Basics of breast diseases and breast cancer

OMAR HAMDY

LECTURER OF SURGICAL ONCOLOGY

OCMU

Presentation Title

2

9/3/20XX

Contents

Inflammatory

• Mastitis
• Lactational mastitis
• Idiopathic lobular granulomatous mastitis

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Non proliferative

• Cysts
• Ductectasia
• Usual ductal epithelial hyperplasia
• Fibroadenomas

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Proliferative

• Without atypia:
• sclerosing adenosis
• radial scar
• complex sclerosing lesions
• florid ductal epithelial hyperplasia
• intraductal papillomas.
• With atypia
• ADH
• ALH

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Neoplastic

Invasive

Non invasive

Inflammatory breast disorders

• Mastitis
• Lactational mastitis
• Idiopathic lobular granulomatous mastitis

Mastitis

• Breast infection can result from recent surgery, tattoos, or nipple piercing, but most causes are unknown.
• An infection of the breast parenchyma that goes unnoticed or untreated can eventually develop into an abscess.

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Mastitis - presentation

One or more of the following symptoms:

• skin erythema
• palpable mass
• Tenderness
• Fever
• pain.

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Mastitis - evaluation

• Careful clinical examination is the cornerstone of diagnosis for acute breast infection.
• Ultrasound to evaluate:
• The presence or absence of an associated underlying abscess.
• The presence of multiple abscesses.
• can help to identify the size and depth of the abscess cavity

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Mastitis - evaluation

• Mammogram:
• in cases of atypical presentation
• patients with recurrent, non-improving symptoms
• After successful management of an acute breast infection or abscess:
• to exclude an underlying or associated malignancy
• to ensure complete resolution

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Mastitis - Treatment

• Antibiotics
• For patients with no fluid or a small fluid collection seen on ultrasound, a trial of oral antibiotics is warranted for 7 to 10 days’ duration.
• Failure to improve should prompt further evaluation with repeat ultrasound to evaluate for the development of an intramammary fluid collection requiring an alteration in the management strategy.

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Mastitis - Treatment

• Invasive Intervention
• Early Abscess. The traditional initial treatment approach of surgical incision and drainage of a breast abscess has been replaced by needle aspiration.
• Aspirated material should always be sent for microbiological analysis, Warm compresses placed over the abscess are recommended for comfort.

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Mastitis - Treatment

• The patients should undergo at minimum biweekly clinical reassessment to determine resolution of the abscess or subsequent requirement for additional treatment
• Patients who fail to improve with multiple aspirations or whose clinical condition deteriorates, require surgical incision and drainage.

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Lactational mastitis

• The general principles for evaluation and management of breast infection, outlined previously, are applicable to lactational abscesses, and underlying malignancy must be excluded.
• During treatment for lactational breast abscess, women are encouraged to continue to breastfeed, and this does not pose a risk to the infant.

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Milk fistula

• Milk fistula is an uncommon condition, which can occur more commonly after incision and drainage of a breast abscess in a lactating woman.
• In this situation, a fistula tract forms between the skin surface and the duct in the breast, resulting in spontaneous drainage of milk from this path of least resistance.
• Most milk fistulas will close primarily with time without the need for surgical intervention.
• On rare occasions, the mother will need to stop breastfeeding to allow the fistula to heal.

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Idiopathic Granulomatous Mastitis

• Idiopathic granulomatous mastitis (IGM) is a rare, chronic, relapsing, benign inflammatory condition of the breast with an unknown etiology. it is also referred to as idiopathic granulomatous lobular mastitis.
• IGM most commonly affects women of childbearing age (age range 20–60 years with a history of pregnancy and lactation within the past 5 years.

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Idiopathic Granulomatous Mastitis

• The most common clinical presentation of IGM is a palpable breast lesion(s) ranging in size from 1 to >5 cm, accompanied by overlying skin induration, tenderness, erythema, sinus tract formation with suppurate drainage, or breast edema that clinically can mimic a bacterial abscess or breast

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Idiopathic Granulomatous Mastitis - Treatment

• Despite management algorithms, there is no standard universal treatment and recurrence and relapse rates are high during the time period.
• Regardless of treatment type, most reports show that, with time, the disease tends to be self-limiting.

