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Breast Development Breast Development Arise from the epidermis forming ducts cappedArise from the epidermis forming ducts capped by alveolar buds
by alveolar buds
Puberty = breast Puberty = breast
DifferentiationDifferentiation
Ducts communicate and lobules developDucts communicate and lobules develop
Final full breast Final full breast
Differentiation Differentiation = Term = Term PregnancyPregnancy Menstrual and Ovarian Cycle
Menstrual and Ovarian Cycle
Epithelial cells proliferate during luteal phaseEpithelial cells proliferate during luteal phase
Programmed cell death after the luteal phaseProgrammed cell death after the luteal phase
Associated with edema of the extracellularAssociated with edema of the extracellular space
space Menopause Menopause
Lobules involuteLobules involute
Collagenous stroma is replaced by fat Collagenous stroma is replaced by fat
Estrogen receptor increasesEstrogen receptor increases History
History
Focus on:Focus on:
Nipple DischargeNipple Discharge
Character of dischargeCharacter of discharge
Breast MassBreast Mass
Association of symptoms with the menstrualAssociation of symptoms with the menstrual cycle
cycle
Change in breast shape, size, or textureChange in breast shape, size, or texture
Previous breast biopsiesPrevious breast biopsies Detection
Detection
The patient should be questioned about theThe patient should be questioned about the following risk factors for breast cancer following risk factors for breast cancer
Family History of Breast CAFamily History of Breast CA
High Fat Diet, Obesity and Alcohol IntakeHigh Fat Diet, Obesity and Alcohol Intake
NulligravidNulligravid
Increasing ageIncreasing age
Age of menarche < 12 yearsAge of menarche < 12 years
Nulliparity or first pregnancy >30 years of ageNulliparity or first pregnancy >30 years of age
Late menopause (older than 55 years of age)Late menopause (older than 55 years of age)
Family history of breast cancer (especiallyFamily history of breast cancer (especially premenopausal or bilateral disease) premenopausal or bilateral disease)
Number of first-degree relatives with breast Number of first-degree relatives with breast cancer and their ages when
cancer and their ages when diagnoseddiagnosed
Family history of male breast cancerFamily history of male breast cancer
Inherited conditions associated with a high risk Inherited conditions associated with a high risk for breast cancer:
for breast cancer:
BRCA1 and BRCA2 genesBRCA1 and BRCA2 genes
Li-Fraumeni syndromeLi-Fraumeni syndrome
Cowden's diseaseCowden's disease
ataxia telangiectasia syndromeataxia telangiectasia syndrome
Peutz-Jeghers syndromePeutz-Jeghers syndrome Evaluation of Breast Lump Evaluation of Breast Lump Triple Test
Triple Test
Clinical examinationClinical examination
ImagingImaging
Pathology / BiopsyPathology / Biopsy Clinical Examination Clinical Examination InspectionInspection SymmetrySymmetry ContourContour
Skin Appearance and skin changesSkin Appearance and skin changes
DimplingDimpling
Nipple dischargeNipple discharge
PalpationPalpation
Location of the mass is reported based onLocation of the mass is reported based on clock position
clock position
Measure distance from the nippleMeasure distance from the nipple
Breast temperatureBreast temperature
TextureTexture
Thickness of the skinThickness of the skin
Generalized or focal tendernessGeneralized or focal tenderness
NodularityNodularity
DensityDensity
Dominant massesDominant masses
Nipple DischargeNipple Discharge Diagnostic imaging Diagnostic imaging MammographyMammography Breast Biopsy Breast Biopsy
Needle biopsyNeedle biopsy
Fine needle biopsyFine needle biopsy
Core needle biopsyCore needle biopsy Breast Cancer Detection Breast Cancer Detection
Self-detection 48%Self-detection 48%
Breast Imaging 41%Breast Imaging 41%
Physician PE 11%Physician PE 11%
Recommendation:Recommendation:
Premenopausal: Monthly 7Premenopausal: Monthly 7 –– 10 days after10 days after the onset of menses
the onset of menses
Menopausal: Menopausal: Select a Select a specific calendar specific calendar datedate and perform monthly Breast self-examination and perform monthly Breast self-examination Breast Imaging
Breast Imaging Mammography Mammography
Detects slow growing breast cancer before it Detects slow growing breast cancer before it reaches a size detectable by palpation
