening the clinically and
radiologically difficult breast
o MRI: In those in whom US/MMG have come back negative, is an
appropriate investigation. May however over-diagnose or alternately
miss low grade cancers; will rule out high grade lesions though. High
sensitivity, low specificity.
 Indications:
 Potentially high risk screening (Medicare eligibility requires
specialist approval)
 Non-medicare rebatable:
o Selectively where the patient is symptomatic but
conventional imaging is negative (10% of cancers
 missed on conventional imaging)
o Selectively in the clinically and radiologically
difficult breast
o Selectively for pre-operative assessment
o Selectively for follow up where PHx of lobular
histology
- Biopsy:
o FNA – gives cytology (not preferred; histology is ideal)
 For palpable cystic lesions; send fluid for cytology if 1) Bloody or
2) Cyst doesn’t resolve
 For palpable solid mass; need experienced practitioner for
adequate sampling
 Indication:
 May differentiate a solid from a cystic lesion
 Where core biopsy is not possible:
o Expertise unavailable
o Location of lesion: Too close to the chest wall to
enable a safe/successful core
o Core biopsy – preferred; gives histology (US guided)
 Indication:
 By imaging: Preferred method of biopsy for any solid
lesion in any age group. Preferably image guided.
 Free hand: Where lump is imaging negative; possible to
miss it this way; ask if this is a representative sample of the
lesion – look for concordance between expectation and
what you see.
o Excision biopsy: Only performed as a second choice to core needle
biopsy; should not be done for diagnosis if possible.
 NOTE: In any biopsy, if the lesion is impalpable, a guide-wire is
inserted by the radiologist which the surgeon then follows under
imaging (US) until the lesion on the day of the procedure.

ADVANTAGES DISADVANTAGES
Core biopsy - Easy to perform - Operator dependent
- Less painful than FNA - Cannot easily be reported
- High sensitivity, immediately
particularly if image - Uncomfortable
guided - Bruising and swelling
- Definitive histology
(differentiates invasive
from in-situ)
- Almost zero false-
positives
FNA - Cheap - Operator dependent
- High sensitivity - Needs experienced
- Provides DDx in most cytopathologist
cases - Painful
- Low incidence false - Cannot differentiate
positives invasive from in-situ
- Can be reported carcinoma
immediately - Some false positives
*NOTE: With biopsies, benign conditions may co-exist with or abut cancer (e.g.
Papilloma, radial scar)

With concordance of all 3, know whether to intervene or not. With discordance, need to
investigate further or act on the side of safety.

 If discordance, have to question whether one of the tests were not

representative/ carried out appropriately.
 Might repeat components at certain intervals if concerned about a suspicious
thing

Other available imaging includes:

 Galactogram/ductogram (for nipple discharge): Identifies lesions in ducts.

 Metastatic workup: Indicated in stage II to IV disease: Bone scan, CT chest-
abdomen-pelvis (or US abdo + CXR), CT-Head if specific neurological symptoms.

Prognostic indicators with tumours include:

 Tumour size, type

 Grade (modified Bloom and Richardson score (I to III)) – histologic, nuclear,
mitotic grade
 Number of axillary nodes positive for malignancy out of total nodes resected,
extranodal extension, SNLB positive or negative.
 Tumour biology: Oestrogen receptor (ER), progesterone receptor (PR),
Her2/neu oncogene status.
 Margins for invasive breast cancer – negative margin is sufficient; for DCIS,
prefer 2mm margin
 Lymphovascular invasion
 Extensive in-situ component: DCIS in surrounding tissue
 Involvement of dermal lymphatics: Automatically IIIb.

NOTE: In pregnant women, FNA should be performed on any lump – if it identifies a

solid mass, then biopsy should be taken.

 Mammography: Is possible as long as proper shielding is used

 Tx: Radiation not advisable in pregnant women;
o For stage I and II, modified radical mastectomy should be undertaken
rather than lumpectomy with axillary node dissection and post-op
radiation.
o If LNs positive, delay chemotherapy until second trimester
o If found in 3rd trimester, lumpectomy can be done and radiation post-
partum.

