BREAST DISEASES (TRIPLE

ASSESSMENT, BENIGN, MALIGNANT,

STAGING AND CPG)
• is a modified sweat gland that lies in subcutaneous
tissue of the anterior chest wall between the
superficial and deep layers of the superficial fascia.

• base of each breast extends from lateral border of

sternum to the mid-axillary line, from the second to
the sixth rib.

• Axillary tail pierces the deep fascia and enters the

axilla

• mammary gland consists of 15-20 lobules that are

drained by lactiferous ducts that open separately on
nipple
• Fibrous septa ( Cooper's ligament) interdigitate the
mammary parenchyma and extend from the posterior
capsule of the breast to superficial layer of fascia
within the dermis, and provide structural support to the
breast (involvement of these ligaments by malignancy
causes dimpling of the overlying skin)
 LYMPHATIC DRAINAGE
• AXILLARY NODES - 75 % of ipsilateral breast drains to
the axillary nodes
* 40-50 nodes in 5 groups : Anterior, posterior, medial,
lateral, apical
* Drains into supraclavicular and jugular nodes

• INTERNAL MAMMARY NODES - 20 % of drainage from

the ipsilateral breast

• INTERPECTORAL (ROTTER'S NODES) - Between pec

major and pec minor muscles.
 BREAST CANCER

• most common cancer among women in Malaysia -

1 in 30 will be diagnosed in their lifetime.

• The incidence of cancer in Malaysia is not as high

as developed countries (1 in 8), but our survival
rate is much lower (49 % compared to 89 % in
the States) - due to being diagnosed at a later
stage.
• When breast cancer is detected at
stage 1 - survival rate is close to 90
%.

• When it is detected at stage 2 - the

survival rate drops to about 70 %.

• At stage 3 and 4 - the outcome is

even less positive and treatment is
more complicated.

• About 43 % of newly diagnosed

breast cancers cases are already in
stages 3 and 4.
• bimodal age distribution: 45 - 55 year old and older ( >
75 year old).
• Gender ration is about 100-150 female : 1 male
 RISK FACTORS
• AGE

• GENETICS: maternal and paternal (breast or ovarian

cancer, especially in a first degree relative, young
onset < 40 years old) - BRCA 1 (on maternal side)
and BRCA 2 (both sides) - Li- Fraumeni syndrome
involving P53 mutation.

• HIGH ESTROGEN EXPOSURE: early menarche < 12

years old, nulliparity, late childbearing at > 30 years
old, late menopause > 55 years old.
* OCP usage ( pure estrogen type)
* HRT ( > 5 years)
• PREVIOUS BREAST
DISEASE
* Previous breast cancer
( 10 x)
* Previous biopsy with
atypical ductal
hyperplasia or LCIS (7-
10 x )

• IONISING RADIATION
TO THE BREAST

• ALCOHOL
CONSUMPTION (DAILY)
 BASED ON THE WHO
CLASISFICATION:
EPITHELIAL AND NON EPITHELIAL
• Non epithelial tumors arise from supporting stroma
eg:-
* angiosarcoma
* malignant phyllodes tumour
* primary sarcomas

• Epithelial tumors arise from cells lining the ducts or

lobules, and can be further divided into : INVASIVE
and NON-INVASIVE based on invasion of the
basement membrane.
 TYPES OF BREAST
CANCERS
• DUCTAL
CARCINOMA

• INFLAMMATORY
BREAST CANCER

• LOBULAR
CARCINOMA
 DUCTAL
• NON - INVASIVE
* From terminal duct lobular unit.
* causes distoriton of lobules
* not ivasive to BM
* non-palpable, detected
microcals
* 35 % multicentric, occult
invasive ca in 10-20 %
* progress to Ca within 10
years - 30 % risk; considered
as pre-malignant
GOOD PROGNOSIS IF
TREATED
• INVASIVE
* 70 -80 % of invasive breast
cancer
Includes all cancers that
cannot be subclassified
into a specialised type
POORER PROGNOSIS than a
carcinoma of specialised
type
2/3 express ER/PR
1/3 over express C-erbB2
• It starts at the lining of the ducts, grows and invades the
breast tissues- then spread to lymph nodes and also to
other organs
 LOBULAR
• LCIS
* From terminal duct lobular unit
* Do not distort lobular
architecture
* usually non-palpable and not
detected by mammo;
incidentally detected
* 60-80 % multicentric and bilateral
* not pre-malignant, but a marker for
increased risk of invasive disease
in both breasts (7-10 x increased
risk )
- if ca develops, will be IDC
usually occurs > 15 years after
diagnosis
• ILC
* 5 - 10 % of invasive
cancers
* 10-20 % multicentric
* cells morphologically
similar to cells of LCIS;
monomorphic, bland
round nuclei
* cells invade individually
into stroma
* SIMILAR PROGNOSIS
TO IDC
• Formed in the lobules, grows throught the wall of
the lobules and spreads
 INFLAMMATORY BREAST CANCER
• Uncommon (1-3 % of all the breast cancers)

• Invasive breast cancer

• Presents as erythematous, enlarged, swollen breast

without palpable mass.

• Diffuse invasion of breast parenchyma by ca cells blocking

numerous dermal lymphatic spaces - swelling

• Histologically not specialised

• Very poor prognosis and RAPIDLY FATAL

 PRESENTATION
• Asymptomatic: detected on mammographic screening

• Self detected lump in the breast > 1/3 of the patients.

