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BREA MAS ST S
JI PABLO, JASPER VAL IAN M. DFM
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Anatomic Consideration

Modified sweat gland Contain 15-20 lobules in each gland Coopers ligament provide structural support Boundaries: 1. Base: 2nd - 6th or 7th rib 2. Lateral: mid-axillary line 3. Medial: Lateral border of sternum 4. Tail of Spence axilla Divided in 4 quadrants

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Anatomic Consideration

Blood Supply

Perforating branches

Lymphatic Drainage

Axillary

Level I lateral to pectoralis minor Level II posterior to pectoralis minor Level III Medial to pectoralis minor
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Internal Mammary Rotters Node interpectoral

Anatomic Consideration

Associated Nerves 1. Intercostobrachial upper medial arm 2. Long Thoracic 1. Innervates serratus anterior muscle 2. Injury produces winging of scapula 3. Thoracodorsal
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Physiologic Consideration

Breast development 1. Estrogen ductal development, fat deposition 2. Progesterone lobular-alveolar development 3. Prolactin milk production 4. Oxytocin milk letdown Menopause . Involution of breast tissue . Atrophy of lobules . Loss of stroma 66

Clinical Consideration

History 1. Age 2. Mass 3. Nipple discharge 1. Bloody 2. Milky 3. Serous 4. Yellow 5. Purulent 4. Breast pain
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Clinical Consideration

History 5. Gynecologic history 6. Past medical history 7. Family history of breast disease 8. Constitutional signs and symptoms

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Clinical Consideration

Physical Examination 1. Inspection 2. Palpation 3. Self Breast Examination

Done on 5th day after completion of menstruation


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Clinical Consideration

Imaging Studies 1. Ultrasonography 2. Mammography

Indication 1. Screening 2. Metastatic adenocarcinoma without known primary 3. Nipple discharge without palpable

mass

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Clinical Consideration

Biopsy - diagnostic confirmation 1. Needle Aspiration 1. Fine needle 2. Core needle 2. Incisional 3. Excisional

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Diseases of the Breast



1. 2.

Congenital Inflammatory Neoplastic


Benign Malignant

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Congenital Lesions

Number of the Breast


1. 2.

Polymastia Amastia

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Congenital Lesions

Number of Nipples
1. 2.

Polythelia Athelia

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Inflammatory Lesions
1.

Mastitis

Cellulitis of breast tissue Lactating women common Staphylococcus and Streptococcus most common etiologic orgainisms Symptoms

Breast enlargement on one side only Breast lump

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Inflammatory Lesions
2.

Breast Abscess
Development of purulent material Staphylococcus most common offending organism Symptoms

Breast engorgement (swelling) Breast pain Itching Nipple discharge Nipple tenderness

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Inflammatory Lesions
3.

Mondors Disease

Thrombophlebitis superficial thoracoepigastric vein Related to trauma Acute pain superolateral breast or axilla Palpable cord-like lesion diagnostic Treatment:

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Inflammatory Lesions
4.

Plasma Cell Mastitis

Mammary duct ectasia Subacute inflammation of ductal system Occurs at or after menopause Manifestation:

Hard, diffuse, illdefined breast mass

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The vast majority of the lesions that occur in the breast are benign. Much concern is given to malignant lesions of the breast because breast cancer is the most common malignancy in women in Western countries; however, benign lesions of the breast are far more frequent than 1919

benign breast diseases encompasses a heterogeneous group of lesions that may present a wide range of symptoms or may be detected as incidental microscopic findings Incidence begins to rise during the second decade of life

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SIGNS AND SYMPTOMS OF BREAST CHANGES

Lumps

The younger a woman is, the more likely it is that a single breast lump will be benign:

In women under 30, the most common cause is a benign solid tumor called a fibroadenoma. In women in their 30s and 40s, benign conditions (such as 2121 fibroadenoma, fibrocystic

In any of these age groups there is a chance that a single lump may be breast cancer, although it is more likely in older women than in younger ones. No matter what age the woman is, lumps and other changes must be checked to be sure they are not breast cancer. Having many lumps in
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Skin thickening and/or redness

