Breast conditions

1. BENIGN BREAST
DISEASE
DR. SAMAN TAHER BARZINJY
MBCHB, F.I.C.M.S(GS),FACS

2. BREAST ANATOMY
►Four quadrants
►Parenchyma
• Alveoli Lobules Lobes
• Three tissue types
►Glandular epithelium
►Fibrous stroma and supporting structures
►Fat
• Suspensory (Cooper) ligaments
►Fibrous continuations of the superficial fascia, which
span the parenchyma of the breast to the deep fascial
layers

3. 15-20 lobes terminates at major lactiferrous ducts, open in constricted
orifices in to nipple ampulla, each of several lobules,
extends from 2nd or 3rd rib to the inframammary fold at
the 6th or 7th rib. lateral border of the sternum to the anterior axillary
line. rests on the fascia of the pectoralis major, serratus anterior, and
external oblique abdominal muscles, and the upper extent of the rectus
sheath.
axillary tail of Spence extends laterally across the anterior axillary fold.
The upper outer quadrantof the breast contains a greater volume of
tissue than do the other quadrants.
has a protuberant conical form. The base of the cone is roughly
circular, measuring 10 to 12 cm in diameter. Considerable variations in
the size, contour, and density of the breast are evident among
individuals.
The nulliparousbreast has a hemispheric configuration with distinct
flattening above the nipple. With the hormonal stimulation that
accompanies pregnancy and lactation, the breast becomes larger and
increases in volume and density, whereas with senescence, it assumes
a flattened, flaccid, and more pendulous configuration with decreased
volume.

4. Nipple-Areola Complex:
The epidermis is pigmented and is variably corrugated.
During puberty, the pigment becomes darker and the nipple
assumes an elevated configuration.
Pregnancy: areola enlarges and pigmentation is further
enhanced. The areola contains sebaceous glands, sweat glands,
and accessory glands, which produce small elevations on the
surface of the areola (Montgomery’s tubercles). Smooth muscle
bundle fibers, which lie circumferentially in the dense connective
tissue and longitudinally along the major ducts, extend upward
into the nipple, where they are responsible for the nipple erection
that occurs with various sensory stimuli. The dermal papilla at
the tip of the nipple contains numerous sensory nerve endings
and Meissner’s corpuscles. This rich sensory innervation is of
functional importance, because the sucking of the infant initiates
a chain of neurohumoral events that results in milk letdown.

5. Arterial supply
► perforating branches of Internal mammary arteries (60%)
►Lateral branches of posterior intercostal arteries (30%)
► branches from the axillary artery, including the highest thoracic,
lateral thoracic, and pectoral branches of the thoracoacromial
artery
Venous return
►Perforating branches of internal thoracic veins
►Tributaries of axillary vein (primary)
►Perforating branche of posterior intercostal vein
► Batson’s vertebral venous plexus, which invests the vertebrae
and extends from the base of the skull to the sacrum, may
provide a route for breast cancer metastases to the vertebrae,
skull, pelvic bones, and CNS.
Lymph vessels generally parallel the course of blood vessels.

7. BREAST ANATOMY
►Lymphatics
• Axillary chain
►Leveal 1 – lateral to pectoralis minor muscle, includes: axillary
vein, external mammary, and scapular groups
►Level 2 – along and under pectoralis minor, includes central and
interpectoral groups Rotter’s.
►Level 3 - medial to pectoralis minor,includes subclavicular group
• Internal mammary chain (relatively minimal drainage)
►Parasternal
►Medial
The axillary LN usually receive >75% of the lymph drainage
from the breast. The rest is derived primarilyfrom the medial
aspect of the breast, flows through the lymph vessels that
accompany the perforating branches of the internal mammary
artery, and enters the parasternal (internal mammary) group of
lymph nodes.

