DISEASES OF THE BREAST AND

THEIR MANAGEMENT
WOMEN’S HEALTH

Repro (Physio) - Female Reproductive System Physiology

OBJECTIVES a

» Discuss the etiology and clinical features of different

forms of benign and malignant breast diseases
> Outline the risk factors predisposing to breast cancer
>» Know the basic management for these breast
conditions
REFERENCES i

>» Hacker et al. 2009; Hacker & Moore's Essentials of

Obstetrics and Gynecology 5th Ed
> Brunicardi et al 2014; Schwariz's Principles of
Surgery, 10th ed
BREAST ANATOMY

> Primarily adipose tissue, glandular tissue and

suspensory ligaments
>» Composed of 15-25 radially arranged lobes of
parenchyma, each associated with a major
lactiferous duct
>» Each major duct extends from the nipple to
terminate ina “terminal duct-lobular unit” via
branching ducts of diminishing caliber
BREAST ANATOMY
EVALUATION
History
>» Change in general appearance of breast (size,
symmetry), new or persistent skin changes
> New nipple inversion
> Breast pain (cyclic vs. noncyclic, duration, location in
breast)
> Breast mass (how it was discovered, duration, change in
size, location) Relationship of mass to menstrual cycles
> Nipple discharge (unilateral vs. bilateral, color)
Medications
> Risk factors for breast cancer
EVALUATION S
Risk Factors
» Age
>» Incidence increases with age
> Incidence increases to the time of menopause and
then decreases
»Uncommon before age 25 years
EVALUATION S
Risk Factors
> Family History
> Approx 10% of breast cancer is due to inherited
genetic predisposition
» A woman whose mother or sister had breast cancer is
at increased relative risk 2 to 3 times compared to
other women
> At least two genes that predispose to breast cancer
have been identified—BRCA 1 and BRCA 2
> Mutations in these tumour-suppressor genes also
predispose affected women to ovarian cancer
EVALUATION
Risk Factors
> Benign Breast Disease
> Certain types of benign breast disease
b
> History of other cancers
>A history of cancer in the other breast or a
history of ovarian or endometrial cancer
EVALUATION
Risk Factors
> Hormonal Factors
>Increased levels of estrogen increases risk
>» Early age at menarche
»>Late age at menopause
> Nulliparity
»>Late age at first child-birth
> Obesity

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EVALUATION
Risk Factors
> Environmental factors
> High fat intake
» Excess alcohol consumption
> lonizing radiation

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EVALUATION
Physical Examination
> Clinical Breast Exam
> Inspect (relaxed, arms raised, hands on hips)
> Breast symmetry
> Skin changes (dimpling, retraction, edema, ulceration)
> Nipples (symmetry, inversion/retraction, discharge)
> Palapation (breasts, axillae, entire chest wall)
> Pain
> Masses
> Regional lymph nodes (Axillary and Supraclavicular)
Documentation
> “Clock” system
>» Location of concern and abnormality Distance from areola
> Size of mass

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BENIGN vs MALIGNANT
emer s Ta melee laced oy Malignant Characteristics
STM) Multiple lesions Single lesion
“Rubbery” Hard
Mobile Immovable
Well circumscribed border Irregular borders
Nipple discharge _ Bilateral Unilateral
Multiductal Uniductal
Milky Bloody, Clear, or Colored
Spontaneous
Moa
SY ame are 184243 Retraction
Dimpling
Thickening

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 MASTALGIA a
> Breast pain
| ON {ei|(e
> Cyclic mastalgia: Normal hormonal changes particularly luteal
phase of menstrual cycle
> Fibrocystic disease
> Non-cyclic
>» Pendulous breasts: Stretching of Cooper's ligaments
aD) eyem SINS
> Mastitis
> Hormone replacement therapy
> Ductal ectasia
> Inflammatory breast cancer
> Extramammary (non-breast) pain

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NON-PROLIFERATIVE
(“FIBROCYSTIC”) CHANGES
>» Most common benign breast disorder
> No associated risk of progression or cancer
» Usually diagnosed in women 20 to 40 years
» Premenstrual breast swelling/tenderness
Nodules/masses/lumps related to dense breast
tissue or cysts

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NON-PROLIFERATIVE S
(“FIBROCYSTIC”) CHANGES
>» Exaggeration of normal physiologic response to
ovarian hormones
> Present as palpable lumps, nipple discharge or
mammographic densities/calcifications
>» Often multifocal and bilateral - general “lumpiness”
» Pathologic features:
>» Cystic change
>» Apocrine metaplasia
eI AON
ances

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NON-PROLIFERATIVE
(“FIBROCYSTIC”) CHANGES
Management
Imaging if indicated
Use of supportive garments Glandular
Decrease caffeine intake tissue
Fibrous
Use of oral contraceptives tissue

Fatty tissue
Cysts

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MASTITIS

> Usually seen in breastfeeding mothers unilateral,

swollen, wedge-shaped area of breast pain, redness,
induration (hardening)
> Most clinically important form of mastitis
>» Cracks/fissures in the nipples
> bacterial infection (esp. Staph. aureus)
> Systemic symptoms (high fever, malaise, chills)
> Management:
ANNU] (els
> Dicloxicllin 500mg QID x 10-14d
> Continue frequent breast feeding

