GYNE 9 1 Breast Diseases PDF

BREAST DISEASES ( . ) ( .
)
Floriza C. Salvador MD, FPOGS, FPSUOG
November 28, 2014; 10 – 12 am
Gynecology
***ITALICIZED– Recording; BLUE – Past Transcription
OUTLINE
A.Normal Breast Anatomy D. Breast malignancy
B. Diagnostic Modalities 1) Risk factors
C. Benign Breast Lesions 2) Classification
1) Types of Benign Breast Diseases E. Principles of management
2) Signs and symptoms of Benign Breast
Diseases
NORMAL BREAST ANATOMY

 The breast comes from the bilateral epithelial
mammary ridges Slide notes:
 Modified sebaceous glands The deep or posterior surface of the breast rests on the fascia
 20% glandular and 80% fat and connective of the pectoralis major, serratus anterior, and external oblique
tissues abdominal muscles, and the upper extent of the rectus
 20 triangular-shaped lobes sheath. The Axillary tail of Spence extends laterally across the
anterior axillary fold.
 Each lobe has 10-100 lobules

nd rd th th
Extends from the 2 or 3 rib to the 6 or 7 rib The breast has a protuberant conical form. The base of the
cone is roughly circular, measuring 10 to 12 cm in diameter.
Considerable variations in the size, contour, and density of the
breast are evident among individuals.
Breast changes during pregnancy
Slide notes:
The nulliparous breast
has a hemispheric
configuration with
Side view of the Breast distinct flattening
above the nipple.
Slide notes: With the hormonal

The breast is composed of 15 to 20 lobes, which are each stimulation that
composed of several lobules. 15 fibrous bands of connective accompanies pregnancy
tissue travel through the breast (Cooper's suspensory and lactation, the breast
ligaments), insert perpendicularly into the dermis, and becomes larger and
provide structural support. The mature female breast increases in volume and
extends from the level of the second or third rib to the density, whereas with
inframammary fold at the sixth or seventh rib. It extends senescence, it assumes a
transversely from the lateral border of the sternum to the flattened, flaccid, and
anterior axillary line. more pendulous
configuration with
decreased volume.
ANATOMY
 Pectoralis Major
 Pectoralis Minor
 Intercostal Muscles
 Fascia
 Axillary Tail of Spence
Transcribers: Alyssa Katreen Villa, Mitchie Gonzales, Monique Ongpin

Formatting:Aibhen B. Naguna, Nerizza Bautista DLS H S I M e d i c i n e B a t c h 2 0 1 6 | 1 of 19
Editor: Chacha Mercado
STAGES OF BREAST DEVELOPMENT
Increase in size and Further enlargement of Production of areola and

pigmentation of areola breast papilla 2nd mound
Tanner II Tanner III Tanner IV
BLOOD SUPPLY VENOUS DRAINAGE

 The breast receives its principal blood supply  Perforating branches of INTERNAL THORACIC
from: VEIN
 Perforating branches of the INTERNAL  Perforating branches of POSTERIOR
MAMMARY ARTERY INTERCOSTAL VEIN
 Lateral branches of the POSTERIOR  Tributaries of the AXILLARY VEIN
INTERCOSTAL ARTERIES
 Branches from the AXILLARY ARTERY, SENSORY INNERVATION
 Lateral cutaneous branches of 2 to 6
nd th
including the:
o Highest thoracic intercostal nerves (sensory innervation of the
o Lateral thoracic, and breast and anterolateral chest wall)

nd
o Pectoral branches of the Lateral and anterior cutaneous branches of 2
th
thoracoacromial artery to 5 intercostal nerves joined by plexus in
subdermal
 Intercostobrachial nerve (lateral cutaneous
nd
branch of the 2 intercostal nerve)
 Anterior branches of supraclavicular nerve
(supply the skin of the upper portion of the breast)

SENTINEL NODE MAPPING Slide notes:
Medial aspect of the breast is drained thru the lymph vessels
together with the perforating branches of the internal
mammary artery and the parasternal group of nodes. The
lymph nodes that are located along the internal
mammary artery supplies the medial side of the chest.
In the superficial aspect of the breast, the lymphatics are

drained through superficial type of nodes. The involvement
of these nodes connotes the possibility of involvement of the
contralateral breast. This is the means of metastasis of
superficial type of nodes to the opposite breast.
HORMONAL INFLUENCE
 The breast is affected by various levels of hormones
such as estrogen and progesterone (due to the
response of breast epithelium and myoepithelial
cells).
 Increase in:
Axillary Lymph Node Groups. This would indicate the level
 Blood flow
of involvement in a malignancy.
 Lumina of ducts
 Secretory activity
PRIMARY NODE
 Parenchymal proliferation
 Injected with dyes (or radioactive tracers)
 Identify first set of nodes reached by the dye
 Dissect only nodes with dyes
 Qualify if there or there isn’t a malignancy
involved
*This also provides the avoidance of lymphedema (of the

involved arm) on the side of breast involved. Before, all
nodes are removed. Later in life, 1 year after the surgery,
this results in edema of the upper extremity. So it is better
to just select the involved nodes.
CONCEPT OF METASTASIS
1. Adjacent
 Most common manner of spread
 This is the basis for sentinel node
mapping.
 The adjacent nodes would precede the
nearest tumor cells or tissues
2. Any nodes in any part of the breast Imaging of the breast is best done 3-5 days after the
3. Across the mediastinum menstrual cycle because this is when the levels of estrogen
 Least common and progesterone are low.
LYMPHATIC DRAINAGE LUTEAL PHASE

