Breast Diseases new

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GYNECOLOGY BREAST DISEASES Page 1

BREAST DISEASESChristiana P. Calagui-Damaso, M.D. FPSMS

ANATOMY

Breastsarelarge, modified sebaceous glands contained within thesuperficial fascia of the anterior chest wall

Axillary tail of Spence A lateral projection of glandular tissue extends from the

upper, outer portion of the breast toward the axilla

200 to 300g average weight of the adult breast during themenstruating years

mature breast consists of approximately 20% glandular tissue and80% fat and connective tissue

The periphery of breast tissue is predominantly fat, and the centralarea contains more glandular tissue

glandular portion of the breast is comprised of 12 to 15 independent ductal systems that each drain about40 lobules

Each lobule consists of 10 to 100 milk-producing acini that drain into small terminal ducts Terminal ducts drain into larger collecting ducts that merge into even larger ducts, which exhibit a

saccular dilation just below the nipple called a lactiferous sinus

12 to 20 lobes arranged in radial fashion from the nipple Each lobe is triangular and has one central excretory duct that opens to the exterior at the nipple Milk originates in the secretory cells of the alveoli

It is subsequently transported by the branching collecting ducts of the lobules into the lactiferoussinuses and terminally into the excretory ducts of each

respective lobe of the breast

Lobules 10 and 100, in each lobe of the breast ductal tissue surrounded by fibrous tissue Terminal ductules (TD) surround the central ductule (ID) EF, extralobularfibrocollagenous tissue

Montgomery glands are accessory glands located around the periphery of the

areola

Because they are structurally intermediate between true mammary and sebaceous glands, theycan secrete milk

Fibrous septa, Cooper's ligaments, extend from the skin to the underlying pectoralis fascia They are believed to offer support to the breast Invasion of these ligaments by malignant cells produces skin retraction, which is a sign of

advanced breast carcinoma

lymphatic distribution 75% of the lymphatic drainage goes to regional nodes in

the axilla

o axilla contains 30 and 60 nodeso axillary lymph nodes include the pectoral (chest),

subscapular (under the scapula), and humeral

(humerus-bone area) lymph-node groups, which

drain to the central axillary lymph nodes and to

the apical axillary lymph nodes
http://en.wikipedia.org/wiki/Axillary_lymph_nodeshttp://en.wikipedia.org/wiki/Axillary_lymph_nodeshttp://en.wikipedia.org/wiki/Axillary_lymph_nodes


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25% of the lymph travels to the parasternal nodes (beside thesternum bone), to the other breast, and to the abdominal

lymph nodes

o Mediastinum intercostal glands subpectoral andsubdiaphragmatic areas

Lymph drainage usually flows toward the most adjacent group ofnodes This represents the basis for sentinel node mapping in breast

cancer

breast cancer spreads in an orderly fashion within the axillarylymph node basin based on the anatomic relationship

between the primary tumor and its associated regional (sentinel) nodes

Development and Physiology

Fetal development the primordial breast arises from the basal layer of the epidermis

Before puberty the breast is a rudimentary bud comprised of a few branching ducts capped with alveolar buds,

end buds, or small lobules

At puberty - between the ages of 10 and 13 years ovarian estrogen and progesterone cooperate to direct organized communication between

breast epithelial cells and mesenchymal cells, resulting in extensive branching of the ductal

system and development of lobules

Final differentiation of the breast is mediated by progesterone and prolactin and is not completed untilthe first full-term pregnancy

Reproductive years - terminal ducts near the acini and the acini themselves are most sensitive to ovarianhormones and prolactin