8. (a) axillary vein group (lateral), consists of 4-6 LN, lie medial or posterior to the
vein and receive most of the lymph drainage from the upper extremity.
(b) external mammary group (anterior or pectoral group), consists of5-6 LN lie
along the lower border of the pectoralis minor muscle contiguous with the lateral
thoracic vessels and receive most of the lymph drainage from the lateral aspect
of the breast.
(c) scapular group (posterior or subscapular), 5-7 LN, lie along the posterior wall
of the axilla at the lateral border of the scapula, receive
lymph drainage principallyfrom the lower posterior neck, the
posterior trunk, and the posterior shoulder.
(d) the central group, 3-4 LN, embedded in the fat of the axilla lying immediately
posterior to the pectoralis minor muscle and receive lymph drainage both from
the axillary vein, external mammary, and scapular groups of lymph nodes, and
directlyfrom the breast.
(e) the subclavicular group (apical), 6-12 LN, lie posterior and superior to the
upper border of the pectoralis minor muscle and receive lymph drainage fromall
of the other groups of axillary lymph nodes.
(f) the interpectoral group (Rotter’s lymph nodes), 1-4 LN, interposed between the
pectoralis major and pectoralis minor muscles and receive lymph drainage
directlyfrom the breast. The lymph fluid that passes through the interpectoral
group of lymph nodes passes directlyinto the central and subclavicular groups.

11. NERVES:
LONG THORACIC NERVE
THORACODORSAL NERVE
MEDIAL PECTORAL NERVE
LATERAL PECTORAL NERVE

12. BENIGN BREAST
DISEASE
►congenital
►Infectious and inflammatory
►Benign lesions
►NippleDischarge
►Mastalgia

13. Polymastia, along milk line, (accessory axillary breast is rare,
usually bilateral)
Polythelia (accessorynipple) along milk line) , 1%.
Symmastia(web between breasts)
Amastia, rare
Breast and chest wall hypoplasia(poland syndrome)
Infantile nipple inversion: During infancy, If there is failure of
a mammary pit to elevate above skin level, incidence 4%.

14. INFECTIOUS AND INFLAMMATORY BREAST DISEASE
►Cellulitis, mastitis
• Usually associated with lactation
• May be bacterial, or mycotic.
• Treat with 10-14 day course antibiotics to cover Staphylococcus and
Streptococcus
▪ Hidradenitis Suppurativa
►Abscess
• Treated by surgical drainage
►Chronic subareolar abscess
• Occurs at base of lactiferous duct, and squamous metaplasia of duct may
occur.
• Sinus tract to areola develops
• Treatment requires complete excision of sinus tract
• Recurrence is common
►Mondor’s disease
• Phlebitis of the lateral thoracic vein, the thoracoepigastric vein, and, less
commonly, the superficial epigastric vein.
• Palpable, visible, tender cord along upper quadrants
• Ultrasound may be helpful in confirming this diagnosis.
• Treatment self-limited within 4-6 Weeks, , can use anti-inflammatories if
necessary or surgical excision.

15. ANDI
spectrum of breast conditions that ranges from normal to disorder to
disease.

17. BENIGN LESIONS OF THE BREAST
►Fibrocystic breasts
• Broad spectrum of clinical and histologic findings
• Loose association of cyst formation, breast nodularity,
stromal proliferation, and epithelial hyperplasia.
• Appears to represent an exaggerated response of breast
stroma and epithelium to hormones and growth factors.
• Dense, firm breast tissue with palpable lumps and
frequently gross cysts, commonly painful and tender to
touch.
• No consistent association between fibrocystic complex and
breast cancer.

