Breast

Breast

ANATOMY

Breast profile: A ducts B lobules C dilated section of duct to hold milk D nipple E fat F pectoralis major muscle G chest wall/rib cage Enlargement: A normal duct cells B basement membrane C lumen (center of duct)

TRIPLE ASSESSMENT

For breast lump

1.  History and Physical Exam

Inspection: lump, asymmetry, skin tethering, dimpling, colour change while pt

• sitting, pressing hands on hip
• lifting arms in the air
• pressing hands on top of head

Palpation

• elevate arm on the side to be examined
• Use flat of right hand to palpate all 4 breast quadrants
• Palpate central part and axillary tail
• If Hx of discharge, press areola in diff area to identify the responsible duct.
• Palpate left/right axillary node with right/left hand by supporting the pt’s arm.

2.  Radiological Assessment

Ultrasound

Mammography

usually for women <35yo not routinely indicated for Diffuse mastalgia Breast heaviness Non-bloody discharge Screening Diffuse lumpiness Longstanding nipple retraction

usually for women >35 yo Indications for Mammography without any clinical symptoms. Previous hx of breast cancer Previous hx of benign surgery with atypia (ADH/ALH) or Phylloides. Fam hx of BC  2 views: mediolateraloblique(MLO) & cranial-caudal (CC) Standard or digital Look for asymmetric density speculation –starburst picture microcalcification Others: skin tethering/thickening, distorted shape, mass lesion

3.  Pathological Assessment

	Fine Needle aspiration	Core Biopsy
Picture
When to use	One stop clinic Fast result required to confirm dx benign disease particularly	One stop clinic Definitive disease required
Advantages	Outpatient procedure Quick to perform No special equipment Quick result	Outpatient procedure Quick to perform Easy to interpret
Disadvantages	Skill in talking, fixing, reading Cannot say if invasive or not ?Too quick	Bruising At least 24h to process If inconclusive, use open biopsy

May use: wire guided biopsy

Multi-Disciplinary Meeting

Discuss results, plan; Surgeon, pathologist, radiologist, oncologist, breast care nurse

Work Up

All invasive cancers regardless of size require staging abdo USS, bone scan, and tumour markers (CEA, CA 15.3) and CXR.

Scoring System

S=Physical Exam, R=Radiolgy, C=FNA Cytology, B=Core Biopsy score

S1/R1/C1/B1 :Inadequate sample (FNA or Bx) or Normal

S2/R2/C2/B2 :Benign abnormality ie fibroadenoma

S3/R3/C3/B3 :Indeterminate abnormality – atypical cells probably benign

S4/R4/C4/B4 :Suspicious for malignancy

S5/R5/C5/B5 :Malignant

Any score of 3 requires investigation by the next modality.

Screening

• National Screening Programme
• 2 dimensional mammography read by two radiologists at 2 yearly intervals in women aged 50-64
• 4 centres and 12 mobiles

Management

Surgery

	Breast Conservation Surgery (BCS)	Mastectomy
Procedure	BCS + radiotherapy	Mastectomy + axillary node sampling + breast construction
Type	Wide local excision: remove tumour & 2-3cm margin	Modified radical mastectomy (Patey): removal of breast, pec minor and axillary structures
	Lumpectomy: remove tumour & 1cm margin	Radical mastectomy(Halsted): remove breast, pec major+minor + axillary+ internal mammary nodes
	Quadrantectomy: remove a quadrant	Simple mastectomy: breast only, need radiotherapy post-op
Selection criteria	Single lesion clinically/radio tumour < 3cm No extensive in situ Tumours >2cm from nipple Low grade lesion 6.  No extensive nodes	Nipple involvement Large tumour/Small breast – no cosmetic involvement Diffuse/multifocal disease. CI to radiation Connective Tissue diseases such as Scleroderma make patient especially sensitive to radiotherapy side-effects Patient preference Previous BCS
Adv/disad	Good cosmetic, but recurrence 8% 5y Risk factor for recurrence: +margin No radiotherapy given Young age High grade tumour LVI Tumour necrosis >4 LNs involved	Poor cosmetic, low recurrence

Pre-op

1. All patients get TED stockings. Only exception is patient with PVD.

2. Patients admitted on night before theatre should be prescribed Enoxaparin 20mg once daily sc. Given 10pm night before theatre. Continue post-op.