• Nipple change; distortion, destruction, retraction, deviation,

discharge, eczema.

• Overlying skin changes: peau d'orange, tethering, fixation,

fungating ulcer

• Other lumps in axilla

• Pain is uncommon with constitutional symptoms

 STAGING
• T
1. T is: carcinoma in situ, Paget's with no tumor
2. T1 : < 2 cm
* T1a - 0.1 to 0.5 cm
* T1b - 0.5 - 1.0 cm
* T1c - 1.0 - 2.0 cm
1. T2: 2 to 5 cm
2. T3: > 5 cm
3. T4
* T4a - chest wall involvement
* T4b - skin involvement
* T4b - both 4 a and 4b
* T4d - inflammatory Ca
• N

1. N1 : mobile ipsilateral
axillary nodes
2. N2 : fixed / matted
ipsilateral axillary
nodes
3. N3:
* N3a - ipsilateral
infraclavicular nodes
* N3b - ipsilateral internal
mammary nodes
* N3c - ipsilateral
supraclavicular nodes
• M

M1: distant mets

• STAGE 0
- T in situ

• STAGE 1
- T1N0

• STAGE 2
- T2N0, T3N0
- T0N1, T1N1, T2N1

• STAGE 3
- skin, rib involvement, matted lymph nodes
- T3N1
- T0N2, T1N2, T2N2, T3N2,
- Any T, N3
- T4 any N
• STAGE 4
- M1 (ADVANCED BREAST CARCINOMA)
 PROGNOSIS
• Stage of disease - tumor size, lymph node involvement

• Histological grade if tumor

• Lymphovascular invasion

• Age - younger patient, higher chance of recurrence,

progress of disease

• C-erbB2/ HER2 positivity indicates more aggressive

tumor

• ER/PR positive is good - predicts 90 % of response to

treatment with tamoxifen; also means tumor is less
undifferentiated
 BENIGN BREAST DISEASE
• Gynaecomastia
• Fat necrosis
• Duct ectasia
• Intra-ductal papilloma
• Fibroadenoma
 GYNAECOMASTIA
• Growth of glandular tissue in the male breasts.
• Came from a Greek word that defines as - female-
like breasts.
• Accumulation of excess fat in the male breast
• Usually unilateral and occurs in young man. No
hormonal dysfunction in unilateral gynaecomastia.
• Bilateral gynaecomastia is due to systemic causes
• Primary gynaecomastia
- Neonatal gynaecomastia
- Pubertal gynaecomastia
- Senile gynaecomastia

• Secondary gynaecomastia
- Primary testicular failure - kneifelters syndrome or
bilateral cryptorchidism
- Secondary testicular failure - hypopituitarism
- Endocrine tumor
- Adrenal or pituitary source

• Drugs - Spironolactone and testosterone target cell

inhibitors ( cimetidine)
 TREATMENT OF
GYNAECOMASTIA

• Stop drugs that are causing it

• Subcutaneous mastectomy in troublesome cases
• Liposuction-assited mastectomy
 FAT NECROSIS
• Traumatic in nature and is usually with women with
large fatty breast

• The patient might develop severe bruising post

trauma. When the bruises settled, swelling will be
obvious and it is clinically impossible to distinguish
from ca of the breast because the irregular mass is
often attached to the skin.
• Microscopically - a
central area of necrotic
fat cells are surrounded
by a granulomatous
reaction consisting of
macrophage cells

• Treatment: surgical
excision
 DUCT ECTASIA

• Widening of the ducts of breast

• Usually occurs in 40-50s age group
• A thick and sticky discharge, usually gray to green in
color, is the most common symptom
• Clinically
- Solitary or multiple tender swelling in the sub or peri
areolar region of the breast.
- nipple retraction, skin adherence, edema and axillary
adenopathy may accompany a hard, diffuse mass
within the breast
- palpation: number of cord like swelling which radiate
from the areola
- inflammatory might be so acute that skin changes
occur and the conditino may be mistaken for a
breast abscess.
• Treatment:
- Small volume of discharge is managed
conservatively
- Major duct excision if condition is unfavorable to the
patient
 INTRA DUCTAL PAPILLOMA
• Occur centrally beneath the areola in 75 % of the
cases
• Most commonly produce a bloody nipple disharge,
sometimes associated with pain
• Solitary proliferation of ductal epithelium
• Treated by wedge resection
 FIBROADENOMA
• Composed of stromal and epithelial elements.

• Commonly seen in young women

• well-circumscribed lesion of the breast and develop

in the breast prior to menopause

• Either breast may be affected and multiple and

successive tumors may develop in the same or
contra-lateral breast

• Pericanalicular tumors usually found in those below

the age of 30 and intracanalicular after the age of 30
• Pericanalicular - firm discrete mass, which is freely
mobile in the breast tissue ( BREAST MOUSE)

• Intracanalicular - softer and may grow to such a

size that there is necrosis of the overlying skin

• May grow rapidly during pregnancy, during hormone

replacement therapy, or during immunosuppression
in which they can simulate malignancy
 CLINICAL FEATURES
• Oval, freely mobile, rubbery mass

• Varies in size from 1 cm to 15 cm in diameter

• Most commonly, the tumor is surgically removed when they

are 2 -4 cm in diameter.

• In young women, the tumor is usually palpable, in older

women; the mass usually appears on mammogram and it
may be palpable or non-palpable

• In post menopausal period, it often regress and develop

calcifications.