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Idiopathic Granulomatous Mastitis - Treatment

• At initial presentation, all abscesses should be treated with percutaneous aspiration.
• After aspiration of the abscess, prophylactic initiation of a broad-spectrum antibiotic is recommended through the period of diagnostic evaluation.
• Use of oral steroids as first-line treatment has frequently been reported with up to 80% success.
• Immune Modulators such as Methotrexate has also been used successfully with variable results to treat this disease as an alternative for patients who are unresponsive to steroid therapy.

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Benign breast disorders

• Non proliferative
• Proliferative

Non proliferative benign breast disorders

• Account for 70% of benign breast lesions
• Include:
• Cysts
• Apocrine metaplasia
• Ductectasia
• ductal epithelial hyperplasia
• Calcifications
• Fibroadenomas
• others.

Breast cyst

• Cysts are defined by the presence of fluid-filled, epithelialized spaces.
• Cysts are categorized by their imaging characteristics as:
• Simple
• Complicated
• complex (can be associated with a wide range of diagnoses from benign to malignant conditions)

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• Simple cysts do not need to be aspirated by their very presence. If mammography and/or ultrasound demonstrate a benign cyst, then no further intervention is required.

• If the cyst is painful or very large, aspiration can be performed under ultrasound guidance.
• A biopsy of the cyst wall should be obtained if :
• the cyst does not resolve after aspiration
• there is asymmetric wall thickening
• there is atypical cellularity in the aspirate.

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Duct Ectasia and Periductal Mastitis

• Duct ectasia is most often recognized by the presence of palpable dilated ducts filled with desquamated ductal epithelium and proteinaceous secretions.
• Periductal inflammation is a distinguishing histologic characteristic in this condition.
• The presenting symptoms of duct ectasia are nipple discharge, nipple retraction, inflammatory masses, and abscesses.

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Mild Ductal Epithelial Hyperplasia

• The fundamental feature of epithelial hyperplasia is an increased number of nonstromal cells relative to the normally observed two cell layers along the basement membrane.
• Mild ductal epithelial hyperplasia, as opposed to florid ductal epithelial hyperplasia, which is discussed later, does not increase the risk for breast cancer.

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Fibroadenoma

• Autopsy studies demonstrate that fibroadenomas are present in approximately 10% of women.
• The peak incidence occurs between the second and third decades of life.
• They are often solitary lesions, but 50% of patients will present with multiple masses.

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Fibroadenoma

Common Clinical Presentation:

• Usually 1-3 cm, rarely grow > 3 cm
• Well-defined shape; round or oval or lobulated
• Solid firm, rubbery
• Smooth, well capsulated
• Discrete with high mobility (Breast mouse)
• Painless, non-tender
• Can enlarge during pregnancy and breast-feeding.

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Fibroadenoma

• Core biopsy–proven fibroadenomas in young women (<35 years) that are mobile, less than 2.5 cm, and otherwise clinically benign can be safely avoided
• Traditionally, symptomatic fibroadenomas, as well as those greater than 3 cm, have been treated by surgical excision.

proliferative benign breast disorders

• Without atypia
• With atypia

proliferative benign breast disorders without atypia

• Proliferative breast disorders without atypia make up approximately 30% of benign breast disease
• They include:
• sclerosing adenosis
• radial scar
• complex sclerosing lesions
• florid ductal epithelial hyperplasia
• intraductal papillomas.

Florid ductal epithelial hyperlpasia

• It is associated with a minor increased risk of breast cancer.
• This entity is characterized by an increase in cell number within the ducts, with a proliferation of cells that occupies at least 70% of the duct lumen.

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Intraduct papilloma

• Solitary intraductal papillomas are tumors of the major lactiferous ducts.
• Common presenting features include serous or bloody nipple discharge.
• Grossly, these lesions are pinkish-tan, friable, and are usually attached to the wall of the involved duct by a stalk.

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Proliferative breast lesions with atypia

• Atypical proliferative lesions include both ductal and lobular lesions.
• These lesions have some, but not all, of the features of carcinoma in situ. At times, even the most experienced pathologists disagree as to whether a given lesion is atypical hyperplasia or carcinoma in situ.

