The Breast Basic Science Conference Cindy M Deutmeyer MUSC Department of Surgery May 25 th , 2010
-
Upload
fuller-knight -
Category
Documents
-
view
26 -
download
1
description
Transcript of The Breast Basic Science Conference Cindy M Deutmeyer MUSC Department of Surgery May 25 th , 2010
The BreastBasic Science Conference
Cindy M DeutmeyerMUSC Department of Surgery
May 25th, 2010
AnatomyDevelop along paired mammary ridgesPrimary bud 15-20 secondary buds epithelial cordsMajor (lactiferous) ducts empty into shallow mammary pit mesenchyme proliferates elevation above skin nipple 4% Inverted nipples (pit not elevated above skin)Puberty: Estrogen & Progesterone proliferation of epithelial & connective tissue elementsPolymastia: accessory breastAmastia: absence of breastPoland’s Sx: hypoplasia or absence of breast w/rib, chest wall, & upper extremity defectsPolythelia: accessory nipples (1%)
Anatomy
3 tissue types: fatty, fibrous, glandular15-20 lobes composed of several Lobules Each lobe drains into Lactiferous Duct/Sinus, and eventually nippleCooper’s suspensory ligaments: fibrous connective tissue bands, perpendicular to dermis, structural support
Breast Boundaries
SuperiorClavicle, 2nd rib
InferiorInframammary Fold, 6th rib
MedialSternum (lateral border)
LateralAnterior axillary line,
Latissimus dorsiPosterior
Pectoral fascia
* Axillary tail of Spence
Blood Supply & LymphaticsInternal Mammary a. perforatorsIntercostal a.Axillary a. branches
* Lateral thoracic* Highest thoracic
Thoracoacromial a. branches
3 principal groups of veins* Internal thoracic v. perforators* Intercostal v. perforators* Axillary v. tributaries
Batson’s plexus: surrounds vertebral column
6 axillary lymph node groupsReceive 75% lymph drainage3 axillary lymph node levels* Level I: lateral to Pec minor* Level II: deep to Pec minor* Level III: medial to Pec minor
Cases
Case 1: Breast Pain
35 y.o. G1P1 presents with complaints of pain in breasts.
Pain is bilateral, diffuse. Feels swollen.
POBHx- SVD x 1
PGYNHx- regular menses
PMHx/PSHx- negative
MEDS- none
FHx- noncontributory
Breast Pain
Differential diagnosisFibrocystic changes
Mastalgia/mastodynia
Cyst
Duct obstruction
Inflammation/infection- mastitis
Trauma
Breast PainFibrocystic change
Most common of benign breast conditions
Replaces “fibrocystic disease”
Multiple tender breast masses
May be cyclic in nature
May be exaggerated response to hormones
Usually present as cyclic, bilateral pain and breast engorgement
Pain diffuse, often radiates to shoulders or upper arms
Prominent thickened plaques of breast tissue, often in upper outer quadrants
Breast PainFibrocystic change
ManagementFine-needle aspiration- diagnostic & therapeuticUltrasound w/needle biopsy if bloody fluid, residual mass, cyst recurrenceRestrict caffeine, foods containing methylxanthinesOCPsPain medications- ibuprofen, salicylates, acetaminophenDiureticsDanazolBromocriptine
Breast PainInfection/inflammation
Presents with pain, erythema, fever
Lactational mastitis- Occurs postpartum, Staph aureus or MRSA colonization
Management- ultrasound, antibiotics (PCN), continue breast feeding or pumping (if not MRSA); incision and drainage of abscess if virulent strain/nosocomial
Nonlactational abscess-Can be due to fistula, tuberculosis, fungi, carcinoma
Mammo & Ultrasound req
Zuska’s Dz: recurrent retroareolar infections
Case 2: Nipple Discharge
35 y.o. G1P1 presents with complaints of spontaneous nipple discharge.
