Breast Development and Pathology

Introduction

• Culturally, the female breast is often linked to the concept of womanhood.
• Breast primary function is lactation, they are frequently considered erotic

Pathology

• Breast conditions range from benign disorders like fibroadenomas to life-threatening malignancies like breast cancer.
• Injury or loss of a breast is emotionally devastating for a woman.
• Normal breast development, current recommendations for breast examination, common benign breast disorders, and an overview of breast cancer will be examined.

Breast Development

• Thelarche, the onset of breast development, is often the first sign of puberty.
• Breast development starts at 10 years of age, on average.
• Estrogen stimulates the ductal portion of the glandular system while progesterone stimulates the alveolar or milk-producing components.
• Optimal growth and development need stimulation of insulin, cortisol, thyroxine, prolactin, and insulin-like growth factor in addition to estrogen and progesterone.
• Breast tissue changes with aging.
• The adolescent breast is denser because it primarily consists of glandular tissue.
• Breasts go through cyclic changes because of estrogen and progesterone during pregnancy. These changes include increased breast size, fluid secretion, and premenstrual tenderness.
• The breasts become less dense and contain more fat and fibrous connective tissues as women age.

Evaluation of Breast Symptoms

• Evaluation of breast symptoms includes a history of presenting symptoms
• Evaluation includes looking at: change in general appearance, changes over time in relation to menstrual cycle, skin changes-thickening (peau d'orange), nipple inversion that is new, nipple discharge whether bilateral or unilateral, cyclic or noncyclic pain also known as mastalgia, and masses
• When evaluating breast symptoms, factors that increase or decrease breast cancer risk should be identified and documented.
• Common risk factors for breast cancer are reviewed when taking a history.
• Breastfeeding & physical activity are protective against breast cancer.

Physical Examination

• Formal breast self-examination is no longer recommended, but is replaced by "breast awareness”. This encourages women to recognize abnormal changes between clinical evaluations.
• The ACOG recommends clinical breast exams every 1-3 years for women aged 25-39 and annually starting at age 40 if they are at average risk for breast cancer

Procedure for Breast Examination

• Wash hands.
• The woman should be seated on the examining table.
• Her chest area should be exposed.
• Drape or gown should be used to cover any parts of the woman's body.
• Check that the breasts hang freely by observing her with her arms loose at her sides, raised overhead, and with her hands on her hips with elbows extended 90 degrees from the plane of her abdomen.
• Note any visible scars.
• Palpate for lymph nodes
• Examine the appearance of the nipples and areolae as nipples can change depending on maturity, pregnancy, breastfeeding and aging
• Do not squeeze the nipple to get a discharge
• Check skin texture and appearance over time
• A pattern for examination includes beginning under the axilla and work towards the sternum, and from the clavicle to below the inframammary ridge.
• Palpate each breast for texture and masses.
• Texture of the breast should be consistent.
• Masses is always further evaluated.
• While the breast exam is happening, discuss what is being felt and how they can learn to recognize breast changes

Breast Findings

• Breast findings characteristic of nonmalignant breast disorders include painful or tender, firm, mobile, well-defined masses that may fluctuate in size and tenderness with menstrual cycle changes.
• Signs of breast cancer is a hard, rocky, immobile mass with irregular edges.
• Breast masses are described as dominant or nondominant measured in centimeters.
• Describe location, consistency, symmetry, tenderness, and mobility, as well as any skin changes.

Breast Assessment Modalities

• Algorithms have been developed for evaluation of dominant breast masses; some recommend a fine-needle biopsy first, while others opt for ultrasound or mammography.
• Variations depend on local radiology, pathology, surgical resources, as well as women's age and preferences.
• Ultrasound is generally recommended for women younger than 30 years.
• For women older than 30 years diagnostic mammography is recommended. Increased breast density in younger women obscures abnormal findings on mammography.

