Transcript 43-Breast & Nipple Discharge

Objectives:
 Anatomy of the breast
 Approach to a patient with breast lump
 Common breast problems (benign & malignant)
 Approach to a patient with nipple discharge
 Modified sweat gland Extends
from 2nd-6th rib & from sternal
edge-midaxillary line.
 Positioned over the muscles of
the chest wall (the pectoralis
major, serratus anterior,
external oblique, and rectus
abdominus fascia)
 Attached to the chest wall by
fibrous strands called
Cooper’s ligaments (
suspensory ligament) which
extend from the deep fascia
beneath the breast and attach Carcinoma invading these ligaments
may result in skin dimpling
to the dermis of the skin.
 The breast is composed of
glandular ducts and lobules,
connective tissue, and fat.
 The nipple and areola are separate
structures. The unique anatomy
explains why 18% of malignant
cancers are found in the
subareolar region
 most breast cancer is thought to
originate in the terminal ductal
lobular unit (TDLU) functional
secretory unit.
 Half of this glandular tissue is
located in the upper outer
quadrant; therefore, nearly one
half of all breast cancers occur in
this area.
- perforating branches of
-internal thoracic vein.
the internal thoracic
artery(internal
-lateral thoracic vein.
mammary artery)60%.
- the lateral thoracic artery .
-Mainly the axillary vein.
- branches of the axillary
artery. ( the thoracoacromial artery& long
thoracic artery ).
- intercostals veins .
- intercostal artery
perforators .
Most major venous pathways lead to the pulmonary
capillary network (why lung metastases are common)
or the vertebral veins (skeletal metastases).
 Interlobular lymphatic
vessels  sub areolar
plexus (sappey’s
plexus) (75%) of the
drainage to the axillary
lymph nodes.
 Medial aspect of the
breast  internal
mammery lymph nodes
or the axillary lymph
nodes.
History :
Personal:
Age
gender
Analysis of C/C
SOCRATES
1- Pain
2- Lump
3- nipple discharge
4- abnormal appearance
Previous Hx of breast problem
Associated symptoms
Constitutional symptoms
Chronic illnesses
Family Hx:
Cont’ History
DDx:
Hx of trauma to the breast
Any medications
ask about the risk factors of breast cancer :
- Radiation exposure
- Menstrual hx:
Early menarche
Late menopause
and late pregnancy.
Lactation
Metastasis Hx
- General malaise, weight loss
- Recent backache, Bone ache
- Jaundice
- Mental changes
Examination
Examination: (A) Local Ex:
- Position
- Inspection
- Palpation: (Feel, press, percussion, move, …. and surrounding tissues)
- Lump: “4S”, “2T”, edge and composition
- L.N.
Axillary and supraclavicular
(B) General Ex: Abdomen, lumbar spine …
Points in Examination: Look for
- Firm mass of variable shape and size
- Fifty percent of masses found in the upper outer quadrant of the breast
- May have associated pain with palpation, but most are painless
- Nipple discharge or inversion
- Skin retraction or tethering
- Axillary lymphadenopathy
- Inflammatory changes of the skin (e.g. peau d'orange)
DDx:
Swelling of the whole breast:
Bilateral
- pregnancy, lactation
- Idiopathic hypertrophy
- Drug induced (e.g. cimetidine)
Unilateral
- Enlargement in the newborn
- Puberty
DDx: of localized swelling
Painless lump Painful lump
- Cyst
- Carcinoma
- Fibroadenosis
(chronic mastitis)
- Fibroadenoma
- Fat necrosis
- Cyst
- Breast abscess
- Fibroadenosis
-Periductal
mastitis
-Carcinoma
(rare)
-Mammography
-US
-MRI
-Other imaging modalities
special type of X-ray imaging used to create detailed images of the breast.
The initial investigation for symptomatic breast in women older than 35
years.
95% accurate ( 5% - 10% ) false – ve.
2 views of each breast is taken as standard mammography:
- 45° oblique. Mediolateral (MLO)
- Craniocaudal position (CC)
Additional views are obtained to clarify questionable lesion:
-latero-medial (LM)
-medio-lateral (ML) views
-exaggerated CC views
-magnification views
-spot compression views
-others
Unreliable:
because of high dense glandular tissue
below the age of 35 years.
Lactating lady .
Screening :
-Baseline mammogram for women ages 35-39 years.