Right breast, bloody discharge
POBHx- SVD x 1
PGYNHx- benign
PMHx/PSHx- negative
MEDS- OCPs
FHx- noncontributory
Nipple discharge
Differential diagnosisBreast lesions-
intraductal papilloma, ductal ectasia, fibrocystic changes, breast abscess
Drug induced-
phenothiazines, reserpine, methyldopa, imipramine, amphetamine, OCPs
CNS lesions-
pituitary adenoma, empty sella, hypothalamic tumor
Medical conditions-
Cushings, hypothyroid, chronic renal failure
Carcinoma
Idiopathic
Nipple discharge
WorkupExam
Labs- Prolactin, TSH
Mammogram
Cytologic evaluation of discharge- not very useful
Ductography
Nipple Discharge Intraductal papilloma
Epithelial tumors arising in ducts of breast
Main cause of nipple discharge in nonpregnant or nonlactating women
Usually women age 40-45
Benign, extremely small increased cancer risk
Size 2-5 mm, usually not palpable
Present with spontaneous, bloody, serous or cloudy nipple discharge
Management- excisional biopsy
Nipple DischargeDuctal ectasia
Second most common cause of nipple discharge
Older patients
Increase in glandular secretion
Discharge thick, gray/black color
Can lead to nipple retraction and breast mass
Management- medical, icepacks, anti-inflammatory agents, broad spectrum antibiotics, surgery if abscess or mass present
Nipple discharge
*Bad signsSerous, serosanguinous, or watery discharge
Associated with mass
Unilateral
Single duct
Positive cytology
Positive mammography
Age >50 yrs old
Case 3: Breast Lump
45 y.o. G2P2 presents with complaints of mass in left breast. Noticed on self exam.
Breast Lump
HistoryLength of time present
Presence of pain
Change in size or texture
Relationship to menstrual cycle
Nipple discharge
Family history of breast or ovarian cancer and ages
Age at first live birth, menarche, menopause
Breast Lump
Differential diagnosisFibroadenoma
Macrocysts
Galactoceles
Lipoma
Abscess
Rare causes- sclerosing adenosis, cystosarcoma phyllodes
Malignancy
Breast Lump
Work up
Exam
Imaging- Diagnostic mammogram- less sensitive in younger women due to breast density
Ultrasound- can distinguish cystic lesions from solid masses (require further evaluation)
Biopsy- GET A TISSUE DIAGNOSIS!!Fine needle aspiration, Core needle biopsy, Open biopsy
Breast MassFibroadenoma
Second most common benign breast disease, most common benign solid tumor
Firm, painless, mobile breast mass, 2-3 cm, commonly in upper outer quadrants
Usually women aged 20-40
Multiple in 15-20% of patients
Slow growing, do not regress spontaneously
Can be stimulated by exogenous estrogen, progesterone, lactation, pregnancy
Management- watch & wait, biopsy, or excision
Breast MassMacrocysts
Most often women age 35-50Fluid-filled sacOften solitary but can be multipleCan have associated nipple dischargeAspiration for diagnosis and therapy
GalactocoeleMilk-filled cystUsually follows lactationFirm, tender massUsually in upper quadrantsDiagnostic aspiration often curative
LipomaNontenderNo associated skin or nipple changesUsually postmenopausal womenManagement- biopsy or excision
Breast cancer>180,000 new cases per year (estimated from 2008)80% in women >50 yrs old, 20% in women <50 yrs old>40,000 deaths per year (estimated from 2008)Second leading cause of cancer-related death in womenLifetime risk of breast cancer 12%One in eight women will develop breast cancerIncreasing incidence but decreasing mortalityLower incidence in Asian/Pacific Islanders, Hispanic/Latina, American Indian/Alaska nativesHigher mortality in African Americans (though lower lifetime risk)Incidence & Mortality lowest in Asia/Africa, underdeveloped nations, those who have not adopted the Westernized reproductive & dietary patterns
Breast cancer
Risk factors (21% of cases)
Factor Relative Risk
+ FHx 1.2-3.0
Menstrual Hx (menarche <12, >40 yrs total) 1.3-2.0
OCP use No effect
Estrogen replacement <10 yrs No effect
Pregnancy (1st >35 y.o., nulliparous) 2.0-3.0
Contralateral breast cancer 5.0
Ovarian/uterine cancer 2.0
Breast cancer
