Common Breast Disease

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Common Breast Disease

• Dr. Chan Wing Cheong
• Surgeon-in-charge
• Breast Surgery, NTEC

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Breast Anatomy and Location of Disease Processes
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Normal Breast Histology
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Lymphatic Drainage

• Axillary nodes level 1,2,3
• most of the breast drain into axilla.
• pectoral nodes /  breast and anterior chest wall
• sub scapular nodes / posterior chest wall and arm
  
• lateral nodes/ arm
• central (medial and apical) nodes/ drains all of
  the above three groups of nodes
• Infraclavicular
• Supra-clavicular nodes
• Internal mammary nodes
• Abdominal nodes

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Normal Breast Development and Physiology

• At puberty the breast develops under the
  influence of the hypothalamus, anterior
  pituitary, and ovaries and also requires insulin
  and thyroid hormone
• During each menstrual cycle 3 to 4 days before
  menses, increasing levels of estrogen and
  progesterone cause cell proliferation and water
  retention. After menstruation cellular
  proliferation regresses and water is lost.
• During pregnancy cellular proliferation occurs
  under the influence of estrogen and progesterone,
  plus placental lactogen, prolactin and chorionic
  gonadotropin. At delivery, there is a loss of
  estrogen and progesterone, and milk production
  occurs under the influence of prolactin.
• At menopause involution of the breast occurs
  because of the progressive loss of glandular
  tissue.

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ANDI classification ( Hughes et al, 1992 )
Normal Aberration ??
Disease Reproductive phases cysts, duct
ectasia, mild epithelial hyperplasia cyclical
mastalgia nodularity fibroadenoma, juvenile
hypertrophy
Periductal mastitis Epithelial hyperplasia with
atypia     Giant fibroadenoma (gt 5cms) Multiple
fibroadenomata (gt 5 per breast)
Involution Cyclical secretory Development
Spectrum of breast changes

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Aetiopathogenesis Some Theories

• Endocrine factors
• 1. Disturbances in the Hypothalamo Pituitary
  Gonadal steroid axis
• 2. Altered Prolactin profile qualitative
  /quantitative change
• Non endocrine factors
• Methyl xanthines, Stress
• Genetic predisposition to catecholamine
  supersensitivity ? Intra cellular
• C - AMP mediated events ? cellular
  proliferation
• 2. Diet rich in saturated fat
• Altered plasma essential fatty acid profile ?
  receptor supersensitivity to normal levels of
  Oestrogen Progesterone
• 3. Iodine deficiency
• Receptor supersensitivity to normal levels of
  Oestrogen Progesterone

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Carcinogenesis Genetic Predisposition
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Common Presenting Symptoms

• Over 80
• Lump
  
• Painful lump or lumpiness
• Pain
• Under 20
  
• Nipple discharge
• Nipple change
  
• Miscellaneous

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Symptoms Possible Diagnosis
1.Lump Carcinoma Fibroadenoma Juvenile Fibroadenoma Giant fibroadenoma Phyllodes tumours Cysts / Galactocele
2.Pain Mastalgia Cyclical Non cyclical
3.Nipple discharge Physiological Bloodstained in pregnancy Intraductal papillomas / papillocarcinoma Duct Ectasia Galactorrhoea
4.Nipple change Developmental inversion of nipple Acquired nipple retraction duct ectasia, periductal mastitis etc Eczema Pagets disease etc.
Infections Lactational Non-lactational
5.Cosmetic other problems Comon cosmetic problems size, shape symmetry of breast mound Uncommon cosmetic problems developmental acquired Trauma Rare problems
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Benign vs. Malignant
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Triple Assessment for Breast Problem

• Clinical
• Symptoms signs
• Assessment of risk factors
• Imaging
• Ultrasonography / Mammography
• Other imaging tests
• Pathological
• Fine needle aspiration cytology
• Core biopsy

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Case Scenario
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Case 1

• F/22
• Right breast swelling for 1 month
• No other symptoms
• What are the questions you want to ask?

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Case 1

• USG breast
• Compatible with a 1.5 cm fibroadenoma
• What would you offer her?
• What is the natural history of fibroadenoma?

