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Breast pathology by Peter Bone
- 2. Objectives Breast anatomy Pathologies Breast cancer Questions
- 3. Breast anatomy 1. Chest wall 2. Pec muscles 3. Lobe 4. Nipple 5. Areolar 6. Duct 7. Fatty tissue 8. Skin
- 4. Quadrants
- 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
- 8. Screening Mammography 50-70 y.o. Every 3 years
- 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
- 13. Management Young- observe Older- remove Excise at any age if patient requests
- 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
- 16. Management No treatment needed if asymptomatic Progesterone supplements can be used NSAIDs
- 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
- 20. Management Persistent/recurrent cases Surgical excision of ducts below nipple Seroma formation, nipple numbness, nipple inversion
- 21. Duct papilloma Benign, warty lesion in 2-3% Can be central or peripheral Peripheral have higher risk of malignancy
- 22. Presentation, investigation Presentation Small lump Bloody discharge Investigation Mammogram? Galactogram FNA or core biopsy
- 23. Management Observational Excision if wanted
- 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
- 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
- 39. http://www.gpnotebook.co.uk/simplepage.cfm? ID=-2120613862 http://www.patient.co.uk/health/breast-lumps http://en.wikipedia.org/wiki/Fibrocystic_breast_ changes http://en.wikipedia.org/wiki/Mastodynia#Treatm ents_for_cyclical_breast_pain http://www.patient.co.uk/doctor/Mammary- Duct-Ectasia.htm http://www.cancerscreening.nhs.uk/breastscre en/index.html
- 40. http://www.patient.co.uk/doctor/puerperal- mastitis http://www.cancer.ca/en/cancer- information/cancer- type/breast/risks/?region=bc#High_SES http://www.cancer.gov/cancertopics/factsheet/ Risk/BRCA http://www.surgical-tutor.org.uk/default- home.htm?core/neoplasia/fibroadenoma.htm~r ight http://www.patient.co.uk/doctor/pagets- disease-of-breast
Editor's Notes
- 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