Luteal phase of the menstrual cycle Breast epithelial cells proliferate when estrogen and progesterone levels are increased, and then

undergo programmed cell death at the end of the luteal phase, when levels of these hormones

decline This effect is mediated by paracrine signaling induced by estrogen receptor activation and is

associated with an increase in the water content of the extracellular matrix

o This is often recognized as breast fullness and tenderness the week preceding menseso Premenstrual breast symptoms are produced by an increase in blood flow, vascular

engorgement, and water retention

o 25 to 30 mL - average increase in volume of the premenstrual breasts Follicular phase

there is parenchymal proliferation of the ducts During the luteal phase

there is dilation of the ductal system and differentiation of the alveolar cells into secretory cells Menstruation begins

there is a regression of cellular activity in the alveoli and the ducts become smaller At menopause

ovarian estrogen production ceases breast lobules involute, and the collagenous stroma is replaced by fat Because estrogen receptor expression is negatively regulated by estrogen, there is an increase in

estrogen receptor expression after menopause


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Breast Anomalies 1% to 2% of women of European descent and 5% to 6% of Asian women Accessory breasts or nipples

o can occur along the breast or milk lines, which run from the axilla to the groin Supernumerary nipples (polythelia) or breasts (polymastia

Massive hypertrophy of the breasts at puberty (virginal hypertrophy) rare occurrence that has a deeply disturbing effect on a teenager's self-image

EVALUATION OF BREAST DISEASES

Detection

1. History Evaluation of a new breast symptom begins with assessment of symptoms based on a thorough

clinical history

Include questions regarding current symptoms, duration of the condition, fluctuation of the signs andsymptoms, and factors that aggravate or relieve the symptom

Assessment of breast problems should focus on the following points: Nipple discharge

o Characteristics of discharge (spontaneous or nonspontaneous, appearance, unilateral orbilateral, single or multiple duct involvement)

Breast mass (size and change in size, density, or texture) Breast pain (cyclic versus continuous) Association of symptoms with menstrual cycle Change in breast shape, size, or texture Previous breast biopsies

Patient should be questioned about the following risk factors for breast cancero Sexo Increasing age (approximately 50% of breast cancers occurafter age 65)o Age of menarche less than 12 yearso Nulliparity or first pregnancy at greater than 30 years of ageo Late menopause (older than 55 years of age)o Family history of breast cancer (especially premenopausal or bilateral disease)o Number of first-degree relatives with breast cancer and their ages when diagnosedo Family history of male breast cancero Inherited conditions associated with a high risk for breast cancer, including BRCA1 and BRCA2

genes, Li-Fraumeni syndrome, Cowden's disease, ataxia telangiectasia syndrome, and Peutz-

Jeghers syndrome

o Other malignancies (ovary, colon, and prostate)o Pathology of previous breast biopsy showing atypia or lobular or ductal carcinoma in situo Hormone therapyo Alcohol consumptiono Postmenopausal weight gaino Personal history of breast cancer

Breast cancer risk can be determined by the Gail Risk assessment model calculates risk based on patient race, age, age of menarche, age of first live birth, number of first -

degree relatives with breast cancer, number of previous breast biopsies, and presence of atypia

on the biopsy


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2. Physical Examination Breast tumors, particularly cancerous ones, usually are asymptomatic and are discovered only by

physical examination or screening mammography

premenstrual phase - most women have increased innocuous nodularity and mild engorgement ofthe breast

a. Inspection performed initially while the patient is seated comfortably with her arms relaxed at her sides Pay attention to the following signs

for symmetry contour edema Discharge or secretions alterations of the nipple

o retractiono eczema on one side

skin modifications or appearanceo redness or erythemao retraction of the skino bulge of the breasto orange skino Skin dimpling

Secretion Tumor infiltrating the skin

Retraction of skin


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Inflammation /Redness/Erythema Bulge of the breast

eczema on one side Retraction of nipple

b. Palpation While the patient is seated, each breast should be palpated methodically palpate the breast in enlarging concentric circles until the entire breast has been covered Palpation should use the pads of the first three fingers placed together, exerting firm but gentle

pressure

Pendulous breast can be palpated by placing one hand between the breast and the chest wall and gently palpatingthe breast between both examining hands.