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Case 2

• Same lady as case 1
• No surgery after discussion
• However
• Come back 7 months later
• Size of lesion increases up to 5 cm
• What investigation do you want to do?

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Case 2

• USG
• Compatible with a giant fibroadenoma or
  phylloides tumour
• Do you want to do FNA?
• What would you offer?

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Case 2

• Wide local resection performed
• Pathology
• Phylloides tumour of undetermined malignant
  potential, margins appear to be clear
• How do you advice this patient?

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Phyllodes Tumours

• Comprise less than 1 of all breast neoplasms
• May occur at any age but usually in 5th decade
  of life
• No clinical or histological features to predict
  recurrence
• 16 - 30 may be malignant
• Common sites of metastasis lungs, skeleton,
  heart and liver

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Treatment of Phyllodes Tumours

• 1. Primary treatment
• Local excision with
• a rim of normal tissue
• 2. Recurrence
• Re excision
• or
• Mastectomy with or without reconstruction
• Response to chemotherapy and radiotherapy for
  recurrences and metastases poor

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Case 3

• F/52
• Recently noticed a left breast lump
• No pain
• No other breast symptoms
• Just menopause
• What other questions regarding her problem that
  you will ask ?

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Risk Estimation for Breast Cancer

• RELATIVE RISK lt2 Early menarche lt 12 years Late
  menopause gt 55 years Nulliparity Proliferative
  benign disease Obesity Alcohol use Hormone
  replacement therapy
• RELATIVE RISK 24 Age 35 first
  birth First-degree relative with breast
  cancer Radiation exposure Prior breast cancer
• RELATIVE RISK gt4 Gene mutation Lobular
  carcinoma in situ Atypical hyperplasia

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Case 3

• P/E
• 2.5 cm mass over upper outer aspect of left
  breast
• Quite mobile
• No palpable axillary LN

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What would you do next ?
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Case 3
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Case 3

• MMG / USG breast
• 2.5 cm mass
• No axillary nodes
• Core needle biopsy
• Invasive carcinoma
• What would you offer?

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Options

• Modified radical mastectomy
• MRM reconstruction
• Autologus tissue flap
• Prosthesis
• Wide local excision axillary dissection
  post-op RT

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Any adjuvant therapy?

• Chemotherapy
• ? Indications
• Radiotherapy
• ? Indications
• Hormonal therapy
• ? Indications

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Case 4

• F/55
• Good past health
• Routine physical check-up
• Screening mammogram
• Left breast microcalcification

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What is your plan?
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Options

• Stereostatic core biopsy
• Mammotome
• Contra-indicated in suspicious lesion ( BIRAD )
• For small likely benign microcalcification
• Hook-wire guided excision biopsy
• For suspicious lesion
• Aims to achieve a clear margin

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Mammotome Biopsy
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Hook-wire Guided Excision
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If core biopsy confirms DCIS, whats next?

• If solitary, lt 3cm, not high grade
• Wide local excision RT
• Otherwise,
• Total mastectomy /- reconstruction
• Axillary node dissection not required
• Hormonal therapy if ER / PR positive

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Case 5

• F/ 43
• Recent onset of left breast mastalgia
• Clinically palpable thickening of breast tissue
  over L3H
• MMG not revealing
• Needle biopsy insufficient material
• Thus open excision biopsy

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Case 5

• Histopathology
• Lobular carcinoma in situ
• No invasive component
• All margins appear to be clear of tumour cells
• What would you suggest to the patient?

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Lobular Carcinoma (15-20)

• LCIS Invasive LC

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Case 6

• F/ 36
• Mother of 2 children
• Brownish stain on the inside of undergarment
• No pain
• No nipple change

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Differential Diagnosis?

• How would you like to investigate furhter?

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Ductogram
What can be offered to the patient ?
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Case 7

• F / 67
• Not significant PMH
• Recent L breast pain
• What is the diagnosis ?
• What would you offer to her ?

