Iloilo Doctors’ College of Medicine – Batch 2020

THE BREAST
Dr. Christine Trespeces

THE BREAST
 2 or 3 rib to the inframammary fold or 6th to 7th
nd rd
 Composed of 15-20 lobes, which are each composed
rib of lobules. Each lobe of the breast terminates in a
 Lateral border of the sternum lactiferous duct through an orifice into the am[ulla of
 Anterior axillary line nipple.
 Deep or posterior border is the fascia of the
pectoralis major, seratus anterior, external FUNCTIONAL ANATOMY
oblique and upper extent of the rectus abdominis  LEVEL I- lateral or below the pectoralis minor(axillary
 Axillary tail of spence – extended up to the axillary vein, external mammary, scapular).
fold  LEVEL II- superficial or deep into the pectoralis
minor.(central,interpectoral).
 LEVEL III- medial to and above the pectoralis minor.

PHYSIOLOGY OF THE BREAST

Hormones responsible for the development, function and
maintenance of the breast tissue
 ESTROGEN- initiates ductal development
 PROGESTERONE- responsible for
differentiation of the epithelium and for lobular
development
 PROLACTIN- primary hormonal stimulus foe
lactogenesis.

BLOOD SUPPLY  NEONATE-HYPOTHALAMIC-PITUITARY-OVARY

Arterial: AXIS
 Lateral branches of the posterior intercostal  is sensitive therefore decrease in the Estrogen
arteries and progesterone levels.
 Perforating branches of the internal mammary  PUBERTY
 Branches from the axillary artery (highest and  Decrease in the sensitivity of the HPO axis
lateral thoracic, pectoral branches of the therefore increase in the Estrogen and
thoracoacromial artery) Progesterone levels.
Venous Drainage:  MENOPAUSE
 Decrease production of the Estrogen and
 Perforating branches of internal thoracic vein
Progesterone by the ovaries.
 Perforating branches of posterior intercostal vein
 Tributaries of axillary vein
**Batson Plexu BENIGN CONDITION OF THE BREAST
Intrinsic or Extrinsic Etiology:
 Acute mastitis
 Mammary Duct ectasia
 Galactocele

ACUTE MASTITS
 Complication of nursing that is due to the
development of cracks and fissures in the skin of