Redness or thickening of an area of skin on the breast can also have different causes. inflammation of the breast, known as mastitis, is common in women who are breastfeeding and is usually caused by an infection.

at least one type of 2323

Pain

Some are related to menstrual cycle. most common in the week or so before a menstrual period. often goes away once menstruation begins. Women with fibrocystic changes have cyclic breast pain. thought to be caused by changes in hormone levels. Some benign breast conditions, such as breast inflammation (mastitis) may cause a more sudden pain in one spot. pain is not related to the menstrual cycle.

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Nipple discharge

A discharge (other than milk) from the nipple may be alarming, but in most cases it is caused by a benign condition. As with breast lumps, the younger a woman is, the more likely it is that the condition is 2525 benign.

Nipple discharge

In benign conditions, a nonmilky discharge is usually clear, yellow, or green.

If the discharge contains blood, the cause is still not likely to be cancer, but it is cause for concern and more testing. 2626

Nipple discharge

If the discharge is coming from more than one breast duct or from both breasts it is usually because of a benign condition such as fibrocystic A milky discharge from both breasts (other than changes or duct while pregnant or breast-feeding) sometimes ectasia. in response to the menstrual cycle. can happen can discharge If thealso be caused by an imbalance of hormones made by the pituitary or thyroid gland, or even (bloodyby certain drugs. caused or non2727

American Cancer Society Recommendations for Early Breast Cancer Detection

Women age 40 and older should have a screening mammogram every year and should continue to do so for as long as they are in good health. Women in their 20s and 30s should have a clinical breast examination (CBE) by a health professional as part of a regular health exam, at least every 3 years. Breast self-examination (BSE) is an option for women starting in their 20s. Women at high risk (greater than 20% lifetime risk) for breast 2828 cancer should

Benign Neoplasms
1.

Fibrocystic Change

Represent exaggerated tissue response to circulating hormones Common after 30 years of age Manifestation may correlate with menstrual cycle Aggravated by xanthine-containing

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Benign Neoplasms
2.

Fibroadenoma
Most common benign lesion in women under 30 Growth hormonally dependent Manifestation:

Well circumscribed mass about 1-5 cm diameter Firm or rubbery consistency Mobile Non-tender

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Benign Neoplasms
3.

Phyllodes Tumor
Variant of fibroadenoma May occur at any age Has a malignant variant Manifestation

Large bulky mass Skin red, warm, shiny, with venous engorgement Size: 4-5 cm median size Rapid growth High rate of recurrence after simple excision
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Treatment: Wide Excision

Benign Neoplasms
4.

Intraductal Papilloma

Solitary polypoid lesion involving lactiferous duct Bloody nipple discharge most common cause Treatment - Excision

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Benign Neoplasms
5. Fat Necrosis

History of trauma Breast pain characteristic Ecchymotic, tender, firm, illdefined mass Sometimes with skin and nipple retraction Treatment Excision

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Benign Neoplasms
7.

Gynecomastia

Breast hypertrophy in males Physiologic


1. 2. 3.

Newborn Pubertal age Senescent

Drug-induced Pathologic Treatment


. . .

Reassurance if physiologic Discontinue medication drug induced

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Non-proliferative lesions do not seem to affect cancer risk Proliferative lesions without atypia slightly increase cancer risk Proliferative lesions with atypia raise the risk of cancer
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How benign breast conditions affect breast cancer risk

Non-proliferative lesions

Fibrosis Cysts Mild hyperplasia Adenosis (nonsclerosing) Simple fibroadenoma Phyllodes tumor (benign)

A single (solitary) papilloma Granular cell tumor Fat necrosis Mastitis Duct ectasia Benign lumps or tumors (lipoma, 3636 hamartoma,

Proliferative lesions without atypia


Usual ductal hyperplasia (without atypia) Complex fibroadenoma Sclerosing adenosis Multiple papillomas or papillomatosis Radial scar