3. Doctor admitting patient marks side of operation.

4. Doctor admitting patient checks all pre-op investigation in order – if any abnormality on bloods, CXR, ECG the appropriate team member informed.

5. Valid group and hold for mastectomy or WLE +/- axillary procedure.

Valid group and crossmatch (2units) for mastectomy and reconstruction.

6. All patients > 45 years need pre-op ECG. All patients > 65 years need pre-op CXR.

7. Anti-coagulants:  patients can undergo procedures whilst on aspirin;  patients on warfarin/plavix should have them stopped 10 days before their operation  and substituted with appropriate anti-coagulation.

Post-op

1. Day 1 post-op repeat FBC.

2.  If mastectomy +/- axillary procedure or mastectomy +/- reconstruction -> oral iron 3 week post-op.

3.  Blood transfusion if post-op Hb < 8g/dl. If adjuvant chemotherapy transfusion given if Hb < 9g/dl.

4.  All patients get intra-op IV abx prophylaxis – continue 48 hours post-op.

Augmentin is abx of choice (Levofloxacin if allergy).

5.  Drains

• A = Axillary Drain
• B = Anterior Breast Drain
• C = Posterior Drain (ie lat dorsi reconstruction)
• Drain removed when draining < 50 ml; or > 2 days for breast drain (B); or > 1 week for axillary drain (A).
• Drains on continuous suction.
• Drains emptied once/24h & amt recorded in Fluid Balance Sheet.

6.  Pressure Dressings

• Left in place for 24 hours post-op
• Remove > 24h & replace with regular dressings.

7.  Post-op arm physiotherapy for major breast/axillary procedure

8.  Mastectomy – three days in Hospital, WLE & Sentinel node bx – op Monday, sent home Tuesday.

9.  Mastectomy has 2 wounds

• Axillary clearance via peri-areolar incision
• Flap for reconstruction.

10.  Ecchymosis is common after mastectomy.

Axillary Surgery: may be done during mastectomy

Type	Sentinel node biopsy	Axillary Clearance
Reason	To biopsy for staging	Therapeutic
Procedure	Lymphoscintigraphy Radioactive substance injected 3h pre-op Localized to sentinel node by Geiger Counter Blue Dye – to identify sentinel lymph node (the 1st axillary node to receive lymphatic drainage from the tumour. Injected 5 min pre-op: ‘Patent Blue’ dye travels via lymphatics Technetium 99 – takes about an hour to migrate to node	Level of nodes related to pec minor: 1(lateral), 2(deep), 3(medial) Usually all 3 levels taken Lvl 1 clearance alone misses skip lesion in 3% If lvl 1 involved, 41% chance of level 2/3 involved
Complications	Patent blue dye can cause tattooing of the skin; urine changes colour; face gets a washed out cyanotic look & scares relatives; Intra-operative allergic reactions are caused mostly by muscle relaxants (70%), latex (10%) and antibiotics with a mortality rate of 3.5–4.7%.	Bleeding/hematoma Wound infection Seroma nerve damage Long thoracic nerve of bell- SA(winging), Thoracodorsal (Lat. Dorsi), Intercostobrachial (upper inner arm sensation) Lymphoedenoma: exercise, pressure support garment Reduced UL mobility

Reconstruction – fill in gap with Lat Dorsi/ TRAM – implant

Mastopexy – bring together remainder of breast tissue.

Deep inferior epigastric flap – no muscle – anastomosis of blood vessels.

