Transcript CommonBreastDisease
Common Breast Disease
Dr. Chan Wing Cheong
Surgeon-in-charge Breast Surgery, NTEC
Breast Anatomy and Location of Disease Processes
Normal Breast Histology
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
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.
ANDI classification ( Hughes et al, 1992 )
Normal Reproductive phases
Involution
Aberration ?? Disease
Periductal mastitis cysts, duct ectasia, mild epithelial hyperplasia Epithelial hyperplasia with atypia Cyclical & secretory cyclical mastalgia & nodularity Development fibroadenoma, juvenile hypertrophy
Spectrum of breast changes
Giant fibroadenoma (> 5cms) Multiple fibroadenomata (> 5 per breast)
Aetiopathogenesis – Some Theories
Endocrine factors
1. Disturbances in the Hypothalamo Pituitary Gonadal steroid axis 2. Altered Prolactin profile – qualitative /quantitative change
Non endocrine factors
1.
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
Carcinogenesis – Genetic Predisposition
Common Presenting Symptoms
Over 80 %
Lump
Painful lump or lumpiness
Pain Under 20 %
Nipple discharge
Nipple change
Miscellaneous
1.Lump
Symptoms & Possible Diagnosis
Carcinoma Fibroadenoma Juvenile Fibroadenoma Giant fibroadenoma Phyllodes tumours Cysts / Galactocele
4.Nipple
change
Developmental inversion of nipple Acquired nipple retraction : duct ectasia, periductal mastitis etc Eczema Paget’s disease etc.
2.Pain 3.Nipple
discharge
Mastalgia : Cyclical & Non cyclical Physiological Bloodstained in pregnancy Intraductal papillomas / papillocarcinoma Duct Ectasia Galactorrhoea 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
Benign vs. Malignant
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
Case Scenario
Case 1
F/22
Right breast swelling for 1 month
No other symptoms
What are the questions you want to ask?
Case 1
USG breast:
Compatible with a 1.5 cm fibroadenoma
What would you offer her?
What is the natural history of fibroadenoma?
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?
Case 2
USG
Compatible with a giant fibroadenoma or phylloides tumour
Do you want to do FNA?
What would you offer?
Case 2
Wide local resection performed
Pathology:
Phylloides tumour of undetermined malignant potential, margins appear to be clear
How do you advice this patient?
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
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
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 ?
Risk Estimation for Breast Cancer
RELATIVE RISK <2 Early menarche < 12 years Late menopause > 55 years Nulliparity Proliferative benign disease Obesity Alcohol use Hormone replacement therapy
RELATIVE RISK 2 –4 Age 35 first birth First-degree relative with breast cancer Radiation exposure Prior breast cancer
RELATIVE RISK >4 Gene mutation Lobular carcinoma in situ Atypical hyperplasia
Case 3
P/E:
2.5 cm mass over upper outer aspect of left breast
Quite mobile
No palpable axillary LN
What would you do next ?
Case 3
Left
Case 3
MMG / USG breast
2.5 cm mass
No axillary nodes
Core needle biopsy
Invasive carcinoma
What would you offer?
Options
Modified radical mastectomy
MRM + reconstruction
Autologus tissue flap
Prosthesis
Wide local excision + axillary dissection + post-op RT
Any adjuvant therapy?
Chemotherapy
? Indications
Radiotherapy
? Indications
Hormonal therapy
? Indications
Case 4
F/55 Good past health Routine physical check-up Screening mammogram
Left breast microcalcification
What is your plan?
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
Mammotome Biopsy
Hook-wire Guided Excision
If core biopsy confirms DCIS, what’s next?
If solitary, < 3cm, not high grade
Wide local excision + RT
Otherwise,
Total mastectomy +/- reconstruction
Axillary node dissection not required
Hormonal therapy if ER / PR positive
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
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?
