Breast Diseases PDF

1 DISEASES OF THE BREAST Clinical Surgery 2 BREAST CANCER Introduction 1:8...

1 DISEASES OF THE BREAST Clinical Surgery 2 BREAST CANCER Introduction 1:871, 4:240 The only life-threatening disease of the breast 2:444 Commonest cancer in Sri Lankan women8 Most common cause of death in middle-aged women in Western countries 1 in 12 lifetime risk for women in the UK 60% present as symptomatic disease 40% detected during screening Incidence of Breast Cancer Clinical Surgery  3 You are the new house officer at the Kantale Base Hospital. On a routine clinic day, a 45 year old female presents with a lump in the upper outer quadrant of her right breast for the past 6 months. It’s progressively increasing in size. She presents to the surgical clinic because she is Concerned. What diagnosis must be ruled out? How are you going to diagnose this condition? Clinical Features 4:240, 2:440-447c Patient Profile Fixity Geographical o Skin: Cannot move the lump separately o Western world o Muscle: Lump becomes less mobile on palpation during Gender contraction2:442 o < 0.5% occur in men § Pectoralis major o Female : Male = 200:1 o Chest wall Age Nipple/Areola o Rare below the age of 20 years Destruction 1:864 o Incidence steadily rises with age o Paget’s disease o At age of 90 years nearly 20% Depression (retraction or inversion) 2:443 o Not easily everted by gentle squeezing of the areola edge Vs. Symptoms and Signs Easily everted Lump o Unilateral Vs. Bilateral 2:444,445,447 o Recent onset Vs. Long standing Commonest presenting symptom Displacement2:445 o Incidental finding Vs. Self breast examination o Elevated Painless Deviation4:240 Progressive o Normally points downward and outwards 60% in the upper outer quadrant 1:874 Discharge 1:864 o Uni-ductal Vs. Multi-ductal Variable size o Blood stained/serous Irregular shape Non-tender Skin3:171, 2:446,447 No increase in temperature Colour changes: Redness o Only the very rare inflammatory breast cancer feels warm Puckering/ dimpling: Infiltration of ligaments of Astley Cooper Irregular surface4:240 Peau dorange appearance: Infiltration of lymphatics Ill-defined edge4:240 Multiple hard nodules Most lumps are hard in consistency Ulceration/ fungation of the carcinoma Clinical Surgery 4 Late Features Loss of appetite (anorexia) o Anaemia o Features of nutritional deficiency § Angular stomatitis § Glossitis § Ankle oedema Loss of weight (late stages) Etilogical/ Risk Factors 1:871 Endocrine: Increased oestrogen exposure Previous radiation o Nulliparity o Mantle/ supra-diaphragmatic radiotherapy for Hodgkin’s disease o Age at first pregnancy > 35 years 9 Smoking o Early menarche: < 12 years o Late menopause: > 55 years6:708 Table 1.1 o Oral contraceptive pill (OCP) Risk of Developing Breast Cancer In Benign Breast Diseases 1:871 § Increased risk during taking the pill and during the 10 (A positive family history significantly increases the risks shown below) years after stopping its usage o Hormone replacement therapy (HRT) for 5 – 10 years Benign Breast Disease Risk § Risk is more with combined oestrogen-progesteron Adenosis, sclerosing or florid preparation Vs. Oestrogen only Apocrine metaplasia o Obesity: Risk factor in post-menopausal women Cysts, macro (>3mm) and/or § Adipocytes metabolizes androstenedione (from the micro ( 35 years4:241 Score X-ray o C1: Inadequate sample o Cranio-caudal view o C2: Benign o Medio-lateral oblique view o C3: Atypical cells (Probably benign) Sensitivity increase with age as the breasts become less dense o C4: Highly suspicious of cancer (Probably malignant) Features of malignancy o C5: Malignant cells o Poorly defined irregular opacity Least invasive technique of obtaining a cell diagnosis1:863 o Isolated density Cannot differentiate CIS from invasive carcinoma1:800 o Tissue asymmetry Stereotactic FNAC: If clinically not palpable o Spiculated margins o Mammogram guided o Linear, branching micro-calcifications: < 0.5mm o USS guided o Skin