The axillary and supraclavicular areas should be palpated for enlarged lymph nodes The entire axilla, the upper outer quadrant of the breast, and the axillary tail of Spence are palpated

for possible masses

PLATEAU SIGN

retraction of the skin is invisible unless you move or shift the skinbetween the fingers of both hands

While the patient is supine with one arm over her head, theipsilateral breast is again methodically palpated from the clavicle

to the costal margin

If the breast is largeo a pillow or towel should be placed beneath the scapula to

elevate the side being examined

o otherwise, the breast tends to fall to the side, makingpalpation of the lateral hemisphere more difficult

Major features to be identified Temperature texture and thickness of skin


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generalized or focal tenderness Nodularity density asymmetry dominant masses nipple discharge mobility

Premenopausal patients nodular breast parenchyma

Breast cancer mass nontender, firm mass with irregular margins A cancerous mass feels distinctly different from the surrounding nodularity A malignant mass may be fixed to the skin or to the underlying fascia

Breast Self-examination

Increases breast health awareness It helps promote early detection of cancer and may improve the survival rates for patients with breast

carcinoma

Most breast cancers are detected by women themselves (48%), followed by breast imaging (41%),and by physician clinical examination in only 11%

Essential components of breast examination Positions Palpation Pads of fingers for palpation Pressure Perimeter Pattern of search Patient education

It is helpful for all women to examine their breasts at the same time each month to develop a routine Premenopausal women

should examine their breasts monthly 7 to 10 days after the onset of the menstrual cycle For postmenopausal women selection of a specific calendar date is a helpful way to remember to perform a monthly BSE Use the pads of her second, third, and fourth fingers to palpate the contralateral breast Using the pads of her fingers, in a massaging motion with firm pressure, she should examine the

entire breast and surrounding chest wall in a systematic fashion

One of the easier techniques to follow is to palpate the breasts in a clockwise fashion beginning atthe nipple and gradually circumscribing larger circles


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3. Breast Imaginga. Mammography

screen-film mammography best method for imaging of the breast

Advantages of digital mammography lower radiation exposure ability to manipulate a computerized image for optimal viewing access to distance consultations through telemammography

Slow-growing breast cancers can be identified by mammography at least 2 years before the massreaches a size detectable by palpation

Mammography is the only reproducible method of detecting nonpalpable breast cancer Most practical method of detecting breast carcinoma at an early and highly curable stage, ideally

discovering an occult cancer (


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Mass margin Shape of mass Density of mass Associated findings Special cases

Malignancy clusters of fine calcifications spiculations poorly defined multinodular masses with irregular contours

Mammograhic Screening Recommendaions of the American Cancer Society

Mammograhic screening at age 40o 24% reduction in mortality in screened populations

For women in their 20s and 30so clinical breast examination is suggested at least every 3 years, and preferably

annually

For women older than age 40 years, annual clinical breast examination For older women, recommendations for mammographic screening may be

individualized based on the presence of any comorbidities

Recommendaions of the American Geriatrics Society annual or at least biennial mammography for women up to age 75 years after 75 years, every 2 to 3 years if the woman has a life expectancy of more than 4

years

For high-risk women, consideration can be given to earlier initiation of screening (5 to10 years earlier than the age of the index case) and shorter intervals between screening

Normal mammogram Breast Tumor


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b. Digital Radiography X-ray photons are detected after passing through the breast tissue and the radiographic image is

recorded electronically in a digital format and stored in a computer

Advantages compared with conventional mammography Image acquisition, display, and storage are much faster image manipulation through adjustments in contrast, brightness, and electronic

magnification of selected regions enables radiologists to obtain superior views Helpful in screening women with very dense breasts and breast implants

Disadvantages high cost of the equipment the limited image storage capacity the reduced spatial resolution due in part to inadequate resolution of current monitors

c. Computed Tomography Has limited value when compared with mammography because of higher radiation dose and

longer study times

Excellent for studying the most medial and lateral aspects of the breast It is sometimes used for preoperative wire location of a mass that is difficult to localize by

mammography

d. Magnetic Resonance Imaging Not be used in screening because of higher cost but as a diagnostic test Proven effective in detecting new tumors in patients with previous lumpectomy because it can

accurately distinguish between scar tissue and cancerous lesions

Indications Stage tumor to rule out multicentric disease Differentiate postoperative scar from recurrence after breast-conserving surgery Find a lesion seen in only one view of mammogram Evaluate positive axillary nodes in the presence of negative mammogram and clinical breast

examination results

Rule out silicone implant rupture Assess focal assymetry

e. Ultrasonography complementary procedure to other imaging techniques in the diagnosis of breast disease,

particularly in differentiating cystic from solid masses

It should not be used as a screening test except for women with very dense breasts whocannot be adequately screened with mammography