-Mammogram every 1-2 years for women ages
40-50 years.
-every year once they reach 50 years of age .
diagnostic:
Metastatic adenocarcinoma without known
primary.
Nipple discharge without palpable mass.
Follow up
Benign
Malignant
Shape
Round, uniform density, large,
coarse
Linear, branching,
pleomorphic, casting
Margins
Circumscribed mass
Smoothly marginated
Spiculation
Content
Fat-containing lesion
Architectural distortion with
no history of prior surgery
Calcification
(very important
Microcalcifications :Widely
scattered
Microcalcifications (<0.5 mm)
:Tightly clustered
Long axis
Long axis of the lesion is along
the normal tissue planes
Lesion is taller than it is wide
read about the
difference
between benign &
malignant)
Homogenicity Homogeneous internal
echotexture
Heterogenous
Echogenecity Hyperechogenicity
Decreased hyperechogenicity,
- The most useful study in younger women < 35 years
with palpable breast mass.
- Effective for lesions > 0.5cm.
- Easily distinguishes cystic from a solid mass.
Cystic: well defined, round, echo-free lesion with posterior
enhancement.
Solid: has echo within it & posterior enhancement.
the introduction of Doppler enable definition of
characteristic blood flow patterns. This can aid in
separating benign and malignant lesions and
distinguishing lymph node metastases from normal
or reactive lymph nodes.
Fibroadenoma
Cyst
 Useful but expensive.
 Usually used in screening of familial cases of breast
cancer rather than X-ray which could be potentially
harmful.
 Distinguish scar from recurrence in women who have had
previous breast conservative therapy for cancer (although
it is not accurate within 9 months of radiotherapy
because of abnormal enhancement).
 The gold standard for imaging the breasts of women with
implant.
CT is primarily used to evaluate for extramammary
involvement of the tumor.
Indications: Establish cytological diagnosis.
Advantages:
Minimally invasive office procedure that is well tolerated by
the patient.
Often allows for a single trip to operating room.
Specimen can be processed and interpreted rapidly.
Disadvantages:
1- False (+) rate for cancer varies from 0%-1% on an
institutional basis.
2- Significant false (-) rate ( >20%) for cancer because of small
sampling size .
Non palpable mass :
stereotactic , Ultrasonographic or MRI- guided
Indications: Establish histological diagnosis for <
3 cm mass.
Advantages:
-Minimally invasive, low-morbidity office procedure
-False (+) rate for cancer is 0.
Disadvantages:
-Rare complications of hematoma and pneumothorax.
-Significant false (-) rate (>20%)for cancer because of
small sampling size.
Non palpable mass : stereotactic (visualization by
mammogram , Ultra-sonographic or MRI- guided CNB
well tolerated & False (-) rate for cancer is approximately
1%.
Indications: Establish histological diagnosis
for a large mass (>3cm) when FNA and CNB
are non-diagnostic.
Advantages:
-Performed under local anaesthesia.
-False (+) rate for cancer is 0.
-False (-) rate for cancer is close to 0.
Disadvantages:
-Substantially higher cost than FNA or CNB.
-Open Surgical procedure with associated risks of
bleeding and wound infection.
Indications: Establish definitive histological diagnosis
for a small (<3cm) mass when FNA and CNB are nondiagnostic.
Advantages:
 Can be therapeutic as well as diagnostic for benign mass
and for malignant mass excised with negative microscopic
margins.
 False (+) and false (-) rates for cancer are 0.
 Performed under local anaesthesia.
Disadvantages:
 Open Surgical procedure with risks of bleeding and wound
infection.
 Substantially higher cost than other biopsy procedures.
Indications: Establish definitive histological diagnosis
for a non-palpable but visualized abnormality.
Advantages:
-Therapeutic as well as diagnostic for benign masses and for
malignant masses excised with negative margins.
-False (+) rate for cancer is 0.
-False (-) rate is 0 if visualized abnormality is completely excised.
Disadvantages:
Open procedure that requires radiological localization before
surgical excision.
Occasional (1%) failure to excise abnormality. May require
relocalization and reoperation.
Cosmetic deformity may result.
Ultrasound-Guided Breast Biopsy
Fibrocystic disease: the most common breast mass in
women.
Fibroadenoma: the most common benign tumor.