ADVANTAGES DISADVANTAGES
Clinical Exam: Easy to perform Low sensitivity in women <50years
Operator dependent
Difficult on already bumpy, firm breasts
 Mammography: Screening women Requires dedicated equipment and
>50 years expertise
3D mammograms take slices through Sensitivity 68%, specificity 75%
breast, showing true lesions (reduces Lower sensitivity <50 years (higher
rates of false positives) breast density)
Unpleasant (causes pain/discomfort)
Ultrasonography: Operator dependent
Same sensitivity at all ages Slightly more sensitive than MMG when
Impalpable lesions/axilla targeted, but not useful as a strand-
Cystic vs solid (Mammogram can’t) alone screening tool – it’s an adjunct
Painless
Targeted core Bx/ FNAC

V high grade breast cancers can look like

a cyst due to necrotic cells
MRI: High sensitivity Costly and time consuming
Better assessment of tumour size Claustrophobic
than others Low specificity and PPV

Complication - Metastases: Liver, lungs, adrenals and bones

s o NOTE: Majority of ductal are Luminal A type; follicular are Her2/Neu type,
medullary is Basal type.
- Recurrence:
o 5-10% at 10 years
o Metastases in <10% of cases
o Local chest wall recurrence most common within 2-3 years, if t all
Management
- In Situ Disease
o Surgical
 Selective lumpectomy + Radiotherapy everyday for 4-5 weeks.
Selective lumpectomy is decided upon if:
 Tumour size (vs breast size; if small breast, only for small
lump; remember: point of this surgery is to preserve
breast shape)
 Breast size
 Multifocality (Cannot be undertaken with multi-focal
disease)
 Need for XRT (cannot be undertaken if contraindications to
radiation therapy: prior radiotherapy, CT disease e.g.
scleroderma patients due to their reaction, pregnant)
 Patient preference
 (selective lumpectomy along if margins >1cm and low
nuclear grade
 *Mastectomy +/- SNLB – no advantage to mastectomy at this
stage.
o Hormonal therapy
 Consider post-operative Tamoxifen for ER+ve, Trastuzumab for
Her2+ve
 - Early Invasive Breast Cancer (Stages I and II)
o Surgical: Mastectomy has no survival benefit at this stage
 Mastectomy with assessment of axillary lymph nodes/SNLB first
 Lumpectomy with SNLB assessment + radiation therapy) are
considered equivalents
 SNLB not possible with tumours >4cm or multifocal
tumours.
o Hormone therapy:
 HR positive women, with cancers larger than 1cm in size –
particularly, Tamoxifen.
 Tamoxifen S/Es include hot flushes, irregular menses,
thromboembolism, increased risk of cancer due to
selective hormone agonist action.
o Adjuvant chemotherapy for early invasive breast cancer considered in:
 All node positive cancers
 Node negative cancers >1cm
 Node negative cancers larger than 0.5cm in size, when blood
vessel or lymph invasion occurs
 High nuclear grade, high histologic grade
 Her2/neu over-expression, negative hormonal status
 Drugs include: (Chemo is delivered over 4-6 months)
 Adriamycin
 5-fluorouracil
 Methotrexate
 Cyclophosphadide
 Paclitaxel
 Immunotherapy: Herceptin – for HER2/neu positive
positive cancers.
- Locally advanced breast cancer (Stage III) – IIIa or IIIb
o Neoadjuvant therapy; check for response:
 Yes: Becomes operable disease with mastectomy + axillary node
dissection + chemotherapy, followed by follow up radiology after
chemotherapy
 No: Inoperable disease requiring individualised treatment
- Advanced Breast Cancer (IV)
o Systemic or palliative treatment
 Some patients need toilet mastectomy for palliation, and relief
from foul discharge and pain.
 Chemotherapy and/or hormone therapy
- Inflammatory
o Mastectomy + axillary node dissection + radiotherapy
o Neoadjuvant therapy

Across Stages:

- Surgery Types
o Mastectomy +/- Radiotherapy
 Simple mastectomy: Removal of all breast tissue INCLUDING THE
NIPPLE; LEAVES A SCAR ALONG THE CHEST and skin
 Modified radical mastectomy: Resection of all breast tissue and
axillary lymph nodes, skin
 Radical mastectomy: Resection of all breast tissue, axillary nodes,
 pectoralis major and minor muscles (no longer performed; due to
increased morbidity without advantage)
 NOTE: Following mastectomy, will have:
 Reconstruction: Done in patients post-mastectomy, using
either:
o Autologous implants: Typically achieve better
results than prostheses; prosthesis is just fat and
muscle over implant.
 Autologous: Rectus muscle muscle or
lattisimus dorsi muscle myocutaneous flap
 TRAM (Transverse rectus
abdominis): Flap borrowing tissue
from the abdomen (works in fat, not
slim)
 DIEP (A muscle sparing free TRAM
flap): Inferior epigastric perforate
arteries and tissue attached to them
transferred from lower abdomen to
breast, following mastectomy.
 Timing:
 Immediate if no radiotherapy;
namely in mastectomies taken as a
precautionary measure, not
obligatorily.
 Delayed: If XRT, flap preferred –
believed that radiotherapy increases
complications.
o Preferred, as you wait for the
pathology to come back.
o Prosthetic implants – May use an expander and
implant at a later date.
 Implant: Saline or silicone based

NOTE: Sentinel lymph node biopsy (in Mastectomy or lumpectomy) is standard of care
for early breast cancer: <3cm intraductal carcinoma that is unifocal with clinically
negative nodes (clinically positive node will be removed anyway). If not satisfied, axillary
clearance regardless.

Prior to Axillary clearance, SNLB (sentinel lymph node biopsy) can be undertaken: Inject
Patent blue 5 (blue dye) or colloid (lymphoscintigraphy) into lymphatics. In latter,
Colloid that is small enough to be taken up by lymphatics, but large enough to sieved
out by the LNs. It lights up the the probes that detect the radioactivity. Takes about 4
hours to reach the LN. In former, Takes about 15-20 minutes to arrive at the lymph
node; inject when patient is asleep. Blue + Fatty yellow nodes = Green. This dye is
excreted through kidneys, so pass bright green urine. 1/20 suffer lymphedema following
this, as opposed to 1/10 with axillary dissection. Sometimes can give false negatives

 Sample is stained with H & E

 Won’t pick up ITC (isolated tumour cells), micrometastases <2mm
 False negative nodes: <10%

US, CT, MRI ARE USELESS to dictate node involvement.

 o Breast conserving surgery -- considered for patients in stage I or II
cancer; important cosmetic advantages.
 (Lumpectomy + Radiotherapy); without radiotherapy, risk of
recurrence is high.
 Resection of mass with rim of normal tissue and sentinel
lymph node biopsy. Gives a good cosmetic result.
 Radiotherapy delivered every day of the week, for 4-5
weeks. Improves outcomes in selective lumpectomy,
otherwise very high risk of local recurrence. 40-50 grays
are delivered.
o SNLB: Done only if no palpable nodes; based on
principle that metastatic cells migrate in an orderly
fashion. Identify nodes by nuclear scintigraphy or
blue dye; axilla is opened and inspected for blue or
hot nodes, identified by gamma probe.
 When sentinel node is positive, dissection is
completed.
 Contraindications include:
o High risk of local recurrence e.g. extensive
malignant type calcifications on mammogram,
multifocal primary cancers
o Failure to obtain tumour free margins after re-
excision
o Not a candidate for radiation therapy (pregnant,
collagen vascular disease, previous radiation)
o Large tumour size relative to the breast
 Quadrantectomy and axillary radiotherapy (QUART)
o + SNLB (if tumour
 Performed in:
 Women with clinically node-negative invasive breast
cancer
 Those with extensive DCIS who are undergoing
mastectomy
 Procedure: Technetium-99 +/- blue dye injected at tumour site
prior to surgery to identify sentinel nodes
 Intra-operative frozen section evaluated can be considered
 Proceed with Axillary lymph node dissection if >3 positive
nodes
 With 1-3 nodes whole breast irradiation may be the
alternative
 5% false positive rate.
o +/- Axillary lymph node dissection
 Perform in patients with pathologic confirmation of nodal
involvement (including positive SNLB as above)
 Risks include:
 Arm lymphoedema (10-15%) especially if getting radiation
therapy
 Decreased arm sensation
 Shoulder pain

