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Breast disorders

Development / anatomy

  • Modified sweat gland
  • 2-6 ICS; sternum to AAL
  • 2/3 on pectoralis major, 1/3 on serratus anterior (with axillary tail of spence)
  • Condensation of fibrous tissue forms suspensory ligament of cooper (supportive framework)

  • Blood supply
  1. Axillary artery (2nd part, lateral thoracic arter)
  2. Internal thoracic artery
  3. Intercostal arteries
  • Nerve supply
  1. Intercostal nerves T4-T6
  • Lymph drainage

Axillary nodes - 75%

  1. Level 1: lateral to pectoralis minor (14 nodes)
  2. Level 2: posterior to pectoralis minor (5 nodes)
  3. Level 3: Medial to pectoralis minor (2-3 nodes)

Internal mammary - 25%

[Anatomy of axilla]

 

 

Congenital / Developmental disroders

  • Athelia / Polytheli: absence / many nipples
  • Amastia: Absence of breast
  • Polymastia: accessory breast
  • Amazia: Absent of breast with nipple present = hypoplasia of breast (90% associated absent/hypoplastic pectoral muscles; ~Poland syndrome)

Gynaecomastia

  • Abnormal breast enlargement
  1. Female
  2. Male
    • Physiological: neonatal, pubertal hormone imbalance
    • Pathological: hypogonadism, neoplasms, drugs - cimetidine, spironalactone, ketoconazole, digitalis, oestrogens

 

Aberrations of normal breast development and involution (ANDI)

Tumour Pathology Features Management
Fibroadenoma
  • Aberation of development; 15-25 years
  • Develops from single lobule of breast (rather than single cell)
  • Hormone dependance (lactating during pregnancy, involuting in peri-menopausal period)
  • Well circumscribed smooth firm lump
  • May be multiple/bilateral
  • FNA/Biopsy
  • Mammography / ultrasonography
  • Rx: Reassure / remove if large >2cm on request
Phylloides Tumour
  • Arise from peri-stromal tissue
  • 40-50 years
  • More common in African countries
  
  • FNA / Biopsy
  • Rx: Complete excision - risk of recurrence
Cystic disease
  • Common 35-55 years
  • Macrocysts ~7% women in West
  • Unknown cause
  • Discreet, smooth lump, may be fluctuant (like all cysts)
  • Aspirate fluid
  • Mammography if > 35years
  • Rx: Excision biopsy
Sclerosing leions
  • Aberration of involution - sclerosing adenosis, papillomatosis, duct adenoma
  • Radial scars present via screening
  • Potential underlying breast cancer
  • Mammography + excision biopsy
Epithelial hyperplasia
  • Epithelial cell increase in terminal duct lobular unit
  • Common pre-menopausal women
  • If atypia plus hyperplasia increased risk of breast cancer
  • Atypical ductal or lobular cells x4-5 greater risk of breast cancer
  • breast lump
  • FNA / NCB
  • Rx: Excision biopsy + screening (increased risk of breast cancer)

Breast pain / inflammatory lesions

  Pathology Features Treatment
Mastalgia

Cyclical Mastaliga

  • Young women (Any age up to menopause)
  • 3-7 days pre menstrual cycle
  • Improves at menstruation
  • Usually lateral part of breast affected
 
  • Weight loss
  • Supportive bra
  • Evening primrose oil
  • NSAIDs
 

Non-Cyclical Mastalgia

  • Older women (45+)
 
  • Supporting bra
  • Weight loss
Breast abscess

Lactating

  • Mastitis neonatorum - first few weeks of life
  • Infected enlarged breast bud
  • Caused by s.aureus / e.coli
 
  • Rx: Antibiotics / I&D
 

 

Non-Lactating

  1. Peri-areolar
    • Complication of periductal mastitis
    • More common than lactating breast abscess
    • 35yrs
  2. Peripheral
    • Ass: DM, RA, Steroids, trauma
  3. Periductal mastitis
    • Bacterial / cigarette smoking / AI basis

 

 

Complications of Abscess

  1. Duct ectasia: dilatation without inflammation
  2. Duct fistula: -
  • Nipple discharg
  • Breast pain
  • Retraction / inversion
  • Antibiotics
  • Aspiration
  • I&DS

 

Benign Neoplasms

Duct papilloma
  • Common
  • Single / multiple
  • Usually small, symptomless
  • Bloody discharge if duct involvement
  • Mammography, ductography
  • Rx: Microdochectomy
Lipoma
  • Soft lobulated radiolucent lesion
    

 

Nipple discharge

  1. White = Milk: lactating breast (physiological / prolactinoma)
  2. Yellow = Exudate: abscess
  3. Green = Cellular debris: duct ectasia
  4. Red = Blood: ductal papilloma or carcinoma

Determine whether single or multiduct (not usually pathological except in hormone producing endocrine tumours)

Mangement

  1. Haemo-stix
  2. Cytology
  3. Mammography / USS
  4. Ductography / ductoscopy (washings can be taken for cytology)

 

 

Breast Cancer: Aetiology & Clinical features

Risk factors: OESTROGEN EXPOSURE

  1. Age
  2. Early menarche, late menopause, nulliparity
  3. Diet / obesity (fat turned into oestrogens/phyto-oestrogens)
  4. Drugs: OCP, HRT
  5. Smoking
  6. Family history + Genetics: BrCa1 (17q), BrCa2(13q)

Linear increase with age

 

