Benign & Malignant breast lesions

Presented by : omar al. Ma’aita

Mais al.shboul 6th year , surgery course , J.U.S.T

Breast

The breasts consist of mammary glands and associated connective tissues and skin

The mammary glands are modified sweat glands

LOCATION

Composition

Lobes Lobules (basic unit) Acini Ductules Lactiferous ducts ampulla Fat Coopers ligament

COMPOSITION

The lobule: is the basic structural unit of the mammary gland.

Histologically lactating vs. Nonlactating young vs. old lady

Suspensory lig

Arterial supply & venous drainage

Internal mammary artery.(aka:Int.Thoracic A. branch of subclavian

artery). Gives mammary branches

Intercostals

Superior ,lateral thoracic ,thoracoacromial &subscapular branches of axillary A

Venous supply mainly Axillary vein but also intercoastals & int.mammary v

Lymphatic drainage

Axillary nodes (75%) subclavian trunk

- lateral - anterior - posterior - central - apical Parasternal nodes

bronchomediastinal trunks

aka: Internal mammary nodes

Anterior

brachial

Subclav.\medial

Subscapular (post.)

Another pic. For L.Ns

Innervation Innervation of the breast is via anterior and lateral cutaneous branches of the

second to sixth intercostal nerves. The nipple is innervated by the fourth intercostal nerve.

Presentation of breast

Diseases&

How to approach

Presentation of breast diseases

Breast disease presents in three main ways:

1. LUMP , which may or may not be painful?

2. PAIN , which may or may not be cyclical?

3. Nipple DISCHARGE or change in appearance

Or Changes in breast size & shape

Approach to patient with breast sx

History Physical exam investigations

History

Age Hx of present illness: chief

complaint ,duration , associated sx ..etc Past medical hx : hx of breast\ovarian ca Parity & lactation (protective) Age of menarche , menstrual pattern , age of

menopause Drug hx :OCP or HRT Family hx

Triple assessment

I. Physical exam

Pt undressed to the waist 450

Inspection : Look at the size ,symmetry , skin , nipple & areola and whether there’s

duplication along the mammary line raise hand above head , on waist , inspect axilla , arms & supraclavicular

fossa Palpation with the flat of your fingers , begin with the normal side , any lump found

comment: site, shape, size , edge , surface , consistency , tender? Temp ? Overlying skin (fixed?color..etc) nipple eversion , express discharge

feel axillary tail , examine axilla , supraclavicular fossa & neck

General exam : for signs of mets

Investigations

• Triple Assessment• II. Imaging :

1. Mammography *(old lady)

2. Ultrasound *(young)

3. MRI

• III. Tissue sampling

1. Cytology (FNA)

2. histological Biopsy (core-cutting needle)

3. Large needle biopsy with vacuuming system

Mammogram

Low dose X-ray

Sensitivity increase with age as the density of the breast decreases.

5% of breast CA (lobular) can be missed by mammograms even in retrospect CA were not apparent.

Normal mammogram doesn’t exclude CA

Signs of malignancy on mammogram

Speculated mass Architectural distortion Micro calcification Asymmetry of breast tissue Dense mass Skin thickening Pathological lymph nodes

Speculation

Calcification

clusters

Linear branching microcalcification

Architectural distortion & L.N

Dense mass

US

Operator dependent.

Used in young women with dense breasts in whom mammograms are difficult to interpret.

Differentiate between solid and cystic lesions

Guide biopsies.

Tissue sampling

Needle cytology / biopsy Under local anesthesia. 21G or 23 G needle (spring loaded) with a

syringe passes through the lump with a negative pressure.

The aspirate is then smeared and examined. Then the needle can be used to take a

biopsy. Aspiration can’t differentiate in-situ from

invasion where biopsy can.

Benign breast lesions

Classification of Benign Breast lesions

developmental abnormalities inflammatory lesions Nipple disorders fibrocystic changes (part of ANDI)

stromal lesions Benign neoplasms

1. Developmental Anomalies

Ectopic breast (mammary heterotopia (accessory)), aberrant breast tissue, is the most common congenital abnormality of the breast.

seen mostly along the milk line (from axilla-groin)

Supernumerary Nipple (polythelia), areola, glandular tissue (polymastia)

Mammary Hypoplasia

Underdevelopment of the breast (hypoplasia)

When congenital, is usually associated with genetic disorders.