 Lymph node groups are named according to their  Enlargement of lumina of ducts (resulting to breast
relationship to the pectoralis minor muscle enlargement)
 Increase in the acinar and ductal cellular secretory
LEVELS: activity (retention of body fluids which results in
 Level I heavier and painful breast)
 Axillary vein  Increased vascular flow around the breast
 External mammary
 Scapular Slide notes:
 Level II There is dilatation of the ductal systems and differentiation
 Central of the alveolar cells to secretory cells.
 Interpectoral (also called the Rotter nodes,
located between the pectoralis major and
minor muscles) FOLLICULAR PHASE
 Level III  First half of the cycle
 Subclavicular  Parenchymal proliferation of the ducts

PREGNANCY
 Completes the cycle of the breast because in
pregnancy, breasts are influenced by other
hormones other than estrogen and progesterone.
 Increase in volume and density
 Hormones that affect development: estrogen,
progesterone, growth hormone, prolactin, and
placental hormones
 Oxytocin
 Induces myoepithelial proliferation and
differentiation
 After delivery, milk let-down occurs as
oxytocin helps in milk expression
MENOPAUSE Breast changes during pregnancy

 Ductal and glandular tissues involute
 Dominance of fat and stroma
 Reduction of ducts and lobules
 Suspensory ligaments relax
 Ptosis of the breast (sagging of the breast)
DIAGNOSTIC MODALITIES
 BSE – self breast examination  Next, do the exam in a lying position wherein
 CBE – clinical breast examination a pillow is placed on the scapular area to
 Imaging emphasize the breast.
SELF BREAST EXAMINATION

 Done few days after menses (because there are
no more hormonal influences after the menses)
 For the postmenopausal woman, set a certain day
of the month when she can examine the breast
 Bilateral soft nodularities are normal
 Firm pressure in massaging motion
 Timing, inspection, and palpation Slide notes:
nd th
 Breast examination may be done in upright Use the pads of the 2 to 4 digits together. Initially in
or sitting position when the breasts are upright then on supine position, with one arm on her side,
relaxed. then with same arm underneath her head. Do it also on the
contralateral side.
 For the second part, hands are raised on the
level of the head One technique is to examine the breast in radial or
 Lastly, hands are placed on the hips to concentric circle fashion, starting on the nipple area then
contract the pectoralis muscles gradually making bigger circles. What is important is to
 Do it on the contralateral side remain consistent.

The most common site of malignancy is on the upper CLINICAL BREAST EXAMINATION
outer quadrant due to the abundance of glandular tissue  Physician-guided
in the area.  Takes about 3-5 minutes
 Sitting and supine
Initially, hands are placed on the sides in either sitting or  Examine the:
standing position. Do the examination first with arms o Contour,
down then arms up. Next, place the hands on the hips to o Symmetry,
examine if there is contraction of the pectoral muscles and o Vascular pattern,
to identify any asymmetry, or any lumps if present. o Skin irritation,
o Retraction, and
SELF BREAST EXAMINATION (continued): o Edema
 Advocated nationally
 Only 50% of women practice
 Detects 0.3 to 0.5cm masses
 Not useful in a research setting
Slide notes:
Self-breast examination does not affect the mortality of
patients with breast carcinoma. But we do not have any
option as this is inexpensive, convenient and accessible.
Patient education is very important in patients in third
world countries wherein access to imaging techniques (such
as mammography) is not possible all the time.
Slide notes:
Initially the woman in sitting position the physician inspects
for edema contour, symmetry, vascular pattern, and skin
changes. The woman must place her hands over her head
then place them on her hips to contract the pectoralis
muscles.
 Done one breast at a time

 Use pads of the first 3 fingers
 Same procedure as the self-breast examination –
standing/sitting, and lying down
 Arms at side, raised above the head, hands on the
hips
There are several methods in palpation. It should be  Include the axilla, supraclavicular and chest wall
done symmetrically. It may be done upward then  Areola is compressed (let the patient do this if
downward, radially from the peripheral to the areola, or you’re not comfortable with this)
circumferentially from the nipple going outwards. The  Excellent screening tool (this may detect lumps
axillary area should also be examined. Nipple has to be that could be an indication of a malignancy)
pressed to check for noticeable discharges.