Advantages of ultrasound ability to produce images of breast tissue on multiple occasions without harmful effects It is most useful in evaluating solitary masses greater than 1 cm in diameter

greatest limitation of ultrasonography The limited spatial resolution Microcalcifications are not visualized because resolution of less than 2 mm is difficult with

ultrasound

Indications for breast ultrasonography Characterization:

o Palpable abnormalityo Ambiguous mammographic findingso Silicone leako Mass in woman younger than 30 years, lactating, or pregnant

Guidance for interventional procedureso guide for needle aspiration, needle core biopsy, and in localization procedures


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o also used to localize tumorsintraoperatively without a guide wire with excellentsuccess rates

Possible role for additional imaging in high-risk individuals Differentiate a cystic breast mass from a solid mass

o most important use of ultrasoundo 96% to 100% accuracy rate

f. Mammoscintigraphy (Scintimammography) Radionuclide imaging test for the detection of breast cancer High diagnostic accuracy for the detection of breast cancer in all women, including women who

may be unsuitable for conventional mammography

Breast Tissue Evaluation: Histology and Cytology

30% of lesions suspected to be cancer prove on biopsy to be benign 15% of lesions believed to be benign prove to be malignant Dominant masses or suspicious nonpalpable mammographic findings must be evaluated by biopsy An apparently fibrocystic lesion that does not completely resolve within several menstrual cycles should

be sampled for biopsy

Any mass in a postmenopausal woman who is not taking estrogen therapy should be presumed to bemalignant

Algorithm for management of breast masses in postmenopausal women

Palpable mass

Not clinically

malignant

Mammography

FNAC or Core

Needle Biopsy

Preoperative

evaluation and

counselling

Definitive Procedure

Excisional Biopsy

Mammography

Not obviously

malignant


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Algorithm for management of breast masses in premenopausal women

Palpable mass

Mammogram

Ultrasound

FNAC or Core

Needle Biopsy

Appears malignantcystic

Solid but not

suggestive of

malignancy

Excise or re-examine

after next menses or

1-2 months

persistence

excision

aspirate

Nonbody fluid

resolves

reexamine

recurrence

excisionRoutine follow up

No recurrence

excision

resolution

Clinically malignant

mammogram

Definitive procedure

Preoperative

evaluation andcounselling

Not clinically

malignant

Routine follow up


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1. Fine-needle Aspiration The color of the fluid obtained via aspiration varies from clear to

grossly bloody

A biopsy should be performed on cysts that recur within 2 weeks orthat necessitate more than one repeat aspiration

sensitivity of FNA for palpable masses is approximately 90% false-negative rate that varies from 0.7% to 22%

2. Biopsy Core Needle or Open Biopsy Indications for tissue biopsy

bloody discharge from the nipple a persistent three-dimensional mass suggestive mammography Nipple retraction or elevation skin changes, such as erythema, induration, or edema

BENIGN BREAST CONDITIONS

Three life cycles reflect different reproductive phases in a woman's life and are associated with uniquebreast manifestations

During the early reproductive period (15-25 years), lobule and stromal formation occurso fibroadenoma (mass) and juvenile hypertrophy (excessive breast development)

During the mature reproductive period (25-40 years), cyclic hormonal changes affect glandulartissue and stroma

o cyclic mastalgia and generalized nodularity involution of lobules and ducts or turnover of epithelia, which occurs during ages 35 to 55 years

o macrocysts (lumps)o sclerosing lesions (mammographic abnormalities)o Those associated with ductal involution - duct dilation (nipple discharge) and periductal

fibrosis (nipple retraction)

o those with epithelial turnover are mild hyperplasia (pathologic description)1. Fibrocystic Change

most common lesion of the breast refers to a histologic picture of fibrosis, cyst formation, and epithelial hyperplasia Cysts arise from the breast lobules and are an aberration of normal breast involution common in women ages of 20 and 50 (35 to 55 years of age) but rare in postmenopausal women not

taking hormone therapy

it is present bilaterally, increased in the perimenopausal age group, and responsive to endocrinetherapy

believed to be an exaggeration of the normal physiologic response of breast tissue to the cyclic levelsof ovarian hormones

imbalance of the ratio of estrogen to progesterone secondary to increased daily prolactin production Women with fibrocystic changes have

enhanced prolactin production in response to thyroid-releasing hormone

Signs and Symptoms - more prevalent during the premen-strual phase of the cycle cyclic bilateral breast pain classic symptom

pain is most frequently located in the upper, outer quadrants of the breasts. Often thepain radiates to the shoulders and upper arms

increased engorgement and density of the breasts excessive nodularity rapid change and fluctuation in the size of cystic areas increased tenderness


