Breast

Dr . Wajdi Zouabi
 Anatomy
• Breast parenchyma located between the superficial fascia (of the
subdermal tissue) and the deep fascia (of the pectoralis major
muscle).
• The breast parenchyma separated from superficial and deep fascia by
subcutaneous tissue.
• Breast parenchyma composed of :-
• Adipose tissue
• Coopers ligament
• Ducts
• Milk glands
• Breast lobes composed of multiple lobules.
• Lobules composed of terminal ducts + acini  milk forming unit.
 Lymphatic drainage
• 75% is directed into the axillary lymph nodes
• 20% through the pectoralis muscle lymph nodes
• 5% through the internal mammary lymph nodes
• Divided into three anatomic levels
• Level 1  lateral border of the pectoralis minor muscle
• Level 2  posterior of the pectoralis minor muscle
• Level 3  medial to the pectoralis minor muscle
• ROTTERS nodes  lymph nodes between pectoralis major and minor.
• SAPPEY plexus  specialized lymph nodes collected under the nipple
and areola.
 Related Nerves
• Long thorasic
• Medial side of the axilla
• Known external respiratory nerve of Bell
• Innervates the serratus anterior muscle
• Important in fixing the scapula
• Injury to the nerve may result in winged scapula
• Thoracodosal nerve
• Innervates the latissmus dorsi muscle
• Under the axillary vein
• Preserved during axillary dissection
• Medial pectoral nerve
• Innervates the pectoralis major muscle
• Landmark of the axillary vein which just cephaled and deep
• Preserved during axillary dissection
• Intercostal brachial
• Supply sensation of the upper part of the arm and the anterior chest
• Injury to the nerve result in cutaneous anesthesia
 Development
• Before puberty
• Composed primarily of dense fibrous stroma
• Scattered ducts lined with epithelium
• Maturation
• Increase deposition of fat
• Formation of new ducts and lobular units
• Controlled by estrogen, progesterone, adrenal, thyroid and insulin hormones.
• Resting breast (mature)
• Contain fat, stroma, lactiferous and lobular unit
• Respond to cyclic stimulation
• Hypertrophy
• Accumulation of fluid and intralobular edema
• Producing breast engorgement and pain
• Pregnancy
• Decrease of fibrous stroma
• Formation of new acini or lobules - adenosis
 Common physical findings during breast
examination
• Nipple discharge
• Common condition
• carcinoma found only 5.9% in bloody discharge.
• Galactorrhea  milky discharge from both breasts (associated with lactation
or increase prolactin production.
• Solitary intraductal papilloma  most common cause for bloody discharge
from single duct.
• Subareolar ductectasia  usually from multiple ducts, result from
inflammation and dilatation of the collecting ducts under the nipple.
• Cancer  unusual cause of discharge in the absence of other signs
• Paget disease
• Malignant ductal cells invade the epidermis without traversing the basement
membrane
• The disease appears as a psoriatic rash that begins on the nipple
• Spreads of onto the areola and into the skin of the breast
• Skin dimpling
• Traction of the cooper ligament
• Usually due to underlying tumor
• Seen like an angle during abduction of the arms upward
• Peau d`orange
• Edema of the skin of the breast
• Due to lymphatic blockage or metastasis
• Pathologic hallmark of inflammatory carcinoma
 Breast biopsy
• Fine needle aspiration
• Doesn't differentiated types of malignant lesions
• Cant use for definitive histologic diagnosis before surgery
• Use for suspected lesions in the ipsilateral breast patient with known malignancy
• Used for suspected lymph nodes in physical examination
• Core needle biopsy
• Method of choice
• Can be perfumed under mammography, ultrasound or MRI.
• A clip can be placed to mark the site
• 10-20% of patients with DCIS, ADH can found to be invasive carcinoma after
definitive surgery.
• Excisional biopsy
• Preferred approach for diagnosis of breast lesions
• Used when ADH, FIBROADENOMA, DCIS are founds in Core needle biopsy.