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Proliferative lesions with atypia


Atypical ductal hyperplasia Atypical lobular hyperplasia

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In patients with a palpable breast mass in which cancer is suspected, BIOPSY is mandatory. ( Level I, Category A ) Fine needle aspiration cytology ( FNAC ) is the initial diagnostic procedure in patients with a palpable breast mass in which cancer is suspected. ( Level I, Category A ) If the FNAC result is malignant, the 3939

If the FNAC is unsatisfactory or interpreted as suspicious, core needle biopsy or open biopsy is advised. ( Level I, Category A ) For tumors 1 cm in size, sonographically guided FNAC or core needle biopsy is recommended. In places where sonography facilities are unavailable, open biopsy is done. ( Level II, Category A )
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Breast Carcinoma

1. 2. 3.

Risk Factors
1st degree relative with breast cancer Prior history of breast cancer Breast biopsy: atypical ductal or lobular hyperplasia Non-invasive lesion (carcinoma-in-situ) Early menarche Late menopause Nulliparity Late pregnancy Exposure to radiation Obesity
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4. 5. 6. 7. 8. 9. 10.

Breast Carcinoma

Clinical Presentation

Mass, palpable or fungating Skin changes Nipple discharge Non-palpable, suspicious mass on mammography Metastatic spread
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Breast Carcinoma

Mammographic findings suggestive of malignancy


1.

2.

3.

4.

Irregularly marginated stellate or spiculated mass Architectural distortion with retraction and spiculation Asymmetric localized fibrosis Fine microcalcification with a linear, branched or rod-like pattern, especially when focal or clustered

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Breast Carcinoma

Diagnosis - BIOPSY
Palpable lesion a. Fine needle aspiration b. Core needle c. Incision d. Excision Non-palpable lesion
.

Needle localization biopsy

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Breast Carcinoma

Histologic Types
Non invasive
a. b.

Ductal carcinoma in situ premalignant lesion Lobular carcinoma in situ marker of increased risk Infiltrating ductal carcinoma most common Invasive lobular carcinoma Pagets disease of the nipple Inflammatory breast carcinoma most 5050 lethal

Invasive
a. b. c. d.

Non-Invasive Breast lesion


Characteristic
Age (years) Incidence Clinical Signs Mammography

LCIS
44 - 47 2 - 5% none none 54 - 58 5 - 10%

DCIS

Mass, pain, nipple discharge microcalcification 2 - 46% 40 - 80% 10 - 20% 1 - 2% 25 70% Ipsilateral 5 10 years Ductal
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Incidence of synchronous invasive 5% CA Multicentricity Bilaterality Axillary node involvement Subsequent Carcinomas Incidence Laterality Interval to diagnosis Histology 60-90% 50-70% 1% 25 - 35% Bilateral 15 - 20 years Ductal

Invasive Carcinoma
a.

Infiltrating ductal carcinoma


a. b. c.

Most common type (80%) Originates from ductal epithelium Infiltrates supporting stroma 8-10% of lesion Originates from lobular epithelium High incidence of bilateral lesion

b.

Invasive lobular carcinoma


a. b. c.

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Invasive Carcinoma
c.

Pagets Disease of the nipple


a. b.

c.

1-3% incidence Associated with DCIS or invasive carcinoma beneath nipple Present with ezcematoid lesion of nipple, with crusting, scaling, erosion or discharge 1-4% of lesion Most rapidly lethal malignancy Poorly differentiated Dermal lymphatic invasion Axillary node and distant metastasis usually present when diagnosed
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d.

Inflammatory breast carcinoma


a. b. c. d. e.

How do we manage breast carcinoma?

A 41 year old with a 4 cm diameter breast carcinoma

A 58 year old with a 10 cm diameter fungating breast carcinoma


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Breast Carcinoma

Management: depends on a. Stage of the disease b. Pre or post menopausal status c. Presence of hormone receptors d. Presence of other medical conditions e. Flow cytometric studies f. Her-2-neu oncogene
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Breast Carcinoma

Treatment a. Surgery for loco-regional control b. Chemotherapy systemic treatment c. Hormonal Therapy systemic treatment d. Radiotherapy for loco-regional control e. Immunotherapy control her-2neu expression
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Breast Carcinoma
1.