18. BENIGN LESIONS OF
THE BREAST
►Cysts
• Fluid-filled, epithelium-lined cavities
• Influenced by ovarian hormones
►Explains sudden appearance during the menstrual cycle, their rapid
growth, and their spontaneous regression with completion of the
menses.
• Common after age 35, and rare before 25. Incidence declines after
menopause.
• Three colors by needle aspiration
►Simple cyst, clear or green fluid and is benign.
►Milk-filled cyst, called galactocele and is benign.
►Bloody cyst is a cause of concern for malignancy.
• Rx depends on whether the cyst completely resolves after aspiration
►Complete resolution, will follow up to ensure it does not recur.
►Incomplete resolution, Treat as breast mass and excise.Fluid-filled,
epithelium-lined

19. BENIGN LESIONS OF THE BREAST
►Fibroadenoma
• Well-defined, mobile, benign.
• 15-25 years.
• Mostly 1-2 cm
• Less than 1 cm is small and normal, 1-3 cm is disorder, giant(more than 3
cm) is disease.
• More than 5 number in one breast is also disease.
• Composed of both stromal and epithelial elements in the breast
• Common in younger women, and is most common tumor in women
younger than age 30 years
• Can be diagnosed by FNA and followed if < 2-3 cm and age < 35
• Otherwise Dx by excision. At operation are well-encapsulated and detach
easily.
• Cryoablation and ultrasound-guided vacuum assisted biopsy are approved
treatments especially lesions <3 cm. Larger lesions need excision.
►Phyllodes tumors (cystosarcoma phyllodes)
• Resembles Giant fibroadenomas
• Rarely malignant
• Treat with wide local excision

23. BENIGN LESIONS OF THE BREAST
►Sclerosing adenosis
characterized by distorted breast lobules and usually
occurs in the context of multiple microcysts, but
occasionally presents as a palpable mass. Benign
calcifications are often associated with this disorder. can
be managed by observation as long as the imaging
features and pathologic findings are concordant.
• Lesions up to 1 cm in diameter are called radial scars,whereas larger
lesions are called complex sclerosing lesions.
• Radial scars originate at sites of terminal duct branching where the
characteristic histologic changes radiate from a central area of fibrosis.
All of the histologic features of a radial scar are seen in the larger
complex sclerosing lesions, but there is a greater disturbance of
structurewith papilloma formation, apocrine metaplasia, and
occasionally sclerosing adenosis. Distinguishing between a radial scar
and invasive breast carcinoma can be challenging based on core needle
biopsy sampling.
• Often the imaging features of a radial scar (which can be quite similar to
• an invasive cancer) will dictate the need for either a vacuum assisted
biopsy or surgical excision in order to exclude the possibility of cancer.

24. ►Epithelial and atypical hyperplasia
• Involves ducts or lobules
• If greater than moderate hyperplasia then indicates
higher risk of breast cancer
►Papilloma
• Polyps of epithelium-lined breast ducts
• Located under the areola in most cases
• When under the nipple and areolar complex it often
present with a bloody nipple discharge.
• Treatment is total excision through a circumareolar
incision.
• Need to rule out invasive papillary carcinoma.

25. BENIGN LESIONS OF
THE BREAST
►Mammary duct ectasia
• Generally found in older women.
• Dilatation of the subareolar ducts can occur.
• A palpable retroareolar mass, nipple discharge, or
retraction can be present.
• Rx involves excision of area.
►Fat necrosis
• Associated with trauma or radiation therapy to
breast.
• Can simulate cancer with mass or skin retraction.
• Bx is diagnostic and generally with lipid-laden
macrophages, scar tissue, and chronic
inflammatory cells.

26. ►Nipple discharge
•Pathologic nipple discharge is persistent and
spontaneous and is not associated with
nursing.
►Requires further evaluation
►Galactorrhea
• Bilateral, milky discharge occurs
• Obtain prolactin levels, if highly elevated, suspect
pituitary adenoma as one of causes.
►Bloody nipple discharge
• Most common cause is intraductal papilloma
• Cancer present 10% of time.
• Cytologic exam on discharge
• Mammogram to rule out associated mass
• If drainage from isolated duct, then it should be
excised.