tethering o Dermal oedema Tru-Cut Biopsy o Nipple inversion If FNAC is inconclusive (C3 / C4) o LNs with absent fatty hilum Done under LA1:862 Reported using BIRADS (Breast Imaging Reporting And Database System) Can check receptor status1:863 Used in screening: A normal mammogram does not exclude cancer1:861 Can differentiate CIS from invasive carcinoma1:863 Grading Ultrasound Scan o B1: Inadequate sample All patients o B2: Benign Young women with dense breast o B3: Uncertain malignant potential o Mammogram is difficult to interpret due to dense breast tissue o B4: Probably malignant Distinguish cyst Vs. solid (More likely to be malignant) o B5a: In-situ maligancy Axilary LNs o B5b: Invasive malignancy Not used in screening Operative Biopsy Types o Incisional biopsy o Excisional biopsy Usually not needed Clinical Surgery  7 What are the advantages of Tru-cut biopsy over FNAC? FNAC Vs. Tru-Cut Biopsy FNAC Tru-Cut Biopsy Least invasive technique of obtaining a cell diagnosis Histological diagnosis Advantages OPD procedure Receptor status can be identified No anesthesia is needed Can differentiate CIS from invasive carcinoma Only a cytological diagnosis Need higher level of training Disadvantages Receptor status cannot be identified Need LA Cannot differentiate CIS from invasive carcinoma What will you see in a Tru-cut biopsy of a malignant breast lump? How is spread assessed in this patient? Proliferating ductal cells with cellular anaplasia Assess Spread/Stage the Disease4:241, 3:171 Loss of double layering of ducts Invasion through the basement membrane Liver o LFT What is BIRADS classification? o If LFT are abnormal: USS/ CECT abdomen BIRADS Classification Lung Breast Imaging Reporting and Data System. It classifies mammographically o Chest X-ray breast pathology into 0 – 6 o If Chest X-ray is abnormal: CECT thorax o 0 – Incomplete o 1 – Negative Bone o 2 – Benign o Bone scan: If symptoms or signs present o 3 – Probable benign o Serum calcium o 4 – Probably malignant (suspicious) o 5 – Probably malignant (highly suspicious) Brain o 6 – Known biopsy with proven malignancy o CECT scan: If symptoms or signs present MRI1:862 If USS and Mammogram are equivocal Imaging a breast with scar tissue due to previous surgery o Scar Vs. Recurrence Assessment of multi-focality and multi-centricity in lobular carcinoma Assess extent of high-grade DCIS (less useful in low-grade DCIS) Best imaging modality if there are breast implants Screening in high risk women (family history) Clinical Surgery 8 Give me a quick over view of TNM classification. UICC and TNM Staging (Union for International Cancer Control) TNM Staging (AJCC-American Joint Committee on Cancer) NCCN (National Comprehensive UICC TNM T: Primary Tumour Cancer Network) Tx: Primary tumour cannot be assessed 0 Tis N0 T0: No evidence of primary tumour Tis: Carcinoma in-situ I T1 N0 o Tis (DCIS) T1 N1 o Tis (LCIS) Early/ Local T2 N0 o Tis (Paget’s) II T2 N1 T1: < 2cm in greatest dimension T3 N0 T2: 2-5cm in greatest dimension T3 N1 T3: > 5cm in greatest dimension IIIA Operable LABC T4: Any tumour size with direct extension to the chest wall or skin: Skin Locally Advanced N2 nodules, peau d’ orange appearance, ulceration or inflammatory carcinoma (LABC) IIIB T4 N: Nodes IIIC N3 Nx: Regional LN can not be assessed N0: No regional LN metastasis Metastatic/ Advanced IV M1 N1: Ipsilateral axillary LN involved, but mobile N2: Ipsilateral axillary LN involved, but fixed What are the stages of Breast Cancer? N3: Ipsilateral internal mammary, infra-clavicular and supra-clavicular LN Stages of Breast Cancer (For Treatment Options) involved Early/ Local M: Metastasis o T1 N0 / N1 Mx: Presence of distant metastasis cannot be assessed o T2 N0 / N1 M0: No clinical or radiographic evidence of distant metastasis o T3 N0 / N1 M1: Distant metastasis present Locally Advanced o T4 o Any T with N2 / N3 Metastatic/ Advanced o M1 Clinical Surgery  9 Fitness for Treatment Blood o FBC o FBS o Coagulation