Staging: TNM Classification a. Tumor (T) T0 no evidence of primary tumor Tis carcinoma in situ T1 tumor 2 cm or smaller T2 tumor > 2 cm but < than 5 cm T3 tumor > than 5 cm T4 tumor of any size with direct extension to skin or chest wall T4a extension to chest wall T4b edema, ulceration of skin of breast, or satellite skin nodule confined on same breast T4c both T4a and T4b 5757 T4d Inflammatory breast carcinoma

Breast Carcinoma
1.

Staging: TNM Classification a. Tumor (T) b. Node (N)


NX regional nodes can not be assessed N0 no regional node involvement N1 movable ipsilateral node involvement N2 fixed or matted ipsilateral node involvement N3 - ipsilateral infraclavicular, supraclavicular node involvement MX distant metastasis can not be assessed M0 no distant metastasis M1 with distant metastasis
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c.

Metastasis (M)

Breast Carcinoma

Staging of Disease Stage 0 Tis N0 M0 Stage 1 T1 N0 M0 Stage IIa T0, T1 N1 M0 T2 N0 M0 Stage IIb T2 N1 M0 T3 N0 M0 Stage IIIa T3 N1 M0 T1-3 N2 M0 Stage IIIb T4 N0-2 M0 Stage IIIc Any T N3 M0 Stage IV Any T Any N M1
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Breast Carcinoma
2. 3.

Menopausal Status Hormone Receptors


Use of anti-estrogen treatment Use of aromatase inhibitor Use of oophorectomy

4.

Co-morbid conditions
Curative vs Palliative treatment

5.

Flow Cytometry / Her-2-Neu oncogene


Aggressiveness of the tumor Recurrence Use of immunotherapy
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Breast Carcinoma

Treatment
1.

Surgery
a. b.

Wide local excision (QUART) Simple mastectomy


a. b.

Prophylactic Therapeutic

c. d.
2. 3. 4. 5.

Radical mastectomy Modified radical mastectomy

Chemotherapy Hormonal Therapy Radiotherapy Immunotherapy


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1.
a.

Surgery

Breast Carcinoma

Wide Local Excision (WLE)


Lumpectomy / segmental mastectomy Breast conserving therapy QUART Goal i. Complete excision of tumor with tumor free margin ii. Good cosmetic appearance Eligibility Critiria . Tumor size < 4.0 cm . Appropriate tumor size to breast size ratio . No fixation of tumor . No involvement of skin . No multicentric cancers . No fixed or matted axillary nodes 6262

Breast Carcinoma
1.
b.

Surgery
Simple Mastectomy (SM)

Total mastectomy Remove breast tissue, nipple-areolar complex and skin Removes breast tissue, nipple-areolar complex, skin, pectoralis major and minor muscle and axillary lymph nodes Leaves bare chest wall with significant cosmetic and functional deformity Historical interest
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c.

Radical Mastectomy

Breast Carcinoma
1.

Surgery
d.

Modified Radical Mastectomy (MRM)

Removes breast tissue, nippleareolar complex, skin, pectoralis fascia and axillary nodes. Spares pectoralis major muscle 2 Surgical Modifications: a. Patey removal of pectoralis minor b. Auchincloss preserves pectoralis minor 6464

Breast Carcinoma
2.

Chemotherapy
Indications: Adjuvant treatment for node positive patients Adjuvant treatment for high-risk node negative patients Induction therapy for advanced lesions Palliation for metastatic disease Treatment regimen
a. b.

CMF CAF

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Breast Carcinoma
3.