27. BENIGN BREAST DISEASE
►Mastalgia
►Cyclical mastalgia and nodularity usually are associated
with premenstrual enlargement of the breast and are
regarded as normal.
►Cyclical pronounced mastalgia and severe painful
nodularity are viewed differently than are physiologic
discomfort and lumpiness. Painful nodularity that persists
for >1 week of the menstrual cycle is considered a disorder.
• Cyclic pain
►Correlates with menstrual cycle.
►Can attempt to treat with danazol or bromocriptine
• Non-cyclic pain
►Drugs can be effective
►NSAIDS may help
►Avoid caffeine and wear a supportive bra
• Cancer must be excluded through examination, mammogram, and
ultrasound if the pain is localized.

28. Involution. When the stroma involutestoo quickly, alveoli remain and
form microcysts, which are precursors of macrocysts. Themacrocysts
are common, often subclinical, and do not require specifictreatment.
Sclerosing adenosis is considered a disorder of both the proliferative
and the involutional phases of the breast cycle.
Duct ectasia (dilated ducts) and periductal mastitis are other important
components of the ANDI classification.
Periductal fibrosis is a sequela of periductal mastitis and may result in
nippleretraction.
About 60% of women ≥70 years of age exhibit some degree of epithelial
hyperplasia . Atypical proliferative diseases include ductal and lobular
hyperplasia, both of which display some features of carcinoma in situ.
Women with atypical ductal or lobular hyperplasiahave a fourfold
increase in breast cancer risk.

31. GYNECOMASTIA
• infantile
• Pubertal gynecomastia, 12-15 years, often unilateral,
►Occurs in 60-70% of pubertal boys.
• Senescent gynecomastia, Bilateral, 40% of aging men have
this to some degree.
►Grade 1: mild breast enlargement without skin
redundancy.
►Grade IIa: moderate breast enlargement without skin
redundancy.
► Grade IIb: moderate breast enlargement with skin
redundancy.
► Grade 3: marked breast enlargement with skin
redundancy and ptosis.
Rx: treat cause, follow up, liposuction, cosmotic surgery.

35. MALIGNANT DISEASES
OF THE BREAST
►A woman has a 1 in 8 chance of developing breast cancer
at some point in her life.
►Risk factors
• Increased age, family history, History of breast, ovary, or
endometrial cancer, >30 age at first pregnancy, high socioeconomic
status, nulliparity, early menarche, and late menopause
►Symptoms
• Lumps
► Presenting symptom in 85% of patients with carcinoma
• Pain
► Must completely evaluate to rule out carcinoma
• Metastatic disease
► Axillary nodes
► Distant organ symptoms, such as neurological
• Asymptomatic
► Why we advise yearly SBE and yearly mammogram after age 50

36. MALIGNANT DISEASES
OF THE BREAST
►Non-invasive breast cancers
• 10% of all types of breast cancer
• Good prognosis
• Ductal carcinoma in situ, lubular carcinoma in situ, and
paget’s disease
►Invasive breast cancers
• Favorable histologic types (85% 5-year survival rate)
►Tubular carcinoma (grade 1 intraductal), colloid or mucinous
carcinoma, and papillary carcinoma
• Less favorable types
►Medullary cancer, invasive lobular cancer, and invasive ductal
cancer
• Least favorable type
►Inflammatory breast cancer

37. DUCTAL CARCINOMA
IN SITU
►Seen as microcalcifications on mammogram
►Confined to ductal cells.
►No invasion of the underlying basement membrane.
►Chance of recurrence 25-50% in 5 years, of these 50%
will be invasive
►Tx
• Mastectomy an option if there is a substantial risk of
local/regional recurrence
• Wide local excision and radiation reduce local recurrence to 2%
• Wide excision alone suitable if <25mm, favorable histology, and
the margins are clear
• Node dissection not necessary (nodal disease < 1%)

38. LOBULAR CARCINOMA
IN SITU
►Not detectable on mammography
• Most commonly found incidentally
►Risk of invasive breast cancer in 20 years
is 15-20% bilaterally
►Tx
• Careful follow-up
• Bilateral masectomy may be considered if other
risk factors are present such as family history or
prior breast cancer, and also dependent on patient
preference.