profile Heart o ECG o 2D Echo Lungs o Chest X-ray Kidneys o Blood urea o Serum creatinine What are the main components in the treament of breast cancer? How do you decide the best treatment plan? TREATMENT 1:875-879 Multi-disciplinary team management (MDT) o Surgeon o Anaesthesiologist o Pathologist o Radiologist o Oncologist o Counsellor o Breast care nurse Depends on the stage Goals o Achieve local disease control and reduce the chance of local recurrence o Achieve regional disease control in the tumour draining LNs o Reduce the risk of metastatic spread Treatment Options Based on Stage Of The Disease Local Locally Advanced3:174 Metastatic3:174 Surgery +/- radiotherapy Neoadjuvant chemotherapy (and other systemic Chemotherapy (and other systemic treatment) Adjuvant chemotherapy (and other systemic treatment) Surgery is only done for local disease control treatment) 3:174 Surgery +/- radiotherapy Radiotherapy for painful bony deposits and Adjuvant chemotherapy (and other systemic internal fixation of pathological fractures1:881 treatment) Clinical Surgery 10 Local Treatment Breast Breast conserving surgery + Radiotherapy Mastectomy + / - Radiotherapy o Wide local excision (1cm margin) o Simple: No axillary node clearance o Quadrantectomy/ lumpectomy o Modified radical (Patey): Includes level II axillary node clearance § The whole breast, skin with the nipple and all of the fat, fascia and lymph nodes of the axilla are removed.1:876 Breast Conserving Surgery Vs. Mastectomy Breast Conserving Surgery Mastectomy Small tumours in a large breast Large tumours in a small breast Peripheral location Central location Not for retro-areolar/multi-focal/multi-centric tumours Retro-areolar/multi-focal/multi-centric tumours Ensure clear margins Late presentation with complications such as ulceration4:242 Local radiotherapy is invariably given to the remaining breast Recurrent cancer following wide local excision Diffuse in-situ carcinoma4:242 Carcinoma in Pregnancy1:881 Radiotherapy is not essential o Indications for radiotherapy- § Large tumours § Large number of positive LNs § Extensive lympho-vascular invasion Clinical Surgery  11 Axilla How is the axilla managed in breast cancer? What is a sentinal LN and what is the principal of sampling it? How is it Options1:876 identified? o FNAC/USS-guided FNAC along with the ultrasound scanning Sentinel node1:877 of the breast o Is the FIRST node that drains the diseased part of the breast o Axillary clearance o Is localized peroperatively by the injection of patent blue dye o Axillary node sampling and radioisotope-labelled albumin o Sentinel node biopsy o The principle of doing this is that, if the sentinel node is unaffected, then the rest of the nodes should also be unaffected Management of the Axilla Clinical Surgery 12 What are the options available for systaemic control in this patient? Systaemic Treatment Chemotherapy: Adjuvant/Neo-Adjuvant1:878 Hormone Therapy Cyclophosphamide Anti-oestrogens: Selective oestrogen receptor modulator (SERM) Methotrexate o Tamoxifen for 5 years post-operatively1:878 5-Fluorouracil o Pre-menopausal women § Oestrogen from the ovaries (CMF is no longer considered an adequate adjuvant chemotherapy and modern o Contraindicated in pregnancy: Potentially teratogenic1:881 regimens include an anthracycline(doxorubicin or epirubicin) and newer agents o Antagonist for breast cancer cells such as the taxanes) o Agonist for § Bones: Protection against osteoporosis Side effects: Affects all rapidly proliferating cells § Endometrium: Risk of endometrial cancer o Nausea/ vomiting/ diarrhoea o Risk of DVT o Hair loss o Can be used as the primary mode of treatment in elderly unfit o Cytopenia patients3:174 o Some cause neuropathy Reduce production of oestrogen1:878 o LHRH agonists (Medical oophoretomy) for premenopausal women o B/L Oophorectomy (Surgical oophorectomy) o Aromatase inhibitors: Anastrazole, Letrozole § Reduce peripheral conversion androgens to oestrogen § Post-menopausal women o Oestrogen from peripheral conversion of androgens Risk of osteoporosis o Add calcium and Vit D Immunotherapy1:878 Her 2 receptor blockers o Trastuzumab (Herceptin) – Monoclonal antibody o Risk of cardiac dysfunction Radiotherapy (Also used in local) Bone and brain metastasis3:174 Clinical Surgery  13 What are the options available for breast reconstruction and when is it done? Breast Reconstruction1:879, 880 During same time or later stage Latissimus dorsi flap TRAM flap (Transverse Rectus Abdominis Myocutaneous) Prosthesis Clinical Surgery 14 The patient gave consent for surgery and a right-sided mastectomy + level II axillary clearance was done in the next available surgical list under general anaesthesia. The post-operative period was uneventful. She recovered well. She was discharged on the 3rd post-operative day and was advised to return to the clinic in 2 weeks to trace the histology report. Histology report Post-Operative complications of surgery Histology1:872,873 What are the types of breast cancer that you know of? Confirm that it’s malignant Pathological Types Pathological type: Ductal or lobular Invasive or non-invasive Ductal Carcinoma Lobular Carcinoma 85% 15% How are breast malignancies graded? Unifocal Commonly multifocal1:872 Unilateral Commonly bilateral1:872 Tumour grading Elderly women Pre-menopausal women o Nuclear pleomorphism: Variations in, Non-invasive: 5% Non-invasive: 1% § Nuclear size o Confined within the duct system o Confined within the § Nuclear shape (DCIS) lobular system § Nuclear staining (especially with hyperchromasia) Invasive: 85% (LCIS) o Tubular formation o Not otherwise specified: 65% o Number of mitoses Invasive: 9% § Bad prognosis6:713 Nottingham grading 13:20 o With specific features: 20% o Low: Grade 1 § Medullary, Tubular, o Intermediate: Grade 2 Mucinous, Papillary, o High: Grade 3 Cribriform, Others Hormone receptor status § Good prognosis6:713 o Oestrogen o Progesterone o Her-2 receptor Clinical Surgery  15 A few weeks after surgery, your patient presents with pain and swelling of the On what factors does prognosis depend on? ipsilateral upper limb. What is the most likely diagnosis? Prognosis1:875 Lymphoedema of upper limb Axillary LN status o Single best determinant of prognosis1:877 Histological grade What could have been done post-operatively to prevent shoulder stiffness? Stage of the tumour Physiotherapy Hormone receptor status o ER/PR: Good prognosis6:713 What other complications can the patient present with or could have o Her 2 (Human epithelial receptors): Bad prognosis6:713 presented with ? o Triple negative: Worst prognosis Post-Operative Complications of Surgery Nottingham prognostic index o 0.2 X Diameter(cm) + Nodal status + Grade3:168 Mastectomy Axillary Clearance 5 year survival Immediate (Within 6 hours of Immediate o Local: > 70% Surgery) o Bleeding o Bleeding o Long thoracic nerve injury: o Locally advanced: 72 hours) Early o Wound infection o Axillary vein thrombosis o Keloid/hypertrophic scar Late formation o Lymphoedema of ipsilateral upper limb o Shoulder stiffness Clinical Surgery 16 What is Paget’s disease? INFLAMMATORY CARCINOMA / MASTITIS PAGET’S DISEASE1:873 CARCINOMATOSA3:176 Rare superficial manifestation of an underlying carcinoma, which maybe in- Occur in pregnancy and lactation situ or invasive Painful, swollen breast, which is warm with cutaneous oedema1:872 An eczema-like condition of the nipple and areola, which persists despite Locally advanced inoperable breast carcinoma1:881 local treatment Characterized by ‘Paget cells’ in epidermis Most aggressive breast cancer Wedge or punch biopsy is diagnostic Metastasize widely and rapidly Same principals of treatment: Mastectomy3:176 Treatment o Palliative What are the differences between Paget’s disease and Eczema? § Chemotherapy Paget’s Disease Vs. Eczema 2: 452 § Radiotherapy § Tamoxifen: If ER + Paget’s Disease Eczema o Prognosis Unilateral Bilateral § 5 year