(turner’s syndrome , CAH )

Different from the acquired, which is usually iatrogenic, most commonly subsequent to trauma or radio-therapy

The complete absence of both breast and nipple (amastia) or presence of only nipple without breast tissue (amazia) is rare

1. Developmental Anomalies

Amazia?

Gynecomastia breast development of male in areolar region noted in males who smoke marijuana at

puberty

Inverted nipple: congenital or due to cancer

2. Infection

Mastitis A cellulitis of the interlobular

connective tissue within the mammary gland

Usually occurs during the first 3 months postpartum as a result of breast feeding.( Staph areus) Also known as puerperal or lactational mastitis.

Can result in abscess formation and septicemia

Treatment •Stop breast feeding and use breast pump instead•Apply Heat compressors•analgesia•Antibiotics

•Supportive counselling

diagnosed based on clinical symptoms and signs indicating inflammation.

A.Lactational mastitis

Risk factors

1. Improper nursing technique; leading to milk stasis and cracks of the nipple, entrance of microorganisms(staph.aureus)

2. Stress and sleep deprivation, which both lower the mother’s immune status and inhibit milk flow, thus causing engorgement

Usually one quadrant \ lobule is inflamed tender hot and swollen

B.Congestive Mastitis (from milk engorgement ) liable to occur around weaning time, and

sometimes in the early days of lactation(2nd -3rd day pp)

The complaint is of a swollen , tender breast which is often bilateral and without fever or erythema

C. Acute breast Abscess   is often associated with lactation* (if in nonlactating woman look for a

predisposing risk factor : DM\immunecompromised )

Staph.aureus gain acess to the favourable growth media (milk) via the nipple & ducts or via the circulation.

Patient present with malaise , fever & throbbing pain

There may be very abvious tender LNs in the epsilateral axilla

Treatment with Antibiotics

2.Inflammation of the breast Duct ectasia/periductal mastitis

This is a dilatation of the lactiferous ducts which are full of inspissated material containing macrophages and chronic inflammatory debris.

It has the following presenting features: Nipple inversion :at first mild and easily

everted.transverse slit appearance difficulty breast feeding

Nipple discharge :sometimes purulent Chronic low-grade infection of the periareolar

area with tender thicknening around the nipple going on to abcess formation known as periductal mastitis

Periductal abcess that may rupture or form a mamillary fistula

Smoking is a risk factor .

Duct ectasia

Treatment: In the case of a mass or nipple retraction, a carcinoma must

be excluded (bx of a mass if present \ cytology of discharge \ mammogram)

If any suspicion remains the mass should be excised Antibiotic therapy may be tried, the most appropriate agents

being co-amoxiclav or flucloxacillin and metronidazole The option to cure this condition is surgical excision of the

dilated ducts (the Hadfield’s operation)

3.ANDI

Stands for: Abberation of normal development and involution.

It’s a term used to describe most benign breast diseases .based on the fact that most benign breast disorders are relatively minor aberrations of the normal processes of development , cyclical hormonal response & involution.

Previousely there was tendency to include all benign breast disorders and pathology under the designation of “Fibrocystic disease”

ANDI Pathology The disease consists essentially of four features that

may vary in extent and degree in any one breast.1-Cyst formation. Cysts are almost inevitable and very

variable in size.2- Fibrosis. Fat and elastic tissues disappear and are

replaced with dense white fibrous trabeculae. The interstitial tissue is infiltrated with chronic inflammatory cells.

3- Hyperplasia of epithelium in the lining of the ducts and acini may occur, with or without atypia.

4- Papillomatosis. The epithelial hyperplasia may be so extensive that it results in papillomatous overgrowth within the ducts.

ANDI Symptoms:

1.Lumps & nodularity occure During years of ovarian activity (begin in the early 20s & peak

in the 30s)

most pt complain of more than one lump which are commonly tender , rubbery , not fixed or tethered

may be bilateral, commonly in the upper outer quadrant. 

The sweeling may be intermittent & clearly related the the menestrual cycle.