Case scenarios

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Case scenario #1

• A 23 year old female, single, presented with right breast painless lump, first discovered 2 months ago
• No family hx of breast cancer or other malignancies

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• O/E:
• Mobile, well circumscribed, non-tender breast mass in the UOQ, about 2 cm in diameter, no LNs

Next step?

The answer is

Bilateral breast Ultrasound

Next step?

Management

• Assurance
• Assurance
• Assurance
• Follow up

When to go for surgery/biopsy ?

• Atypical age (>35)
• Atypical size (>3)
• Atypical radiologic criteria (BIRADS 4)

• 69 year old female, mobile left breast lump

Back to the ultrasound

Break

Breast density

• A,B,C,D

BIRADS?

Breast Imaging-Reporting and Data System

Back again

Next step?

Next step?

What type of surgery?

• Excision
• Wide local excision
• Mastectomy & reconstruction

What if … ?

• Biopsy: malignant pyllodes

What type of surgery?

• Excision
• Wide local excision
• Mastectomy & reconstruction

Case scenario #2

• 35 year old female, 2 offspring, acute onset of left breast painful swelling
• O/E: redness, hotness, tenderness, enlarged axillary LNs

Next step?

• Antibiotics
• Evacuation of abscess
• Ultrasound
• Biopsy

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If mastitis

• Antibiotics + anti-inflammatory

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• If resolved, follow up
• If residual chronic abscess, excision
• If residual suspicious finding, biopsy

If abscess

• Frequent sets of US guided aspiration + antibiotics

If mastitis carcinomatosis

• Confirm by biopsy then ??

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• Mastectomy
• Drainage
• Neoadjuvant therapy

Case scenario #3

• In a primary health care unit, a worried mother came with her daughter, 10 year old female, newly appearing breast swelling

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• O/E: firm, clinically suspicious swelling, no LNs

Next step?

• Ultrasound revealed increased thickness of glandular breast

• Assurance only

Case scenario #4

• A 23 year old female, single, presented with bilateral mastalgia, more on the right side UOQ
• No family hx of breast cancer or other malignancies

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• O/E:
• Ill defined bilateral UOQ breast coarse nodularity, mildly tender on examination, no LNs

Next step?

The answer is

• Bilateral breast Ultrasound

Before ultrasound ??

Pain analysis

• Site
• Onset
• Course
• Duration
• Factors affecting, relation to menstrual period
• Character
• Severity
• Radiation

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Pain analysis

Exclude:

• Chest pain
• Chest wall pain
• Cervical nerves compression symptoms

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Next step?

Management

• Assurance (Not malignant, Does not turn malignant, no need for surgery at all)
• Assurance
• Assurance
• Follow up

When to prescribe Treatment?

• If Non tolerable pain

Treatment

• Non- medical
• Medical

Non-medical treatment

• Assurance
• Supporting brassiere
• Stop: smoking – salty & spicy food – stimulants
• Stop: Hormonal contraception

Medical treatment

• Simple analgesics
• Evening primrose oil containing GLA (gamma-linolenic acid)
• Anti-prolactin
• Anti-estrogen
• Androgen

What if …?

• Large symptomatic breast cyst

If

Case scenario #5

• 30 year old female, 2 offspring, presented with right nipple discharge associated with localized mastalgia
• By examination: NAD

What are the criteria of suspicious nipple discharge?

• Unifocal
• Bloody
• Spontaneous
• Non responsive to medical treatment

Back to our patient

• The patient received medical treatment on her own for two weeks (AB + anti-inflammatory)
• The pain disappeared completely
• Yet, there is residual bloody discharge

Next step?

• Breast imaging
• Follow up
• Cytological examination of discharge

Next step?

• Surgery
• Follow up

Aetiology of bloody nipple discharge

• Duct papilloma
• DCIS
• Severe ductectasia
• General causes of bleeding

Neoplastic breast lesions

• Non invasive
• Invasive

Approach to suspicious breast mass

• History
• Examination
• Investigations
• Treatment

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History

• A thorough and accurate history is the cornerstone of approaching any new breast mass.
• Particular emphasis should be placed on the chronological development of the lump and the symptoms associated with it.