39. PAGET’S DISEASE
►Uncommon
►Usually involves the nipple
►Histologically, vacuolated cells are seen in the
epidermis of the nipple and result in an
eczematous dermatitis of the nipple.
►It is generally associated with an underlying
intraductal or invasive carcinoma.
• Mammography should be performed
►About 30% of patients have axillary node
metastasis at diagnosis.
►Mastectomy is the standard of treatment
• 80% have a 10 year survival rate if there is no mass present
and no axillary nodes are involved.

40. INVASIVE BREAST
CANCERS
►Favorable histologic types (85% 5-year survival rate)
►Tubular carcinoma (grade 1 intraductal), colloid or mucinous
carcinoma, and papillary carcinoma
►Less favorable types
►Medullary , invasive lobular, and invasive ductal carcinoma
►Least favorabletype
►Inflammatory breast carcinoma
►Staging, prognosis, and treatment

41. FAVORABLE
HISTOLOGIC TYPES
►Tubular carcinoma
• 2% of all invasive breast cancers
• Generally diagnosed by mammography
• Distinctive under microscope
• Long-term survival aproaches 100%
►Mucinous (colloid) carcinoma
• 3% of all invasive breast cancers
• Generally confined to elderly population
• Bulky, mucinous tumor with characteristic microscopic features
• 5 and 10 year survival rates are 73 and 59 percent, respectively
►Papillary carcinoma
• <2% of all invasive breast cancers
• Generally presents in seventh decade, and is a slowly progressive
disease
• 5 and 10 year survival rates are 83 and 56 percent, respectively

42. LESS FAVORABLE
HISTOLOGIC TYPES
►Medullary carcinoma
• 4% of all invasive breast cancers
• Soft, hemorrhagic bulky presentation
• Diagnosed microscopically (lymphocytic infiltration)
• Metastases to axillary nodes in 44%
• 5 and 10 year survival rates are 63 and 50 percent respectively
►Invasive ductal carcinoma
• Most common and occurs in 78% of all invasive breast cancers.
• Metastases to axillary nodes in 60%
• 5 and 10 year survival rates are 54 and 38 percent respectively
►Invasive lobular carcinoma
• 9% of all invasive breast cancers
• Metastases to axillary nodes in 60%
• 5 and 10 year survival rates are 50 and 32 percent respectively
• Higher incidence of bilaterality

43. INFLAMMATORY
CARCINOMA
►1.5-3% of breast cancers
►Characteristic clinical features of erythema, peau
d’orange, and skin ridging with or without a
palpable mass.
►Commonly mistaken for cellulitis.
• Will generally fail antibiotics before being diagnosed
►Disease progresses rapidly, and more than 75%
of patients present with palpable axillary nodes.
►Distant metastatic disease also at much higher
frequency than the more common breast cancers.
►30% 5 year survival rate
►Requires chemotherapy treatment immediately

44. DIAGNOSIS
►Fine-needle aspiration
• Sensitivity is 80-98%, specificity 100%
• False negatives are 2-10%
►Core-needle biopsy
• More tissue, however still possibility of false
“negative” and could represent sampling error
►Incisional biopsy
• For large (>4 cm) lesions for whom pre-op
chemotherapy or radiation will be desirable.
►Excisional biopsy
• Removal of entire lesion and a margin of normal
breast parenchyma