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the nipple which allow bacteria (Staph and strep)
to invade the breast parenchyma
 Rx-surgical drainage/antibiotics
 Biopsy of the abscess cavity may be necessary
FAT NECROSIS
 Usually follows trauma (may be iatrogenic, as in
surgical biopsy)
 Focus of necrotic parenchyma with marked acute
and chronic inflammation which includes foreign
body giant cells and lipid-laden macrophages
 May calcify and mimic carcinoma on
mammogram
GALACTOCELE
 Cystic dilatation of duct during lactation
 May become infected (acute mastitis) with
abscess formation
INFLAMMATORY/INFECTIOUS CONDITIONS
Intrinsic or Extrinsic Etiology:
 Acute mastitis
 Breast abscess
 Fat necrosis
 Tuberculous mastitis
 Galactocele
 Skin diseases
 MYCOTIC INFECTIONS- fungal infection
erythematous scaly lesions.
 HIDRADENITIS SUPPURATIVA- originates within
the accessory sreolar glands of Montgomery
 MONDOR’s DISEASE- variant of thrombophlebitis
*** DERMOID CYST
Tuberculosis of the breast
BENIGN DISOORDERS AND DISEASES OF
THE BREAST
Aberration of Normal Development and Involution
(ANDI)
 Benign breat disorders/diseases related to
normal processes of reproductive life and
involution.
 Spectrum of breast diseases from normal to
disorder to disease
 Encompasses all aspects of breast condition.
PATHOLOGY OF BENIGN BREAST
DISEASE
 Non-proliferative lesions (RR= 1.0)
 cysts, mild hyperplasia of the usual type
 Proliferative lesions without atypia (RR=1.5-2.0)
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 moderate or florid hyperplasia,
intraductal pappiloma, sclerosing
adenosis, fibroadenoma
 Atypical hyperplasia(RR=4.0-5.0)
 atypical ductal hyperplasia (ADH),
atypical lobular hyperplasia
FIBROCYSTIC DISEASE OF THE BREAST
Common disorder and accounts for the majority of
surgical procedures performed on the female breast
 Morphological changes affect glandular and
stromal elements of the breast
 Morphologic changes are due to Estrogen-
progesterone imbalance
 Produces breast mass that must be differentiated
from carcinoma
 Atypical hyperplasia of the ductal epithelium
(present in 5% of fibrocystic lesions) is associated
with increased risk of carcinoma)
 Changes includes: Ductal dilatation, fibrosis of
the stroma, hyperplasia of the ductal epithelium,
sclerosing adenosis, apocrine metaplasia, radial
scar
 Usually is associated with menstrual cycle
 Age group varies common though in 20-40
 Associated with pain
FIBROADENOMA
 Most common benign tumor of the female breast
 Occurs after puberty and usually before 30 years
of age
 Most commonly present as solitary, freely
moveable mass in upper outer quadrant of the
breast (which is also the most common location
of breast carcinoma)
 Histologically is composed of fibrous stroma
compressing glands
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 Respond to estrogen and progesterone and thus of treating all conservatively, without considering
size may fluctuate with the menstrual cycle all the facets of the problem.
 Pregnancy may cause increased growth..than a
true neoplasm MASTALGIA
 Represents a hyperplastic mass process rather  common problem
than a true neoplasm  report as high as 70%
 ANDI- aberration of normal development and  more commonin the western world
involution  mild premenstrual breast pain lasting 2-3 days is
 Cause is unknown but believed to be due to common
hormonal imbalance  more prolonged, severe pain is less common
 Firm, rubbery, well circumscribed, freely and considered mastalgia
movable, rounded, oval and sometimes  mastalgia has been shown to impact QOL
lobulated, usually painless. scores.
 Sometimes tender with high estrogen levels TYPES OF MASTALGIA
 Usually presents as a single breast mass. CYCLICAL
 Associated with luteal phase of menstrual
So what do we tell the patient (and mom) cycle(near end)
 Other bilateral
How do we confirm the diagnosis? Biopsy options  Sharp, shouting, stabbing, heaviness
“to excise or not to excise” NON-cyclical
 Not associated with menstrual cycle
NATURAL HISTORY
 More localized
 May grow, regress or remain unchanged as the
 Lateral or subareolar
hormonal environment changes
 Heavy, achy, tender, burning
 Most feel fibroadenomas grow to a size of 2-3 cm,
CHEST WALL
then remain unchanged for several year
 Not associated with menstrual cycle
 Could present as a giant fibroadenoma
 Usually unilateral
 Regression or complete resolution has been noted.
 Costochondritis (Tietze’s syndrome)
 Hormonally responsive and change with the
 Musculo-skeletal, surgical trauma, referred pain
menstrual cycle, pregnancy, menopause
DIETARY /SUPPLEMENT
RECOMMENDATIONS
MANAGEMENT: THINGS THAT MAY WORK:
 Observation with TRIPLE TEST if necessary  VIT. E
(Clinical Exam, Mammogram, Biopsy)  Low fat diet
 Aspiration of the cyst  Flaxseed
 Excision Biopsy- still preferred because of the fear of  Chasteberry
the risk of malignancy. Many will remain palpable High dose iodine
especially if >2cm.
THINGS THAT DON’T WORK:
NON-OPERATIVE POTENTIAL THERAPY  Caffeine restriction
 Mechanical devices  Evening primerose oil
 vacuum assisted side cutting)
 large intact sample devices  Ginseng
 RF assisted  Other vitamins
 Cryoablation
MEDICATIONS:
 The management of fibroadenoma is often in a 1. BROMOCRIPTINE- dopamine agonist
state of flux, and when this is the case there is a -Proposed mechanism of action decrease in
prolactin
tendency for swings from one extreme to another
2. DANAZOL- suppresses gonadotropin secretion,
to occur. With such a common condition, it is prevents Lh and inhibits ovarian steroid
important to try to maintain a balance between an formation.
excessively reactionary approach (removing 3. TAMOXIFEN- selective estrogen receptor
every fibroadenoma) and the opposite approach modifier.
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INTRADUCTAL PAPILLOMA TREATMENT OF SPONTANOEUS NIPPLE