reaches a size detectable by palpation
Indications:Indications:
Screening for women at risk for breast CAScreening for women at risk for breast CA
Evaluate a questionable/ ill-defined breast Evaluate a questionable/ ill-defined breast mass or other suspicious change in
mass or other suspicious change in the breast the breast detected by breast examination
detected by breast examination
Baseline breast mammogram and reevaluateBaseline breast mammogram and reevaluate patients at yearly intervals to diagnose a patients at yearly intervals to diagnose a potentially curable breast cancer before it has potentially curable breast cancer before it has been diagnosed clinically
been diagnosed clinically
Search for occult breast CA in those withSearch for occult breast CA in those with metastatic disease in axillary nodes or metastatic disease in axillary nodes or elsewhere from the primary origin elsewhere from the primary origin
Screen for unsuspected CA before Screen for unsuspected CA before cosmeticcosmetic operations or biopsy of a mass
operations or biopsy of a mass
Monitor breast CA pts. Treated with breast-Monitor breast CA pts. Treated with breast-conserving surgery and radiation
conserving surgery and radiation Screening
Screening
American Cancer SocietyAmerican Cancer Society
Women with average risk for breast CA beginWomen with average risk for breast CA begin mammography by 40 years old
mammography by 40 years old
Women 20s to 30s clinical breast exam everyWomen 20s to 30s clinical breast exam every 3 years or annually
3 years or annually
Women >40 years old annual breast examWomen >40 years old annual breast exam plus mammography
plus mammography
American Geriatric SocietyAmerican Geriatric Society
Annual/ biennial mammography up to 75Annual/ biennial mammography up to 75 years old
years old
For high risk women initiation of For high risk women initiation of screeningscreening must be earlier and more frequent
Mammographic Abnormalities
Morphologic Categories of Mammographic Abnormalities: Calcification distribution Number of calcifications Description of calcifications Mass margin Shape of mass Density of mass Associated findings Special cases Mammographic Reports Six Categories:
Incomplete, needs further imaging Negative
Benign finding
Probably benign, short-interval follow-up recommended
Suspicious finding and biopsy should be considered
Highly suggestive of malignancy and appropriate action should be undertaken Known malignancy
Correlation of Findings
Biopsy is done on a dominant/suspicious mass despite absent mammographic findings
Ultrasonography
Used for focused scanning of a questionable finding/ evaluation of a mammographic finding Preferred method to distinguish between solid
and cystic masses
Not recommended for routine screening
Indications:
Characterization:
Palpable abnormality
Ambiguous mammographic findings Silicone leak
Mass in woman <30 y/o, lactating/pregnant
Guidance for interventional procedures: i.e biopsy
Possible role for additional imaging in high-risk individuals
Magnetic Resonance Imaging
Used to assess indeterminate breast lesions detected by clinical or mammographic exam Highly sensitive but not very specific
Indications:
Stage tumor to r/o multicentric disease Differentiate postoperative scar from
recurrence after breast conserving surgery Find lesion seen in one view of
mammography
Evaluate (+) axillary nodes but w/ (-) mammogram and breast examination Rule out silicone implant rupture Assess focal asymmetry
Breast Tissue Evaluation Tissue Biopsy
Fine Needle Aspiration Cytology Core Needle Biopsy
Excision Biopsy (less accurate) FNAC CNB False (+) 1.7% 0% False (-) 7.1% 5.7% Triple Test Result
Concordant test if >99% accurate
If benign – follow-up PE every 6 months. If malignant, refer to surgery
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Algorithm for Management of Breast masses in Postmenopausal women
Benign Breast Disorders Fibrocystic Change
Most common lesions of the breast Histologically refers to:
Fibrosis in the breast
Cyst formation in the breast
Epithelial hyperplasia in the breast 33-55 years old
Associated with benign breast epithelium Clinical Findings:
Asymptomatic mass Smooth and mobile Nipple discharge
May be accompanied by pain or tenderness during the premenstrual phase
Cyclic breast pain is the most common associated
