Benign & Malignant

breast lesions Presented by : omar al. Maaita Mais

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

Subclav.\medial

brachial

Anterior 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

1. 2. 3.

Breast disease presents in three main ways: LUMP , which may or may not be painful? PAIN , which may or may not be cyclical? 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 45 Inspection :
0

Look at the size ,symmetry , skin , nipple & areola and whether theres 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
1. 2. 3.

Triple Assessment II. Imaging : Mammography *(old lady) Ultrasound *(young) 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

can be missed by mammograms even in retrospect CA were not apparent.

(lobular)

Normal mammogram doesnt 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 cant differentiate in-situ from invasion where biopsy can.

Benign breast lesions

Benign Breast Lesions

may present a wide range of symptoms or may be

detected as incidental microscopic findings.

This is the most common cause of breast problems

up to 30 per cent of women will suffer from a benign breast disorder requiring treatment at some time in their lives The most common symptoms are pain, lumpiness. The aim of treatment is to exclude cancer, and once this has been done, to treat any remaining symptoms.

Classification of Benign Breast lesions

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

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)

1. Developmental Anomalies
Mammary Hypoplasia
Underdevelopment of the breast

(hypoplasia) When congenital, is usually associated with genetic disorders.

(turners syndrome , CAH )

Different from the acquired, which is

usually iatrogenic, most commonly subsequent to trauma or radiotherapy

The complete absence of both breast

and nipple (amastia) or presence of only nipple without breast tissue (amazia) is rare

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
diagnosed based on

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

clinical symptoms and signs indicating inflammation. Treatment Stop breast feeding and use breast pump instead Apply Heat compressors analgesia Antibiotics Supportive counselling

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 mothers 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 Hadfields operation)

3.ANDI
Stands for: Abberation of normal

development and involution. Its 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 40s During the luteal phase Hormonal related but curiuosly Unilateral Pain throughout the breast but mostly in the lateral upper quadrant No discrete lump May be so sever (cant bear the pressure of bra !!) Relived , sometimes dramatically , when mense commense No need for investigations Noncyclical pain Girls at menarche Women in their 20s Around or postmenopausal (suspect underlying malignancy)\referred MSS

Treatment
Lumps & nodularity

reassurance. Review patient 6 weeks after the initial visit, and often the clinical signs will have resolved by that time. Mastalgia: firm reassurance symptom diary will help her to chart the pattern of pain throughout the month and thus determine whether this is cyclical mastalgia evening 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 reaspiration. 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 23 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 Doesnt 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.

Risk factors
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

Histological Classification

.1

Lobular carcinomas (5%) Ductal carcinomas (95%) In situ Invasive

LCIS & DCIS

lobule duct

Incidental in PM
Lobular carcinoma In Situ (LCIS) A:Normal cells C: Basement membrane B: Cancer cells

Micro calcification
Ductal carcinoma in situ (DCIS)

lumen

Note the intact basement membrane

ILC & IDC

Commonest form of breast

cancer.

Invasive Lobular Carcinoma (ILC)

Invasive Ductal Carcinoma (IDC)

"dysmoplastic

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 multicentric (multiple lesions within the same breast)

More likely to be bilateral and/or

Small uniform cells arranged as

strands or columns within a fibrous stroma around uninvolved ducts. CSF, serosal surfaces and pelvic organs

Metastasize more frequently to

Invasive Lobular Carcinoma (ILC)

Pagets 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.

.2

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

3.

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

1. 2. 3. 4. 5. 6.

Any portion of the breast may be affected, but frequently the tumor is found in the outer upper quadrant. Lump Nipple changes (retraction, destruction, discharge) Puckering Peau dorange Ulceration fixation

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

T size of tumor
Tx: tumor cant be measured or found. T0: no evidence of primary tumor Tis: the tumor is in-situ (no invasion) T1: 0 2 cm T2: 2 5 cm T3: > 5cm T4: involvement of the skin

N - Node
Nx: nearby lymph nodes cant be measured. N0: nearby nodes contain no tumor N1 N3: nodal involvment

M - Mets
Mx: mets cant be measured or found M0: no mets M1: distant mets were found

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