Fat necrosis
Abscess
Cyst
Others :
- Intraductal papilloma
- Ductal/ lobular Hyperplasia
- Ductectasia
- Lipoma
- Granulomatous mastitis
Note :1- in general, Mass: cystic or solid, Tumor: solid
2- the difference between fibrocystic changes and fibroadenoma is that in fibrocystic
changes u cant define a mass while fibroadenoam is a mass
Benign changes
- Age: 30 – menopause (and after if HRT used)
- C./F. : Breast pain, swelling, with focal area of
nodularity, freq. bilateral, mobile and varies with
menstrual cycle…
- No increase risk of breast cancer but makes
evaluation of mammographic malignant changes
more difficult.
- Treatment:
If >40 y : mammography every 3 years
analgesia, OCP or danazol for sever symptoms.
- Most common benign breast tumor in women < 30y
- No malignant potential except if sclerosing adenosis present.
- C./F. nodules: smooth, rubbery, discrete, well-circumscibed, non-tender, mobile,
hormone dependent .
- Unlike cysts, needle aspiration yield no fluid
Investigations:
- Mammogram
- US
- FNA to R/O solid lesion
Rx:
- Generally conservative – serial observation
-Excision if mass rapidly growing, if >5cm in size or if Pt. wants , equivocal result
, if the pt has no access for follow up, if there is family history of cancer.
 Rare type of fibroadenoma.
 typically large, fast growing masses that form from the
periductal stromal cells of the breast.
 most common between the ages of 40 and 50, prior to
the menopause.
 Although it is mostly benign , It can recur after excision .
 The malignant form (10%) can metastasize
hematogenously most commonly to the lungs .
 The common treatment for phyllodes is wide local
excision.
- Result of trauma (may be minor, +ve trauma Hx in
only 50%)
- Firm, ill-defined mass with skin or nipple
retraction +/- tenderness
- Regress spontaneously, but complete excisional
biopsy to rule out carcinoma .
- It resembles cancer clinically & radiologically.
The only way to differentiate is by biopsy.
- Unilateral localized pain and erythema.
- R/O inflammatory carcinoma, as indicated
- Staphylococcus aureus are the most common
organisms .
C\F :Fluid-filled sacs that often feel like soft grapes.
Can sometimes be tender, especially just before the
menstrual period.
- Cysts may be drained in the clinic.
Rx:
- If the fluid removed is clear or greenish,
and the lump disappears completely after it is drained,
no further treatment is needed.
-If the fluid is bloody, it is sent to the lab to look for
cancer cells. If the lump doesn't disappear, or
recurs, it is usually removed surgically.
 is a cystic tumor containing milk or a milky substance that is




usually located in the mammary glands.
Galactoceles are benign and are not a cause for concern.
It is caused by a protein plug that blocks off the outlet. Once
lactation has ended the cyst will resolve on its own without
intervention.
A galactocele does not cause infection as the milk within is
sterile and has no outlet for which to become contaminated.
Attempts to drain the cyst are unsuccessful because the
protein plug remains intact and milk production continues.
Granulomatous mastitis:
 Characteristic for granulomatous mastitis are multinucleated
giant cells and epithelioid histiocytes around lobules. Often
minor ductal and periductal inflammation is present. The
lesion is in some cases very difficult to distinguish from breast
cancer.
 most often completely aseptic but infectious causes must
be considered as well.
 C\F:distinct firm mass mostly in the subareolar region.
 PREDISPOSING FACTORS:
-2 years and up to 6 years after pregnancy, usual age range is 17
to 42 years.
-Use of hormonal contraceptives, prolactin raising medications
and hyperprolactinemia .
Epidemiology:
 The 2nd leading cause of cancer mortality in women
(1st?)
 - Lifetime risk : 11-13%
Risk factors of breast cancer:





- 99% female
- 80% >40 y.o.
- Prior Hx of BC, prior breast biopsy.
1st degree relative with BC( incr. risk if premenopausal )
risk in (HYPERESTROGENEMIA STATE):
- early menarche <12y
- late menopause>55y
- 1st pregnancy >30y,
- nulliparity
- OCP
- HRT for 5y
 - risk with lactation, early menopause, early childbirth
 - Radiation exposure
 - Hx of specific benign breast disease ( Atypical hyperplsia 4x )
Types and presentation :
1- Non- invasive:
a) Ductal carcinoma in situ (DCIS)
- Completely contained within breast ducts
- 80% non-palpable, detected by screening
mammogram
b) Lobular carcinoma in situ (LCIS)
-Completely contained within breast lobule
-No palpable mass, no mammographic findings, usually
incidental finding on breast biopsy.