Common Breast Assessment Methods

• Breast awareness/breast self-examination is general screening for breast masses and allows a woman to have knowledge about her own breasts. It is not restricted to screening for breast cancer.
• Clinical breast examination is an essential part of the physical examination. Similar to self-examination, it is not limited to screening for breast cancer.
• Mammography uses X rays to assess abnormalities of the breast, like masses, density, and architectural changes. It is used to screen and during evaluation.
• Digital breast tomosynthesis gives 3-D views of the breast and is more FDA approved for those with high risk of breast cancer
• Ultrasound may screen women with dense breasts at high risk for breast cancer and is often used for those with mammograms of palpable masses.
• MRI is for women who have palpable masses, especially those not identifiable on mammograms and can screen women at high risk for for breast cancer, assess the breasts.
• A fine-needle biopsy is for the evaluation of cell to test and identify malignancy. Core biopsies are recommended based on the size of the mass and can be done during a surgery

Consultation and Transfer Notes for Breast Mass Case:

• Include risk factors , current and past use of hormone therapy, how the mass was discovered, what the mass is like, etc.

Benign Breast Disorders

• Benign breast disorders are classified as nonproliferative, proliferative without atypia, or atypical hyperplasia's.
• Nonproliferative disorders are not related to risk of malignancy, proliferative without atypia have a modest increase in risk for malignancy, while atypical ductal/lobular hyperplasia are associated with a significant risk for malignancy.

Mastalgia

• Mastalgia, or breast pain, can be either cyclic or noncyclic.
• Cyclic breast pain occurs during the luteal phase of the menstrual cycle and goes away after menses.
• Noncyclic breast pain may be caused by mastitis, cysts, tumors, history of breast surgery, or medications
• 15% of women with experience mastalgia pain which can be treated with pain relieving therapy.

Nipple Discharge

• Nipple discharge is common in reproductive-age women and it is generally benign.
• Benign discharge is generally bilateral, multiductal, and milky or green and occurs with breast manipulation.
• Discharge that is unilateral, clear, serous, or bloody, and is more likely associated with cancer, specifically if with a breast mass and if the woman is older than 40 years.
• "Galactorrhea is bilateral discharge in women who have not been pregnant or lactating."
• Galactorrhea is usually idiopathic but can be caused by prolactin-secreting pituitary adenomas, dopamine inhibiting-medications, hypothyroidism, breast stimulation, trauma, and herpes zoster.
• Unilateral, uniductal, spontaneous, and clear/serous/bloody discharge means a expert should be consulted

Fibrocystic Changes

• Fibrocystic changes are common in women of reproductive age and associated with hormonal stimulation. Thus, it is rare in postmenopausal women.
• These changes may be asymptomatic or associated with pain, tenderness, and bumpy areas throughout the breast tissue.
• Clinical findings include symmetrical nodularity, with nodularity being more prominent in the upper outer region of the breast, and consistency described as a ""bag of beans""
• Managing options for this include expectant watchful waiting, aspiration of large cysts, and combined oral contraceptives to decrease fibrocystic breast changes

Breast Cysts

• Breast cysts are smooth, round or oval, mobile, fluid-filled masses with well-described borders that develop from terminal breast lobules.
• Breast cysts can be single or clusters.
• These cyst can be painful/painless, and are "hormonally influenced".
• Classifications include simple, complex, or complicated

Fibroadenomas

• Fibroadenomas most frequently arise in adolescent and young women but occur through menopause.
• Examination: the tumors are non-tender, with a firm or rubbery consistency, mobile, and well circumscribed.
• Mammogram or ultrasound determines whether the mass is solid or cystic, and then confirmed through core needle or open biopsy.
• A biopsy is not needed if a biopsy indicates it is not needed and the tumor is not enlarged.
• Fibroadenomas can enlarge rapidly during pregnancy or estrogen therapy and then regress after menopause.
• Fibroadenomas are not associated with increased risk of breast cancer.