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Breast Mass
Etiology
> Fibrocystic changes
> Fibroadenoma
> Fat necrosis
>» Phyllodes tumor
> Intraductal papilloma
AKO KiMere
| aler>)6

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BENIGN TUMOURS S
Fibroadenoma
> Most common benign tumour
> Circumscribed lesion composed of both proliferating
glandular and stromal elements
> Patients usually present < 30 years
> Classic presentation is that of a firm, mobile, solitary lump
> Giant forms can occur, especially in younger patients
> Can be associated with proliferative changes in the
adjacent breast tissue

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Breast Mass
Intraductal Papilloma
> Unilateral bloody nipple discharge
> Sub-areolar intraductal mass

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Fat Necrosis

> Caused by trauma

> Tender, firm mass with indistinct borders
>» May appear suspicious on physical exam
> Benign breast calcification seen on
mammography

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Breast Mass: Evaluation

> Initial evaluation

> < 30 yr — Diagnostic ulirasound + Diagnostic
mammogram
> > 30 yr — Diagnostic mammogram
> Further evaluation
> Simple cyst
> Symptomatic — Aspirate
>» Asymptomatic — Observe for 2-4 months
> Complicated cyst — Ultrasound-guided aspiration
> Solid mass — Core needle biopsy (CNB) or Excision
>» No specific findings — Re-examine after two cycles

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BREAST ULTRASOUND

ae tae 3 FIBROADENOMA

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MAMMOGRAM

bal tee) (ater)

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NIPPLE DISCHARGE
Etiology
> Lactation
>» Physiologic nipple discharge
> Hyperprolactinemia
> Hypothyroidism
>» Medication related
> Neurogenic stimulation
> Pathologic
> Intraductal papilloma
> Ductal ectasia
| ADIs

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Nipple Discharge: Evaluation

> Unilateral vs. bilateral

>» Spontaneous vs. provoked discharge
>» Appearance of discharge
>» Medications (e.g. antipsychotics, antidepressants)
> History of trauma
> History of amenorrhea
> History of hypogonadism (e.g. hot flashes, vaginal
dryness)

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RISK FOR INVASIVE BREAST CANCER

No Increased Risk (NIR)

> Mastitis, Fat necrosis
> Mammary duct ectasia
> Non-proliferative (“fibrocystic”) disease
> Fibroadenoma (simple)
> Slightly increased Risk (SIR)
>» Moderate/florid hyperplasia
>» Sclerosing adenosis
> Fibroadenoma (complex)
> Duct papilloma
> Moderately Risk (MIR)
>» Atypical ductal hyperplasia
> Atypical lobular hyperplasia

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BREAST CANCER

> The etiology of breast cancer in most women is

unknown
> Most likely due to a combination of risk factors i.e.
genetic, hormonal and environmental factors
> Histologic classification
> Ductal: DCIS, IDC (75%)
> Lobular: LCIS, ILC

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DUCTAL CARCINOMA IN SITU a

> Increased incidence with increased use of

mammographic screening and early cancer detection
> 50% screen-detected cancers
> Can also produce palpable mass
>» Characterized by proliferating malignant cells within
ducts that do not breach the basement membrane
> Different patterns e.g. comedo (central necrosis);
cribiform (cells arranged around “punched-out”
spaces); papillary and solid (cells fill soaces)
> Often multifocal—malignant population can spread
widely through the duct system

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LOBULAR CARCINOMA IN-SITU a

> Relatively Uncommon lesion

> Malignant proliferation of small, uniform epithelial cells
within the lobules
> Also at marked increased relative risk for invasive
cancer (8 to 10 times) in either breast

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INVASIVE DUCTAL CARCINOMA S
> Commonest form of breast cancer especially in poorer
populations
> increasing incidence of screen—detected cancer in
developed couniries (Usually smaller; much better prognosis)
> Clinical presentation:
> Hard, irregular palpable lump
>» Peau d’orange (lymphatic obstruction, thickening/dimpling
of the skin)
> Tethering of the skin
> Retraction of the nipple
> Axillary mass (spread to regional lymph nodes)
> Distant mets (lung, brain, bone)

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INVASIVE LOBULAR CARCINOMA

> Much less common than IDC

> Can present with similar features
> More likely to be bilateral and/or multicentric (multiple
lesions within the same breast)
> Classic histology = small, uniform cells arranged as:
> Strands/columns within a fibrous stroma (“Indian-file”’)
>» Around uninvolved ducts ( “bull’s-eye” pattern)
> Metastasize more frequently to CSF, serosal surfaces and
pelvic organs

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PROGNOSIS a
» Staging systems (INM, Manchester classification)
>» Tumour size and axillary node status are important parameters
>» 10-year survival rate for lymph node negative disease is 80% vs
35% for tumours with positive nodes
> Tumour Grade
>» Histologic Subtypes
>» Hormone Receptors
» Estrogenreceptors
>» Progesterone receptors
> Molecular Markers
> c-erb-B2, c-myc and p53

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TREATMENT OPTIONS

Surgery
Mastectomy
Breast conservation
+/- Axillary dissection

Radiation therapy (local control)

Chemotherapy (systemic control)
>» Hormonal therapy (systemic control)

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THANK YOU