Surgical Breast Pathology

1. Surgical Breast Pathology Juan C. Cendan, MD Assistant Professor of Surgery

2. Objectives of Lecture • Categorize risk factors for cancer • Describe diagnostic workup for breast masses and tools available to the clinician • Provide up-to-date guidelines in the screening and diagnosis of breast masses • Brief review of surgical options and implications in patients with breast cancer

3. Assessment of Risk/History • Four major risks (increase RR by 4x): • Family history • 1st degree relatives • Age at diagnosis, BRCA1/2 risk • Atypical hyperplasia on prior biopsies • Personal breast cancer history • LCIS

4. Assessment of Risk/History • Four Minor Risk Factors: 1-2x RR • Early menarche • Long interval from menarche to 1st child • Nulliparity • Ovarian or endometrial cancer • Estrogen therapy after menopause

5. Physical Exam • Be systematic • Inspection of breasts: sitting up, then recumbent • “Strip method” • Nipples • Lymph nodes

6. Diagnostics • Standard screening mammogram • CC and MLO • Diagnostic mammogram • Above, plus compression/additional views • In either case, 5-10% false negative and 90-95% sensitivity

7. Cranio-caudal (CC) view and mediolateral oblique (MLO) mammographic view

8. Atypical Hyperplasia

9. Diagnostics • Ultrasound • Useful in the young • Useful in pregnant women • Delineates solid vs cystic • MRI • Possibly the future of breast diagnostics, not there yet, limitations with biopsy

11. Solid (Suspicious) Breast Mass

12. Cyst Fibroadenoma

13. Biopsy techniques • Palpable solid mass • Needle or core biopsy • Incisional or excisional biopsy • Non-palpable mass • Stereotactic core • Stereotactic “mammotome” • Needle localized biopsy

15. Some Benign Conditions • Nipple Discharge • Incidence of malignancy when bloody (10-15%) and unilateral, though usually papilloma • More likely cystic or duct ectasia • Consider prolactin if bilateral

16. Benign, con’t • Fibroadenoma • Very common in young women • Freely mobile and smooth • Characteristic u/s appearance • Half of adenomas resolve if <3cm over 5yrs • Large adenomas should be biopsied to exclude rare phylloides tumor

17. Benign, con’t • Cysts • Due to relative excess estrogen, usually in 4-5th decades • Fluctuate with menses • Aspirate, if bloody then excise, send fluid for path the first time

18. Benign, con’t • Abscess, • Usually in lactating women • Painful and erythematous • Usually staph and strep • Drainage and antibiotics indicated • Rarely, can aspirate and treat with antibiotics • Caveats, in nonlactating (Ca), non-resolving (atypical infection), inflammatory cancer

19. Cancer • Most women with breast cancer have no risk factors! • Role of dietary fat, estrogen • Breast cancer genes responsible for 3-5% only

20. Cancer • DCIS • Carcinoma in situ • Usually found on mammography as microcalcifications • Felt to progress to invasive in 30-50% if untreated • Subtypes: comedo highest risk

21. Cancer • DCIS, con’t • Treatment • Non-invasive, so risk of LN disease is minimal • Must treat the breast, options: • Excise with large enough margins (>1cm) in a small tumor • Or, Excise and radiate • Or, Mastectomy +/- reconstruction

22. Cancer • Invasive Ductal Cancer • “Garden variety breast cancer” • More often presents with mass than DCIS • Treatment: • BREAST: Excise and RT or mastectomy, Cannot just excise with margins (30-40% recur) • Lymph Nodes: Must be sampled for staging • Sentinel Node vs Axillary Dissection

24. Cancer • Chemotherapy • Recommended for tumors >1cm in most patients • Recommended if lymph nodes are positive • 8 recommended chemo protocols at this time!! • ER positivity and Tamoxifen

25. Cancer • Survival