Lobular Carcinoma (15-20%)
LCIS Invasive LC
Case 6
F/ 36
Mother of 2 children
Brownish stain on the inside of undergarment
No pain
No nipple change
Differential Diagnosis?
How would you like to investigate furhter?
Ductogram
What can be offered to the patient
?
Case 7
F / 67
Not significant PMH
Recent L breast pain
What is the diagnosis ?
What would you offer to her ?
Management for individual problem
Pain
Mastalgia
•
Cyclical mastalgia
•
Non cyclical mastalgia
•
True (breast related)
•
Musculoskeletal : costochondral or lateral chest wall
Infections
•
Lactational infections
•
Nonlactational infections
True breast pain
•
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.
Mastalgia
Definition : Pain severe enough to interfere with daily life or lasting
over 2 weeks of menstrual cycle
Lateral chest wall pain Costo Chondral pain mild Musculo skeletal pain
• • • •
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
Drug Evening primrose oil Danazol Bromocriptine Tamoxifen
2.5 mg twice / day (incremental dose regime) 10 mg / day
Goserelin
Drugs of Established Value in Mastalgia
Dose Clinical response
3 g / day 200mg / day reduced to 100 mg on alternate days (low dose regime) Cyclical mastalgia 44 % Non cyclical mastalgia 27% Cyclical mastalgia 70% Non cyclical mastalgia 30% 3.75 mg / month intramuscular depot injection Cyclical mastalgia 47% Non cyclical mastalgia 20% Cyclical mastalgia 94% Non cyclical mastalgia 56% Cyclical mastalgia 91% Non cyclical mastalgia 67%
Side effects
Low ( 2% ) High (22%) High (45%)
Comments
Efficacy as medicine questioned. Marketing authority withdrawn. More effective in Cyclical mastalgia. Some side effects may be permanent. Not recommended due to serious side effects High (21%) High Not licensed for use in Mastalgia. Used in Refractory mastalgia & relapse Major loss of trabecular bone limits use in Refractory mastalgia & relapse
Nipple Discharge
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
Characteristics of Nipple Discharges
Non significant nipple discharge Significant nipple discharge
Elicited Age < 40 years Spontaneous Age > 60 years (new symtom) Bilateral Intermittent Thick Non troublesome Multiductal Unilateral Persistent Watery Troublesome Uniductal Negative test for blood (reagent stick test for Positive test for blood blood)
Management of Spontaneous Nipple Discharge
Multi ductal Distressing symptoms Minor symptoms Reassure Spontaneous nipple dischare Triple assessment Normal Abnormal Surgery Minor symptoms/ No suspicion of malignancy Distressing symptoms/ No suspicion of malignancy Distressing symptoms/ Suspicion of malignancy Reassure Uniductal Microdochectomy Surgery Total duct excision
Galactorrhoea
Physiological causes
Extremes of age Stress Mechanical stimulation
Causes of galactorrhoea Drugs
Oestrogen therapy
Pathological causes
Hypothalamic lesions Anaesthesia Dopamine receptor blocking agents Dopamine re-uptake blocker s Dopamine depleting agents Pituitary tumors Reflex causes : Chest wall injury, Herpes zoster neuritis, Upper abdominal surgery Hypothyroidism Inhibitors of Dopamine turnover Stimulation of serotoninergic system Histamine H2-receptor antagonists Renal failure Ectopic production : Bronchogenic and renal carcinoma
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 )
Breast Mass
Just prominent glandular tissue
Cyst
Simple vs. complex
Abscess if painful and inflammed
Solid mass
Benign tumors
Fibrocystic disease
Carcinoma Fat necrosis
Benign Lumps
Cysts
Common in the West ( 70 % of women )
50% are solitary cysts 30% 2 - 5 cysts & rest have > 5 cysts
Types
