Breast Diseases

Assistant Professor
Dr. Hiwa Omer Ahmed
Why Evaluate Breast Masses?
„ Breast cancer
most common malignancy in women
lifetime risk = 1:8
2/3 of cases arise post-menopause, but
15% occur before the age of 40
Screening earlier detection BUT has
not changed mortality rate significantly

„ HRT rather than OCPs)

Risk Factors
Age
Family History – ž 2-8x depending on type
and timing of cancer.
Atypical Hyperplasia (3-6x)
Prior contralateral breast cancer
High SES
Western hemisphere extraction
Nulliparous (2-3x)
Early menarche/late menopause
Estrogen (associated with
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„ Radiation – known breast carcinogen;

exposures during childhood particularly
important

„ The role of endogenous hormones

Seroepidemiologic studies:
high vs. low risk women,
cases vs. controls
Hormones affect breast cell proliferation,
differentiation and growth
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„ Age at menopause – earlier is better

„ Postmenopausal obesity – risk

increases with increasing obesity/weight
gain during adulthood
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„ Race and age – variation in incidence

„ Age at menarche – for every year
menarche is delayed risk decreases about 5-
6% (effect observed primarily among
younger women)
„ Age at full-term delivery – nulliparous
women and women with late age at first full-
term pregnancy have highest risk (effect
observed most clearly among older women)
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„ More on reproduction – longer duration

of breast feeding lowers risk – > 16
months: 30% risk reduction ; induced
abortions do not increase risk

„ Alcohol – average intake of one alcoholic

drink/day increases breast cancer risk
11%
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„ The role of exogenous hormones

5 years of estrogen replacement therapy increases
breast cancer risk about 6%,

5 years of combined therapy associated with 24%

increase in risk
(WHI confirmed latter finding in a clinical trial)

Oral contraceptives, as currently formulated, do not

increase risk (potential to proliferate existing tumor
or bring women into health care system for
diagnosis)
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„ Pregnancy permanently lowers circulating estradiol
and prolactin levels
… Bernstein et al. JNCI 1985; 74:741-745.
… Bernstein et al. JNCI 1986; 76:1035-1039.

„ Asian women have a low risk estrogen profile

relative to Caucasian women
… Bernstein et al. Cancer Cause Control 1990; 1:51-58.
… Shimizu et al. Br J Cancer 1990; 62:451-454.

„ Cases have higher estrogen levels (as well as levels

of related hormones) than controls
… Bernstein et al. Br J Cancer 1990; 61:298-302.
… Bernstein et al. Cancer Cause Control 1990; 1:51-58.
Survival Rate
Differential Diagnoses of Breast
Mass
„ Benign Disease
• Fibrocystic Disease
• Fibroadenoma
• Cyst
• Cellulitis/Mastitis
• Cystosarcoma Phyllodes
• Fat Necrosis
• Chronic Subareolar Abscess
• Mondor’s Disease
• Mammary Duct Ectasia
• Sclerosing Adenosis/Papillomatosis/Stromal Fibrosis
Benign Dz with Increased Risk of
BrCA
„ Epithelial Hyperplasia – ducts or lobules. Ï 1.5-3x.
„ Atypical Hyperplasia – Ï 3-6x
„ Cyst with Bloody Contents
Aspiration of Cyst:

„ Nipple Discharge
– persistent, spontaneous. Not associated c
breastfeeding.
„ Localized Mastalgia
Non-invasive Malignant DDx
„ DCIS – a premalignant, non-invasive carcinoma
„ LCIS – a marker of malignancy (usually DCIS) in either or both
breasts

„ Paget’s Disease
Invasive Malignant DDx
„ Favorable (85% 5 yr survival)
• Tubular cancer (grade 1 intraductal)
• Colloid/mucinous Cancer
• Papillary Cancer
„ Less Favorable
• Medullary Cancer
• Invasive Lobular Cancer
• Invasive Ductal Cancer
„ Least Favorable (30% 5 yr survival)
• Inflammatory Breast Cancer
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400 20

Progesterone (ng/ml)
Day 14 - ovulation
Estradiol (pg/ml)

300 Ovulation 15

200 10

100 5

0 0
1 3 5 7 9 11 13 15 17 19 21 23 25 27
Day of cycle
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Hunter-
Factor gatherers Americans
Age at menarche 16.1 12.5
Age at first birth 19.5 24.0
Menarche to first birth (yrs) 3.4 11.5
Yrs of lactation per birth 2.9 0.25
Completed family size 5.9 1.8
Age at menopause 47 50.5
Total number of
ovulations 160 450

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Male 1%
Treatment of Breast Cancer
„ Non-surgical
• Local Radiation
– Similar to mastectomy in overall survival.
• Systemic Chemotherapy
– Eradicates occult metastasis in Stages I/II.
• Neoadjuvant Therapy
– Chemo before surgery for debulking of tumor.
• Hormonal Therapy
– Anti-estrogen (tamoxifen)
Treatment of Breast Cancer
„ Surgical
• Breast Conservation
• Lumpectomy
• Axillary Lymphadenectomy
• Sentinel Node Biopsy
• Post-Op Radiation
• Modified Radical Mastectomy (Patey’s)
• Halsted Radical Mastectomy
• Simple Mastectomy
„ Haagensen Criteria of Inoperability:
• Extensive edema of breast; Satellite nodules of CA;
Inflammatory CA; Parasternal node tumor; Supraclavicular
mets; Edema of Arm; Distant Mets
Surgical Treatments

Lumpectomy

Radical Mastectomy Simple Mastectomy

Silicon prosthesis after mastectomy
Augmentation Mammoplasty
COMBINED CHEMOTHERAPY
Hormonal
therapy
Side effects of Radiotherapy
Internal radiation
Staging of Breast Cancer
TNM:
5-yr Survival
N0 60%
N1 50%
N2 20%
N3 14%

Staging: 5-year Survival

0 Tis
I T1N0M0 93%
IIa/b T1N1, T2N0/T2N1, T3N0 72%
IIIa/b T1/2N2, T3N1/2 | T4 Any N 41%
IV Any T Any N M1 10%