ANDI Symptoms:

2.Breast pain (Mastalgia): commoner in perimenopausal and postmenopausal women. It may be associated with ANDI

or with periductal mastitis, or referred (a musculoskeletal disorder Cyclical pain (never a sx of cancer )Rare before 30 yo and resolve spontaneously in the 40sDuring the luteal phaseHormonal related but curiuosly Unilateral Pain throughout the breast but mostly in the lateral upper quadrant No discrete lumpMay be so sever (can’t bear the pressure of bra !!) Relived , sometimes dramatically , when mense commense No need for investigations

Noncyclical painGirls at menarcheWomen in their 20sAround or postmenopausal (suspect underlying malignancy)\referred MSS

Treatment Lumps & nodularityreassurance.Review patient 6 weeks after the initial visit, and often the clinical

signs will have resolved by that time.  Mastalgia:firm reassurancesymptom diary will help her to chart the pattern of pain throughout

the month and thus determine whether this is cyclical mastalgiaevening primrose oil, in adequate doses given over 3 months, will

help more than half of these women., NSAIDS or OCP Prolactin inhibitor such as Danazol may be given. Anti-estrogen (tamoxifen or a LHRH agonist) to deprive the breast

epithelium of estrogenic drive

ANDI Symptoms: 3.Breast Cysts These occur most commonly in the last

decade of reproductive life (around menopause 40s-50s)

due to a nonintegrated involution of stroma and epithelium.

(Changing hormonal environment)

(HRT extend the age to 70s) They are often multiple, may be

bilateral and can mimic malignancy. They may develop suddenly ! Smooth , spherical (soft&cystichard) Never tethering \ fixation Are not usually mobile Recurrent

Diagnosis can be confirmed by aspiration and/or ultrasound(triple assessment)

Treatment

Aspiration of solitary cyst or small collection of cysts.

If they resolve completely, and if the fluid is not bloodstained, no further treatment is required.

However, 30% will recur and require re-aspiration.

If there is a residual lump, if the fluid is bloodstained, or if the cyst repeatedly reforms a local excision for histological diagnosis is advisable

Galactocele

Rare usually presents as a solitary, subareolar

cyst, and always caused by lactation. It contains milk and in long-standing cases its walls tend to calcify. It can become enormous

Aspiration reveals milk

But the cyst rapidly refills &

Resolution must await

Breast-feeding cessation

Injuries of the breast

Haematoma  Hematoma, particularly a

resolving hematoma, gives rise to a lump which, in the absence of overlying bruising, is difficult to diagnose correctly unless it is aspirated or incised.

Traumatic fat necrosis 

Traumatic fat necrosis may be acute or chronic, and usually occurs in middle-aged women. Following a blow, or even indirect violence (e.g. contraction of the pectoralis major), a lump, often painless, appears. This may mimic a carcinoma, even displaying skin tethering and nipple retraction, and biopsy is required for diagnosis.

5.Benign Neoplasms

Fibroadenoma

Phylloides tumor

Fibroadenoma Hyperplasia of a single lobule, and usually

grow up to 2—3 cm in size. Peri\intracanalicular surrounded by a well marked capsule The most Mobile (breast mouse) ,

smooth ,rubbery painless lump , spherical , sometimes lobulated

Happens in fully developed breast, mostly between the ages of 15 and 25 years.

In a patient under 30 years these do not require excision unless  associated with suspicious cytology, or if they become very large, or for cosmetic reasons

Dx : US (vs. cyst) Tt : observation

Giant fibroadenomas: occur occasionally during puberty. They are over 5 cm in diameter and are often rapidly growing.

Phyllodes Tumor previously sometimes known as

serocystic disease of Brodie or cystosarcoma phyllodes

These mostly benign tumors, usually occur in women over the age of 40 but can appear in younger women

They present as a large, sometimes massive tumor, with an unevenly bosselated surface.

Occasionally ulceration of overlying skin occurs owing to pressure necrosis

Doesn’t metastasize May Recure locally after simple

excision

Treatment

Benign type: enucleation in very young women or wide local excision.

Massive tumors, recurrent tumors and those of the malignant type will require mastectomy

Malignant breast lesions

Breast cancer

Breast cancer is the most common cancer all over the world and it's a leading cause of death in women

- in Jordan it's the First leading cause of death from cancers among Jordanian women

- In Jordan , Breast ca accounts for 35.8 % of Female cancers . which is close to the general trend in the world (32%)

Risk factors

1. Genetic predisposition sporadic (70%) Familial Breast ca (20%) Hereditary (10%)(AD) mostly in the

Young

BRCA-1 , BRCA-2 , p53 mutation .