Apocrine cysts Lined by secretory epithelium Cyst fluid has a Na : K ratio < 3 Likely to have multiple cysts Likely to develop further cysts Non-apocrine cysts Cyst fluid has a Na : K ratio >3 Resembles plasma Mixture of both
Management Algorithm for Cysts
Cyst (Clinical diagnosis) Fine needle aspiration Non blood stained aspirate Blood stained aspirate No residual mass No cyst recurrence Residual mass Cyst recurrence (X3) FNAC/Surgical biopsy No routine followup Surgical biopsy
Fibroadenoma
Types
Solitary Few ( < 5 / breast ) Multiple ( > 5 / breast ) Giant ( > 4 / 5 cm ) & Juvenile
Natural history
Majority remain small & static 50% involute spontaneously No future risk of malignancy
Management Algorithm for Fibroadenoma
All results concurr Age < 30 years Results do not concurr Age > 30 years Fibroadenoma (clinical diagnosis) Triple assessment Multiple fibroadenomas (Selective triple assessment) Giant fibroadenoma/ Juvenile fibroadenoma Clinical observation for 2 years Excision with rim of normal tissue Excision of largest Clinical observation of rest Extracapsular Excision No change/ shrinkage / disappearence Increase in size/ At patient request Discharge with advice on BSE Extra capsular Excision
Chances of malignancy masquerading as Fibroadenoma
Age 20 – 25 yrs 1: 3000 possibility Age 25 – 30 yrs 1: 300 possibility
Breast Carcinoma
Breast Cancer – No. 1 Cancer Among 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
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
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.
The Importance of Staging
TNM Classification
TX T0 Tis Primary tumour cannot be assessed No evidence of primary tumour Carcinoma in situ or Paget’s disease of the nipple with no tumour.
T1
T1a 2cm or less in greatest dimension 0.5cm or less in greatest dimension
T1b
T1c More than 0.5cm, but not more than 1cm in greatest dimension More than 1cm but not more than 2cm in greatest dimension T2 Tumour more than 2cm but not more than 5cm in greatest dimension
TNM Classification
T3 tumour more than 5cm in greatest dimension T4 tumour of any size with direct extension to chest wall or skin
T4a
T4b
T4c T4d Extension to chest wall Oedema (including peau d orange) or ulceration of the skin of breast or satellite skin nodules confined to same breast Both T4a and T4b Inflammatory carcinoma
Regional Lymph Nodes (TNM)
NX
N0 N1
N2
N3 Regional lymph nodes cannot be assessed (e.g. Previously removed or removed for pathologic study) No regional lymph node metastasis Metastasis to movable ipsilateral axillary lymph node(s) Metastasis to ipsilateral axillary lymph nodes that are fixed to one another or to other structures Metastasis to ipsilateral internal mammary lymph nodes(s)
Distant Metastasis (TNM)
MX
M0 M1 Presence of distant metastasis cannot be assessed No distant metastasis Distant metastasis (includes metastasis to ipsilateral supraclavicular lymph node)
AJCC/UICC Stage Grouping
Tis
Stage 0
N0 T1 T0 T1 T2 M0
Stage I
N0 N1 M0
Stage IIA
N1 M0 M0 T2 T3 N0
Stage IIB
M0 N1 N0 M0 M0 T0 T1 T2
Stage IIIA
N2 M0 N2 N2 M0 M0 T3 T3 N1 N2 M0 M0
Stage IIIB
T4 Any N M0 Any T N3 M0
Stage IV
Any T Any N M1
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
Axillary Dissection
Therapeutic vs. staging
SLNB
Systemic Control
Chemotherapy
AC or Taxol
Indications:
Positive axilla nodes
Node negative
Young age
High grade tumor
Size > 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
Cosmetic Consideration
BCT
Reconstruction
Prosthesis
Flap
Prosthesis + flap
Breast Conservation Treatment
Must be accompanied with post-op RT
Prosthesis
Silicone gel saline bag
Latissmus Dorsi Flap
TRAM Flap
TRAM Flap
Questions & Answers
Dr. Chan Wing Cheong
Surgeon-in-charge Breast Surgery, NTEC