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occasionally spontaneous nipple discharge Differential diagnosis of breast pain

Referred pain from a dorsal radiculitis Inflammation of the costal chondral junction (Tietze's syndrome)

Physical Examination Excessive nodularity of fibrocystic changes is similar to palpating the surface of a plateful of

peas Multiple solid areas are described as ill-defined thicknesses or areas of palpable lumpiness

that are rubbery in consistency and may seem more two-dimensional than the three-

dimensional mass usually associated with a carcinoma

The larger cysts have a consistency similar to a balloon filled with water Clinical Stages

a. mazoplasia (mastoplasia) first stage occurs in women in their 20s Breast pain is noted primarily in the upper, outer quadrants of the breast The indurated axillary tail is in the most tender area of the breast There is intense proliferation of the stroma

b. Adenosis second stage women in their 30s breast pain and tenderness are premenstrual but less severe Multiple small breast nodules vary from 2 to 10 mm in diameter marked proliferation and hyperplasia of ducts, ductules, and alveolar cells

c. Cysticphase - third stage

women in their 40s There is no severe breast pain unless a cyst increases rapidly in size woman experiences a sudden pain with point tenderness and discovers a lump Cysts are tender to palpation and vary from microscopic to 5 cm in diameter fluid aspirated from a large cyst is straw-colored, dark brown, or green

Diagnostic Tests Characteristic findings on ultrasonography

o Mass with thin wallso Smooth round shapeo Absence of internal echoeso Posterior acoustic enhancement

If these imaging criteria are not met, a tissue diagnosis of the mass usually requires a FNA, FNAC,or EB

Fine needle aspiration Benign cyst fluid - straw colored to dark green to brownish

Fibrocystic change is not associated with an increased risk of breast cancer unless there is histologicevidence of epithelial proliferative changes, with or without atypia

If there is a persistent dominant mass or any uncertainty in the examination, a biopsy of the areashould be performed to rule out a malignancy

Management patient wearing a support bra, which provides adequate support for the breasts both night

and day

Diuretics during the premenstrual phase occasionally relieve breast discomfort Oral contraceptives or supplemental progestins administered during the secretory phase of

the cycle

Danazol drug of choice for severe symptoms 100, 200, and 400 mg daily continuously for 46 months should not continue more than 6 months because side effects are common

Bromocriptine or Tamoxifen Patients who do not respond to danazol


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Bromocriptine - an inhibitor of prolactin given continuously of 5 mg daily

Tamoxifen - a synthetic antiestrogen 70% relief of breast symptoms when prescribed for fibrocystic changes

2. Fibroadenomas firm, rubbery, freely mobile, solid, usually solitary breast masses second most common type of benign breast disease adolescents and women in their 20s Usually discovered accidentally while bathing Do not change in size with the menstrual cycle, and they do not produce breast pain or tenderness 30% will disappear and 10% to 12% become smaller average fibroadenoma is 2.5 cm in diameter responsive to estrogen stimulation not associated with an increased risk for breast cancer Sonography - differentiating a solid from a cystic mass FNAB Open biopsy or surgical removal

3. CystosarcomaPhyllodes fibroepithelial breast tumors hypercellularity of the connective tissue rare - represent only 2.5% of fibroepithelialtumors and 1% of breast malignancies They are the most frequent breast sarcoma Rapidly growing tumors Most common in the fifth decade of life Rarely bilateral and usually appear as isolated masses that are difficult to distinguish clinically from a

fibroadenoma

Patients often relate a long history of a previously stable nodule that suddenly increases in size Reported sizes range from 1.0 to 50 cm