2- invasive:

Infiltrating ductal carcinoma (most common 80%):
hard ,scirrhousthe most common type ,infiltrating tentacles
Papillary ,medullary ,mucinouse ,tubular cancers
Generally better prognosis.
 Invasive lobular carcinoma (8-15%):
-20% bilatral
-Dose not form microcalcification , harder to detect
mammographically .
 Paget’s disease (1-3%):
Ductal carcinoma that invades nipple with scaling
,eczematous lesion .
 Inflammatory carcinoma (1-4%)
Ductal carcinoma that invades dermal lymphatics
Most aggressive form of breast cancer
Erythema , skin edema ,warm, swollon ,tender +- lump
 Male breast cancer (<1%)
Most commonly infiltrating ductal carcinoma
Often diagnosed at later stages
 Sarcoma
Rare ,most commonly cystosarcoma phyllodes , a variant of
fibroadenoma
 Lymphoma –rare
1-TNM Classification
2-Clinical staging
Primary tumor (T):
TIS –carcinoma in situ
T0- no primary tumour located
T1- tumour less than 2 cm
T2- tumour 2-5 cm
T3- tumour greater than 5cm
T4 – extension to chest wall
Regional lymph nodes (N):
 N0-no
nodal involvement
 N1-mobile ipsilateral axillary nodes
 N2-fixed ipsilateral axillary nodes
 N3 - ipsilateral supraclavicular
nodes
Metastasis (M):
M0: No distant spread.
M1: Spread to distant organs is present.
(The most common sites are bone, lung, brain,
and liver.)
Clinical staging
AJCC stage groupings
Stage
T
N
M
Survival (5 year)
O
In situ
None
None
99%
I
Less 2cm
None
None
94%
II A
Less 2cm
Mobile ipsilatral
None
85%
IIB
2-5 cm or
more 5 cm
None or mobile ipsilatral
None
None
None
70%
IIIA
Any size
Fixed ipsilatral or internal
mammary
None
52%
IIIB
Skin /chest
wall invasion
Any
None
48%
IIIC
Any size
Ipsilatral infraclavicular /internal
mammary plus axillary node
;ipsilatral supraclavicular nodes
=axillary nodes
None
33%
IV
Any
Any
Distant
18%
Primary: Surgical
1- Breast – conserving surgery (BCS)- lumpectomy
with wide local excision
-for stage I and II
-Combined with radiation
-axillary lymph node dissection (ALND) :
 For staging of nodes and reduced recurrance in axilla
 Complication of ALND :
Arm lymphedema (10%-15%),decreased arm sensation
,shoulder pain .
BCS not appropriate if:
 Factors present that increase risk of local recurrance :
extensive malignant –type calcification on mammogram ,
multifocal primary tumuor .
 Contraindication to radiation therapy( pregnancy, cardiac
or skin disease, pnumonitis)
 Large tumor size (stage :????3
 Patient prefers mastectomy .
 Bad cosmetic result.
(In all the previous we do mastectomy)
2- Mastectomy:
- Modified radical mastectomy (MRM)-removes
all breast tissue ,nipple –areolar complex ,skin ,
axillary nodes .
- Simple (total) mastectomy
–similar to MRM but axillary nodes not removed .
- Offer breast reconstruction
Adjuvant:
Radiation:
 Decrease risk of local recurrence and almost always
used before BCS, sometimes after mastectomy .
 Axillary nodal radiation may added if nodal
involvement .
 For high risk of local recurrence , inoperable locally
advanced cancer (no clear margins after excision)
,metastases.
 In Stage I/II .
Chemotherapy :
Classically CMF ( cyclophosphamide, methotrexate,
5-fluorouracil)
 Almost all pt. with stage III disease
 In stage I at high risk
 ER (Estrogen receptor ) –ve plus node +ve /high risk
node –ve .
 ER +ve and young age .
 Palliation for metastatic disease.
( premenopausal pt with +ve or –ve nodes need chemo,
post-menopausal with +ve node need chemo)
Hormonal :
Indication :
 ER +ve (pre-/post-menopausal )plus node +ve or high
risk node –ve .