TNM  Staging

T0 : No evidence of primary tumour Tis : Carcinoma in situ (DCIS, LCIS, Paget’s disease of the nipple with no mass) T1 : Tumor <2cm T2 : Tumor 2-5cm T3 : Tumor >5cm T4 : Attach to overlying skin/muscle

N0 : no axillary nodal involvement N1 : Mobile ipsilateral axillary nodes (<3) N2 : >3 axillary nodes or fixed ipsilateral axillary nodes N3 : ipsilateral internal mammary/supraclavicular node

M0 : No metastases M1 : distant mets

Nottingham Prognostic Index

Tumour size in cm

Node status: 1 if no nodes, 2 if 1-3 nodes, 3 if >4 nodes

Grade

NPI= (0.2 x size) + node status + grade

Results

• <3.4 : need for chemo is doubtful
• 3.4-5.4: may benefit
• >5.4 : chemo needed

Radiotherapy

To ↓ local recurrence in post-mastectomy/ WLE, to axilla if node+ve

Radiotherapy after mastectomy if: T4 tumour, 4 LN+, >4cm

S/E: erythematous rash, shoulder fibrosis, pneumonitis, pericarditis, rib fracture, lymphoedema, angiosarcoma

Chemotherapy

Improve survival rate esp if young and node+ve

No survival benefit of neoadjuvant over adjuvant chemotherapy but may make surgery possible ie in inflammatory BC.

Chemo Regimes

• CMF: Cyclophosphamide MTX 5-FU
• FEC : 5-FU Epirubicin Cyclophosphamide

S/E: hair loss, fatigue, nausea, vomitting

Hormonal Therapy

1.  Tamoxifen(SERM)-  oestrogen receptor agonist

• ↓risk of recurrence & decreases risk for contralateral breast cancer
• for pre-menopause and ER+ve
• SE : vaginal dryness, hot flushes, thrombosis, endometrial cancer.

2.  Anastrazole – aromatase inhibitor

• for post-menopause with ER+ve cancer, advanced cancer in postmenopausal
• small benefit in disease free survival 4% over Tamoxifen but no difference in overall survival
• SE: osteoporosis, no endometrial SE. Joint stiffness and arthralgia in 30%+.
• Use GnRH analogues or oophorectomy to suppress ovaries – Goseralin/Leuprolide. Not superior to tamoxifen in most cases. Consider for very young patients.

HRT x 10 years RR=1.2 (ie +20%) for BC.

However, if used in premature menopause no extra risk.

Biological Therapy

Herceptin- monoclonal Ab that acts on HER2/neu receptor

• Use for advanced HER2+ve tumour (> aggressive) or metastatic cancer
• Duration 1 year, either weekly or q 3/52
• S/E: cardiac dysfunction, SOB, effusion

BREAST CANCER

Presentation

1. breast lump

-Benign: firm, rubbery, painful, regular margin, mobile

-Malignant: hard, painless (90%), irregular margin, fixed

2. changes in breast size
3. skin dimpling
4. nipple inversion
5. nipple discharge

-Benign: bilateral, spontaneous/induced, multiple duct orifices, thick green yellow

-Malignant: unilateral, spontaneous, one duct orifice, bloody, serosanguinous, serous

6. In inflammatory breast cancer: pain, swelling, warmth, peau d’orange
7. axilla – palpable nodes? Mobile/fixed?

Risk Factors

1.   Sex- female(99%)

2.   Age (>30)

3.   Genetics

• gene mutation: ATM, CHEK2, P53, tumour suppressor, Li Fraumeni Syndrome
• 5-10% are hereditary
• BRCA 1 & 2 : 85% lifetime risk, 50% by age 50, found in Ashkenazi Jews (20%) : use MRI to assess

4.   Family history

• 1/12 : is normal risk
• 1/10 :grandmother or aunt > 60
• 1/8 :sister or mum > 60
• 1/4  :sister or mum < 40; or Two 1st/2nd degree < 60 or Three 1st/2nd relatives any age             