Slide notes:  Craniocaudal (CC)
At the end of the examination documentation is important,  Most of the breast tissue is seen
and take note if a mass is tender, attached to skin or deeper  Better visualization and greater breast
structures. CBE discovered about 15-20 % of breast cancers. compression
IMAGING TECHNIQUES
 The three main diagnostic procedures for patients
with suspected breast lesion: mammography,
clinical/self-breast examination, and
histopathology.
 Mammography
 Most common
 Best method for screening
 Helpful in detection of non-palpable lesions
 For patients reaching 40 years old
 May detect early stages of cancer
(will decrease morbidity and mortality)
 The 5-year survival rate of women with
negative nodes is 85% while those with (+)
 Mediolateral oblique (MLO)
nodes is only 53%.
 Medial aspect of the breast is seen
 Digital mammography  Gives greatest volume of the breast including
 Useful in women with dense breast and upper outer quadrant and axillary tail of
with breast implants Spence
 Provides better resolution and the images
can be readily manipulated
 MRI
 Can differentiate benign from malignant
tissue
 Ultrasound
 Can differentiate cystic from solid masses
 Complementary procedure
 For younger patients
 Computed tomography
 Thermography
 Unreliable screening method for breast
carcinoma
 Dynamic Optical Breast Imaging (DOBI)
 Scintimammography  90-degree lateral view
 Radionuclide imaging test for the detection  Used in diagnostic type of mammography
of breast cancer  Used with CC to TRIANGULATE an
 High diagnostic accuracy for breast cancer abnormality
 Diffraction-Enhanced Imaging (DEI)
MAMMOGRAPHY
 Spot compression view

 Only a certain point in the breast is seen
 Compression device minimizes motion
 Two Types: artifact
 Screening – used to detect unexpected
lesion in asymptomatic women; as part of
annual check-up
 Diagnostic – used in cases with abnormal
findings
 Views:

American College of Radiology Breast Imaging
Reporting and Data System Assessment Categories
 They usually classify the results into five or six
categories.
CATEGORY O: NEEDS ADDITIONAL EVALUATION CATEGORY 3: PROBABLY BENIGN

 Radiologist cannot commit if the lesion is benign or  Probably benign but the use of other imaging
malignant. So, it needs additional evaluation. techniques (probably an ultrasound) is needed
Usually, the additional evaluation is a sonogram or
ultrasound of the breast. But you don’t do solely the CATEGORY 4: SUSPICIOUS FOR MALIGNANCY
ultrasound as a screening tool.  Looking at the edges, the presence of spicules is
suspicious for malignancy because we cannot
exactly determine the periphery of the lesion, where
are they located, we don’t know
CATEGORY 5: HIGHLY SUSPICIOUS FOR

CATEGORY 1: NORMAL MALIGNANCY
 Negative for breast disease  Kapag ganyan kalaki siguro, malignancy
 Normal mammographic study  Other techniques would be under histopathologic
 Radiologist able to commit that this is normal
Note the presence of spicules

CATEGORY 2: BENIGN
 Presence of well-circumscribed lesion with borders, CATEGORY 6: KNOWN BIOPSY-PROVEN
can be separated visually with the rest of breast MALIGNANCY; APPROPRIATE ACTION SHOULD BE
tissue TAKEN
 Most common finding: FIBROADENOMA  Already with biopsy, usually not requested
 Done to determine the extent

BI- Description Probability of Follow-up
RAD malignancy
class (%)
0 Needs 1 Diagnostic
additional mammogram,
evaluation ultrasound
1 Normal 0 Yearly screening
mammogram
2 Benign lesion 0 Yearly screening
3 Probably <2 Short interval
benign lesion follow-up
4 Suspicious 20 Biopsy ULTRASOUND
for  Differentiates cystic from solid masses
malignancy  Not done as a screening test except for women
5 Highly 90 Biopsy with very dense breasts who cannot be
suspicious adequately screened with mammography
malignancy
*BI-RAD: Breast Imaging Reporting and Data Systems
DIGITAL MAMMOGRAPHY
COMPUTED TOMOGRAPHY
 Limited use because of higher radiation dose and
cost and longer study times
 Excellent for studying the most medial and lateral
 Useful in women with dense breast (and with aspects of the breast
breast implants)
 Image storage and display are faster
 Adjustments can be done to get superior views.
 This is like a camera in which there is better
resolution. Images can be manipulated already.
 The areas are so crisp that you can easily see the
different areas of the breast.  
 It may provide superior views of the breast.
 In film, the demarcations are not that clear
compared to digital. And you can further evaluate
in digital.
MRI
 Differentiates benign from malignant and
reduces the frequency of breast biopsy especially
in women with dense, fibroglandular breasts
 Proven effective in detecting new tumors in THERMOGRAPHY
patients with previous lumpectomy because it can  Unreliable as a screening technique for breast
accurately distinguish between scar tissue and carcinoma or as a technique to determine women
cancerous lesions. Best accomplished by the at increased risk for subsequent breast neoplasia
gadolinium-enhanced MRI.  Although thermography has been used clinically,
 Not used for mass screening because the average it has extremely high false- positive and false-
examination takes about 45 minutes to an hour negative rates
and is expensive  Ineffective in detection of occult or preclinical
 It is useful in the patient who present with axillary cancers.
adenopathy and no apparent mass in the breast
 Cannot identify microcalcifications

