Disordered of the breast
Abdelkarim Barqawi
Breast Anatomy
Four quadrants
Parenchyma
Alveoli
Lobules
Three tissue types
Lobes
Glandular epithelium
Fibrous stroma and supporting structures
Fat
Cooper ligaments
Fibrous continuations of the superficial fascia, which span the
parenchyma of the breast to the deep fascial layers
Breast Anatomy
Vasculature
Arterial supply
Internal mammary artery(60%)
Lateral thoracic artery(30%)
Venous return
Intercostals
Axillary vein(primary)
Internal mammary vein
Lymphatics
Breast Anatomy
Lymphatics
Axillary chain (85 % of drainage)
Level 1 lateral to pectoralis minor muscle
Level 2 along and under pectoralis minor
Level 3 - medial to pectoralis minor
Rotters nodes
Between pectorial minor and major
muscles
Internal mammary (15% of drainage)
Parasternal
medial
Breast Anatomy
Nerves
Long thoracic nerve
Thoracodorsal nerve
Medial pectoral nerve
Lateral pectoral nerve
Structure
Diagnostic Work Up
Ultrasound
Mammography
MRI
FNA vs. Core Biopsy
Incisional biopsy
Excisional biopsy
Cyst aspiration
BI-RADS Classification
BI-RADS Classification features
0 - Need additional imaging
1 - Negative routine in 1 yr
2 - Benign finding routine in 1 yr
3 - Probably benign, 6mo follow-up
4 - Suspicious abnormality, biopsy recommended
5 - Highly suggestive of malignancy; appropriate action
should be taken
Benign Breast Disease
Infectious and inflammatory
Benign lesions
Nipple Discharge
Mastalgia
Nipple discharge
Clear, serous:
physiological in a parous woman
Associated with a duct papilloma
Mammary dysplasia.
Blood-stained :
Duct ectasia,
Duct papilloma or carcinoma.
A duct papilloma is usually single and situated in one
of the larger lactiferous ducts.
Black or green: usually the result of duct ectasia.
Nipple discharge
Associated mass should be excluded
clinically or by US
Bloody discharge from a single duct
should be excised
Galactorrhea: Obtain prolactin levels
Reassurance if multiduct green or black
discharge
Congenital abnormalities
A m azia
Polym azia
M astitis of infants
In boys and girls
Started in the 2nd 3rd day and lasted to 3 WKs
Associated with milk discharge
Stimulated by prolactine & drop of maternal
estrogene
Diffuse hypertrophy
Infectious and Inflammatory
Breast Disease
Mastitis & Abscess
Cellulitis, mastitis
Usually associated with lactation
The intermediary is the infant
Treatment:
Breast rest for 24 hours
10-14 day course antibiotics to cover Staphylococcus aurius
Breast evacuation & worm compressors
Abscess
If treatment of mastitis failed after 48 hours abscess should be
suspected
Fluctuation is a late sign
Diagnosis can be confirmed by US
Treatment is multiple aspiration and antibiotics OR surgical drainage
Chronic subareolar abscess
Occurs at base of lactiferous duct,
Squamous metaplasia of duct may occur.
Sinus tract to areola develops
Treatment requires complete excision of sinus tract
Recurrence is common
Mondors disease
Phlebitis of the thoracoepigastric vein
Palpable, visible, tender cord along upper quadrants
Ultrasound may be helpful in confirming this diagnosis.
Treatment self-limited, can use anti-inflammatories if necessary
Duct ectasia
Pathogenesis:
Lactiferous duct dilatation stagnation of secretion
irritation & periductal mastitis fibrosis &
nipple retraction
Periductal mastitis by anaerobes fibrosis
retraction
Strong relation with smoking suggest underlying
arteriopathy
Duct ectasia
Presentation:
Retroaureolar mass
Nipple discharge of any colour
Nipple retraction
Treatment:
Malignancy should be excluded if mass present
Antibiotics
Surgery is the definitive therapy
Fat necrosis
Uncommon lesion; may be a history of trauma,
prior surgical intervention or adiation therapy
Characterized by a central focus of necrotic fat
cells with lipid-laden macrophages and
neutrophils
Major clinical significance is its possible
confusion with carcinoma (e.g. fibrosis
clinically palpable mass / Ca2+ seen on
mammography)
Aberrations of Normal
Development and Involution
Benign breast disorders and diseases are
related to the normal processes of
reproductive life and to involution
There is a spectrum of breast conditions that
ranges from normal to disorder to disease.