45. STAGING AND PROGNOSIS
►Primary Tumor
• T1 = Tumor < 2 cm. in greatestdimension
• T2 = Tumor > 2 cm. but < 5 cm.
• T3 = Tumor > 5 cm. in greatestdimension
• T4 = Tumor of any size with direct extension to chest wall or skin
►Regional Lymph Nodes
• N0 = No palpable axillary nodes
• N1 = Metastases to movable axillary nodes
• N2 = Metastases to fixed, matted axillary nodes
►Distant Metastases
• M0 = No distant metastases
• M1 = Distant metastases including ipsilateral supraclavicular nodes
►Clinical Staging and prognosis
• Clinical Stage I T1 N0 M0 Stage Prognosis (5 year surv. Rate)
• Clinical Stage IIA T1 N1 M0 I 93%
• T2 N0 M0 II 72%
• Clinical Stage IIB T2 N1 M0 III 41%
• T3 N0 M0 IV 18%
• Clinical Stage IIIA T1 N2 M0
• T2 N2 M0
• T3 N1 M0
• T3 N2 M0
• Clinical Stage IIIB T4 any N M0
• Clinical Stage IV any T any N M1

46. PROGNOSTIC
FEATURES
►Tumor size important prognostic factor
►Poor prognostic features of tumor:
• Presence of edema or ulceration of skin, mass fixed to chest wall or skin,
satellite skin nodules, peau d’orange (dermal lymphatic invasion), skin
retraction and dimpling, and involvement of medial portion of inner lower
quadrant involved.
►Axillary node status:
• Best source of predicting survival or outcome
• N0 has 10 year survival rate of 60%
• N1 has 10 year survival rate of 50%
• N2 has 10 year survival rate of 20%
• If 10 or more nodes are diseased (N3) 10 yr surv. Rate is 14%
• Poor prognostic feature of nodes:
► Capsular invasion, extranodal spread,and edemaof arm
►Distant metastases is very poor prognostic indicator
►Postive estrogen and progesterone receptor indicates likely
response to hormonal treatment and is a positive prognostic
indicator

47. TREATMENT
►Modalities (palliative vs. curative)
• Surgery
►Local treatment
• Radiation
►Local treatment
• Chemotherapy and hormonal therapy
►Systemic treatment

48. SURGERY
• Breast conservation therapy
► Stage I, stage II, and sometime stageIII carcinomas
► Lumpectomy,axillary lymphadenectomy,and postoperative radiation therapy
► Contraindications: tumors > 5 cm , gross multifocaldisease,and diffuse
malignant microcalcifications
► Local recurrence more than mastectomyso follow up important
• Modified radical mastectomy (most common mastectomy procedure for
invasive breast cancer)
► Entire breast and axillary contents are removed
► Pectoralis muscles remains
• Halsted radical mastectomy
► Removes breast,axillary contents, and pectoralis major muscle
► Cosmeticallydeforming
► Only indicated when pectoralis muscle involved
• Simple mastectomy
► All breast tissue is removed,axillary contents not removed
► Treatment for non-invasive breastcancer

49. RADIATION
►Utilized for primaryand metastatic disease
►Useful in breast conservation therapy to reduce rate of
recurrence.
• Radiate entire breast

50. CHEMOTHERAPY
AND HORMONAL
THERAPY
►Chemotherapy
• Eradicates risk of occult distant disease in stage I and stage
II patients.
• All patients with axillary node involvement are candidates
along with patients with negative axillary node involvement
who are high risk by other prognostic indicators.
• Example treatment is 6 months of cyclophosphamide,
methotrexate or adriamycin, and flourouracil along with
paclitaxel.
►Improvement in disease free interval and overall survival
►Hormonal therapy
• Tamoxifen
►Generally taken for five years in patientss with estrogen
receptor positive tumors.
• As effective as chemotherapy in post-menopausal patients
with estrogen receptor positive tumors

51. THE MALE BREAST
►Male breast carcinoma
• 0.7% of all breast cancers
• <1% of male cancers
• Average age of diagnosis is 63.6 years old
• Painless unilateral mass that is usually subareolar with skin fixation, chest
wall fixation,, and ulceration.
• Mostly ductal carcinoma
• Males generally present at later stage than woman
► Overall survival worse in men, however when comparedstage for stage the
survival rates are similar.