Disordered of the breast

Abdelkarim Barqawi

Breast Anatomy
Four quadrants
Parenchyma
Alveoli
Lobules
Three tissue types

Lobes

Glandular epithelium
Fibrous stroma and supporting structures
Fat

Cooper ligaments
Fibrous continuations of the superficial fascia, which span the
parenchyma of the breast to the deep fascial layers

Breast Anatomy
Vasculature
Arterial supply
Internal mammary artery(60%)
Lateral thoracic artery(30%)

Venous return
Intercostals
Axillary vein(primary)
Internal mammary vein

Lymphatics

Breast Anatomy
Lymphatics
Axillary chain (85 % of drainage)
Level 1 lateral to pectoralis minor muscle
Level 2 along and under pectoralis minor
Level 3 - medial to pectoralis minor

Rotters nodes
Between pectorial minor and major
muscles

Internal mammary (15% of drainage)

Parasternal
medial

Breast Anatomy
Nerves

Long thoracic nerve

Thoracodorsal nerve
Medial pectoral nerve
Lateral pectoral nerve

Structure

Diagnostic Work Up

Ultrasound

Mammography

MRI

FNA vs. Core Biopsy

Incisional biopsy

Excisional biopsy

Cyst aspiration

BI-RADS Classification
BI-RADS Classification features
0 - Need additional imaging
1 - Negative routine in 1 yr
2 - Benign finding routine in 1 yr
3 - Probably benign, 6mo follow-up
4 - Suspicious abnormality, biopsy recommended
5 - Highly suggestive of malignancy; appropriate action
should be taken

Benign Breast Disease

Infectious and inflammatory

Benign lesions
Nipple Discharge
Mastalgia

Nipple discharge
Clear, serous:
physiological in a parous woman
Associated with a duct papilloma
Mammary dysplasia.

Blood-stained :
Duct ectasia,
Duct papilloma or carcinoma.
A duct papilloma is usually single and situated in one
of the larger lactiferous ducts.

Black or green: usually the result of duct ectasia.

Nipple discharge
Associated mass should be excluded
clinically or by US
Bloody discharge from a single duct 
should be excised
Galactorrhea: Obtain prolactin levels
Reassurance if multiduct green or black
discharge

Congenital abnormalities
A m azia
Polym azia
M astitis of infants

In boys and girls

Started in the 2nd 3rd day and lasted to 3 WKs
Associated with milk discharge
Stimulated by prolactine & drop of maternal
estrogene

Diffuse hypertrophy

Infectious and Inflammatory

Breast Disease

Mastitis & Abscess

Cellulitis, mastitis
Usually associated with lactation
The intermediary is the infant
Treatment:
Breast rest for 24 hours
10-14 day course antibiotics to cover Staphylococcus aurius
Breast evacuation & worm compressors

Abscess
If treatment of mastitis failed after 48 hours abscess should be
suspected
Fluctuation is a late sign
Diagnosis can be confirmed by US
Treatment is multiple aspiration and antibiotics OR surgical drainage

Chronic subareolar abscess

Occurs at base of lactiferous duct,
Squamous metaplasia of duct may occur.
Sinus tract to areola develops
Treatment requires complete excision of sinus tract
Recurrence is common

Mondors disease
Phlebitis of the thoracoepigastric vein
Palpable, visible, tender cord along upper quadrants
Ultrasound may be helpful in confirming this diagnosis.
Treatment self-limited, can use anti-inflammatories if necessary

Duct ectasia
Pathogenesis:
Lactiferous duct dilatation  stagnation of secretion
 irritation & periductal mastitis  fibrosis &
nipple retraction
Periductal mastitis by anaerobes  fibrosis 
retraction
Strong relation with smoking suggest underlying
arteriopathy

Duct ectasia
Presentation:
Retroaureolar mass
Nipple discharge of any colour
Nipple retraction

Treatment:
Malignancy should be excluded if mass present
Antibiotics
Surgery is the definitive therapy

Fat necrosis
Uncommon lesion; may be a history of trauma,

prior surgical intervention or adiation therapy

Characterized by a central focus of necrotic fat
cells with lipid-laden macrophages and
neutrophils
Major clinical significance is its possible
confusion with carcinoma (e.g. fibrosis 
clinically palpable mass / Ca2+ seen on
mammography)

Aberrations of Normal
Development and Involution
Benign breast disorders and diseases are
related to the normal processes of
reproductive life and to involution
There is a spectrum of breast conditions that
ranges from normal to disorder to disease.

