Transcript Benign Breast Disease - Mount Sinai St. Luke's Roosevelt

Benign Breast Disease
Juhi Asad, DO
Sharon Rosenbaum Smith, MD
Dept. of Breast Surgery
Outline
Anatomy
Benign disease
Management
Genetics
Anatomy
Modified sweat gland
between the
superficial and deep
layers of the chest
wall
Cooper’s Ligament
– Fibrous band of tissue
Anatomy
Ducts
– Terminal ductules
Milking forming glands
Lobule
Question
Axillary lymph nodes are classified
accordingly to the relationship with the
– Axillary vein
– Pec.major
– Pec.minor
– Latissimus dorsi
– Serratus anterior
Anatomy
Axillary lymph nodes
defined by pectoralis
minor muscle
– Level 1 – lateral
– Level 2 – posterior
– Level 3 – medial
Long Thoracic Nerve
– Serratus anterior
Thoracodorsal Nerve
– Latissimus Dorsi
Intercostalbrachial Nerve
– Lateral cutaneous
– Sensory to medial arm &
axilla
Anatomy
Hormonal Effects
– Estrogen
Development of the breast and lactiferous ducts
– Progesterone
Secretory acinar tissue – lobules
– Prolactin
Synergizes the effect of estrogen and
progesterone
Benign Breast Diseases
Glandular breast parenchyma
– Mass
– Asymmetric nodularity
– Pain
Nipple-Areolar Complex
– Discharge
– Rash
– Retraction
Surrounding breast skin
– Dimpling
Management
History
Clinical Breast Exam
Breast imaging
Tissue sampling
Therapy
History
Age
– Menarche
– Pregnancy
Breast feeding
– Menopause
Family History
Prior biopsies
Hormone therapy
Question
What are the risk factors that are part of
the Gail Model?
– Race
– Age
– Age of 1st menses
– Age at 1st pregnancy
– # of 1st degree relatives
– # of biopsies
Clinical Exam
Inspection
– Skin
– Symmetry
– Masses
Palpable
– Gland
– Axilla, Supraclavicular
spaces
– Nipple-areola complex
Question
22 yo female presents with a new right breast
mass. Complains of mild tenderness. No other
complaints. On physical exam, there is a 1 cm
nodule at the 2:00 position. Your diagnostic test
of choice is….
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–
–
–
Mammogram
Ultrasound
Excisional biopsy
Incisional biopsy
Breast Mass
Breast Cysts
– Fluid-filled
– 1 out of every 14 women
50% multiple and recurrent
– Hormonally influenced
– Needle aspirated
Breast Cyst
Breast Mass
Fibroadenoma
– Stromal and epithelial elements
– Most common in women <30yo
– Firm, solitary tumors
Multiple
Increase in size
– Management
Biopsy
Excisional biopsy
Fibroadenoma
Breast Mass
Phyllodes Tumor
– Proliferation of connective tissue with ductal
elements
Whorled and cellular stroma
– Firm, lobulated
– 2 to 40 cm in size
– 10% malignant
– Treatment
Wide excision
Fibrocystic Disease
Clinical, mammographic and histologic
findings
Exaggerated response from hormones
and growth factors
– Cyclical pain
– Nodularity – upper outer quadrants
Fibrocystic Disease
Histology
– Adenosis
– Apocrine metaplasia
– Fibrosis
– Duct ectasia
– Mild ductal hyperplasia
Fibrocystic Disease
Risk Factors
– Dense breast
– Sclerosing adenosis
– Atypical ductal, papillary, or lobular
hyperplasia
Question
34 yo female referred to you for evaluation
of breast pain. The pain is burning and
sharp in nature. Always present. On
physical exam, dense glandular tissue
bilaterally. Your working diagnosis is….
– Cyclical breast pain
– Noncyclical breast pain
– cancer
Breast Pain
Cyclical pain – hormonal
– Dull, diffuse and bilateral
– Luteal phase
– Treatment
Reassurance
NSAIDS
Evening primrose oil
Non-cyclical pain
– Non-breast vs breast
– Imaging
– Treatment
Reassurance
NSAIDS
Evening primrose oil
Breast Infections
Mastitis
– Generalized cellulitis of the breast
– Ascending infection subareolar ducts
commonly occurs during lactation
– Staph. aureus
– Erythema, pain, tenderness
Mastitis
Treatment
– Abx
– Continue to breast
feed
– Close follow-up
Breast Abscess
Abscess
– Breast tissue
– Treatment
Abx
Needle aspiration
Incision and drainage
Question
What is the difference between
spontaneous vs non-spontaneous nipple
discharge?