Left to Right: Normal, Fibrocystic with vascular areas, Inflammatory, Carcinoma (if extended)
DOBI (DYNAMIC OPTICAL BREAST IMAGING)

 Radiation-free technique that measures the light
transmitted through breast tissue
 The breast acts as a filter for the light; the
hypothesis is that malignant tissue absorbs more
infrared light than does benign tissue
 Although inexpensive, it is still experimental and
unproven
 Provides transillumination to the breast
 Not locally available
DIFFRACTION ENHANCED IMAGING (DEI)

 Uses an analyzing crystal placed in the x-ray beam
between the breast and an imaging-enhancing
material such as film or digital detector
SCINTIMAMMOGRAM
 Radionuclide type using Technicium-99 m
 Technetium-99m sestamibi (radioisotope used)
is a radiotracer with reported high sensitivity
and high negative predictive value for breast
cancer
 Has a high diagnostic accuracy for the detection
of breast cancer in all women, including women  The crystal diffracts the X-ray beam and produces
who may be unsuitable for conventional two separate images, one based on standard
mammography radiograph and the other based on refraction
 There could be an uptake or non-uptake of the  Results to an excellent quality image with superior
Technetium tumor visibility
 Super high-tech!

TISSUE DIAGNOSIS
 The definitive diagnosis and ultimate
foundation for treatment of breast carcinoma
depends on histologic diagnosis of the biopsy
material
 Breast biopsy is one of the most common surgical
procedures performed, but with the increasing
acceptance of mammography and the development of
less invasive procedures there has been a shift from the
traditional open biopsy to the less invasive and more
popular core-needle biopsy.
CORE NEEDLE BIOPSY

 Usually performed with 14-16 gauge needle,
ultrasound-guided
 Can be sent for hormone receptors, gene profiling
and histologic assessment.
FINE NEEDLE ASPIRATION BIOPSY (FNAB)

 The needle is projected within the lumen of the
cyst
 Most physicians do not use anesthesia, although
some prefer to use a small amount of local
anesthetic (1 mL of 1% lidocaine)
 The skin over the breast is the most sensitive area,
but the breast tissue itself has few pain fibers.
 Complications of needle aspiration are minimal,
with hematoma formation being the only
substantial one. Infection is very rare.
IMAGING GUIDES FOR NON-PALPABLE LESIONS:

 Mammography
 Ultrasound
 Stereotactic
BENIGN BREAST LESIONS

TYPES  “Plateful of peas” to a consistency of balloon
1. Fibrocystic changes filled with water; mongo-like
2. Inflammatory disease  Exaggerated physiologic response including
3. Intraductal Papilloma increased engorgement of the density of the
4. Fibroadenoma breast, excessive nodularity, rapid change in and
5. Fat Necrosis fluctuation of the cystic areas and increased
6. Cystosarcoma phyllodes tenderness
 General descriptive term that includes any
FIBROCYSTIC CHANGES change in contour of breast tissue. There is a
 Cyclic bilateral breast pain wide spectrum and variation in clinical
 Excessive nodularity symptoms and palpable findings. Similarly, this

term refers to a broad spectrum of benign THREE STAGES:
histopathologic changes in the breast. 1. MAZOPLASIA
 Most common terminologies: mammary  Occurs in women in 20s (younger women)
dysplasia and chronic cystic mastitis  Intense proliferation of STROMA
 Most common in women between the ages of  Upper outer quadrant (most commonly
20 and 50 and unusual after menopause unless affected)
associated with exogenous hormone use  Most tender and indurated is the axillary
tail
 Differential diagnoses include referred
 pain from a dorsal radiculitis or
inflammation of the costal chondral
junction (Tietze’s syndrome) or
costochondritis. The latter two conditions
have non-cyclic symptoms and are
unrelated to the menstrual cycle.
2. ADENOSIS
 Occurs in women in 30s (older women)
 Less severe breast pain and tenderness
 Cysts vary from 2-10 mm
 Marked proliferation and hyperplasia of
ducts, ductules and alveolar cells
 There is formation of GLANDS
From Past Transcription:

Possible Causes:
a. Subtle imbalance between estrogen and
progesterone 
b. Increased daily prolactin production secondary
to thyroid-releasing hormone  
Signs and Symptoms (more prevalent in
premenstrual phase):
1. Cyclic bilateral breast pain (diffuse) - classical
 symptom
2. Exaggeration of normal physiologic response to
cyclic levels of ovarian hormones (Meaning the
woman experiences these all the time and often
it’s bilateral.
 Increased engorgement and density
 Excessive nodularity
 Rapid changes and fluctuation in the size
of the cystic areas
 Increased tenderness
 Occasional nipple discharge 3. CYSTIC CHANGE
 On physical examination, the findings of  In women in their 40’s
excessive nodularity of fibrocystic  No severe pain
changes have been described as similar to  Sudden pain with point tenderness (can
palpating the surface of a plateful of only be appreciated at a certain point of the
peas. cyst)
Premenstrual Phase  Vary from microscopic to 5 cm (bigger
 Pain usually located at the upper outer compared to adenosis)
quadrant and radiates to shoulders and arms   Regress or can be aspirated
 Multiple solid areas described as ill-defined  Fluid is straw-colored, dark brown, or green
thicknesses or areas of “palpable lumpiness” depending on the chronicity of the cyst
that are rubbery in consistency; more 2D than  Upon palpation: indentable
3D    Besides hyperplasia, there could be
 During palpation, larger cysts have consistency ATYPIA which is indicative of malignancy
similar to a “balloon filled with water.”
Pathophysiology
 Fibrosis 
 Adenomatous changes
 Cyst formation

 Since it’s physiologic, management would be
symptomatic
 Initial therapy of fibrocystic changes consists of
the patient wearing a “support” bra, which
provides adequate support for the breasts both
night and day.
From the book:  

Minton has advocated advising patients to reduce their
consumption of methylxanthines and tobacco.
Methylxanthines are commonly found in coffee, tea, cola
drinks, chocolate, and many non-prescription medications.
Minton studied 106 women with clinical fibrocystic changes
and found that in 68% the condition resolved and in another
24% the clinical symptoms improved by decreasing
consumption of methylxanthines and nicotine. However, four
recent case-control studies have found no association
between caffeine or methylxanthine consumption and benign
breast disease.
INFLAMMATORY DISEASE/MASTITIS
 Infectious agent
 Ductal system, sebaceous glands – deeper
infection
 S. aureus – MOST COMMON
 May also be due to trauma
Slide notes:
 May also happen during puerperium or after
If upon histopath it revealed ductal hyperplasia with atypia,
breast feeding
lifetime risk increases to 12% to 15% as much as 20%.
From Past Transcriptions:

Histology of fibrocystic changes is characterized by
proliferation and hyperplasia of the lobular, ductal and
acinar epithelium. Variants of fibrocystic change include
cysts (from microscopic to large, blue, domed cyst), adenosis
(florid and sclerosing), fibrosis (periductal and stroma), duct
ectasia, apocrine metaplasia, intraductal epithelial
hyperplasia, and papillomatosis.
Ductal epithelial hyperplasia with atypia and apocrine

metaplasia with atypia are the most prominent histologic
findings directly associated with development of breast
carcinoma. If these 2 conditions are discovered on breast
biopsy, the chance of breast CA in the future is approximately
five-fold increase greater than the controls.
Diagnosis
 Imaging techniques
 Fine needle aspiration cytology MANAGEMENT
 Core needle or excision biopsy  Antibiotics for Gram positive organisms: usually
Amoxicillin
 Obtaining cultures
MANAGEMENT
 Empirical treatment: Cephalosporins
 Depends on woman’s age
 Antibiotics may include (if resistant)
 MEDICAL:
sulfamethoxazole or quinine. For puerperal
 OCP/progestins recur in 40% - to modify the
mastitis, cephalosphorins may be enough.
cycle
 Danazol, not >6 months – because of the
INTRADUCTAL PAPILLOMA
effects like mass colonization, voice changes,
 Benign lesion
increase in size of the breasts, hypertrichosis
 Bromocriptine, with elevated prolactin  Spontaneous bloody discharge – discharge
maybe watery, yellowish, serous-sanguinous or
 Tamoxifen
bloody; may be from one nipple or one or few ducts
 GnRH
 Others – others would give diuretics due to  Located beneath areola
water retention during the premenstrual  Ductography recommended aside from
phase. To some, avoid methylxanthine mammography
compounds such as chocolates and teas, but  Seen in perimenopausal group
these recommendations are not evidence-  May also be intermittent
based.  During PE it is important to circumferentially put
radial pressure on different areas of areola