 Neoplastic papillary growth within the lactiferous DISCHARGE
duct  Milky, unilateral-no treatment necessary
 Presents as bloody nipple discharge  Milky, bilateral- if greater than two years since
 Probably a variant of epithelial hyperplasia of lactation, check plasma protein
fibrocystic disease  Bloody- excisional biopsy of draining duct
 Benign  Some practitioners find ductography
useful for surgical planning
NIPPLE DISCHARGE  Spontaneous, non-bloody unilateral discharge-
evaluate with mammography and clinical exam. If
2TYPES: normal, no other treatment usually needed.
PHYSIOLOGIC
 Bilateral
 Multiple ducts
 Inducible
PATHOLOGIC
 Unilateral
 Single duct
 Spontaneous

PHYLLODES TUMOR
 Mixed epithelial and stromal/mesenchymal
proliferation of breast characterized by increased
stromal cellularity and characteristic broad “leaf-like”
papillae inserted into cleft-like spaces.
 Morphologically resembles fibroadenoma but may
grow to large size up to 10-15cm.
 Increassed cellular anaplasia and mitotic rate and
BENIGN NIPPLE DISCHARGE infilrative growth pattern
ENDOCRINE RELATED  Classified as BENIGN,BORDERLINE or
 Increased prolactin production MALIGNANT
 Pituitary adenoma  Stromal overgrowth
 Ectopic prolactin producing cancer, is  High mitotic index
brochogenic lung ca  Sarcomatous stromal infiltration
 Hypothyroidism  Despite appellation ‘cystosarcoma’ these tumors can
be benign or malignant in their behavior
IF CLINICALLY SUSPICIOUS SEND FOR PROLACTIN  Morphologically the malignant variants exhibit
LEVEL AND/OR TSH increased stromal cellularity, increased cellular
MEDICATIONS: anaplasia and mitotic rate, and infiltrative growth
 psychoactive drugs pattern
 antidepressants  Malignant variants tend to recur locally but may
 anti-hypertensive medications metastasize (!5% of cases)
 gastrointestinal medications(H2 blockers)  Treatment
 Opiates  Simple mastectomy
 Oral contraceptive or estrogen replacement
therapy

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 Wide excision  Invasive carcinomas in the inner quadrants