2. Diet :

Fresh fruits and vegetables containing antioxidants and food containing Vitamin C are a risk lowering factors (protective)

While a diet rich in red meat and animal fat can put you in danger.

3. Smoking 4. Alcohol consumption OCP have Nothing to do with breast ca if they are taken in the proper age (childbearing age )

5. Nulliparity 6. Early menarche, late menopause 7. A history of a previous primary Breast ca or other

gynecological ca or Radiation exposure 8. Obesity is a risk factor in Postmenopausal women

9. Stress 10. Gender 11. geography 12. age

Risk factors

Risk factors

Histological Classification

Lobular carcinomas (5%) Ductal carcinomas (95%)

In situ Invasive

1.

LCIS & DCIS

Note the intact basement membrane

Ductal carcinoma in situ (DCIS)

lumen

C: Basement membrane

B: Cancer cellsA:Normal cells

Lobular carcinoma In Situ (LCIS)

lobule

duct

Incidental in PM

Micro calcification

ILC & IDC

Invasive Lobular Carcinoma (ILC) Invasive Ductal Carcinoma (IDC)

•Commonest form of breast cancer.

"dysmoplastic reaction"

Invasive Ductal Carcinoma

Special histologic types of IDC:

Carcinoma of no special type (NOS), which contain a big amount of fibrous tissue(extensive dysmoplastic reaction) that's why it's also called "scirrhous carcinoma" and it is the commonest type of breast ca

Medullary carcinoma(5%) = well circumscribed tumour;

sheets of malignant cells in dense lymphoid stroma.

Tubular carcinoma (10%)= infiltrating tubular

structures on histology.

Mucinous/colloid carcinoma(5%) = malignant cells in pools of mucin.

Papillary carcinoma = papillary formations like papilloma invasion     Invasive Ductal Carcinoma (IDC)

Inflammatory CA

Rare but worst type of Ca (IDC) Highly aggressive, most of these

tumors have distant met. Presents as painful, swollen

breast, which is warm with cutaneous edema because of blockage of the sub-dermal lymphatic's with carcinoma cells without a palpable mass (peau d'orange appearance)

Treat with aggressive chemo and radiotherapy, and salvage surgery.

Extremely poor prognosis

Invasive Lobular Carcinoma

Much less common than IDC accounts for 5-10% of breast CA

More likely to be bilateral and/or multicentric (multiple lesions within the same breast)

Small uniform cells arranged as strands or columns within a fibrous stroma around uninvolved ducts.

Metastasize more frequently to CSF, serosal surfaces and pelvic organs

Invasive Lobular Carcinoma (ILC)

Paget’s disease of the nipple

A superficial manifestation of an underlying Breast CA. Presents as an eczema-like

condition of the nipple and the areola, which slowly erodes.

An underlying carcinoma will sooner or later become clinically evident.

Dx by biopsy, paget cells in epidermis.

3.

Sarcoma of Breast 0.5% of breast CA Usually of spindle-cell variety

2.

Fibroadenoma

Phylloides tumor

Local – invade other breast tissue and chest wall. Lymphatic's – axillary, internal mammary,

supraclavicular, and contralateral nodes.

Hematogenous – lungs, brain, liver, bone…

Presentation

Any portion of the breast may be affected, but frequently the tumor is found in the outer upper quadrant.

1. Lump2. Nipple changes (retraction,

destruction, discharge)3. Puckering4. Peau d’orange5. Ulceration6. fixation

Tumor, Node, Mets. Indicate how much the tumor has spread. Detected by means of clinical, X-ray, CT, bone scan.

Prognosis

stage Histological grade Hormone receptor status Growth factor analysis (VEGF , HER-2)

Hormone receptor status

Growth factor analysis (VEGF , HER-2)

Aims to reduce the chances or recurrence and the risk of mets spread.

Surgery (lumpectomy, simple mastectomy, radical mastectomy, axillary procedures ).

growth fraction ,, initial Debulking

Adjuvant or neoadjuvant therapy (radio\chemo)

Hormonal therapy

Surgery

Radiotherapy

Chemotherapy

Hormonal

Targeted Drugs (ex. Herceptin)

The patient must be followed up life long to detect recurrence and dissemination.

Yearly or twice a year mammogram from the treated side and the other side.

Screening is essential because the prognosis depends mostly on the stage (early detection)

Mammographic screening start at the age of 40

Or 10 years before the age at which cancer was detected in a family member