survival: < 5% At menopause Common at lactation No itching Itching No vesicles Vesicles Nipple destroyed Nipple intact May have an underlying lump No lumps Clinical Surgery  17 BENIGN BREAST DISEASES Classification1:870 ANDI (Aberration of Normal Development and Involution) Congenital disorders Aberration of Normal Development o Inverted nipple Early reproductive period (15-25y) o Supernumerary breasts/nipples o Fibroadenoma Non-breast disorders including Tietze's disease(costochondritis) Mature reproductive period (25-40y) Sebaceous cysts and other skin conditions o Fibroadenosis (cyclical nodularity and mastalgia) Injury Inflammation/Infection Aberration of Normal Involution (40-55y) o ANDI (Aberrations of Normal Differentiation and Involution): Breast cysts § Fibroadenoma Duct ectasia § Cyclical nodularity and mastalgia § Cysts Benign Neoplasm § Duct ectasia/periductal mastitis Fibroadenoma o Pregnancy-related: Phyllodes tumour § Galactocoele Intraductal Papilloma § Lactational abscess Lipoma Clinical Surgery 18 A 20 year old female presents with a mobile lump in the inner lower quadrant A 35 year old female complains of a lumpy area in the lower inner quadrant of her right breast for the past 6 months. It’s painless, but she is concerned of her right breast for the past 6 months. It’s painful and disturbs her day to because she has recently attended an educational programme at her day activities. On examination you find it difficult to palpate and define a workplace regarding breast cancer. lump. What is the most likely diagnosis? What is the most likely diagnosis? FIBROADENOMA FIBROADENOSIS/ FIBROCYSTIC DISEASE4:246 Introduction1:870 Introduction Overgrowth/ hyperplasia of a single lobule Combination of localized fibrosis, inflammation, cyst formation Fibrous + glandular components2:448 No well-formed capsule/ No discrete mass3:168 Well-formed capsule: Therefore enucleated easily Not pre-malignant, but proliferative type of fibroadenosis has an increased risk Not pre-malignant Clinical Features2:448,449 Clinical Features Commonest age: < 35 years (15-25 years) 1:870 Almost exclusively between menarche and menopause (15-55y) Oestrogen-dependant Oestrogendependant o Increases in size with menstruation o Cyclical pain o Involutes after menopause3:168 o Worse before a period1:868 Painless Multiple breast cysts May be multiple or giant ( > 5cm )1:870 Bilateral Unilateral May have a nipple discharge1:864 No nipple discharge o Serous Freely mobile (Breast mouse), smooth, firm/rubbery, discrete lump o Blood stained ‘Lumpy’ breasts If suspected, examination should be repeated at different stages of the menstrual cycle3:168 Investigations3:168 Investigations Ultrasound scan Ultrasound scan FNAC FNAC Treatment Treatment Reassurance Reassurance 1:869 o 1/3 regress spontaneously Anti-inflammatories: NSAIDs Surgical excision1:870 Analgesics o Doubtful diagnosis/Lump increasing in size Adequate support1:869 o Cosmesis/Patient preference o Firm bra during the day and a softer bra at night o Pain/ symptoms4:246 Vit E Alternatives to surgery1:870 Hormone or ‘cellular’ manipulation o Cryoablation o Evening primrose oil (gamma-linoleic acid) o Heating with high-frequency ultrasound (echotherapy) o Danazol (Androgen)1:869 o Removal with a large core biopsy vacuum system o COC pill Clinical Surgery  19 A 30 year old breast feeding mother presents with severe pain in her right A 50 year old mother of 5 children presents with a greenish nipple discharge. breast. On examination, the breast is swollen, red, warm and tender. She’s a smoker. What is the most likely diagnosis? What is the most likely diagnosis? ACUTE BACTERIAL MASTITIS/ BREAST ABSCESS1:866 DUCT ECTASIA/ PERIDUCTAL MASTITIS1:867,868 Introduction Introduction Acute Staphylococcus auerus infection of mammary ducts4:246 Dilated, scarred, chronically inflamed subareolar mammary ducts4:246 From the baby’s mouth Enters through cracks and fissures in the nipple Clinical Features 