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Triple assessment

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Examination

• Clinical examination of a breast lump is the first stage in the triple-assessment approach.
• Both breasts, axillae and ipsilateral supraclavicular region should be examined meticulously by the clinician, as well as carrying out a physical examination of other body systems as indicated by the history.
• Each breast and axilla should undergo a visual inspection, looking for skin changes, nipple discharge, visible masses or asymmetry, and tethering to underlying structure

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Examination

• Palpation of the breast must proceed in a structured manner; generally, clinicians will use a four-quadrant approach (upper outer, upper inner, lower outer, lower inner quadrants), followed by palpating the areola and then the axillary tail.
• Particular attention should focus on the inframammary fold and the axillary tail.
• The normal breast is examined first, and the tissue is assessed for its overall consistency.

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Three Methods for systematic examination of the breast

1- vertical strips

2- pie or radial spoke pattern

3- circular pattern

Examination

• Palpable breast masses should be described in location, size, shape, tenderness, fluctuance, mobility, texture, and pulsatility.
• If the patient describes nipple discharge that is not immediately visualized, it is appropriate to ask the patient to express the discharge themselves before the clinician attempting to do so.
• Following palpation of the breast, the clinician must always palpate the axilla and supraclavicular region for lymphadenopathy.

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Breast imaging

• Mammogram
• Breast ultrasound
• Breast MRI

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• You are dealing with a patient, not a document
• Always analyze the patient complaint, then look at his radiology report/film

How to interpret?

What is mammogram?

• Mammogram = breast X ray
• It is the process of using low-energy X-rays to examine the human breast for diagnosis and screening.

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The procedure

• The breast is compressed using a dedicated mammography unit.
• Parallel-plate compression evens out the thickness of breast tissue to increase image quality by:
• reducing the thickness of tissue that x-rays must penetrate
• reducing the required radiation dose
• decreasing the amount of scattered radiation (scatter degrades image quality)
• holding the breast still (preventing motion blur).

Findings

• Mass
• calcifications
• Asymmetric Breast Tissue
• Architectural Distortion
• Lymphadenopathy
• Interval Changes in comparison to previous films
• Other Miscellaneous Findings

Mass

Mass

• Site
• Size
• Shape
• Density
• Borders
• Calcifications

Mass - Shape

Mass - border

Mass - Density

Calcifications

• Size
• Shape
• Distribution
• Number

Asymmetry

Focal asymmetry

Global asymmetry

Nipple retraction

Axillary lymphadenopathy

Ultrasonography

• Ultrasonography (US) has been playing an increasingly important role in the evaluation of breast cancer.
• US is useful in:
• evaluation of palpable masses that are mammographically occult
• clinically suspected breast lesions in women younger than 30 years
• many abnormalities seen on mammograms.
• guidance of biopsies and therapeutic procedures.

Magnetic resonance imaging (MRI)

• MRI is a powerful imaging modality used in both screening (in conjunction with mammography) and diagnostic imaging and for guiding interventional procedures.

Advantages of MRI

• No ionizing radiation
• All imaging planes possible
• Capability of imaging the entire breast volume and chest wall
• Superb 3-D lesion mapping
• Greater than 90% sensitivity to invasive carcinoma
• Detection of occult, multifocal, or residual malignancy
• Accurate size estimation for invasive carcinoma
• Good spatial resolution
• Ability to image regional lymph nodes

Disadvantages of MRI

• High equipment and examination costs
• Limited scanner availability
• Need for the injection of a contrast agent
• No standard technique
• Poor throughput compared with that of ultrasonography or mammography
• Large number of images
• Long learning curve for interpretation
• False-positive enhancement in some benign tissues (limited specificity)
• Variable enhancement of in situ carcinoma
• A 5% incidence of slowly or poorly enhancing invasive carcinomas

Pathological evaluation

Presentation Title

149

9/3/20XX

Presentation Title

150

9/3/20XX

The 1^st step in breast cancer management is

Staging

Molecular types

Management of early breast cancer

• Surgery
• Chemotherapy
• Radiotherapy
• Hormonal therapy
• Target therapy

Surgery

Primary tumor

Axilla

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Surgery for 1ry tumor

A- Breast conservative surgery

=

Wide local excision of the tumor with negative margins + radiotherapy +- axillary staging

Breast conservative surgery

• Indications:
• Early breast cancer

Breast conservative surgery

Contraindications:

• Mastitis carcinomatosis.
• Multicentric disease (if unable to achieve negative margin).
• Persistent positive margins after reasonable surgical attempts.

