5. Breast pathology
Breast cancer
Fibroadenoma
Fibrocystic
breast changes
Duct ectasia
Duct papilloma
Infective mastitis
6. Breast cancer
Most common tumour in women- 1 in 9
Risk increases with age
Risk factors:
Oestrogen therapy
Nulliparity, early menarche, late menopause
PMHx and FHx
High socioeconomic status
Some benign conditions
7. Presentation
Local:
Painless, irregular
increasing mass
Skin tethering
Nipple discharge
Nipple inversion
Skin dimpling
• Systemic:
– Bone pain
– Malaise
– Weight loss
– SOB
9. Investigations
Triple assessment:
Clinical examination
Imaging (USS or mammography)
Cytology (Fine needle aspiration or core biopsy)
Other:
Receptor statuses- oestrogen, progesterone, Her2
Staging (CXR, CT/MRI, PET, bone and liver
scans)
Bloods and biochem testing
10. Staging
Stage 0 - Carcinoma in situ
Stage I – 2cm, no lymph or mets
Stage II – 2-5cm, axillary lymph
Stage IIIA - >5cm or 4-9 lymph nodes
Stage IIIB – spread to breast skin, chest wall
or intermal mammary lymph
Stage IV – beyond breast, axilla and internal
mammary lymph nodes
11. Management
Surgical
Wide local excision, segmental mastectomy,
simple mastectomy
Sentinel node biopsy/axillary node clearance
Radiotherapy
Chemotherapy +/- endocrine therapy
Herceptin
Long term follow up
12. Fibroadenoma
Common benign tumour in women below 40 y.o.
10% disappear each year, tend to regress after
menopause
S/S: “breast mouse” round, firm, painless mass
that can move when being palpated
Investigation: exam and ultrasound, cytology if
needed
14. Fibrocystic breast changes
Physiological swelling of the breast
A.k.a. Mammary dysplasia, fibroadenosis, etc
Peak incidence 35-50 y.o.
Related to hormones
S/S- pain, tenderness, lumpiness
Comes on week before period, then goes when
periods start
15. Diagnosis
Can be clinical from Hx and Ex- reassess in a
few weeks
Imaging often used to help (mammography)
Cytology (FNA) if needed
17. Duct ectasia
Benign breast disease
Dilation of ducts in the subareolar region
Calcification of secretions
Middle aged and elderly women (esp smokers!)
18. Presentation
Microcalcification on routine mammogram
Nipple discharge (blood?)
Palpable subareolar mass
Non-cyclic mastalgia
Nipple inversion or retraction
19. Diagnosis
Imaging required- some specific tests
Ultrasound
Mammography
Ductography (galactogram)- contrast dye into
milk duct
Ductal lavage and cytology
24. Infective mastitis
Usually occurs with lactation (rarely without)
Breast ducts become blocked, bacteria enter
Staph aureus, staph epidermidis, streptococci
10-33% of breast feeding women
Usually first few weeks post-partum
25. Risk factors
Nipple fissures, cracks and sores are
predisposing factor
Age >30 y.o.
PMHx of mastitis
Gestational age >41 weeks
Poor technique, causing incomplete emptying
26. Presentation
One breast affected, only one quadrant or
lobule affected
Erythema, oedema, tenderness
Pus on aspiration
Axillary lymph nodes
DDx- congestive mastitis (engorgement):
swollen and tender, bilateral, no fever or
erythema
27. Investigations
Breast milk culture
Not always useful
Abscess suspected (tender hard breast
mass, fluctuant with oedema) -> Refer! ->
Ultrasound
28. Management
Conservative- technique, manual expression,
fluids, analgesia, ice packs, etc
Medical- early prescription- flucloxacillin or
erythromycin
Surgical- incision and drainage or needle
aspiration
Investigate persisting mass
29. A 29 year old woman comes to see you, the
GP, about a lump she has felt in her breast. On
examination, it is small, firm, and mobile. An
ultrasound shows a small, round mass
What is the most likely diagnosis?
a) Fibrocystic change of the breast
b) Duct ectasia
c) Fibroadenoma
d) Breast cancer
e) Cannot tell without cytology
30. Answer: c) Fibroadenoma
The examination points towards a fibroadenoma
over any of the other causes of breast lumps
Cytology is useful to help confirm this, but the
history, exam and ultrasound make this the most
likely diagnosis
31. 3 days after birth, a breastfeeding lady
complains of swollen, tender breasts. This is
bilateral. She is not pyrexial, and there is no
erythema
What is the most likely diagnosis?
a) Infective mastitis
b) Congestive mastitis (breast engorgement)
c) Fibrocystic changes
d) Breast cancer
e) Duct ectasia
32. Answer: b) Congestive mastitis (breast
engorgement)
Infective mastitis is more common after a week or
two, not a few days post-partum
The lack of fever, redness, and the fact that it is
bilateral suggest congestive mastitis
33. A 39 woman presents to the GP with bloody
discharge from the nipple.
What is the most common cause of bloody
discharge in a woman at this age?
a) Breast cancer
b) Fibrocystic changes
c) Paget’s disease of the breast
d) Duct papilloma
e) Duct ectasia
34. Answer: d) Duct papilloma
All answers other than fibrocystic changes can
give bloody nipple discharge, but duct
papilloma is the most common in younger
women
Pagets disease of the breast is an uncommon
type of breast cancer. It typically affects the
nipple (can also affect the areolar)
35. A 54 y.o. woman has recently been diagnosed
with breast cancer. The tumour is large, and has
spread to the axillary lymph nodes. She is Her2
receptor positive.