ADJUVANT/NEOADJUVANT
- Radiation:
o Indication (receive 40-50 grays over 4-5 weeks of therapy everyday).
 Decrease risk of local recurrence; almost always used after breast
conservation surgery, sometimes after mastectomy
 Inoperable locally advanced cancer
 Breast
o >5cm
o Skin, muscle involvement
o LV1
 Axilla:
o >2 nodes involved
o Side effects of radiotherapy include:
 Breast
 Skin reactions: Redness, desquamation
 Firmness, swelling breast
 Tiredness
 Chest wall pain
- Medical: Indicated by 1) Size of primary 2) Grade 3) Nodal status and 4) Invasion
of lymphatics, vessels. Type is decided by 1) Receptor status and 2) Menopausal
status.
o Chemical castration/Hormonal therapy indications:
 ER+ve AND node positive OR high risk node negative
 Oestrogens: Continued for 5-10 years
o SERM if premenopausal (e.g. Tamoxifen)
o Aromatase inhibitors (if post-menopausal (e.g.
Anastrazole) – prevent oestrogen production from
androgens. Decreases risk of further breast cancer.
 Main S/E: Bone/joint pain and osteoporosis;
require 2 yearly bone scans.
 Other options include:
o Ovarian ablation, for instance:
 Goserelin/GnRH agonist
 Oophorectomy: Indicated in pre-
menopausal, node positive, metastatic (i.e.
nasty cancers)
o Progestins (e.g. megestrol acetate)
o Androgens (fluoxymestrone)
o Her2: Immunotherapy; monoclonal antibody
against Her2; main danger is cardiomyopathy.
 Palliation for metastatic disease
o Chemotherapy
 Multiple regimens; prolonged course over 4-6 months
 Side effects include:
 Hair, skin mutation
 Mucosa: Gut, mouth ulcers
 Bone marrow suppression
 Early menopause
 Indications include:
 ER negative plus node positive or high risk node negative
 ER positive and young age
  Stage I disease at high risk of recurrence (high grade,
lymphovascular invasion)
 Palliation for metastatic disease

NOTE: Radiotherapy can only be done once; will not be offered a second time. Other
contraindications for radiotherapy include Scleroderma (CT disorders) and pregnancy.

FOLLOW UP

 Post-treatment follow up
o Medical
 Assessment and physical exam q3-6mo x 3 years, q6-12mo x 2
years and annually thereafter
 Following breast conserving surgery, mammography q6-12
months – can reduce to annually once stable, no other routine
imaging unless clearly indicated
 Tamoxifen: Women receiving Tamoxifen should have regular
gynaecologic follow-up (higher risk of endometrial cancer)
o Psychosocial support, counselling
o Delayed breast reconstruction if underwent a mastectomy:
 Local/regional recurrence
o Recurrence in treated breast or ipsilateral axilla
o 1% per year up to maximum of 15% risk of developing contralateral
malignancy
o 5x increased risk of developing metastases
 Metastasis
o Bone ? lungs ? pleura > liver > brain
o Treatment is palliative hormone therapy, chemotherapy, radiation
o Overall survival of metastatic breast cancer is 36-60 months.

NOTE: Patient education is very important.

Side effects of surgery:

- Breast/chest
o Bruising
o Change in shape
- Axilla
o Seroma
o Numbness
o Stiff shoulder
o Lymphoedema

Special cases for management:

 Inflammatory breast cancer

o Neoadjuvant chemotherapy
o Mastectomy
o Post-operative radiotherapy
 Locally advanced breast cancer
o Multi-disciplinary approach
  Breast cancer in medically unfit patients
o ER+ve so may just use hormonal therapy; not as dramatic, but may take
several months
 Phyllodes tumour: mostly benign soft tissue tumour, with malignant potential.

Prognosis Metastasis: median survival of 2 years. Palliation is indicated.

 Stage I: 94%
 Stage II: 70-85%
 Stage III: 48-52%
 Stage IV: 18%

Prognosis is determined by:

 Type:
o DCIS: Unifocal and short latency; tends to become an invasive carcinoma
within a woman’s lifetime
o LCIS: Multi-focal, could be at different sites, but may have longer latency
and not develop into cancer within a woman’s lifetime.
 Close yearly surveillance (yearly mammograms)
 No surgery required until transformation
o Carcinoma in-situ: Basement membrane containing cancer; contained
within duct so cannot get into lymph nodes – surgical treatment is the
same as for carcinoma, but don’t require axillary or general therapy.
 Grade: Lower better than higher
 Size: Larger size is worse
 Nodal status: Worse with nodes
 Lymphatic/vascular invasion
 Receptor Status: ER, PR, Her2 (bad)
 DNA profile (DNA profiled cancers and found certain profiles did better than
others; worse profiles will require more treatment)