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Management for individual problem
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Pain

• Mastalgia
• Cyclical mastalgia
• Non cyclical mastalgia
• True (breast related)
• Musculoskeletal costochondral or lateral
  chest wall
• Infections
• Lactational infections
• Nonlactational infections
• Central Periductal mastitis (inflammation,
  mass, abscess, mammary duct fistula)
• Peripheral associated with diabetes,
  rheumatoid arthritis, steroid usage, trauma etc.
• Rare Tuberculosis, Granulomatous mastitis,
  Diabetic (lymphocytic) mastitis, etc.
• Skin associated infected Sebaceous cyst,
  Hidradenitis suppurativa etc.

True breast pain

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• Mastalgia
• Definition Pain severe enough to interfere
  with daily life or lasting
  over 2 weeks of menstrual cycle

True breast pain
True breast pain
Lateral chest wall pain
Costo Chondral pain
mild
Musculo skeletal pain
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Management Protocol for True Mastalgia

• Assess type of pain
• Assess severity of pain ( Pain diary Visual
  analogue scale )
• Evaluation with Triple assessment
• Treatment
• Reassurance is the key to management
• Use of supportive undergarments
• Low fat, Methyl xanthine restricted diet
• Stop Oral contraceptives / HRT etc
• Review patient. Successful in the majority ( 80
  85 ) of patients
• Use drugs in those not responding to
  non-pharmacological treatment
• Review and assess response

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Drugs of Established Value in Mastalgia
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Nipple Discharge

Causes of nipple discharge Benign (common) Malignant (less common) Causes of nipple discharge Benign (common) Malignant (less common)
Physiological causes Intraductal pailloma Blood stained nipple discharge of pregnancy Galactorrhoea Periductal Mastitis Duct Ectasia In situ carcinoma (DCIS) Invasive carcinoma
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Characteristics of Nipple Discharges
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Management of Spontaneous Nipple Discharge
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Galactorrhoea

• Management
• Estimate Prolactin levels. If very high,
  evaluate for pituitary lesion
• Physiological - Reassurance, cessation of
  stimulation
• Drug induced - Stop or change drug if possible
• Pathological - Cabergoline / Bromocriptine,
  treat cause if possible ( e.g. Pituitary
  surgery )

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Breast Mass

• Just prominent glandular tissue
• Cyst
• Simple vs. complex
• Abscess if painful and inflammed
• Solid mass
• Benign tumors
• Fibrocystic disease
• Carcinoma
• Fat necrosis

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Benign Lumps
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Cysts

• Common in the West ( 70 of women )
• 50 are solitary cysts
• 30 2 - 5 cysts
• rest have gt 5 cysts
• Types
• Apocrine cysts
• Lined by secretory epithelium
• Cyst fluid has a Na K ratio lt 3
• Likely to have multiple cysts
• Likely to develop further cysts
• Non-apocrine cysts
• Cyst fluid has a Na K ratio gt3
• Resembles plasma
• Mixture of both

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Management Algorithm for Cysts
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Fibroadenoma

• 
  

• Natural history
• Majority remain small static
• 50 involute spontaneously
• No future risk of malignancy

• Types
• Solitary
• Few ( lt 5 / breast )
• Multiple ( gt 5 / breast )
• Giant ( gt 4 / 5 cm ) Juvenile

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• Management Algorithm for Fibroadenoma

• Chances of malignancy masquerading as
  Fibroadenoma
• Age 20 25 yrs 1 3000 possibility
• Age 25 30 yrs 1 300 possibility

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Breast Carcinoma
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Breast Cancer No. 1 CancerAmong Women in HK

• Most common cancer among women since 1994
• No. 2 cancer killer among women in HK between
  1981-1998
• Due to decline in mortality rate, emerged as No.
  3 cancer killer since 1999
• According to 2002 figures, an average of 1 in 23
  women would develop cancer
• An average of 1 in around 100 women would die
  from breast cancer
• In 2002, 2,059 new cases and 425 deaths were
  registered

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Risk Factors

• Cause of breast cancer is undetermined. However,
• the following risk factors are identified
• History of breast cancer
• Family history of breast cancer, especially in
  first degree relatives
• Benign breast lesions ADH, ALH etc.
• Early menarche, late menopause
• Late first pregnancy / no pregnancy
• Exogenous estrogen (HRT)
• Radiation

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How is Breast Cancer Treated ?