Factors that are considered in recommending excision include older age new mass in a well-screened individual rapid growth size greater than 2.5 to 3 cm suspicious FNAC or CB mammographic or ultrasonographic features that demonstrate lobulation and intramural

cysts

Treatment - wide local excision, attempting to obtain a 1- to 2-cm margin Prognosis

benign phyllodestumors can recur locally in up to 10% of patients Malignant phyllodestumors tend to recur locally and occasionally may metastasize to the lung,

although brain, pelvic, and bone metastases also may occur

Borderline tumor Malignanttumor


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4. Intraductal Papilloma spontaneous bloody discharge from one nipple - classical symptom

discharge from the nipple is spontaneous and intermittent watery, serous, or serosanguineous When the discharge comes from a single duct, the differential diagnosis involves both intraductal

papilloma and carcinoma

If multiple ducts are involved, the diagnosis of carcinoma is more likely perimenopausal age group 75% of intraductalpapillomas are located beneath the areola difficult to palpate because they are small and soft Treatment - excisional biopsy of the involved duct and a small amount of surrounding tissue

5. Nipple Discharge complaint of 10% to 15% of women with benign breast disease spontaneous nipple discharge is infrequently found to be associated with carcinoma, ranging from 4%

to 10%

Nonneoplastic processes galactorrhea physiologic changes resulting from mechanical manipulation parous condition periductal mastitis subareolar abscess fibrocystic change mammary duct ectasia

Neoplastic causes in nonlactating women solitary intraductal papilloma carcinoma papillomatosis squamous metaplasia adenosis

Characteristics of the discharge to be evaluated Nature of discharge (serous, bloody, or milky) Association with a mass Unilateral or bilateral Single or multiple ducts Discharge that is spontaneous (persistent or intermittent) or expressed by pressure at a

single site or on entire breast

Relation to menses Premenopausal or postmenopausal Hormonal medication (contraceptive pills or estrogen)

Chronic unilateral nipple discharge, especially if it is bloody, is an indication for resection of theinvolved ducts

Treatment surgical excision

o periareolar incision adjacent to the trigger point, the pressure point that elicits nippledischarge

6. Fat Necrosis Rare but clinically important because it produces a mass, often accompanied by skin or nipple

retraction, which is indistinguishable from carcinoma


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firm, tender, indurated, ill-defined mass that may have an area of surrounding ecchymosis Sometimes the area of fat necrosis liquefies and becomes cystic in consistency needle-core excisional biopsy of the entire mass to rule out carcinoma

7. Breast Abscess Lactational Abscesses

Staphylococcus aureus mastitis is diagnosed, manual pressure, antibiotics, and continued breastfeeding are

recommended

dicloxacillin 250 mg four times daily, or oxacillin, 500 mg four times daily for 7 to 10 days If the lesion progresses to a localized mass with local and systemic signs of infection, an abscess is

present

It should be drained, and breastfeeding should be discontinued Nonlactational Abscess

Staphylococcus epidermidis Staphylococcus aureus Proteus mirabilis Pseudomonas aeruginosa sterile abscess

If these infections recur after multiple aspirations, incision and drainage followed by excision of theinvolved lactiferous duct or ducts at the base of the nipple may be necessary during a quiescent

interval

BREAST CARCINOMA

Epidemiology

Established and Probable Risk Factors for Breast Cancer

Risk Factor ComparisonCategory Risk Category

Typical

RelativeRisk

Family history of breast cancer - 5% to 10%

- BRCA1 (chromosome 17q21) and BRCA2 No first-degreerelatives affected Mother affectedbefore the age of60

2.0

Mother affected

after the age of 60

1.4

Two first-degree

relatives affected

46

Age at menarche - There is no clear association between

the risk of breast cancer and menstrual irregularity and the

duration of menses

16 yr 11 yr 1.3

12 yr 1.3

13 yr 1.3

14 yr 1.3

15 yr 1.1


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Age at birth of 1st child

If a woman's first term birth occurs before age 20, she has 50% less

risk than a nulliparous woman.