Signs and Symptoms

 Watery, serous or sero-sanguinous (then
becomes bloody)
 Small, soft, usually microscopic
 2-3 mm in diameter extending radially from
the alveolar margin
 Discharge emanates from one duct or multiple
 openings
Management:
 Excision biopsy of lesion + small amount of
surrounding tissue
From the book:
 If lesion comes from one duct only, consider Non-operative management is appropriate for small
malignancy fibroadenomas discovered in women younger than 35 if three
separate clinical parameters support the diagnosis of
fibroadenoma. The three parameters are clinical exam,
FIBROADENOMA imaging evaluation (either mammogram or ultrasound), and
 Most common benign lesion fine-needle aspiration cytology. The characteristic features
 Present in adolescent and women in their 20s – of a fibroadenoma are found in approximately 95% of all
rd th
most common in women in 3 or 4 decade of life fibroadenomas. Thus, conservative management can be
 No change in size with menstrual cycle considered with follow-up every 6 months. The only way to
 Rubbery, well circumscribed, easily delineated distinguish a fibroadenoma from a malignancy is with either
a histologic or cytologic evaluation. Despite the option of
borders
conservative management of a fibroadenoma, most women
 Management: Excision usually prefer to have the lesion excised.
 When you visualize it under mammogram, lesion is
whiter, but under ultrasound, it is dark
 Not a true neoplasm PHYLLODES TUMOR or
 30% regress CYSTOSARCOMA PHYLLODES
 Divided into benign, borderline and malignant
 Once it invaded the ductus, it presents with leafy
projections
 Fibroepithelial tumor w/ hypercellularity of the
Signs and Symptoms
connective tissues
 Firm, rubbery, freely mobile, solid, solitary
 Fibroepithelial breast tumors that are rare and
 Well circumscribed 
may arise from fibroadenomas
 Average size is 2.5 cm 
 Most frequent breast sarcoma
 Usual slow growth (no pain)
 Seen in 5th decade of life
 Can also metastasize (only 10%)
DIAGNOSIS:TRIPLE TEST (3 parameters)  
 Clinical exam  SIGNS AND SYMPTOMS
 Imaging (mammogram or UTZ)   Rapidly growing
 Fine absorption biopsy (or excision)  May reach a mean diameter of 5 cm at time of
diagnosis
 1 out of 4 is malignant
 1 out of 10 metastasize

DIAGNOSIS:TRIPLE TEST (3 parameters)  
 Clinical exam 
 Imaging (mammogram or UTZ) 
 Fine absorption biopsy (or excision)
MANAGEMENT:
 Wide excision including normal tissue with wide
margin
SIGNS AND SYMPTOMS
FAT NECROSIS BREAST PAIN (MASTALGIA)
 Confused with malignancy  Divided into cyclic and non-cyclic
 Ill-defined indurated (medyo matigas), mass
surrounded with ecchymosis
 Usually may have skin retractions
 Sometimes the area of fat necrosis liquefies and
 becomes cystic in consistency
 Usual cause is trauma
 No relationship between fat necrosis and  Drugs associated with mastalgia
subsequent breast carcinoma  Antihypertensives
 Antidepressants/antipsychotic
DIAGNOSIS:    Estrogen/progestogens
 Mammography: presents with stippled  Ginseng
calcifications and stellate contractions  Clomiphene citrate
 In imaging, it can present with retractions and  Digoxin
calcifications; thus, it can mimic malignancy  Metochlorpromide
MANAGEMENT:
 Excision with margins of normal tissues
 Give antibiotics if with secondary infection
BREAST MALIGNANCY
DIAGNOSIS
 Triple Screening Tests
 Self Breast Examination
 Clinical Breast Examination
 Mammography
The kinetic growth of cancer cells is the mass doubles every 100 days and the diameter doubles every 300 days.

 More than 5 children
Note: 5. Decreased postmenopausal body mass
Breast carcinoma can only be detected via mammography 6. Increased physical activity
after 4 years so awareness is very important to prevent 7. Intake with vitamin D/calcium
growth. Be highly suspicious and know the risk factors! 8. Olive oil/ Omega 3 fatty acids intake
9. Aspirin
 Decreased risk, recurrence, mortality
RISK FACTORS
1. Age CHARACTERISTICS
 Strongest risk factor  Presence of a solitary solid three-dimensional
 Risk increases by 40 years of age dominant ill-defined breast mass
 Given birth after 35 years old (1.5 times)  Most often in upper outer quadrant
 If a 21 year old patient has a breast mass,  Pain is 10%
primary impression should not be  Not mobile
malignancy because it is not common in that  Ulceration
age group  Peau d’orange
2. Estrogen exposure  Inflammation
 Longer use, higher risk
 Less risk than alcohol
 First generation OCPs in the 1960s (higher
estrogen content)
3. Alcohol use
 Dose related (>2 times per day)
 Metabolism of alcohol occurs in the liver.
Liver malfunction causes decrease in sex
hormone binding globulin thus increase in
circulating estrogen
4. Late menopause
 Menopause before 45 years old decreases
risk
 51-54: average menopausal age among
Filipinos
 Women still menstruating at 54 years old
have increased risk for breast malignancy or
CLASSIFICATION:
endometrial carcinoma
*Based on History and Gene Profiling
5. Obesity
 Increase during menopause
1. Intraductal carcinoma in situ
 There is increased peripheral conversion to
 Limited to the ductal epithelium and does
estrogen
not involve the basement membrane
6. Breast characteristics
 Mammography exhibits stipplings of
 5x increased risk in dense breasts
microcalcifications
 Biopsy reports indicating atypia or
 Usually not detected: it is a premalignant
hyperplasia have increased risk
lesion and only 1/3 will develop into
7. Familial
carcinoma within 10 years from the diagnosis
 2 or more 1st degree (premenopausal)
 Diagnosis: by core needle biopsy
relatives with breast cancer
 Treatment: excision with radiation to
 Inherited the breast cancer syndrome
ipsilateral breast (radiation is optional since
8. Radiation
it is premalignant)
 With mantle type used in treatment of
malignancy
 Less with CXR, CT scan
9. Use of HRT
 Estrogen alone with a RR of 0.8
 Estrogen and progesterone with a RR of
1.24
FACTORS ASSOCIATED WITH DECREASED RISK