metastasize to the ipsilateral axillary lymph nodes and
internal mammary lmyp nodes (40% of the cases)
 Invasive carcinomas occasionally metastasize to the
ipsilateral supraclavicular nodes
 Invasive carcinomas also metastasize via
hematogenous route, most commonly to the lungs,
bone, brain and liver
 Breast cancer (predominantly carcinoma) is the most
common cancer in females and is the second leading
cause of death due to cancer in females (lung
carcinoma is now #1)
 Etiology is unknown but many of the risk factors (early
menarche and late menopause, nulliparity and
CARCINOMA OF THE BREAST obesity) implicate prolonged endogenous estrogen
Over 80% are variants of ductal carcinoma exposure (or estrogen excess)
two types:
 Noninvasive (ductal carcinoma-in-situ)-tumor cells
are confined to the duct epithelium and do not
LOBULAR CARCINOMA
Morphologically distinct variant of breast cancer that
penetrate the basement membrane occurs in younger women (premenopausal)
 Invasive-tumor cells penetrate the basement Two types:
membrane and invade stroma  Non invasive (lobular carcinoma in-situ)
 Invasive ductal carcinoma is the most common type  Invasive
of breast cancer
 Invasive ductal carcinoma is more likely to have BREAST CARCINOMA
metastasized at the time of diagnosis as compared to
non invasive ductal carcinoma PROVEN RISK FACTORS FOR DEVELOPMENT OF
 Invasive ductal carcinoma has a worse prognosis BREAST CANCER
 Gender
(30% five year survival as compared to 75% for
 Age
noninvasive ductal carcinoma)
 Family history
Carcinoma (clinical Features)  Presence of high risk lesions(atypical
 Most common location is the upper outer quadrant hyperplasia, LCIS)
 In-site (non invasive) carcinomas rarely, if ever  Early menarche
metastasize  Late menopause
 Invasive carcinomas arising in the upper outer  Nulliparity or first birth after age 30
quadrant primarily metastasize to the ipsilateral  Radiation exposure
axillary lymph nodes  HRT
GENETIC FACTORS
Some variants of invasive ductal carcinoma are  Li-fraumeni syndrome (germline p53 mutation)
histologically distinct and are associated with a higher  BRCA-1, BRCA-2 mutations
survival rate  Cowden’s disease (multiple hamartomas) -10q
These include:
mutation
 colloid (mucinous) carcinoma
 Heterozygous ATM genes (11q22-23) mutation
 medullary carcinoma
– ataxia telangiectasia in homozygotes
 tubular carcinoma
Carcinoma (clinical Features)
 10% of the breast cancers are caused by germline
 Multiple factors affect prognosis but the single most
mutations
important factor is the presence or absence of lymph
 BRCA 1- in chromosome 17q
node metastases
 -90% risk in developing breast cancer
 -40% risk in developing ovarian cancer- approx
50% of the children inherit the trait
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THE DIFFERENCE BETWEEN ATYPIA AND LOW

 BRCA2- in chromosome 13q GRADE DCIS
 -almost 85% risk for breast cancer  Is usually amount, not even degree of abnormality
 -close to 20% risk for ovarian  Enormous difficulty distinguishing between the two
 Li Fraumen Syndrome-germline p53 mutation  Confers over a 10-20 year period
 Cowders disease-multiple hamartomas, 10q  Perhaps this should just be considered one entity,
mutation treated as high risk disease, amenable to prevention
strategies.
LOBULAR CARCINOMA-IN-SITU  -NSABP P-01 Tamoxifen vs. Not in high risk women
 Associated with increased risk of lobular or ductal
carcinoma developing in the same or contralateral
breast
 One estimate places the risk of the development of
subsequent lobular or ductal carcinoma at 9 times
that of the general population
MODIFIABLE RISK FACTORS
 High Fat diet/obesity
 Alcohol and smoking
 Exogenous Hormones(pills/HRT)
 Radiation
 Almost 70% have no identifiable risk factors

WARNING SIGNS OF BREAST CANCER PAGET DISEASE

1. Lump or thickening in or near the breast or in the
underarm that persists through the menstrual
cycle.
2. Mass or lump, which may feel as small as a pea.
3. Change in the siz, shape or contour of the breast.
4. Blood stained or clear fluid discharge from the
nipple.
5. Change in the feel or appearance of the skin on
the breast or nipple(dimpled, puckered, scaly or
inflamed)
6. Redness of the skin on the breast or nipple
7. In area that is distinctly different from any other
area on either breast
8. Marble like hardened area under the skin.
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 Paget disease of the nipple and mammary
 Paget disease- is a rare type of cancer involving the
skin of the nipple and, usually, the darker circle of skin
around it, which is called the areola. Most people with
Pagets disease of the breast also have one or more
tumors inside the same breast. These breast tumors
are either ductal carcinoma in situ or invasive breast
cancer.
 Itching, tingling or redness in the nipple and/or areola
 Flaking, crusty or thickened skin on or around the
nipple
 A flattened nipple
 Discharge from the nipple that may be yellowish or
bloody
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 Represents <5% of all breast cancers cases