If the first full-term pregnancy occurs after age 35, the risk is 1.5

times greater than for women who have their first baby before age

26

It was believed that nursing an infant offered a protective effect for

the future development of breast neoplasia

related to the intensity and duration of exposure to unopposed

endogenous estrogen

Before 20 yr 2024 yr 1.3

2529 yr 1.6

30 yr 1.9

Nulliparous 1.9

Age at menopause - After menopause the incidence of breast

carcinoma increases directly with a woman's age

-twofold increased risk for women who menstruated for 40 years or

longer

- Bilateral oophorectomy before age 35, without hormonalreplacement, reduces the risk of breast carcinoma by 70%

4554 yr After 55 yr 1.5

Before 45 yr 0.7

Oophorectomy

before 35 yr

0.4

Benign breast disease No biopsy or

aspiration

Any benign disease 1.5

Proliferation only 2.0

Atypical hyperplasia 4.0

Radiation - Ionizing radiation is a definite risk factor because of the

long-accepted relationship between radiation and malignant

transformation

No special

exposure

Atomic bomb (100

rad)

3.0

Repeated

fluoroscopy

1.5

2.0

Obesity - increased amount of peripheral conversion ofandrostenedione to estrone and decreased levels of sex hormone-

binding globulin

10th percentile 90th percentile:

Age, 3049 yr 0.8

Age, 50 yr 1.2

Height 10th percentile 90th percentile:

Age, 3049 yr 1.3

Age, 50 yr 1.4

Oral contraceptive use - no consensus on the association of

exogenous estrogen administration

Never used Current use 1.5

Past use[*]

1.0

Postmenopausal estrogen-replacement therapy - no consensus on

the association of exogenous estrogen administration

Never used Current use all ages 1.4

Age,


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Detection and Diagnosis

use of screening tests in asymptomatic women at periodic intervals to discover breast malignancies Physical examination

detects 10% to 20% of cancers not seen radiographically 10% to 50% of cancers detected mammographically are not palpable

Breast cancer most commonly arises in the upper outer quadrant, where there is proportionally morebreast tissue

Masses are easier to palpate in older women with fatty breasts than in younger women with dense,nodular breasts

When a dominant breast mass is identified, the presence of a carcinoma must be considered biopsy should be performed to establish a tissue diagnosis

About 30% to 40% of lesions believed clinically to be malignant will be benign on histologic examinationPrevention

lifestyle modifications associated with good general health weight control, avoidance of smoking, decreased alcohol consumption, and exercise

tamoxifen had a significant decrease in the incidence of contralateral breast cancers

Surgical prophylaxisClassification

classic sign solitary, solid, three-dimensional, dominant breast mass borders of the mass are usually indistinct, which makes it difficult to define precisely the size of

the mass

mass is not freely mobile Far-advanced local disease

produces changes in the skin and nipples of the breast, includ-ing retraction, dimpling,induration, edema (peaud'orange), ulceration, and signs of inflammation

Simplified Classification of Breast Carcinoma

Type of Carcinoma Percentage of All Cases Diagnosed

Ductal Carcinoma

- in situ

- infiltrating

5

80

Lobular Carcinoma

- In situ

- Infiltrating

- Inflammatory carcinoma

- Paget's disease

3

9

2

1

Intraductalcarcinomain situ

the cellular abnormalities are limited to the ductal epithelium and have not penetrated the basemembrane

It is most commonly discovered in perimenopausal and postmenopausal women. not usually detected by palpation because the disease does not produce a definitive mass Mammography sometimes demonstrates the fine stippling of microcalcifications. The histologic diagnosis includes a heterogeneous group of tumors with varying malignant potential


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Lobular carcinoma in situ

considered to be a marker for an increased breast cancer risk It does not have the same malignant potential as intraductal carcinoma in situ has a much greater tendency to be bilateral and to present as multifocal disease

Infiltrating ductal carcinoma

most common breast malignancy Histologically, nonuniform malignant epithelial cells of varying sizes and shapes infiltrate the surrounding

tissue

Infiltrating lobular carcinomas

characterized by the uniformity of the small, round neoplastic cells the malignant epithelial cells infiltrate the stroma in a singlefile fashion tends to have a multicentric origin in the same breast and tends to involve both breasts more often than

infiltrating ductal carcinoma

Histologic subdivisions small cell round cell signet cell carcinomas

Inflammatory carcinomas

2% of breast cancers initially appear to have acute inflammation of the breast with corresponding redness and edema recognized clinically as a rapidly growing, highly malignant carcinoma Infiltration of malignant cells into the lymphatics of the skin produces a clinical picture that simulates a

skin infection

Paget's disease

less than 1% has an innocent appearance and looks like eczema or a dermatitis of the nipple erosion results from invasion of the nipple and surrounding areola by characteristic large cells with

irregular nuclei, called Paget cells produced by an infiltrating ductal carcinoma that invades the epidermis has an excellent prognosis