DCIS
Pathology Review Pathology Notes (T5W4)
Clinical Usually asymptomatic; may present with:

- Paget’s: Associated with underlying LCIS or ductal carcinoma extending within

epithelium of main excretory ducts to skin of nipple, areola. Presents as tender,
itchy, with or without bloody D/C, w or without palpable mass.
- Discharge
- Pain
Investigations Triple investigation:

 Mammogram: Shows micro-calcification

 Biopsy: If Paget’s present, do a biopsy and sentinel lymph node biopsy (almost
always an underlying carcinoma)
Complications
Management  Surgery + Irradiation
o NOTE: Shashi screwed up: If Paget’s is present, modified radical
mastectomy is required.
 Risk of recurrence reduced by Tamoxifen
Prognosis Short latent period 00 tends to become invasive within a woman’s lifetime and should
be removed.

LCIS
Pathology Review Pathology Notes (T5W4)
Clinical Usually asymptomatic
Investigations Triple Investigation:

 Mammogram: Often incidental finding; no microcalcifications

Complications
Management  Close yearly surveillance (mammograms) but no surgery required until
transformation.
 Chemoprevention with Tamoxifen
Prognosis Multi-focal, could be at different sites, but has longer latency. May/may not develop
into cancer in a woman’s lifetime.

Mastitis  Diagnosis
o US: Can be used to localise an abscess; if abscess present, aspirate fluid
for gram stain and culture; often S. aureus or S. pyogenes.
 Management
o Prevent engorgement of breast – continue breast feeding or use pump as
an alternative
 Cellulitis: Wound care and IV antibiotics (?Flucloxacillin)
 Abscess: Incision and drainage followed by IV antibiotics
Fat Necrosis  Due to trauma often; firm irregular mass of varying tenderness. May be
indistinguishable from a carcinoma by clinical exam or mammography
 Diagnosed by excisional biopsy, pathological examination
ANDI Review ANDI disorders of the breast
Fibroadenom  Diagnosis: FNA
a  Treatment:
o If FNA is diagnostic and patient is under 30, may observe depending on
severity of symptoms and size (<3cm)
o If FNA is non-diagnostic, patient is over 30, or is symptomatic, must
excise mass. Mass will be well-encapsulated, easily shelled out at
surgery.
Fibrocystic  Diagnosis
disease o Serial examination withdocumentation of fluctuating nature of
symptoms;
o Mammogram may show areas of calcification
o Aspiration/biopsy: Definitive diagnosis requires pathologic evaluation
 Treatment:
o For those with a classic history and lacking a persistent mass,
conservative management including:
 NSAIDs
 OCP
 Danazol
 Tamoxifen
 Avoid products involving xanthine (cola drinks, tobacco, caffeine)
o If dominant cyst, aspirate:
 Cloudy/green: can discard
  Bloody: Excise and send for cytology
Mammary  Non-cyclic breast pain, with lumps under nipple/areola w or without discharge
duct ectasia  Diagnosis:
o Exam: Palpable lumps under areola, possible nipple D/C
o Based on exam, Excision to rule out cancer
 Treatment:
o Excision of affected ducts (central duct excision)
o Complications of procedure include:
 General surgical complications
 Nipple necrosis
 Sexual dysfunction
Intraductal  Subareolar mass with unilateral serosanguineous or bloody nipple D/C
papilloma  Diagnosis: Pathologic examination of resected specimen
 Treatment: Excise the affected duct

NIPPLE DISCHARGE

There are 3 instances in which lactation may occur:

1. Lactational
2. Physiological (Galactorrhoea): Characterised by multi-duct involvement and negative for blood
regardless of colour of nipple discharge. Due to hyperprolactinemia due to:
a. Medications (e.g. dopamine antagonists)
b. Endocrine tumours
c. Endocrinopathies
d. Other medical conditions
e. Neurogenic stimulation
3. Pathological

Indications for surgery (microdochectomy – removal of the lactiferous duct) are:

 Unilateral
 Persistent
 Spontaneous
 Serous/haemoserous/sanguinous
 If associated with abnormal clinical (retraction, Paget’s, lump) or radiological examinations
(investigate as per mass lesion/abnormality if present).