 Palliation for metastases .
Tamoxifen or aromatase inhibitor (eg. anastrozole) ,
ovarian ablation (GnRH agonist ,oophorectomy ),
Progestins (e.g. megestrol acetate ), androgens
(fluoxymesterone ).
Stage 0
 Ductal Carcinoma In Situ (DCIS)




Ipsilateral total mastectomy.
WLE and radiation therapy.
No need for axillary node dissection.
Overall 5-year survival rate is 95-100%.
 Lobular Carcinoma In Situ (LCIS)
 Bilateral total mastectomy.
 Tamoxifen 20mg daily for 5 years with close observation.
 No need for axillary node dissection.
 Invasive carcinoma (invasive on biopsy but no mass, no nodes)
 Modified radical mastectomy.
 WLE with axillary node dissection and radiation therapy.
 Paget’s disease
 Total mastectomy.
 Modified radical mastectomy.
Stage I and II
 Modified radical mastectomy.
 WLE with axillary node dissection and radiation
therapy.
 Adjuvant chemotherapy for node-positive or high risk
node-negative patients.
 Overall 5-year survival rate is 80% for stage I and 60%
for stage II.
Stage III and IV
 Multimodality therapy.
 Mastectomy remains the mainstay of surgical
treatment.
 Overall 5-year survival rate is 20% for stage III and 0%
for stage IV.
Post-Treatment follow up:
 - Regular visits (3-6 m x 2y)
 - Annual mammography
 - Psychosocial support and counseling
 - Signs of recurrence : (CXR, CT abdomen, liver
enzymes, bone sacan, CT brain, MRI spine….)
Metastasis:
 - Bone > lungs > pleura > liver > brain
 - Rx: is palliative – hormonal therapy, chemotherapy,
radiation.
Key points:
 The most common breast lumps occurring < 35 yrs are
fibroadenomas & fibrocystic disease.
 The most common breast lumps occurring > 50 yrs are
Carcinomas & Cysts.
 Pain is more characteristic of infection / inflammation
than tumors.
 Skin tethering is more characteristic of tumors than
benign disease
 Multiple lesions are usually benign (cystic or
fibrocystic) disease.
Nipple Discharge
Definition:
 Abnormal nipple discharge is abnormal fluid leakage
from one or both nipples of the breast.
 The likelihood of nipple discharge increase with age
and number of pregnancies.
Causes:
 common cause:
1. Duct ectasia (periductal mastitis).
2. Intraduct papilloma (small noncancerous growth in
the breast).
 Other causes:
a) Prolactinoma ( tumor in the brain).
b) Breast abscess (most commonly seen in women
during breastfeeding).
c) Breast cancer.
d) Fibrocystic change in the breast.
DDx of nipple discharge :
Serous
Early pregnancy
fibroadenosis
Milky
Late pregnancy
Lactation
Puberty
prolactinoma
Yellow,
brown,
green
fibroadenosis
Thick and
creamy
Purulent
Bloody
Duct ectasia
Retroareolar abscess
Breast abscess
TB
Intraduct. ca
Intraduct. papilloma
Paget’s disease
Duct ectasia (periductal mastitis):
Etiology: unknown.
Pathological feature:
Dilated duct → engorged with breast secretion → infection →
retroareolar abscess → fibrosis → nipple retraction.
Clinical features:
- Pain: usually cyclical.
- Periareolar erythema.
- Nipple discharge: thick & creamy or greenish brown.
- Periareolar tender mass.
- Nipple retraction (when healing occurs by fibrosis).
Investigations:
- Mammogram: opaque mass of
dilated ducts & skin
indentation.
- Cytology: for discharge.
Managements:
- Infection: aspiration &
antibiotic.
- Abscess: drainage.
- Severe discharge or recurrent
sepsis: mammadochectomy
(nipple ducts excised through a
circumareolar incision
preserving the nipple).
Intraduct papilloma
 Benign.
 Occurring in middle-aged women.
 Clinical features:
- Bloodstained discharge.
- Bleeding from a single duct orifice
- (pressure over a certain spot or the palpable mass).
- Small mass: NOT usually.
 Investigation:
- Mammogram (exclude carcinoma).
- Cytology assessment.
 Managements:
- Duct orifice (bleeding) is identified: microdochectomy.
- If not: excision of the major nipple ducts.
Thank you