Clinical features

  1. From the lesion
    • Painless breast lump +/- lymph node involvment (I-III; relative to pec. minor)
    • Hard lump with poorly defined margins
    • Skin tethering or fixation to underlying structures
    • Pain / skin ulceration "peau d'orange" - due to involvement of suspensory ligaments of cooper
    • Nipple discharge / retraction
  2. Systemic features
    • Weight loss
    • Ascities
  3. Features of spread
    • Bone pain / pathological fractures
  4. Paraneoplastic manifestations

 

Diagnosis

  1. History (including risk factors)
  2. Examination - "Triple assessment"
  3. Investigations:
    • Blood tests: Tumour markers Ca 15-3 (mucin marker)
    • Imaging: Mammography, Ultrasound (if young pair of titties)
  4. Tissue diagnosis
    • FNA / NCB - 95% pre-operative diagnostic sensitivity
      FNA Cytology NCB Histology
      C1 - Inadequate
      C2 - Benign
      C3 - Equivocal
      C4 - Suspicious
      C5 - Malignant       		H1 - Normal
      H2 - Benign
      H3 - Equivocal
      H4 - Suspicous
      H5 - Malignant

    • Excision biopsy

 

Pathology

  1. Epithelial cell origin
    1. Non-invasive
      • DCIS - cured by total mastectomy
      • LCIS
    2. Invasive
      • Ductal carcinoma: 80-90% (NB Paget's disease of nipple = Ductal carcinoma involving epidermis; starts at nipple with some evidence of destruction)
      • Lobular carcinoma: 1-10%
      • Mucinous 5%
      • Medullary 1-5%
      • Metaplastic
  2. Connective tissue origin

 

Prognostic indicators

  1. Node positive = <20% survival
  2. High Grade (1-well, 3-poor)
  3. Size
  4. Vascular invasion
  5. Oestrogen receptor: based on H (histochemical score) out of 300
    • H Score > 50: Receptor positive
    • H Score < 50: Receptor negative

 

Nottingham Prognostic Index (NPI)

NPI = Size (in cm) x 0.2 + Grade (1 - 3) + Stage (Lymph node)

NPI < 3.4 - excellent: 15y 90% survival
NPI > 5.4 - poor: 15 8% survival

 

Grading

Bloom & Richardson grading system

Based on tubule formation, nuclear pleomorphism ("many different forms"), and mitotic activity

  1. Grade 1: Well differentiated
  2. Grade 2
  3. Grade 3: Poorly differentiated

 

Tissue Staging

  • TNM system

      T - Tumour
    		 N - Node M - Metastasis
    0 Subclinical No nodes No mets
    1 <2cm Ipsilateral axillary (mobile) Distant mets
    2 2-5 Ipsilateral axillary (fixed)  
    3 >5 Ipsilateral mammary  
    4 Any size with (a) chest wall or (b) skin extension    

  • Manchester system / Columbia system

    TNM
    		 Manchester Columbia
    - T1
    - N0-N1    		 Stage 1
    • Confined to breast < 5cm
    • With or without skin involvement
    		 Stage A
    T2N1b Stage 2
    • Confined to breast <5cm
    • Nodes involved but not fixed
    		 Stage B
    T3-T4
    N2-N3    		 Stage 3
    • Locally advanced disease >5cm
    • Affects underlying muscle/overlying skin or fixed lymph nodes
    		 Stage C
    M1 Stage 4
    • Distant metastatic disease (lung, liver, brain, bone)
    		Stage D

Managment

  1. Diagnose
    • Triple assessment: high positive predicitive value and prevents erros in diagnosis
  2. Stage disease
  3. Good cosmesis

 

  1. Surgery
    • WLE / Quadranetectomy / Segementectomy
    • Remove tumour + adequate resection margins (>5mm margins)
    • Adequate skin flaps for cover
    • Breast reconstruction: pedicled flaps, free flaps (DIEP)
  2. Axilla
    • Level II (up to medial border of pec minor) clearance accepted as best balance between adequate staging and morbidity
    • Sentinel node technique - finds first draining node (technetium + blue dye); contra-indicated in pregnancy [NB also has use in melanoma and penile cancer]
    • Morbidity: haematoma, wound infection, seroma, lymphoedema, intercostobrachial neuralgia, injury to thoracodorsal nerve, long thoracic nerve injury, axillary vein injury, brachial plexus injury, post-op frozen shoulder
  3. Hormonal therapy
    • 1st Line: Tamoxifen (Selective oEstrogen Receptor Modulator (SERM)) - reduce circulating oestradiol
    • 2nd Line: Aromatase inhibitors (Anastrazole[Arimadex], fromenstane, aminogluthethimide) - block oestrogen via aromatase pathway
    • LHRH antagonists (Goserelinp [Zoladex] - prevents oestrogen production by ovaries
    • 3rd Line: Progesterone
  4. Chemotherapy
    1. Antimetabolites (impair production of DNA):5-FU, Methotrexate
    2. Vinca alkaloids (inhibit microtubule formation): Vincristine, vinblastine
    3. Alkylating agents (bind to and disrupt DNA): Cyclophosphamide
    4. Platinum-based agents
  5. Radiotherapy

Follow up

  1. Early detection + treatment of recurrence
    • Local recurrence: - single spot,
    • Regional recurrence: axilla, brachial plexus, supraclavicular nodes
    • Distant mets
  2. Early detection of metastatic disease
  3. Psychiatric morbidity

 

 

[Screening]

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