3:169, Chiefly in the fifth decade Multiparous women Clinical Features2:453 Associated with smoking First few weeks after delivery Breast Common in smokers o Nipple discharge: Any colour Fever § Recurrent yellow-green discharge, blood, serous Breast o Pain3:169 o Pain o Recurrent abscesses4:246 o Swelling o Mass beneath the nipple o Redness o Nipple retraction: Highly characteristic transverse slit appearance o Tenderness due to fibrosis2:452 o Lactating breast Investigations Investigations To exclude carcinoma in the case of a mass or nipple retraction No investigations: Clinical diagnosis o USS o Mammogram Treatment o Cytology or histology Antibiotics Ductography o Flucloxacillin or co-amoxiclav Ductoscopy: Technically feasible but generally disappointing1:864 Repeated aspirations if an abscess has formed Incision and drainage if aspirations fail and if there is marked skin thinning Treatment Analgesics Antibiotics if associated infection If the nipple was cracked, it should be rested for 24-48 hours and the breast I and D if abscess should be emptied with a breast pump1:863 Duct excision No need to stop lactation: If the inflamed area communicated with the duct o If severe discharge, recurrent sepsis system, the infection would have discharged this way and the abscess Surgery would not have formed2:453 o Hadfield's operation: Excision of all the major ducts1:868 o Microdochectomy: Removal of a single affected duct Clinical Surgery 20 PHYLLODES TUMOUR1:870 BREAST CYSTS4:246 Usually > 40 years Almost always benign Rare: < 1% of all breast lumps Filled with green-yellow fluid, even black2:451 Large Often associated with fibrocystic disease1:869 Rapidly growing3:176 Spherical2:451 Variant of fibroadenoma Symmetrical lump/s Potentially malignant May be discrete or multiple o Lung metsastasis via bloodstream Occasionally painful2:451 Need triple assessment Diagnosis: Triple assessment Treatment o USS o Wide local excision o Mammography o Mastectomy o FNAC/Aspiration: Typical fluid aspirated § Massive tumours o Core biopsy/ local excision: If,1:869 § Recurrent tumours § Residual mass § Malignant type § Recurrent cysts § Bloody aspirate Treatment o Repeated aspiration § 30% of breast cysts will require reaspiration1:869 o Hormone manipulation FAT NECROSIS4:247, 1:866 Causes o Trauma o Surgery o Radiotherapy Common in obese women Organized local haematoma Occasional calcification Mimics carcinoma o New, painless or painful breast lump o Poorly defined o Nipple retraction and skin tethering History of trauma is often absent2:447 Diagnosis o Triple assessment: Need to exclude malignancy Clinical Surgery  21 1:864 NIPPLE DISCHARGE Causes Sinister Features of a Discharge1:864 Discharge from surface Presence of a lump o Paget’s disease Presence of blood in the discharge o Skin diseases Discharge from a single duct § Eczema § Psoriasis Features of a Physiological Discharge1:864 o Chancre of syphilis Non-bloody Multi-duc Discharge from a single duct Clear/ serous o Blood stained Usually need manipulation to produce § Intraduct papilloma (Bloody or purulent discharge are NEVER physiological) § Intraduct carcinoma § Duct ectasia o Serous (any colour) § Fibrocystic disease MASTALGIA § Duct ectasia Cyclical: 80% § Carcinoma o Co-relates with the menstrual cycle1:868 § Early pregnancy3:167 o Fibrocystic disease Non-cyclical Discharge from multiple ducts o Periductal mastitis1:869 o Blood-stained o Breast abscess1:866 Mondor's disease : Superficial thrombophlebitis § Carcinoma Referred pain § Ectasia o From the neck, chest wall, back in postmenopausal women1:869 § Fibrocystic disease o Breast pain in the elderly is often skeletal in origin, referred from o Black or green conditions such as frozen shoulder and osteoporosis of the spine2:450 § Duct ectasia o Purulent § Infection o Serous § Fibrocystic disease § Duct ectasia § Carcinoma o Milk § Late pregnancy3:167/Lactation § Hypothyroidism § Pituitary tumour: Hyperprolactinaemia Clinical Surgery