1. Estrogen exposure
 Late menarche (>14 yo) thus with less
estrogen exposure
2. Lactation
 >12 months
st
3. Age at 1 birth
 Less than 20 years of age
4. Parity

2. Lobular carcinoma in situ
 Marker for increased risk for full blown
carcinoma
 Not considered a cancer
 Common to be multifocal and bilateral
 Latent period of 20 years
5. Inflammatory
 Recognized clinically
 Rapidly growing and very virulent
 Predominantly ductal in type
 2% of cases of malignancies
3. Infiltrating ductal carcinoma

 75% of cases
 Presence of non uniform malignant cells
 Extensive stromal reaction
 Classified as comedone, colloid, medullary,
tubular and papillary
6. Paget’s disease
 Less than 1%
 Looks like eczema or dermatitis (of the
nipple area)
 An infiltrating ductal CA that invades the
epidermis
 Has good prognosis
4. Infiltrating lobular carcinoma

 Uniformity of small round neoplastic cells
 Highly staining cells that infiltrate the
stroma in single file fashion
 Multicentric origin
 Tend to involve both breasts
 Histologic subdivisions include small cell,
round cell and signet ring

SURVIVAL RATES
Stage Description 5 year Survival Rate
Lesion <2 cm in diameter
1 85%
Nodes, if present not felt to contain metastases
Lesion <5cm in size
2 66%
Affectation of nearby lymph nodes (not fixed)
Lesion >5 cm in size
With nearby lymph node involvement
Dimpling
3 Inflammation 41%
Change in skin color
Nodes in supraclavicular area
Tumor of any size with invasion of skin or attached to chest wall
4 With distant metastasis 10%
*Transcriber’s note: This table was obtained from Katz. The one she read during the lecture was incomplete so I decided to get the table in
Katz since that was her source. Although if you listen to the recordings, the values she said were different.)
TYPES OF MALIGNANCIES BASED ON HORMONAL RECEPTOR
PRINCIPLES OF MANAGEMENT
CHEMOPROPHYLAXIS AND CHEMOTHERAPEUTIC  Designed to assess the efficacy on
RISK REDUCTION bone fractures
 Breast Cancer Prevention Trial  7705 postmenopausal women
 Designed to assess whether Tamoxifen can  76% reduction in the incidence of breast CA
reduce the incidence
 Double blind, randomized placebo  Study of Tamoxifen and Raloxifene STAR trial
controlled trial  Similar reductions in carcinoma with
 13,388 less uterine complication on raloxifene
 Reduce by 49% with p value of <0.00001  For women with BRCA1 mutations-
Tamoxifen is not effective
 Raloxifene Study
SURGICAL

 Hartman  Medscape: procedure in which the entire
 Retrospective cohort study of 639 subjects breast is removed, including the skin, areola,
 90% reduction nipple, and most axillary lymph nodes; the
 Risk reduction with BRCA gene mutations pectoralis major muscle is spared.
 Associated physiologic and complicated  Simple mastectomy
psychological consequences
MEDICAL
 Adjuvant chemotherapy
 Hormonal therapy
OBJECTIVES OF MANAGEMENT
 Tamoxifen
 Control of local disease
 Arimidex
 Lumpectomy or quadrantectomy with
 Trastuzumab
sentinel node mapping
 Combination of cytotoxic drugs
 Treatment of distant metastasis
 Paclitaxel
 Chemotherapy
 Adriamycin (antibiotic type)
 Improve the quality of life  Cyclophosphamide
 Reconstructive surgery after mastectomy
SURGICAL (continued)
 Lumpectomy
 Breast tissue is removed and skin is closed
(no skin removed)
 Quadrantectomy
 Remove breast tissue plus portion of the
skin
 Radical mastectomy
 Remove entire breast plus pectoralis muscles
(major and minor)
 Modified radical mastectomy
Note: For most organizations, they recommend annual mammography starting 40 years of age but if the result is normal in a given year, a
repeat mammography is done after 2 years. BUT! Once the patient reaches 50 years old, it’s mandatory that yearly mammography is done.