Nipple Discharge
Physiologic
– Bilateral
– Involves multiple ducts
– Heme (-)
– Non-spontaneous
Nipple Discharge
Pathologic
– Unilateral
– Spontaneous
– Heme (+)
Most common cause intraductal papilloma
Bloody Nipple Discharge
Intraductal Papilloma
Single duct
Benign
4% of intraductal ca
Imaging
Mammography
Ultrasound
MRI
Mammography
Screening tool
– Age of 40
Estimated reduction
in mortality 15-25%
10% false positive
rate
Densities &
calcifications
Calcification
Macrocalcifications
– Large white dots
– Almost always noncancerous and require no
further follow-up.
Microcalcifications
– Very fine white specks
– Usually noncancerous but can sometimes be
a sign of cancer.
– Size, shape and pattern
BI-RADS
BI-RADS
Classification
Features
0
1
2
3
4
Need additional imaging
Negative – routine in 1 yr
Benign finding – routine in 1 yr
Probably benign, 6mo follow-up
Suspicious abnormality, biopsy
recommended
Highly suggestive of malignancy;
appropriate action should be taken
5
Ultrasound
Not a screening tool
Palpable vs cystic
Mammographic detected lesion
Ultrasound
Benign
– Pure and intensely
hyperechoic
– Elliptical shape (wider
than tall)
– Lobulated
– Complete tine capsule
Malignant
– Hypoechoic,
spiculated
– Taller than wide
– Duct extension
– microlobulation
Ultrasound
Malignant or Benign
Malignant vs Benign
MRI
High risk patients
– Personal history of breast ca
– LCIS, atypia
– 1st degree relative with breast cancer
– Very dense breast
High sensitivity (95-100%)
– 10-20% will have a biopsy
MRI
Pre Gad
Post Gad
Color Overlay
Diagnosis
Fine needle aspiration
– Cytology
Core biopsy
– Image guided
– Stereotactic
Excisional biopsy
– Needle localization
FNA
Fast, inexpensive
96% accuracy
Institution dependent
Unable to differentiate
b/w in situ vs CA
Core Needle Biopsy
14-18 gauge spring loaded needle
Tissue
Multiple
Large Core Biopsy
6-14 gauge core
Large samples
Single insertion
Core biopsy
Vacuum Assisted
Stereotactic Biopsy
Suspicious
mammographic
abnormalities
Patients lay prone
Stereo View
Excisional Biopsy
Atypical lesions
LCIS
Radial scar
Atypical papillary lesions
Radiologic-pathologic discordance
Phyllodes
Inadequate tissue harvesting
High-Risk
Prior breast cancer
Family history of breast cancer
– Ovarian cancer
– BRCA-1 or BRC-2 gene
Prior mantle radiation
Biopsy proven of atypia or LCIS
Screening
Prior breast cancer or atypia
– Annual mammography
– 6 mo CBE
Family Hx
– 10 yrs younger than relative’s diagnosis
– 6 mo CBE
BRCA
– 25 yo – annual mammography
– 6 mo CBE
Genetics
Early age of onset
2 breast primaries or breast and ovarian CA
Clustering of breast CA with:
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–
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Male breast CA,
Thyroid CA,
Sarcoma,
Adrenocortical CA,
Pancreatic CA
leukemia/lymphoma on same side of family
Family member with BRCA gene
Male breast CA
Ovarian CA
Genetics
Hereditary Breast/Ovarian Syndrome
– BRCA 1 – chromosome 17
– BRCA 2 – chromosome 13
Li-Fraumeni Syndrome
– P53 mutation – chromosome 17
Cowden Syndrome
– PTEN mutation – chromosome 10
Autosomal dominant pattern
BRCA
Account to 25% of early-onset breast
cancers
36%-85% lifetime risk of breast CA
16-60% lifetime risk of ovarian CA
BRCA
BRCA 1 gene
– Ovarian CA
BRCA 2 gene
– Male breast CA
– Prostate CA
– Pancreatic CA
BRCA
Management
– Monthly BSE -- 18yo
– 6 mo CBE & annual mammo -- 25yo
– Discuss risk reducing options
Prophylactic mastectomies
Salpingo-oophorectomy – upon completion of child
bearing
– 6 mo transvaginal US & CA125 – 35 yo
Li-Fraumeni Syndrome
Mutation of p53 gene
– Tumor suppressor
Premenopausal breast CA
– Childhood sarcoma
– Brain tumors
– Leukemia
– Adrenocortical CA
Accounts for 1% of breast CA
Cowden Syndrome
Major criteria
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Thyroid CA (follicular)
Marcocephaly
Cerebellar tumors
Endometrial CA
Breast CA – 25%-50% risk
Skin and mucosal lesions
Minor criteria
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Thyroid lesions
GU tumors
GI hamartomas
Fibrocystic breast
Mental retardation