5.   Past Breast Ca history

6.   Uninterrupted oestrogen exposure nulliparity

7.   1st pregnancy >30yo

8.   early mernache, late menopause

9.  Not breast feeding

10.  HRT, OCP

11.  Previous breast biopsies showing non-malignant abnormalities

• Non-proliferative (cyst, fibrosis, benign phylloides, papilloma)  – very little risk
• Proliferative(sclerosing adenosis, radial scar) – moderate risk
• Proliferative with atypia(atypical ductal/lobular hyperplasia) – higher risk

12   Race- greater in caucassion

Ddx for breast lump

• Carcinoma
• Fibroadenoma
• Cyst
• Fibroadenosis
• rare: periductal mastitis, fat necrosis, galactocoele, abscess, lipoma, sebaceous cyst

Histology

Ductal

• Invasive ductal carcinoma (85%), DCIS, scirrhous, tubular, medullary, mucinous, papillary, inflammatory, comedo

Lobular

• LCIS, invasive lobular

Nipple

• Pagets- epidermal infiltration by neoplastic cells from an underlying ductal carcinoma by spreading along the mammary duct.
• Pagets with invasive ductal

Undifferentiate

Rare : cytosarcoma phylloides, lymphmoma

DCIS

• confined within epithelium
• basement membrane intact
• arises from lactiferous ducts
• more localized than LCIS, lump
• Types; comedo, non comedo

DCIS	comedo	non-comedo
nuclear grade	high	Low
differentiation	poor	high
ER	-ve	+ve
HER2	+ve	-ve
local recurrence	high	low
Prognosis	poor	good

• invasive ductal Ca develops in 50% in 10 yrs, usually in same area, thus true pre-cancerous process
• Treatment
  • Surgery: <0.5cm- WLE, 0.5-1.9cm – WLE & RTx, >2cm – simple mastectomy
  • Indication for mastectomy: comedo necrosis, diffuse, bloody discharge, +ve margins, Pagets disease
  • Radiotherapy
  • Axillary sampling in high Grade DCIS+ve node in 1%

LCIS

• From terminal duct lobular apparatus
• Diffuse distributiln
• No mass usually
• High incidence of synchronicity in bilateral/contralateral breast
• 10% with LCIS develop Ca- mainly ductal, either breast
• No Tx- close follow-up

Breast Phatology

Pathology	Presentation	Management
Cyst	distended, ovulated lobules, Women 40-55yo (perimenopausal), Usually fluctuant, can be painful, Well defined and smooth, can be multipled	freehand/US-guided aspiration
Fibroadenoma	benign tumours developing from a single breast lobule, Hormonally dependent – involute after menopause and ↑size with, menstruation, Women 15-25yo , Well defined, regular, smooth, can be multiple	biopsy
fibroadenosis	lump(s), painful & tender premenstrually	Gomolenic acid(GLA), danazol, bromocryptine
Duct papilloma	spontaneous blood-stained or clear watery nipple discharge, a retroareolar mass may be palpable	microrochectomy
Traumatic fat necrosis	hard irregular lump + skin dimpling	core biopsy
Breast infection	diffuse cellulitis or abscess	flucloxacilin, benzopenicilin
Duct ectasia	spontaneous multiple duct discharges (creamish to blue-green), nipple retraction, mass	Ab, subareolar excision

Men with gynaecomastia

• Physiological – reassure – advise them to lose some weight
• Too much hash or steroids for bodybuilding
• Drugs – antiandrogens for Prostate
• Do LFT and TFT
• beta-hCG and alpha-FP for testicular cancers
• BRCA2
• bx esp if unilateral
• surgical options: subcutaneous mastectomy leaves fat pad behind; or liposuction.
• Gynaecomastia is NOT a risk factor for breast cancer