• The type of treatment recommended will depend on
  the size and location of the tumor in the breast,
  the results of lab. tests done on the cancer
  cells and the stage or extent of the disease.
• Treatment can be divided into local treatment or
  systemic treatment.
• Local treatments are used to remove, destroy or
  control the cancer cells in a specific area, such
  as the breast.
• Surgery and radiation treatment are local
  treatments.
• Systemic treatments are used to destroy or
  control cancer cells all over the body.
• Chemotherapy and hormone therapy are systemic
  treatments.
• A patient may have just on form of treatment or a
  combination, depending on her needs.

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The Importance of Staging
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TNM Classification

• TX Primary tumour cannot be assessed
• T0 No evidence of primary tumour
• Tis Carcinoma in situ or Pagets disease of
  the nipple with no tumour.
• T1 2cm or less in greatest dimension
• T1a 0.5cm or less in greatest dimension
• T1b More than 0.5cm, but not more than 1cm in
  greatest dimension
• T1c More than 1cm but not more than 2cm in
  greatest dimension
• T2 Tumour more than 2cm but not more than 5cm
  in greatest dimension

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TNM Classification

• T3 tumour more than 5cm in greatest dimension
• T4 tumour of any size with direct extension to
  chest wall or skin
• T4a Extension to chest wall
• T4b Oedema (including peau d orange) or
  ulceration of the skin of breast or
  satellite skin nodules confined
  to same breast
• T4c Both T4a and T4b
• T4d Inflammatory carcinoma

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Regional Lymph Nodes (TNM)

• NX Regional lymph nodes cannot be assessed
  (e.g. Previously removed or removed for
  pathologic study)
• N0 No regional lymph node metastasis
• N1 Metastasis to movable ipsilateral axillary
  lymph node(s)
• N2 Metastasis to ipsilateral axillary lymph
  nodes that are fixed to one another or to
  other structures
• N3 Metastasis to ipsilateral internal mammary
  lymph nodes(s)

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Distant Metastasis (TNM)

• MX Presence of distant metastasis
  cannot be assessed
• M0 No distant metastasis
• M1 Distant metastasis (includes metastasis
  to ipsilateral supraclavicular lymph node)

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AJCC/UICC Stage Grouping

• Stage 0
• Tis N0 M0
• Stage I
• T1 N0 M0
• Stage IIA T0 N1 M0
• T1 N1 M0
• T2 N0 M0
• Stage IIB
• T2 N1 M0
• T3 N0 M0

• Stage IIIA
• T0 N2 M0
• T1 N2 M0
  
• T2 N2 M0
• T3 N1 M0
• T3 N2 M0
• Stage IIIB
• T4 Any N M0
• Any T N3 M0
• Stage IV
• Any T Any N M1

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Local-regional Control

• Surgery
• Toileting mastectomy
• Modified radical mastectomy (MRM)
• Wide local excision axilla dissection
• Wide local excision sentinel node biopsy
• Radiotherapy
• Must be given if breast conservative treatment is
  applied
• Otherwise depends on staging or resection margin

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Axillary Dissection

• Therapeutic vs. staging
• SLNB

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Systemic Control

• Chemotherapy
• AC or Taxol
• Indications
• Positive axilla nodes
• Node negative
• Young age
• High grade tumor
• Size gt 1 cm
• Hormonal receptors negative
• C-erb 2 positive ( Herceptin )
• Hormonal therapy
• Mainly for tumors expressing hormonal receptors
• No age limit now
• Usually 5 years
• Tamoxifen, AI

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Cosmetic Consideration

• BCT
• Reconstruction
• Prosthesis
• Flap
• Prosthesis flap

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Breast Conservation Treatment
Must be accompanied with post-op RT
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Prosthesis
Silicone gel saline bag
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Latissmus Dorsi Flap
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TRAM Flap
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TRAM Flap
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Questions Answers

• Dr. Chan Wing Cheong
• Surgeon-in-charge
• Breast Surgery, NTEC