Classification
Ductal carcinoma (>80% of cancers)
In situ: progresses to invasive cancer; cribiform, solid, comedo types; classified by nuclear grade & necrosis; calcifications on mammo
Medullary carcinoma: soft, hemorrhagic, BRCA1
Colloid/Mucinous carcinoma: elderly, bulky, gelatinous
Tubular: peri- early menopausal, rarely metastasizes
Papillary: 7th decade, nonwhite women, small, rarely metastasize
Inflammatory: dermal lymphatics invaded, erythema & warmth
Paget’s disease: eczematous lesion on nipple, usu assoc w/underlying malignancy,
Apocrine duct
Breast Cancer
Lobular carcinoma
In situ: only in female breast; calcifications on mammo in adjacent tissue; 12x more common in white women; not premalignant lesion, but marker for future development of invasive cancer
Infiltrative- multifocal, multicentric, bilateral; no distinct mass; signet-ring cell variant
Rare variants
Juvenile, epidermoid, carcinoid, squamous cell, spindle cell
Sarcoma and carcinosarcoma
Cystosarcoma phyllodes, angiosarcoma, malignant lymphoma
Breast cancer
Symptoms33% discovered by self-examBreast enlargement or asymmetryNipple changes, retraction, or dischargeUlceration or erythema of skinAxillary massMusculoskeletal complaintsEarly- mammo abnormality, painless, mobile tumor
Breast cancer
Screening Mammogram Annually every year >age 40, before age 40 in selected high-risk patients, w/annual clinical breast examStart 5-10 yrs before age of affected family memberDecreases mortality by up to 33% (not proven in women age 40-49)10% False-positive rate7% False-negative rateClustered microcalcifications, fine/stippled calcium around a lesion, solid mass, & asymmetric tissue thickening are suspicious for cancerIf equivocal findings on mammo, get ultrasound
Hereditary breast cancersHereditary breast cancers 5-10% of breast cancersAppropriate counseling must be provided to patient and family before testing for BRCA mutationsBRCA1 mutation (Breast & Ovary; some colon & prostate)
AD inheritance, chromosome 17q21, thought to be tumor suppressor genelifetime risk of breast cancer 90%, lifetime risk of ovarian cancer 40%Early age onset breast cancerBilateralUsu invasive ductal CA, poorly differentiated, hormone receptor (-)
BRCA2 mutation (Breast, less Ovary; some GI, Prostate, Melanoma, & Pancreas)chromosome 13q12, early age of onset, male breast cancerlifetime risk of breast cancer is 85%, lifetime risk of ovarian cancer 20%Well differentiated, hormone receptor (+)Ashkenazi Jews, Icelandic & Finnish populations
Clinical breast exam Q6 mo, w/yearly mammo (MRI) & transvaginal ultrasound w/CA-125 level starting at age 25 (if options below not excercised)Prophylactic mastectomy after child-bearingProphylactic oophorectomy after age 40
Breast Cancer Staging
Clinical staging based on physical examPathological staging more accurateTNM Staging systemT1:<2cm, T2:>2cm, T3:>5, T4: any size + involvement of chest wall or skinN0:0 nodes, N1:movable, N2:fixed, N3:infraclavicular, supraclavicular, internal mammary M0:no mets, M1:metsMost important predictor of survival is…
Breast Cancer Treatment
In Situ (Stage 0)LCIS:observation, chemoprevention w/Tamoxifen, & bilateral total mastectomyDCIS: >4 cm disease or disease in >1quadrant = mastectomyLow-grade DCIS <0.5cm: Needle-localized Lumpectomy alone if margins are widely free of diseaseHigh-grade DCIS or larger size: Lumpectomy w/Adjuvant radiation tx, or MastectomyRecurrence rate greater (9%) w/Lumpectomy + Rad, but mortality rate similar to mastectomyRisk for recurrence increases with: >2.5 cm size, comedo type, close margins