Hormonal Therapy
Indications:

Adjuvant therapy for hormone receptor positive patient Palliative therapy for indolent metastatic disease with hormone receptor positive tumors Tumor response: a. ER+/PR+ = 78% b. ER+/PR- = 54% c. ER-/PR+ = 45% d. ER-/PR- = 10% Anti-estrogen Aromatase inhibitor Oophorectomy
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Forms of hormonal therapy


a. b. c.

Breast Carcinoma
4.

Radiotherapy
Indications:

Breast conserving surgery Adjuvant treatment after surgery for tumor positive margins of resection Adjuvant treatment for node positive patient after axillary node dissection Treatment for local recurrence Treatment for bone and brain metastasis Induction therapy for advanced lesion

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Breast Carcinoma
5.

Immunotherapy

Trastuzumab (Herceptin)

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Breast Carcinoma

1. 2. 3.

Treatment Options
Stage 0 WLE vs SM Stage I MRM vs WLE Stage II MRM vs WLE

If node positive adjuvant chemotherapy If high-risk node negative adjuvant chemotherapy If hormone receptor positive hormonal therapy MRM + adjuvant therapy Induction chemotx &/or radiotx + MRM

4.

Stage III multi-modality treatment


5.

6969 Stage IV Palliative treatment

How do we manage breast carcinoma?

A 41 year old with a 4 cm diameter breast carcinoma

A 58 year old with a 10 cm diameter fungating breast carcinoma


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Breast Carcinoma
Stag eI Stage II

Staging of Disease Stage IV Palliati ve

Stage III Stage IIIa, IIIb, & IIIc

II a

IIb

Workup IIIa w/ operable disease

Surge ry

Operable disease Surge ry

IIIa w/ inoperable disease,, IIIb & IIIc Neoadjuvant Tx Respon No se response Inoperable disease Individualiz ed therapy 7171

Follow -up

Adjuvant therapy

Breast Carcinoma

a. b. c. d. e. f.

High-Risk Patients
Tumor size > 2.0 cm Poor histologic grade Absence of ER/PR receptors High proliferative (S-phase) fraction Aneuploid DNA content Overexpression of epidermal growth factor receptor (EGF-2) Presence of cathepsin-D Expression of her-2-neu oncogene
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g. h.

Breast Carcinoma

Male Breast Cancer


Hyperestrogenic state risk Delay in diagnosis poorer prognosis Infiltrating ductal carcinoma most common Node negative disease same prognosis as in women Node positive disease poorer prognosis than in women Treatment depend of the stage and extent of tumor
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Breast Carcinoma

Breast Reconstruction after Mastectomy Improves patients body image Does not compromise adjuvant chemotherapy Does not increase incidence of local recurrence Does not contribute to delay in diagnosis of chest wall recurrence May be done immediately or delayed after adjuvant treatment Reconstructive Procedure:
a. b.

Prosthetic breast implant 7474 Myocutaneous flap reconstruction

BREAST SELF-EXAM
1. Make a regular date for your BSE If you are premenopausal:Set a regular time to examine your breasts a few days after your period ends, when hormone levels are relatively stable and breasts are less

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BREAST SELF-EXAM
2. Visual Exam Hands on Hips In the privacy of your bathroom, strip to the waist and stand before a mirror. Stand with your hands on your hips and check the appearance of your breasts.

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BREAST SELF-EXAM
3. Visual Exam Arms Over Your Head Still standing in front of the mirror, raise your arms over your head and see if your breasts move in the same way, and note any differences. Look at size, shape, and drape, checking

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BREAST SELF-EXAM
4. Manual Exam Stand and Stroke Raise your left arm overhead, and use your right-hand fingers to apply gentle pressure to the left breast. Stroke from the top to the bottom of the breast, moving across

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BREAST SELF-EXAM
5. Manual Exam Check Your Nipples Still facing the mirror, lower both arms. With the index and middle fingers of your right hand, gently squeeze the left nipple and pull forward. Does the nipple spring back into place?

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BREAST SELF-EXAM
6. Manual Exam Recline and Stroke Place a pillow on the bed so that you can lie with both your head and shoulders on the pillow. Lie down and put your left hand behind your head. Use your right hand to

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