What is the most appropriate management?
a) Radiotherapy, chemotherapy and Herceptin
b) Breast conserving surgery, radiotherapy,
chemotherapy and Herceptin
c) Wide local excision, axillary clearance,
radiotherapy, chemotherapy, Herceptin
d) Total mastectomy, axillary clearance,
radiotherapy
e) Total mastectomy, axillary clearance,
radiotherapy, chemotherapy and Herceptin
36. • Answer: e) Total mastectomy, axillary
clearance, radiotherapy, chemotherapy
and Herceptin
• There tumour is large, thus breast
conserving surgery and wide local excision
are less likely to be used
• Axillary clearance is needed as it has
spread to local nodes
• Radio and chemo are helpful to reduce
recurrence
• As the patient is Her2+, Herceptin is
recommended
37.
38. Sources
Principles of Anatomy and Physiology (Tortora
and Derrickson), 13th ed.
Medicine at a Glance (Davey) 3rd ed
Clinical Medicine (Kumar and Clark) 7th ed
http://en.wikipedia.org/wiki/Lobe_(anatomy)
http://www.patient.co.uk/doctor/benign-breast-
disease
http://radiopaedia.org/articles/fibroadenoma-of-
the-breast-1
http://en.wikipedia.org/wiki/Lobe_(anatomy)Milk is produced in the lobes, which are subdivided into lobules, and carried to the nipple via ducts, in response to hormonal stimulation.
http://www.breastcare.ie/referralform
Breast cancer is the most common tumour in women, with a lifetime risk of 1 in 9The risk increases with ageRisk factors include oestrogen therapy like HRT, especially if it is unopposed by progesteroneNulliparity, early menarche and late menopause have also been linkedPMHx of breast, ovarian or endometrial cancer are associated as they can indicate a genetic risk of cancerFHx is also important. Can anyone name the genes commonly assc with breast cancer? BRCA-1 and 2. What inheritance pattern do they follow?55-65% of women with BRCA 1, and 45% with BRCA 2, will develop breast cancer by 70.P53 gene is also linkedHigh socioeconomic status could be linked to certain groups having fewer children, or having them later, or having HRT
So, in breast cancer, there are a few symptoms which you should be looking out forPresents as a painless mass, which tends to have a hard consistency and irregular mardins. Often, this mass is fixed to the skin or chest wall. You can also get nipple discharge, which is generally bloody and unilateralNipple inversion may also occur.Skin dimpling is known as peaud’orange as it looks like orange peel. This is a significant finding as the cancer is likely to be more aggressiveYou might get a few systemic symptoms like bone pain, malaise, weight loss and SOB.
A mammogram is just an x-ray of the breast, and is a very useful screening tool and method of investigating potential malignanciesThe UK has a screening programme in which women between 50 and 70 years old receive a mammogram every 3 years.By 2016, this will likely be changed to include women up to 74 years oldAbout a third of breast cancers are diagnosed via screening
The triple assessment is a method used to help diagnose breast lumps, and combines examination, imaging (mammography or ultrasound) and cytology (FNA or core biopsy).For second years: why is ultrasound better for younger women? (Breast is more dense, and less irradiation => less cancer risk)Post menopause, mammography is superior and used in the majority of casesThe choice between FNA and core biopsy depends on a few different factors.Core biopsy tends to be used for non-palpable lesions or larger, palpable lesions, and can use image-guidance.FNA tends to be highly accurate when used with mammography with a hgih false positive, but do have a high false negative rate. You can also use excision or incision biopsies as well.Once you have a diagnosis, receptor status is one of the most important investigations to carry out, as it has treatment implications. The receptors tested for are oestrogen receptors, progesterone receptors, and human epidermal growth factor 2 (Her2). I will explain the treatment importance of these in a short while.Using techniques such as chest x-ray, CT/MRI, PET scans can help with staging by detecting metastases.
I don’t want to dwell on this slide as it’s a bit too much information, but I put it in so if you want to look at the slides later it’s included.
For masses less than 4cm, surgeons often use a wide local excision or segmental mastectomy. The benefits of these procedures is that there is a conservation of the breast, thus improving the cosmesis of the operation.For larger tumours, simple (a.k.a. total) mastectomy can be used, with or without reconstruction.The decision is based on size, location, and patient preference.To find out if the cancer has spread to the sentinel nodes, a process called sentinel node biopsy is performed. If there has been axillary node involvement, then axillary clearance (dissection of the nodes) is performed to prevent further spread.Radiotherapy should be usef if breast-conserving surgery has been used to reduce the risk of local reccurence. If axillary nodes are positive, it is always recommended. However, if clearance has been used, it is not recommended due to limited benefit and high rate of lymphoedemaChemotherapy is useful in patients with moderate to high-risk disease (not small, low-grade disease with no lymph invasion.Endocrine therapies can be used in patients who had oestrogen receptor positive tumours. _____, tell me what anti-oestrogen drug they use. (answer: tamoxifen). This is an excellent treatment in premenopausal women. In post-menopausal, aromatase inhibitors are first-line.Targeted therapy- this is for the Her2 positive cancers I mentioned earlier. Does anyone know the most well known Her2 anitbody used? (Herceptin = trastuzumab). As it is a monoclonal antibody, it targets the cancer cells which express the Her2 receptorsFinally, due to the 4X increase in recurrence in breast cancer, long-term followup is important. For this, yearly mammography is performed
Rare in under 25sSometimes increases risk of breast cancer (depending on the histological changes)
Treatment is reserved for persistent or recurrent cases. It involves surgical excision of the ducts below the nipple. Focused excision prefered due to lower rates of complications such as seroma formation, nipple numbness and nipple inversion
Medical- early prescription reduces risk of abscess or sepsisSurgical intervention can be considered if the mastitis progresses to an abscess.- incision and drainage of abscess cavity if overlying skin is thin or necrotic- Needle aspiration of abscess every other day is an alternative