Atypical Hyperplasia and Lobular Carcinoma In Situ

• Atypical hyperplasia have atypical ductal and lobular hyperplasia.
• Atypical hyperplasia is a pathologic diagnosis, they describe abnormalities of the breast that are associated with an increased risk of breast cancer.
• Atypical hyperplasia can be surgically treated
• LCIS is found in a area of abnormal cell growth and is histologic diagnosis. LCIS is not a precursor lesion for breast cancer.
• Increased monitoring of breast cancer, risk reduction, and medication are recommended.

Breast Cancer

• Cancer may develop in any of the tissues present in the breast: epithelial, muscle, connective tissue, or fat.
• The mass majority of breast cancers are carcinomas in the epithelial cells.
• Breast carcinomas are categorized as invasive or noninvasive.
• Breast cancer is the most commonly diagnosed cancer and a leading cause of death worldwide for women age 40-55.
• The risk of developing breast cancer increases but overall mortality rates have decreased.

Factors That Affect Breast Cancer Risk

• Several personal characteristics increase or decrease the risk for breast cancer.
• Breastfeeding, 3-5 hours of moderate to vigorous physical exercise, limiting alcohol intake, and maintaining a healthy body weight may be associated with lowering the risk of breast cancer.
• The Gail Model can assess one's risk of developing breast cancer, which uses the following factors: age, period in life, age at birth, family history, number of breast biopsies, breast biopsies showing hyperplasia, and race/ethnicity

Breast Self-Examination (BSE) for Screening

• After menarche, all women have been encouraged to perform monthly breast self-exams for early diagnosis of cancerous tumors and, therefore, early treatment to decrease the mortality associated with breast cancer.
• Nowadays, ""breast awareness"" is generally recommended in place of BSE.
• Clinical Breast Examination (CBE) can be performed regularly by a healthcare worker to potentially influence accuracy

Mammography

• Mammography uses X rays to image breast tissue that can be either a screening modality or diagnostic test.
• A Mammogram checks for suspicious cancer changes, microcalcification, architectures of breast, etc
• Mammography reduces breast cancer mortality by 30% overall in women over age 40.
• Mammography can detect an estimated 80% to 90% of breast cancers in asymptomatic women as early stage breast cancer.
• The sensitivity of mammography is highest among women ages 50 and olders.
• The ACS states women ages 40-44 can choose to have annual mammography, women ages 45-54 have annual mammography, and women age 55 and older had biennial/annual mammography with good overall health
• Digital breast tomosynthesis is mammographic technique that display in 3-D dimension and using X rays
• Magnetic resonance Imaging (MRI) for cancer is seen as most sensitive and only recommenced if its very necessary.

Ultransonography

• Ultrasonography can screen breast tissue for younger women and can be used to separate cystic from solid masses

Diagnosis of Breast Cancer

• Tissue sampling is typically used to diagnose a cancer, through needle aspirations, , mammography, etc
• With the modalities of the breast biopsy, its sent out to do a histologic examination to examine cancer.
• After one is diagnosed with cancer, its important to treat with lungs, bone, etc.

Treatment of Breast Cancer

• Surgery, may be followed with radiation therapy, chemotherapy, hormonal therapy, or immunotherapy can treat breast cancer.
• Women are generally managed with breast conserving surgery and sentinel node dissection, for stage I and II cancer to preserve lymph nodes from radiation.
• Mastectomy involves pectoralis muscle, with removing nipple and areolar and the lymph node dissection
• It is important to discuss short/long team information about side effects of radiation
• Breast reconstruction is a option if one goes through surgery.
• Follow ups should happen within 3-6 months.

Ovarian Dysfunction

• Ovarian dysfunction is common among women of reproductive age who are treated for breast cancer and the agents used.
• In women, 83.1% of them resume mentstruation at 3.5 months.

Contraception

• Breast cancer hormone sensitive tumors so contraception is not recommended
• For history of breast cancer, it is recommended
• IUDs, tubal ligation, and vasectomy are the better option.