 Breast imaging
• Mammography
• Primary modality for screening (annually for women older than 40 years)
• 10-15% of breast cancers have no abnormalities on mammography.
• Not effective in women younger than 30 years whose breast tissue is dense with stroma and
epithelium.
• Ultrasound
• Can detect whether the lesion solid nor cystic
• Not ben found to be used for breast screening
• MRI
• Identifying primary tumor in patient with
metastatic axillary lymph node without detecting
primary tumor in physical examination or
mammography.
• Extend of the primary tumor
(particularly in young women)
• In multifocal or multicentric breast cancer
• Screening of the contralateral breast
• For evaluating invasive lobular cancer
 Risk factors for breast cancer
• Age and sex
• The most important risk factor
• Increase with advancing age
• Most breast cancer in women (men less than 1 %)
• Personal history of breast cancer
• Risk from 0.5% to 1% per year
• Histologic risk factors
• ADH, ALH, DCIS, LCIS.
• Genetic risk factors
• BRCA1  tumor suppressor gene, 40% of all genetic cases, 40% with ovarian cancer,
mutation in chromosome 17, associated with negative hormone receptors
• BRCA2 30% of all genetic cases, mutation in chromosome 13, increase risk for
cancer in men, associated with positive hormone receptors.
• Reproduction risk factors
• The more the cycle, the more the risk for cancer.
• Exogenous hormone used
 Benign breast tumors
• Breast cysts
• Usually resolved spontaneously
• May resolved after aspiration
• Suspicion of malignancy if recurrent or multiple  biopsy must taken.
• Fibroadenoma
• Second most tumor in the breast (after carcinoma)
• Composed of stromal and epithelial elements
• Mammography is of little help
• Ultrasound can be distinguish
• Resection if continuous to grow or the patient is bothered from the mass
• Hemartoma
• Breast infection
• Mastitis  in lactating women, staphylococcus infection, treatment requires antibiotics.
• Abscess  needle aspiration and antibiotics, if not resolved should be drained surgically
• Duct ectasia  associated the smoking and diabetes, with chronic infection and scaring of the subareolar
tissue
• Papillomas  polyps of epithelial lined breast ducts.
• Sclerosing adenosis  increase number of small terminal ductules or acini.
• Radial scars  excision to role out malignancy
• Fat necrosis
Malignant breast tumors
• Non invasive breast cancer
• LCIS
• 3%
• Pleomorphic, classic, comedo necrosis, and calcifications
• Treated with close observation, chemoprevention, bilateral mastectomy
• DCIS
• 25%
• Low grade lesions  Papillary, cribriform.
• High grade lesions  solid, comedo.
• If not treated may transforms into invasive cancer.
• Associated with clustered calcification on mammography
• Treatment  breast conserving therapy with radiation,
patients with c/I for radiotherapy should treated with
Mastectomy.
• Invasive breast cancer
• Invasive ductal carcinoma
• Most common form of breast cancer
• Lobular, tubular, medullary, metaplastic.
• Treated with breast conserving therapy, radiation therapy and SLNB
• Positive clinical L.N before surgery treated with axillary dissection
• Huge breast cancer / not operable breast cancer treated with neo adjuvant chemo
or/and hormonal therapy.
• High grade breast cancer treated with adjuvant chemo or/and hormonal therapy (her2,
ER, PR)
• Invasive breast cancer
• Invasive lobular carcinoma
• 10%
• Treated as invasive ductal carcinoma
• Phyllodes tumors
• Mixed connective tissue and epithelium.
• No lymphatic metastasis (hematogenous spread, mediastinum, lung, bone and
abdominal viscera)
• Range from fibroadenoma to malignant sarcoma
• Diagnosed b excisional biopsy
• Treatment  mastectomy, radiation when the tumor size > 5 cm, involves the chest
fascia or muscle, closed margins.
• Angiosarcoma
• Vascular tumor
• Usually after irradiation for breast cancer, lymphedema of the upper extremity
• Treated with resection, may require irradiation
• No lymph node metastasis