Common Breast Disease Dr. Chan Wing Cheong Surgeon-in-charge Breast Surgery, NTEC
Lymphatic Drainage • Axillary nodes level 1,2,3 • most of the breast drain into axilla. • pectoral nodes / breast and anterior chest wall • sub scapular nodes / posterior chest wall and arm • lateral nodes/ arm • central (medial and apical) nodes/ drains all of the above three groups of nodes • Infraclavicular • Supra-clavicular nodes • Internal mammary nodes • Abdominal nodes
Normal Breast Development and Physiology • At puberty the breast develops under the influence of the hypothalamus, anterior pituitary, and ovaries and also requires insulin and thyroid hormone • During each menstrual cycle 3 to 4 days before menses, increasing levels of estrogen and progesterone cause cell proliferation and water retention. After menstruation cellular proliferation regresses and water is lost. • During pregnancy cellular proliferation occurs under the influence of estrogen and progesterone, plus placental lactogen, prolactin and chorionic gonadotropin. At delivery, there is a loss of estrogen and progesterone, and milk production occurs under the influence of prolactin. • At menopause involution of the breast occurs because of the progressive loss of glandular tissue.
ANDI classification ( Hughes et al, 1992 ) Normal Aberration ?? Disease Reproductive phases cysts, duct ectasia, mild epithelial hyperplasia cyclical mastalgia & nodularity fibroadenoma, juvenile hypertrophy Periductal mastitis Epithelial hyperplasia with atypia Giant fibroadenoma (> 5cms) Multiple fibroadenomata (> 5 per breast) Involution Cyclical & secretory Development Spectrum of breast changes
Aetiopathogenesis – Some Theories • Endocrine factors 1. Disturbances in the Hypothalamo Pituitary Gonadal steroid axis 2. Altered Prolactin profile – qualitative /quantitative change Non endocrine factors • Methyl xanthines, Stress Genetic predisposition to catecholamine supersensitivity Intra cellular C - AMP mediated events cellular proliferation 2. Diet rich in saturated fat Altered plasma essential fatty acid profile receptor supersensitivity to normal levels of Oestrogen & Progesterone 3. Iodine deficiency Receptor supersensitivity to normal levels of Oestrogen & Progesterone
Common Presenting Symptoms Over 80 % • Lump • Painful lump or lumpiness • Pain Under 20 % • Nipple discharge • Nipple change • Miscellaneous
Symptoms & Possible Diagnosis Infections : Lactational & Non-lactational
Triple Assessment for Breast Problem • Clinical • Symptoms & signs • Assessment of risk factors • Imaging • Ultrasonography / Mammography • Other imaging tests • Pathological • Fine needle aspiration cytology • Core biopsy
Case 1 • F/22 • Right breast swelling for 1 month • No other symptoms • What are the questions you want to ask?
Case 1 • USG breast: • Compatible with a 1.5 cm fibroadenoma • What would you offer her? • What is the natural history of fibroadenoma?
Case 2 • Same lady as case 1 • No surgery after discussion • However • Come back 7 months later • Size of lesion increases up to 5 cm • What investigation do you want to do?
Case 2 • USG • Compatible with a giant fibroadenoma or phylloides tumour • Do you want to do FNA? • What would you offer?
Case 2 • Wide local resection performed • Pathology: • Phylloides tumour of undetermined malignant potential, margins appear to be clear • How do you advice this patient?
Phyllodes Tumours • Comprise less than 1% of all breast neoplasms • May occur at any age but usually in 5th decade of life • No clinical or histological features to predict recurrence • 16-30% may be malignant • Common sites of metastasis : lungs, skeleton, heart and liver
Treatment of Phyllodes Tumours • 1. Primary treatment • Local excision with • a rim of normal tissue • 2. Recurrence • Re excision or • Mastectomy with or without reconstruction • Response to chemotherapy and radiotherapy for recurrences and metastases poor
Case 3 • F/52 • Recently noticed a left breast lump • No pain • No other breast symptoms • Just menopause • What other questions regarding her problem that you will ask ?
Risk Estimation for Breast Cancer • RELATIVE RISK <2 Early menarche < 12 years Late menopause > 55 years Nulliparity Proliferative benign disease Obesity Alcohol use Hormone replacement therapy • RELATIVE RISK 2–4 Age 35 first birth First-degree relative with breast cancer Radiation exposure Prior breast cancer • RELATIVE RISK >4 Gene mutation Lobular carcinoma in situ Atypical hyperplasia
Case 3 • P/E: • 2.5 cm mass over upper outer aspect of left breast • Quite mobile • No palpable axillary LN
Left Case 3
Case 3 • MMG / USG breast • 2.5 cm mass • No axillary nodes • Core needle biopsy • Invasive carcinoma • What would you offer?
Options • Modified radical mastectomy • MRM + reconstruction • Autologus tissue flap • Prosthesis • Wide local excision + axillary dissection + post-op RT
Any adjuvant therapy? • Chemotherapy • ? Indications • Radiotherapy • ? Indications • Hormonal therapy • ? Indications
Case 4 • F/55 • Good past health • Routine physical check-up • Screening mammogram • Left breast microcalcification
Options • Stereostatic core biopsy • Mammotome • Contra-indicated in suspicious lesion ( BIRAD ) • For small & likely benign microcalcification • Hook-wire guided excision biopsy • For suspicious lesion • Aims to achieve a clear margin
If core biopsy confirms DCIS, what’s next? • If solitary, < 3cm, not high grade • Wide local excision + RT • Otherwise, • Total mastectomy +/- reconstruction • Axillary node dissection not required • Hormonal therapy if ER / PR positive
Case 5 • F/ 43 • Recent onset of left breast mastalgia • Clinically palpable thickening of breast tissue over L3H • MMG not revealing • Needle biopsy: insufficient material • Thus open excision biopsy
Case 5 • Histopathology: • Lobular carcinoma in situ • No invasive component • All margins appear to be clear of tumour cells What would you suggest to the patient?
Lobular Carcinoma (15-20%) LCIS Invasive LC
Case 6 • F/ 36 • Mother of 2 children • Brownish stain on the inside of undergarment • No pain • No nipple change
Differential Diagnosis? How would you like to investigate furhter?
Ductogram What can be offered to the patient ?
Case 7 • F / 67 • Not significant PMH • Recent L breast pain • What is the diagnosis ? • What would you offer to her ?
Pain • Mastalgia • Cyclical mastalgia • Non cyclical mastalgia • True (breast related) • Musculoskeletal : costochondral or lateral chest wall • Infections • Lactational infections • Nonlactational infections • Central : Periductal mastitis (inflammation, mass, abscess, mammary duct fistula) • Peripheral : associated with diabetes, rheumatoid arthritis, steroid usage, trauma etc. • Rare : Tuberculosis, Granulomatous mastitis, Diabetic (lymphocytic) mastitis, etc. • Skin associated : infected Sebaceous cyst, Hidradenitis suppurativa etc. True breast pain
Mastalgia Definition : Pain severe enough to interfere with daily life or lasting over 2weeks of menstrual cycle True breast pain True breast pain Lateral chest wall pain Costo Chondral pain mild Musculo skeletal pain
Management Protocol for True Mastalgia • Assess type of pain • Assess severity of pain ( Pain diary + Visual analogue scale ) • Evaluation with Triple assessment • Treatment : • Reassurance is the key to management • Use of supportive undergarments • Low fat, Methyl xanthine restricted diet • Stop Oral contraceptives / HRT etc • Review patient. Successful in the majority ( 80 – 85 % ) ofpatients • Use drugs in those not responding to non-pharmacological treatment • Review and assess response