Smooth round shape Absence of internal echoes Posterior acoustic enhancement Fine Needle Biopsy
Tissue Biopsy
No cyst fluid is obtained Bloody fluid
Fluid is thick Complex cyst
There is an intracystic mass Mass persist after aspiration
Persistent mass noted at any time during follow up
Risk for Breast CA
Not associate with increased risk of breast CA Unless with histological evidence of:
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Mastalgia
Types of Mastalgia Cyclic Mastalgia
Related to exaggerated premenstrual cycle
Breast engorgement, pain, heaviness and bilateral tenderness
Common in the 3rdand 4thdecade of life
Accounts for 2/3 of all breast pain symptoms
Noncyclic Mastalgia
Independent of the menstrual cycle Achy, burning soreness
Intermittent/ constant Unilateral
Common in the 4thand 5thdecade
Extramammary Pain
Perceived to be breast in origin but extramammary in nature
May be:
Chest wall muscular pain Coastal cartilage symptoms Costochondritis Herpes zoster Rib fracture Management of Mastalgia Reassurance Medications: Anesthetics Diuretics Bromocriptine Tamoxifen Vitamins Primrose oil Mechanical support
Discontinuation of hormone therapy Fibroepithelial Lesions
Fibroadenoma
Most Common Benign Tumor Common in women < 25 years old Rare after menopause
May be single or multiple lesions Most are detected at 2 – 3 cm mass Physical Examination: Firm Smooth Rubbery Mobile Bilobed On Imaging: Well defined Smooth
Solid mass with clear defined margins and borders
Risk to Breast CA
Not associated with increased risk to Breast CA
Management:
Conservative Complete Excision
Phyllodes Tumor
Rare fibroepithelial tumors Maybe:
Benign 70% Borderline 7% Malignant 23% Rarely bilateral
Difficult to distinguish clinically w/ fibroadenoma Management:
Wide local excision w/ 1-2 cm margin Mastectomy for women with small breast Axillary node dissection not indicated Breast Conditions Requiring Evaluation Nipple Discharge
Spontaneous 48%
Provoked 52% = no pathologic significance Spontaneous discharge + Breast CA : 4 – 10% Non neoplastic causes:
Galactorrhea: most common
Physiologic conditions due to mechanical manipulation
Parous condition Periductal mastitis Subareolar abscess Fibrocystic changes Mammary duct ectasia
Neoplastic causes in non-lactating women: Solitary intraductal papilloma
Carcinoma Papillomatosis
Squamous Metaplasia Adenosis
Extramammary causes: Hormones and drugs
Important Characteristics of the Discharge Nature of Discharge
Association with a mass Unilateral or bilateral Single or multiple ducts Spontaneous/ expressed Relations to menses
Premenopausal/ postmenopausal Hormonal medication
Nipple discharge cytology is rarely performed Surgical excision of trigger point
Lacrimal probe is done
Breast resection for 3 to 5 cm Patient is warned against:
Possible loss of: Skin
Nipple
Nipple sensation deformity Inability to breast feed
Erosive Adenomatosis of the Nipple
Rare benign condition that mimics Paget’s disease Present with pruritus, burning and pain
Physical Examination:
Nipple maybe ulcerated, crusting, scaling, indurated and erythematous
Nipple is enlarged and prominent during menses
Differential Diagnosis: Squamous Cell CA, Psoriasis, Contact Dermatitis, Seborrheic Keratosis, AdenoCA of the skin and unusual primary tumor of the nipple
Local Excision is curative Fat Necrosis
With a history of trauma in 50% Seen in active women
Ecchymosis may be seen near the tumor Tenderness may be (+)/ (-)
May spontaneously disappear Breast Abscess
Lactational Abscess
Common in first time breast feeders, this is true if baby is not properly latched.
Lactational mastitis is due to transmission of bacteria during nursing and poor hygien e Staphylococcus aureus most common cause Management:
Early stages: continue breast feeding plus dicloxacillin 250mg QID or oxacillin 500 mg QID for 7 – 10 days
If with a local mass and with signs of systemic infectiondrainage and discontinue
breastfeeding NonLactational Abscess
Develop in young/ middle age women Due to trauma, or even hair.
Abscess is evaluated with ultrasound
Antibiotics and drainage is indicated if the fluid collection is > 3 ml
Otherwise aspiration of the pus is enough Subareolar Abscess and Lactiferous Duct Fistula Due to obstruction of the distal ducts with
inspissated debris
Most common organism Staphylococcus aureus Definitive Management
Excision and drainage of lactiferous duct sinus Disorders of Breast Augmentation