BREAST CANCER POSTTREATMENT SURVEILLANCE EDUCATION
GOALS:  Locoregional recurrences
 Detect potentially curable locoregional  Mass in ipsilateral breast after conserving
recurrences, second primary tumors and systemic therapy
relapses  Mass in the chest wall
 If there are recurrences (usually within 2-3 years),  Rash localized to the treated breast or
you allow patient to decide if she wishes for chest wall
retreatment or stop treatment. If the WBC count is  Axillary, supraclavicular, infraclavicular or
low, you defer treatment since they are prone to cervical lymph node enlargement
infection.  Systemic Recurrence
 However most of the most of the recurrences are  Skeletal relapse (localized, progressive bone
symptomatic and occurred in between scheduled pain)
follow-ups.  Pulmonary metastasis (pleuritic chest pain,
cough, dyspnea)
CORNERSTONE  Liver relapse (RUQ discomfort, fullness,
 Thorough PE every 3 to 6 months weight loss, anorexia)
 Regular gynecologic follow up and  CNS metastasis (headache, new onset
mammographic imaging every 6 to 12 months seizure, focal or sensory loss, bowel or
 Request for CT scan of liver (most common site), bladder [autonomic] dysfunction)
pelvis, brain if you are suspecting metastasis
-END-
TRANSCRIPTION DETAILS
PPT, Past
BASIS RECORDINGS + NOTES + DEVIATIONS 8-10% CREDITS Ro-Janna Jamiri for the powerpoint 
Tranx
th
Lentz Comprehensive Gynecology 6 Edition as main reference.
REMARKS
Transcribers included info from past transcription!!! Read up, people! 
-BATCH 2016 Transcribers’ Guild Transcriptions. Version 1.0.0.0.0 Build 3214-
RISK FACTORS FOR BREAST CARCINOMA DECREASED RISK FOR BREAST CARCINOMA


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BREAST DISEASES ( . ) ( .

***ITALICIZED– Recording; BLUE – Past Transcription

NORMAL BREAST ANATOMY

Breast changes during pregnancy

Slide notes: With the hormonal

Transcribers: Alyssa Katreen Villa, Mitchie Gonzales, Monique Ongpin

Increase in size and Further enlargement of Production of areola and

BLOOD SUPPLY VENOUS DRAINAGE

Transcribers: Alyssa Katreen Villa, Mitchie Gonzales, Monique Ongpin

In the superficial aspect of the breast, the lymphatics are

*This also provides the avoidance of lymphedema (of the

LYMPHATIC DRAINAGE LUTEAL PHASE

Transcribers: Alyssa Katreen Villa, Mitchie Gonzales, Monique Ongpin

MENOPAUSE Breast changes during pregnancy

SELF BREAST EXAMINATION

Transcribers: Alyssa Katreen Villa, Mitchie Gonzales, Monique Ongpin

 Done one breast at a time

Transcribers: Alyssa Katreen Villa, Mitchie Gonzales, Monique Ongpin

 Spot compression view

Transcribers: Alyssa Katreen Villa, Mitchie Gonzales, Monique Ongpin

CATEGORY O: NEEDS ADDITIONAL EVALUATION CATEGORY 3: PROBABLY BENIGN

CATEGORY 5: HIGHLY SUSPICIOUS FOR

Note the presence of spicules

Transcribers: Alyssa Katreen Villa, Mitchie Gonzales, Monique Ongpin

Transcribers: Alyssa Katreen Villa, Mitchie Gonzales, Monique Ongpin

DOBI (DYNAMIC OPTICAL BREAST IMAGING)

DIFFRACTION ENHANCED IMAGING (DEI)

Transcribers: Alyssa Katreen Villa, Mitchie Gonzales, Monique Ongpin

CORE NEEDLE BIOPSY

FINE NEEDLE ASPIRATION BIOPSY (FNAB)

IMAGING GUIDES FOR NON-PALPABLE LESIONS:

BENIGN BREAST LESIONS

Transcribers: Alyssa Katreen Villa, Mitchie Gonzales, Monique Ongpin

From Past Transcription:

Transcribers: Alyssa Katreen Villa, Mitchie Gonzales, Monique Ongpin

From the book:

From Past Transcriptions:

Ductal epithelial hyperplasia with atypia and apocrine

Transcribers: Alyssa Katreen Villa, Mitchie Gonzales, Monique Ongpin

Signs and Symptoms

Transcribers: Alyssa Katreen Villa, Mitchie Gonzales, Monique Ongpin

Transcribers: Alyssa Katreen Villa, Mitchie Gonzales, Monique Ongpin

FACTORS ASSOCIATED WITH DECREASED RISK

Transcribers: Alyssa Katreen Villa, Mitchie Gonzales, Monique Ongpin

3. Infiltrating ductal carcinoma

4. Infiltrating lobular carcinoma

Transcribers: Alyssa Katreen Villa, Mitchie Gonzales, Monique Ongpin

TYPES OF MALIGNANCIES BASED ON HORMONAL RECEPTOR

Transcribers: Alyssa Katreen Villa, Mitchie Gonzales, Monique Ongpin

Transcribers: Alyssa Katreen Villa, Mitchie Gonzales, Monique Ongpin

Transcribers: Alyssa Katreen Villa, Mitchie Gonzales, Monique Ongpin

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From the book:  