 Associated with an underlying malignancy in >95%
INVASIVE DUCTAL CARCINOMA
 Most common type
 Has gone beyond the basement membrane high
chance of metastasis
 Single most important factor for prognosis is number
of positive lymph nodes
 Hematogenous spread- lung, bones, brain, liver
Prognosis
 Stage of the tumor
 Histologic type and grade of the tumor
 Estrogen and progesterone receptor status of
the tumor
 Presence of aneuploid population of tumor cells

THE following variants are associated with better

prognosis:
 COLLOID(MUCINOUS)
 MEDULLARY
 TUBULAR

LOBULAR CARCINOMA
 younger women
 multicentric
 bilateral

INFLAMMATORY BREAST CANCER

 This is a stage III-B
 Less than 3%
 Skin changes: brawny induration, erythema, peau
d’orange 4 Molecular subtypes
 May or may not have a breast mass 1. LUMUNAL A
 Poor prognosiss  Estrogen receptor-positive (ER-positive)
 HER2 receptor-negative (HER2-negative)
UNCOMMON TUMORS  Tumor grade ½
High grade sarcoma  About 30-70% of breast cancers are luminal
 Angiosarcoma A tumors
 Fibrosarcoma  Of the Four subtypes, luminal A tumors tend
 Liposarcoma to have the best prognosis with fairly high
 Metastatic tumors survival rates and fairly low recurrence rates.
 Melanoma 2. LUMUNAL B
 Lymphoma  Lumunal tumor cells that look like those of
 Other adenosarcoma breast cancers that start in the inner (luminal)
cells lining the mammary ducts.
 Luminal B tumors tend to be ER-positive.
They may be HER2-negative or HER2-
positive.
 Women with luminal B tumors are often
diagnosed at a younger age than those with
luminal A tumors.
 Compared to luminal A tumors, they also tend
to have factors that lead to a poorer
prognosis including:
-poorer tumor grade
-larger tumor size

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-Lymph node-positive
 About 10-20% of breast cancers are luminal
B tumors
3. TRIPLE NEGATIVE / BASAL LIKE
 (-) ER/PR and HER2
 One subset is basal-like, have cells that look
similar to those of the outer (Basal) cells
surrounding the mammary ducts.
 Most triple negative tumors are basal-like and
most are triple negative
 About 15-20% of breast cancer are tripe
negative/basal-like
 Occur more in younger, African-American
and Hispanic
 Most BRCA 1 related breast cancers
 Triple negative/basal-like tumors are often
aggressive and have a poorer prognosis
DIAGNOSTICS:
compared to the ER-positive subtypes
 Self breast examination
(liumional A and luminal B tumors)
 Clinical breast examination
4. HER 2 TYPE
 The molecular subtype HER2 type is not the  Mammography
same as HER2-positive and is not used to  Digital mammography
guide treatment  Breast ultrasound
 Although most HER2 type tumors are HER2-  MRI
positive (and named for this reason) about  Metastatic work-up
30% are HER2-negative  Biopsy
 HER2 type tumors tend to be:
 ER-negative, PR-negative, Lymph node-
positive, Poorer tumor grade
 About 5-15% of breast cancer are HER2 tpye
 Women with HER2 type tumors may be
diagnosed at a younger age than those with
luminal A and luminal B

Staging
 Site of tumor
 Presence of absence of lymph node metastasis
 Involvement of skin and or chest wall
 Presence or absence of distant metastasis

BREAST CANCER SCREENING PROS AND

CONS
 ‘Cancer screening trade- offs.Screening offers the
potential benefit of avoiding advanced cancer and
subsequent cancer death. It also produces the harms
of false alarms, over diagnosis and unnecessary
treatment.”
Cancer prevention for BRCA Mutation Carriers
 Prophylactic mastectomy and reconstruction
 Prophylactic Oophorectomy and hormone
replacement therapy
 Intensive surveillance for breast and ovarian cancer
 Chemoprevention based on Gail’s risk index