ANDI classification

Pathology
Consest of four features:
Cyst formation
Fibrosis
Hyperplasia
papillomatosis

Clinical features
The symptoms are many but often include
lumpiness and mastalgia
Lump is commonly fibroadenoma or cyst
Lumpiness could be bilateral commonly in the
upper outer quadrant with cyclic increase the
nodularity & tenderness
Noncyclic breast pain is common in premenoposal
women, refaired pain should be excluded

Treatment of lumpy breast

If malignancy can be excluded clinically
and supported by mammography or US 
reassurance
If malignancy cant be excluded  tissue
biopsy and histopathology

Treatment of noncyclic mastalgia

Exclude cancer
Reassure
Adequate support
Exclude caffeine
Consider medication
Evening primrose oil (GLA)
Danazol, 100 mg t.d.s.
Tamoxifen

Breast cyst

Common in the last reproductive decade

Usually multiple
Dx by US & mamography
Treatment :
If no residual mass & not bloody  no further
management
If residual mass core or excisional biopsy
If bloody send for cytology
If recur more than 2 times  excisional Bx

Fibroadenoma

Simple: Second most common benign breast lesion
 Benign solid tumors containing glandular as well as fibrous tissue .
Usually present as well defined, mobile mass
 Commonly found in women between the ages of 15 and 25 years
 Cause is unknown, thought to be due to hormonal influence
 May increase in size during pregnancy or with estrogen therapy
 Excision is not required if no suspicious of malignancy

Giant: Fibroadenomas over 5 cm in size

 Excision is recommended

Phyllodes tumors

Women above 40 year old

Usually mobile
Small tumors resembling fibroadenoma
Can cause skin ulceration
Rarely malignant
Treat with wide local excision for benign tumors and
mstectomy for malignant

RELATIVE RISK FOR

INVASIVE BREAST CANCER
FOR BENIGN BREAST
LESIONS

RISK FOR INVASIVE BREAST

CANCER

No Increased R isk (NIR )

 Mastitis
 Fat necrosis
 Mammary duct ectasia
 Non-proliferative

(fibrocystic) disease
 Fibroadenoma (simple)

RISK FOR INVASIVE BREAST

CANCER


Slightly R isk (SIR )

= R isk 1.5-2 T im es

 Moderate/florid hyperplasia
 Sclerosing adenosis
 Fibroadenoma (complex)
 Duct papilloma

RISK FOR INVASIVE BREAST

CANCER


M oderately R isk (M IR )
= R isk 4-5 T im es

Atypical ductal hyperplasia

 Atypical lobular hyperplasia


Breast cancer

Breast Cancer Facts

2nd leading cause of death

2nd most common cancer

Incidence increases with

age


All women are at risk

Breast Cancer in USA

One out of eight American
women will be diagnosed
with breast cancer

Breast Cancer Risk Factors

that cannot be changed
Age
Family/Personal
History

GENDER - All
women are
at risk

Race
Radiation
Treatment with
Diethylstilbestrol

Reproductive
History

Menstrual
History
Genetic
Factors

Breast Cancer Risk Factors

that can be controlled

Obesity
All
women are
at risk

Exercise
Breastfeeding
Alcohol

Hormone
Replacement
Therapy

Not having
children

Birth Control
Pills

Fam ily History

 Approx 10% of breast cancer is due to

inherited genetic predisposition

 A woman whose mother or sister has

had breast cancer is at relative risk 2

to 3 times compared to other women

Fam ily History

 At least two genes that predispose to

breast cancer have been identified

BR CA 1 and BR CA 2
 Mutations in these tumour-suppressor

genes also predispose affected women

to ovarian cancer

ETIOLOGY

T he etiology of breast cancer in m ost

wom en is unk nown

M ost lik ely due to a com bination of

risk factors i.e. genetic, horm onal and
environm ental factors

HISTOLOGIC
CLASSIFICATION

Breast Cancer

Ductal

Lobular

(85%)