Breast Cancer in Pregnancy

complicates 1 in 3,000 pregnancies second most common malignancy seen in association with pregnancy Generalized recommendations for treatment

cancers diagnosed during the first or second trimester of pregnancy have been treated withmodified radical mastectomy. Sentinel node biopsy remains a controversial procedure in

pregnancy

Localized tumors found during the third trimester of pregnancy can be managed with breastconservation therapy, with radiation delayed until after delivery, or with modified radical

mastectomy

If the breast cancer is diagnosed during lactation, lactation should be suppressed and the cancershould be treated definitively

Advanced, incurable cancer should be treated with palliative therapy


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Treatment of Breast Cancer

four most important variables for treatment selection tumor'ssiz its inherent aggressiveness, as determined by the histology of the initial lesion the presence of positive nodes the receptor status of the tumor

TNM system widely recognized staging system based on both clinical and pathologic criteria

Surgical Therapy radical mastectomy

o standard operation for carcinoma of the breasto designed to control local disease by an extensive en bloc removal of the breast and

underlying pectoralis major and pectoralis minor muscles and complete axillary

dissection

o It is a cosmetically disfiguring operation, leaving a major deformity of the chest wall modified radical mastectomy removes the breast and only the fascia over the pectoralis major muscle. The pectoralis minor

muscle may be removed to facilitate the axillary dissection

Simple mastectomyo removal of the breast without underlying muscle tissue

Stages I and II breast cancero conservative surgery, which preserves the breast, followed by radiation therapy

Medical Therapy Adjuvant systemic chemotherapy decreases the odds of dying from breast cancer during the first

10 years following diagnosis by approximately 25%

Tamoxifen Medroxyprogesterone (Depo-Provera) Androgens danazol gonadotropin hormone-releasing hormone (GH-RH) agonists Combination therapy

o paclitaxel Adriamycin cyclophosphamideo cyclophosphamide (C), methotrexate (M), and 5-fluorouracil (5-FU).
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Primary Tumor (T)

TX Primary tumor cannot be assessed

T0 No evidence of primary tumor

Tis[*]

Carcinoma in situ. Intraductal carcinoma, lobular carcinoma in situ, or Paget's disease of the nipple with no tumor

T1 Tumor is 2.0 cm in greater dimension

T1a Tumor is 0.5 cm in greatest dimension

T1b Tumor is >0.5 cm but not more than 1.0 cm in greatest dimension

T1c Tumor is more than 1.0 cm but not more than 2.0 cm in greatest dimension

T2 Tumor is >2.0 cm but not more than 5.0 cm in greatest dimension

T3 Tumor is >5.0 cm in greatest dimension

T4 Tumor of any size with direct extension to chest wall or skin

T4a Extension to chest wall

T4b Edema (including peau d'orange) or ulceration of the skin of the breast or satellite skin nodules confined to the same breast

T4c Both T4a and T4b above

T4d Inflammatory carcinoma

Regional Lymph Node Involvement (N) (Clinical)

NX Regional lymph nodes cannot be assessed (e.g., previously removed)

N0 No regional lymph node metastasis

N1 Metastasis to movable ipsilateral axillary lymph node(s)

N2 Metastasis to ipsilateral axillary lymph node(s) fixed to one another or the other structures

N3 Metastasis to ipsilateral mammary lymph node(s)

Distant Metastasis (M)

MX Presence of distant metastasis cannot be assessed

M0 No distant metastasis

M1 Distant metastasis (includes metastasis to ipsilateral supraclavicular lymph node[s])

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, N2 M0

Stage IIIb T4 Any N M0

Any T N3 M0

Stage IV Any T Any N M1


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