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MANAGEMENT  Molecular breast imaging(MBI)

MULTIDISCIPLINARY
 SURGERY Simple mastectomy CONTRAST ENHANCED SPECTRAL
 Sentinel node biopsy MAMMOGARPHY
 Conservative (quart)  Intravenous iodinated contrast administered
 Modified radical mastectomy  Two images acquired at different energies, stradding
 Toilette mastectomy k-edge of iodine(33 keV)
 BSE- done monthly beginning age 20 years old.  Weighted subtraction performed, unenhanced tissue
 MAMMOGRAPHY- most sensitive screening tool eliminated and iodine is shown
 SENSITIVITY 85-90%  FDA Approved October 2011
 SPECIFICITY 90-98%
 Done annually starting at age 40 years old ADJUVANT TREATMENT
The choice of adjuvant treatment will be dependent on
 For high risk 35 years old.
different factors:
1. Pre/post menopausal
MAMMOGRAPHY AND CLINICAL EXAM ARE 2. Age
COMPLEMENTARY 3. Stage
 The use of mammography, CBE and BSE offers 4. Number of nodes
women the best opportunity for reducing the breast 5. ER/PR status
cancer death rate through early detection. 6. Her 2 neu receptor
 About 10-15% of breast cancrs are not visualized by
mammography
 Many women do not obtain mammography
 The majority of breast cancers are found by
palpation.

SENSITIVITY OF SCREENING MAMMOGRAPHY

AGE SENSITIVITY(%)
NOT DENSE DENSE
40-49 89 70
50-64 86 78
>65 83 64

SCREENING WITH ULTRASOUND ADVANTAGES

 Non-invasive
 No compression or radiation
 No intravenous contrast
 Readily available
 Relatively inexpensive
 Sensitivity not adversely affected by increased
parenchymal density

BREAST TOMOSYNTHESIS
 Series of low dose digital mammograms
 Reconstructed to produce 3-D image
 One unit FDA approved in February 2011
 Originally approved only to use in addition to standard
2d digital mammogram
 Synthesized image approved 2013
 Approximately 1000 units in clinical use

NUCLEAR MEDICINE TECHNIQUES

 Tc99m sestimibi based
 Breast specific gamma imaging (BSGI)
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BIOMARKERS
 These are cells in the body that would be indicative of
biologic alterations between cancer initiation and
development. This will provide information on cancer
outcome or response to therapy e.g. Ki67, VEGF,
HER2/neu

COEXPRESSION OF BIOMARKERS
 Predictive indices are being developed based on the
cellular, biochemical and molecular aspect.
 Can measure the expression of multiple genes in a
tumor for profiling for assessment of prognosis and
response to therapy
 LYMPHADENOPATHY
 Wound care
 Self esteem
 ASCO, NCCN, ACS recommend a heart-healthy diet
and a regular exercise regimen for all cancer
patients

GYNECOMASTIA
 enlargement of the male breast due to an excess of
estrogen
 Most commonly due to excess endogenous estrogen
secondary to liver disease, most commonly cirrhosis
 histologically there is fibrosis around the ducts and
hyperplasia of the ductal epithelium
 TRIMODAL DISTRIBUTION- neonates, puberty,
senescence
 50% of all men have GM at autopsy
 75% of men seeking treatment for GM have drug
induced GM, persistent GM after pubery or
idiopathic
 GM IS common
 H and P- best diagnostic tool
 Majority of men can be reassured and onserved
 Persistent symptoms may need intervention that
should be individulaized according to cause, body
habitus, and breast shape.

CARCINOMA OF THE BREAST MALE

 Rare
 Usually occur in older age groups
 Are usually invasive carcinoma at the time of
diagnosis
 Behave as invasive duct carcinoma of the
female breast

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