(15%)


DCIS

IDC

LCIS

ILC

Ductal Carcinoma In-situ

increased incidence with increased use

of mammographic screening and

early cancer detection
50% screen-detected cancers
Can also produce palpable mass

Ductal Carcinoma In-situ

Characterized by proliferating malignant

cells within ducts that do not breach the

basement membrane
Different patterns:
com edo (central necrosis);
cribiform (cells arranged around punched-out
spaces);

papillary and solid (cells fill spaces)

Ductal Carcinoma In-situ

Different grades i.e. low, intermediate and

high gradecomedo DCIS is classically high
grade

Often m ultifocalmalignant population can

spread widely through the duct system

Ductal Carcinoma In-situ

Women with DCIS are at risk of:
Recurrent DCIS following Rx
Invasive cancer (rel. risk 8 to 10 times)

especially in the same breast

Lobular Carcinoma In-situ

Relatively uncommon lesion

Malignant proliferation of small, uniform

epithelial cells within the lobules

Also at marked increased relative risk for

invasive cancer (8 to 10 times) in either
breast

Invasive Ductal Carcinoma

Commonest form of breast cancer

especially in poorer populations

Increasing incidence of screendetected

cancer in developed countries (usually

smaller; much better prognosis)

Invasive Ductal Carcinoma

 Clinical presentation:
Hard, irregular palpable lump

Peau dorange (lymphatic obstruction +

thickening/dimpling of the skin)

Pagets disease of the nipple

(ulceration/inflammation due to intraductal
spread to the nipple)

Invasive Ductal Carcinoma

Clinical presentation:
Tethering of the skin
Retraction of the nipple
Axillary mass (spread to regional

lymph nodes)
Distant mets (liver, lung, bone)

Invasive Ductal Carcinoma

Different histologic types exist
The most common is scirrhous carcinom a (IDC of no

special type)
This type is characterized grossly by an irregular,

hard mass
Histology shows infiltrating clusters of malignant

cells in a dense, fibrous stroma

Invasive Ductal Carcinoma

 Special histologic types of IDC:

M edullary carcinom a = circumscribed

tumour; sheets of malignant cells in dense
lymphoid stroma

T ubular carcinom a = infiltrating

tubular structures on histology

Invasive Ductal Carcinoma

 Special histologic types of IDC:

M ucinous/colloid carcinom a = malignant

cells in pools of mucin

Papillary carcinom a = papillary formations

like papilloma + invasion

Invasive Lobular Carcinoma

Much less common than IDC

Can present with similar features

More likely to be bilateral and/or

m ulticentric (multiple lesions within the

same breast)

Invasive Lobular Carcinoma

 Classic histology = small, uniform cells

arranged as:
 Strands/columns within a fibrous stroma
(Indian-file)
 Around uninvolved ducts ( bulls-eye
pattern)
 Metastasize more frequently to CSF, serosal

surfaces and pelvic organs

PROGNOSIS
 Stage
Staging systems inc.TNM and the Manchester

classification

T um or size and axillary node status are important

parameters

10-year survival rate for lymph node neg. disease is

80% vs 35% for tumors with positive nodes

PROGNOSIS
 T um or Grade
Different grading systems exist
tumour grade = worse prognosis

 Histologic Subtypes

PROGNOSIS
 Horm one R eceptors
Estrogen receptors
Progesterone receptors

 M olecular M ark ers

Inc. c-erb-B2, c-myc and p53

Treatment
Curative VS palliative
Surgery:
Breast conservation therapy
Modified radical mastectomy
Simple mastectomy

Chemotherapy
Radiation therapy
Hormonal therapy

The Male Breast

Gynecomastia
Prepubertal gynecomastia
Rare, adrenal carcinoma and testicular tumor can
cause this.
Pubertal gynecomastia
Occurs in 60-70% of pubertal boys.
Senescent gynecomastia
40% of aging men have this to some degree.
Drugs, such as steroids, digitalis, hormones,
spironolactone, and antidepressants can cause this.

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
compared stage for stage the survival rates are
similar.

Dr.ALBARQAWI

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