DDx in this instance include:

 Intraductal papilloma
 DCIS
 Carcinoma

May require central duct excision if … If these symptoms are intractable/distressing, they may require a
central duct excision:

 Infection
 Periductal mastitis
 Ductal ectasia

MASTALGIA
Breast pain is common in pre-menstrual women.

 Breast pain is a rare symptom of breast cancer

o About 3% of mastalgia patients are diagnosed with cancer
o <5% of cancer patients present with pain
 Causes
o True breast pain (cyclical, non-cyclical, diffuse, focal)
o Non breast causes (be sure to consider other differentials)
 Chest pain
 Lung
 Gallstones
 Other
 True breast pain? Hormonally mediated
o No unifying hypothesis to explain

Principles of this pain are:

 Assess origin of pain

o True breast pain
o Chest wall pain
 Exclude Cancer
o Triple assessment
 Provide reassurance and information
o +/- non-specific and specific measures

Treatments for True Mastalgia:

 Non-specific
o Reassurance, supportive bra, lifestyle, gentle exercise
o Caffeine reduction (unproven benefit)
o Low fat diet
o Evening primrose oil (no good study showing benefit)
 Specific
o NSAIDS (oral, topical), compresses
o Tamoxifen (mainstay) – sERM (selective oestrogen receptor modulator)
 10-20mg od (luteal phase – D15-25 menstrual cycle)
 S/Es: mood disturbance (completely nuts), hot flushes, vaginal discharge, TED
o Danazol (Gonadotropin inhibitor)
 200mg od (luteal phase or continuous)
 Significant androgenic effects limit use
o Goseralin (Zoladex) – GnRH superantagonist (can be used to suppress the ovaries; good for
breast pain but lasts the entire month)
 3.6 mg s/c inj q28 days

BREAST INFECTIONS

Breast infection is less common than it used to be. Normally seen in breast feeding mothers. It includes:

 Diffuse cellulitis
 Abscess
  NOTE: Inflammatory breast cancer should be excluded in patients with inflammatory changes not
settling rapidly on appropriate therapy.
o Particularly in non-lactating women
o It will need neoadjuvant chemotherapy

Early prescription of appropriate antibiotics will limit abscess formation. Delay in referral if not settling
remains problematic.

 Abscess can be aspirated or I&D

Types of infection include:

Type Comments Organism

Neonatal Breast bud (0-3 weeks S. aureus (rarely E. coli)
age)
Lactating S aureus (rarely S.
epidermidis and
streptococci)
Non-lactating Periductal mastitis Smokers S auereus, enterococci,
Peri-areolar infection bacteroides spp
Peripheral abscess (Mammary duct
fistulae)
Skin associated Hidradenitis Smokers
Sebaceous cysts S. aureus
Cellulitis Obese S aureus
Llarge breasts
Poor hygiene
PHx surgery or RT

GYNAECOMASTIA AND MALES

 Physiological
o Boys in teens and old men; related to hormonal imbalances
 Pathological
o Drug induced
 Hormone supplements
 Alcohol
 Cimetidine
 Digoxin
  Phenothiazine’s
 TCA’s
 Some antihypertensive agents
o Increased oestrogen production
 Hepatoma
 Testicular/adrenal tumours
 Paraneoplastic syndrome
o Reduced testosterone production
 Klinefelter’s syndrome
 Mumps Orchitis
o Testicular feminisation syndrome

Management

 Will do History + triple assessment to exclude cancer

o However unlikely if bilateral and smooth, even tissue
 May include surgical excision/liposuction techniques

1% of all breast cancers occur in Males.

DDx for a red breast:

- Infective
o Mastitis (lactational or non-lactational)
o Candida
o Tinea
- Other
o Duct ectasia
o Paget’s
o Inflammatory cancer: Presents with redness, swelling and pain – woman with mastitis that
isn’t responding, consider it could be an inflammatory cancer.
 Treating with chemotherapy first has significantly improved outcomes.
 Hasn’t been as successful with other cancers
 Is being considered from triple negative cancers, but not for regular ++- cancers.
o Intertrigo
o Dermatitis

Lump DDx:

- Cancer
- Fibrocystic disease
- Diabetic Mastopathy
- Granulomatous disease (TB, Silicone)
- Fat necrosis/radial scar
- Fibroadenoma