• Diffuse suspicious microcalcifications on mammography (due to extensive DCIS).
• Contraindications to radiotherapy:
• Pregnancy in 1st & early 2nd trimester (radiotherapy cannot be delivered).
• Prior therapeutic chest irradiation
• Collagen vascular disease as scleroderma (high toxicity of radiotherapy).
• Patients who prefer mastectomy.

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B- breast reconstruction

• It is indicated when > 50% of the breast volume is removed, particularly when this is resected from the central zone, lower pole and medial quadrants of the breast.
• For partial or total breast reconstruction

• *It includes the following techniques:
• 1- Autologous tissue reconstruction:
• Latissimus dorsi flap (conventional or mini LDF).
• TRAM
• Free flaps (DIEP, SIEP, free gluteal flaps).
• 2- Prosthetic implants: saline or silicon.
• 3- Lipomodelling: It uses the patient's own fat cells to replace volume after breast reconstruction, or to fill defects in the breast following breast-conserving surgery.

LDF

TRAM

Free flap

Silicone implant

Lipomodelling

C- Mastectomy�

• Indications = contraindications for BCS

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Surgery for the axilla

• 1- Positive lymph nodes: Axillary dissection.

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2- Negative lymph nodes = sentinel lymph node biopsy

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Why not ALND?

• Interpretation
• 1- If negative SLNB no further surgery
• 2- If positive SLNB classically axillary clearance is recommended, although recent studies confirmed the safety of omitting it if ALL the following criteria met:
• T1-2 tumour.
• 1-2 positive sentinel nodes.
• Whole breast radiotherapy is planned.
• No preoperative chemotherapy.

3- If sentinel lymph node cannot be identified do axillary clearance.

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Radiotherapy

• Indications:
• After mastectomy if:
• Primary tumor > 5 cm &/or infiltrating dermis or pectoralis muscle.
• > 4 positive axillary lymph nodes (consider in 1-3 positive nodes).
• After conservative breast surgery.

Hormonal (endocrine) therapy

• Advantages:
• It decreases the risk of local, regional and distant recurrence of breast cancer.
• It also reduces the risk of developing a contralateral breast cancer.
• Indication:
• In luminal A and B breast cancers.

Chemotherapy

• Indications:
• 1- adjuvant therapy:
• - Malignant lymph nodes.
• - Invasive tumor > 0.5cm except for luminal A type
• - Luminal A breast cancer > 0.5cm if oncotype DX score > 31 (consider if score 18-30 or test is not available).

• 2- neoadjuvant therapy:
• increasing the rate of breast conservation.
• Converting patients who require mastectomy to patients who can undergo BCS (some T3 and all T4 cases).
• Rendering inoperable breast cancer (some T4 and inflammatory breast cancer cases) into operable.
• decrease micrometastatic disease
• Nodal downstaging, which can reduce the extent of axillary surgery.
• In vivo evaluation of tumor resistance or sensitivity.
• Prognostic information based on tumor response.

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Target (anti-Her2 therapy)

• Trastuzumab (Herceptin®) & Pertuzumab
• It is a humanized monoclonal antibody that targets the human epidermal growth factor HER-2.
• It is given for patients with overexpression of HER 2
• It increases the response rate and survival of patients when added to taxane chemotherapy.

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DCIS

• A- Tumor:
• - Conservative breast surgery: Wide local excision with safety margin at least 2 mm + Postoperative radiotherapy: In low risk patients radiotherapy can be omitted.
• - Mastectomy + immediate reconstruction.
• - Tamoxifen for 5 years if ER positive.

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• B- Axilla:
• - No axillary staging, in this case if microinvasion or frank invasion is identified on final pathology after breast-conserving surgery, the patient should return to the operating room for sentinel lymph node biopsy
• - SLNB, especially indicated if >4 cm tumor or if treated with mastectomy.

Case scenario

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Case scenario

• 37 year old female
• No previous medical or surgical history
• Presented with left breast mass

• Triphasic CT:
• Enlarged liver with marginally enhanced focal lesions measures 3.7x4.9 cm … Metastatic.

Next step?

• Palliative therapy
• New biopsy
• New radiology
• New biopsy & radiology

Thank you