Breast Cancer TreatmentEarly Invasive (Stage I, IIA, or IIB)Mastectomy with assessment of axillary lymph node status Breast conserving surgery with assessment of axillary lymph node status + radiation (standard of care)Sentinel lymph node bx is now standard care for women with clinically negative nodes; metastatic disease in an axillary or sentinel lymph node requires full axillary dissectionContraindications to sentinel node bx: T3/T4, Inflammatory CA, palpable axillary nodes, pregnancy, DCIS without mastectomy, prior axillary surgery, after neoadjuvant chemo, prior nononcologic breast surgeryRelative contraindications to breast conserving tx: prior radiation, positive surgical margins after re-excision, multicentric disease, scleroderma, lupusChemo tx: for all node (+), cancers >1cm,and cancers >0.5cm with adverse prognostic features (BV or lymph invasion, high nuclear or histological grade, HER-2-neu amplification, & (-) hormone receptorsTamoxifen: for hormone receptor (+), >1cm; 5yr tx if premenopausal; 1-2 yr tx then aromatase inhibitor if menopausalHerceptin: for HER-2-neu (+) cancers
Breast Cancer TreatmentAdvanced Local-Regional (Stage IIIA or IIIB)No clinically detected distant metsNeoadjuvant chemo to shrink tumor & allow for breast conservation tx w/radiation (doxorubicin or taxane regiminMost get Mastectomy with evaluation of axillary status followed by radiation, +/- chemoSLNBx acceptable after neoadjuvant tx if no clinical nodes prior to chemo (need axillary dissection then)Distant Metastases (Stage IV)Tx mostly aimed at enhancing quality of lifeHormonal therapy: bone or soft tissue mets only and receptor (+)Cytotoxic chemo: hormone receptor (-) or refractory, or symptomatic visceral metsBisphosphonates: bony mets
Radiation Therapy
Can be used for all stages of Breast cancerReduces risk of local recurrenceStandard in breast conservation txNot needed for low-grade DCIS of the solid, cribiform, or papillary subtypes that is <0.5 cm & excised widely w/negative margins Mastectomy radiation: positive margins, 4 or more lymph nodes positive (or 3 or more in premenopausal woman)Chest wall & supraclavicular lymph nodes are radiated
Surgical Approach- Breast Conservation
Resection of primary cancer with a 2mm margin of normal-appearing tissue + assessment of regional node status + radiation txSegmental mastectomy, lumpectomy, partial mastectomy, wide local excisionUse areolar incision when possibleShould be able to encompass in mastectomy incision if completion mastectomy neededUpper breast lesion: follow lines of ZahnLower breast lesion: radial incisionOncoplastic techniques if possible
Surgical Approach- MastectomySkin sparing: removes all breast tissue, NAC, & prev biopsy scars (recurrence rate 6-8%)Total (simple): all breast tissue, NAC, skinModified radical: all breast tissue, NAC, skin & Level I & II axillary lymph nodesHalstead radical: same as modified, with pectoralis major & minor removed & Level III nodesPatey modification of MRM: removes pectoralis minor for dissection of Level III nodesSkin flap thickness usu 7-8 mmComplications: seroma (30%), hematoma, wound infection, skin flap necrosisLymphedema w/MRM: 10-20% (tx w/compression sleeve)
Breast Reconstruction
Immediate for prophylactic mastectomy or early invasive cancer
Delayed for advanced cancer (radiation needed)
Immediate: Expander/Implant, or Autologous tissue (latissimus dorsi myocutaneous flap; abdominal TRAM or DIEP flap)
If 2 or less ribs resected, no recon needed (scar tissue provides stabilization)
Special SituationsBreast CA in Pregnancy: usu present w/advanced disease; MRM in 1st & 2nd trimesters; lumpectomy w/axillary node dissection,radiation after delivery; chemo acceptable in 2nd & 3rd trimesters onlyMale Breast CA: <1% of all breast CA; usu invasive ductal; highest in Jewish & African-Americans; preceded by gynecomastia in 20%; similar survival rates as women; tx similar to womenPhyllodes tumor: benign, borderline, or malignant; mammo findings cannot distinguish type; sharp demarcation from normal breast tissue; Tx w/lumpectomy or mastectomy; no axillary dissection neededInflammatory Breast CA: induration, erythema, & edema; invasion of dermal lymphatics classic finding; 75% have palpable lymph nodes;Tx is neoadjuvant chemo w/MRM, radiation, +/- adjuvant chemo; poor prognosis