ANDI classification
Pathology
Consest of four features:
Cyst formation
Fibrosis
Hyperplasia
papillomatosis
Clinical features
The symptoms are many but often include
lumpiness and mastalgia
Lump is commonly fibroadenoma or cyst
Lumpiness could be bilateral commonly in the
upper outer quadrant with cyclic increase the
nodularity & tenderness
Noncyclic breast pain is common in premenoposal
women, refaired pain should be excluded
Treatment of lumpy breast
If malignancy can be excluded clinically
and supported by mammography or US
reassurance
If malignancy cant be excluded tissue
biopsy and histopathology
Treatment of noncyclic mastalgia
Exclude cancer
Reassure
Adequate support
Exclude caffeine
Consider medication
Evening primrose oil (GLA)
Danazol, 100 mg t.d.s.
Tamoxifen
Breast cyst
Common in the last reproductive decade
Usually multiple
Dx by US & mamography
Treatment :
If no residual mass & not bloody no further
management
If residual mass core or excisional biopsy
If bloody send for cytology
If recur more than 2 times excisional Bx
Fibroadenoma
Simple: Second most common benign breast lesion
Benign solid tumors containing glandular as well as fibrous tissue .
Usually present as well defined, mobile mass
Commonly found in women between the ages of 15 and 25 years
Cause is unknown, thought to be due to hormonal influence
May increase in size during pregnancy or with estrogen therapy
Excision is not required if no suspicious of malignancy
Giant: Fibroadenomas over 5 cm in size
Excision is recommended
Phyllodes tumors
Women above 40 year old
Usually mobile
Small tumors resembling fibroadenoma
Can cause skin ulceration
Rarely malignant
Treat with wide local excision for benign tumors and
mstectomy for malignant
RELATIVE RISK FOR
INVASIVE BREAST CANCER
FOR BENIGN BREAST
LESIONS
RISK FOR INVASIVE BREAST
CANCER
No Increased R isk (NIR )
Mastitis
Fat necrosis
Mammary duct ectasia
Non-proliferative
(fibrocystic) disease
Fibroadenoma (simple)
RISK FOR INVASIVE BREAST
CANCER
Slightly R isk (SIR )
= R isk 1.5-2 T im es
Moderate/florid hyperplasia
Sclerosing adenosis
Fibroadenoma (complex)
Duct papilloma
RISK FOR INVASIVE BREAST
CANCER
M oderately R isk (M IR )
= R isk 4-5 T im es
Atypical ductal hyperplasia
Atypical lobular hyperplasia
Breast cancer
Breast Cancer Facts
2nd leading cause of death
2nd most common cancer
Incidence increases with
age
All women are at risk
Breast Cancer in USA
One out of eight American
women will be diagnosed
with breast cancer
Breast Cancer Risk Factors
that cannot be changed
Age
Family/Personal
History
GENDER - All
women are
at risk
Race
Radiation
Treatment with
Diethylstilbestrol
Reproductive
History
Menstrual
History
Genetic
Factors
Breast Cancer Risk Factors
that can be controlled
Obesity
All
women are
at risk
Exercise
Breastfeeding
Alcohol
Hormone
Replacement
Therapy
Not having
children
Birth Control
Pills
Fam ily History
Approx 10% of breast cancer is due to
inherited genetic predisposition
A woman whose mother or sister has
had breast cancer is at relative risk 2
to 3 times compared to other women
Fam ily History
At least two genes that predispose to
breast cancer have been identified
BR CA 1 and BR CA 2
Mutations in these tumour-suppressor
genes also predispose affected women
to ovarian cancer
ETIOLOGY
T he etiology of breast cancer in m ost
wom en is unk nown
M ost lik ely due to a com bination of
risk factors i.e. genetic, horm onal and
environm ental factors
HISTOLOGIC
CLASSIFICATION
Breast Cancer
Ductal
Lobular
(85%)
(15%)
DCIS
IDC
LCIS
ILC
Ductal Carcinoma In-situ
increased incidence with increased use
of mammographic screening and
early cancer detection
50% screen-detected cancers
Can also produce palpable mass
Ductal Carcinoma In-situ
Characterized by proliferating malignant
cells within ducts that do not breach the
basement membrane
Different patterns:
com edo (central necrosis);
cribiform (cells arranged around punched-out
spaces);
papillary and solid (cells fill spaces)
Ductal Carcinoma In-situ
Different grades i.e. low, intermediate and
high gradecomedo DCIS is classically high
grade
Often m ultifocalmalignant population can
spread widely through the duct system
Ductal Carcinoma In-situ
Women with DCIS are at risk of:
Recurrent DCIS following Rx
Invasive cancer (rel. risk 8 to 10 times)
especially in the same breast
Lobular Carcinoma In-situ
Relatively uncommon lesion
Malignant proliferation of small, uniform
epithelial cells within the lobules
Also at marked increased relative risk for
invasive cancer (8 to 10 times) in either
breast
Invasive Ductal Carcinoma
Commonest form of breast cancer
especially in poorer populations
Increasing incidence of screendetected
cancer in developed countries (usually
smaller; much better prognosis)
Invasive Ductal Carcinoma
Clinical presentation:
Hard, irregular palpable lump
Peau dorange (lymphatic obstruction +
thickening/dimpling of the skin)
Pagets disease of the nipple
(ulceration/inflammation due to intraductal
spread to the nipple)
Invasive Ductal Carcinoma
Clinical presentation:
Tethering of the skin
Retraction of the nipple
Axillary mass (spread to regional
lymph nodes)
Distant mets (liver, lung, bone)
Invasive Ductal Carcinoma
Different histologic types exist
The most common is scirrhous carcinom a (IDC of no
special type)
This type is characterized grossly by an irregular,
hard mass
Histology shows infiltrating clusters of malignant
cells in a dense, fibrous stroma
Invasive Ductal Carcinoma
Special histologic types of IDC:
M edullary carcinom a = circumscribed
tumour; sheets of malignant cells in dense
lymphoid stroma
T ubular carcinom a = infiltrating
tubular structures on histology
Invasive Ductal Carcinoma
Special histologic types of IDC:
M ucinous/colloid carcinom a = malignant
cells in pools of mucin
Papillary carcinom a = papillary formations
like papilloma + invasion
Invasive Lobular Carcinoma
Much less common than IDC
Can present with similar features
More likely to be bilateral and/or
m ulticentric (multiple lesions within the
same breast)
Invasive Lobular Carcinoma
Classic histology = small, uniform cells
arranged as:
Strands/columns within a fibrous stroma
(Indian-file)
Around uninvolved ducts ( bulls-eye
pattern)
Metastasize more frequently to CSF, serosal
surfaces and pelvic organs
PROGNOSIS
Stage
Staging systems inc.TNM and the Manchester
classification
T um or size and axillary node status are important
parameters
10-year survival rate for lymph node neg. disease is
80% vs 35% for tumors with positive nodes
PROGNOSIS
T um or Grade
Different grading systems exist
tumour grade = worse prognosis
Histologic Subtypes
PROGNOSIS
Horm one R eceptors
Estrogen receptors
Progesterone receptors
M olecular M ark ers
Inc. c-erb-B2, c-myc and p53
Treatment
Curative VS palliative
Surgery:
Breast conservation therapy
Modified radical mastectomy
Simple mastectomy
Chemotherapy
Radiation therapy
Hormonal therapy
The Male Breast
Gynecomastia
Prepubertal gynecomastia
Rare, adrenal carcinoma and testicular tumor can
cause this.
Pubertal gynecomastia
Occurs in 60-70% of pubertal boys.
Senescent gynecomastia
40% of aging men have this to some degree.
Drugs, such as steroids, digitalis, hormones,
spironolactone, and antidepressants can cause this.
Male breast carcinoma
0.7% of all breast cancers
<1% of male cancers
Average age of diagnosis is 63.6 years old
Painless unilateral mass that is usually subareolar
with skin fixation, chest wall fixation,, and
ulceration.
Mostly ductal carcinoma
Males generally present at later stage than woman
Overall survival worse in men, however when
compared stage for stage the survival rates are
similar.
Dr.ALBARQAWI
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