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Breast Clinical Correlation

Breast Clinical Correlation . Anne T. Mancino MD. Breast Cancer Facts. An estimated 178,000 new cases of female invasive breast cancer will be diagnosed An estimated 43,500 women will die from breast cancer Approximately 37,000 cases of female in situ breast cancer will be diagnosed.

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Breast Clinical Correlation

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  1. Breast Clinical Correlation Anne T. Mancino MD

  2. Breast Cancer Facts • An estimated 178,000 new cases of female invasive breast cancer will be diagnosed • An estimated 43,500 women will die from breast cancer • Approximately 37,000 cases of female in situ breast cancer will be diagnosed American Cancer Society 1999Cancer Facts & Figures

  3. Risk Factors for Breast Cancer • Age • Personal history - 0.5-1% per year risk new cancer • Family history • First degree relative • Pre-menopausal  risk 3-4 fold • Germline mutation (BRCA1/2) 60-85% risk • Previous biopsy, especially with atypia • Early menses, late menopause, parity

  4. ACS Screening Guidelines • Screening Mammography • Yearly starting at age 40 • Clinical Breast Exam • Every 3 years age 20-39 • Yearly after age 40 • Breast Self Exam • monthly after age 20

  5. Breast Exam: Anatomy • Variety of sizes and shapes • Composed of fatty, fibrous and glandular tissue • Lymph nodes are important

  6. Accessory Breast Tissue • Should always be examined as carefully as the other breast tissue.

  7. Physical Findings Suspicious for Malignancy • Venous patterns • Skin edema • Nipple inversion • Retraction • Scaling or ulceration of the nipple • Inflammation

  8. Venous Patterns • Increased prominence or engorgement of blood vessels in an asymmetric patterns • Suggestive of angiogenesis of tumor

  9. Skin Edema • Produced by lymphatic blockade by tumor, lymph node removal • Appears as thickened skin with enlarged pores • aka “peau d’orange”

  10. Nipple Inversion • Can be a normal variant • Unilateral or bilateral • Be suspicious for cancer in recently developed cases

  11. Retraction • Can be caused by fibrosis formation in breast cancer • Fibrosis may produce retraction signs: • Dimpling of skin • Alteration in breast contour • Flattening or deviation of nipple

  12. Retraction As Seen on Mammogram

  13. Scaling or Ulceration • Seen in nipple and/or areola • “Paget’s disease”

  14. Paget’s Disease • Tumor cells in epidermis

  15. Inflammation - Breast Abscess • need to distinguish from inflammatory breast cancer • needs incision and drainage

  16. Inflammatory Cancer • no discrete mass • erythema and warmth • cutaneous lymphedema • obstruction of dermal lymphatics by tumor

  17. Inflammatory Cancer

  18. Nipple Discharge • Spontaneous • Unilateral • One Duct • Clear, Serous, Bloody or Serosanguinous • Green • White or Milky

  19. Nipple Discharge • Milky, clear, green, grey or black appearing discharge is usually physiologic • Referral not normally necessary, especially if bilateral or multiple ducts

  20. Nipple Discharge • Bloody discharge • Could be a sign of benign intraductal papilloma • Should always be a referral to a breast specialist

  21. Intraductal Papilloma • Most common cause of bloody nipple discharge • papilla have central fibrovascular core covered by myoepithelial and epithelial cell layers

  22. Nipple Discharge • Serous drainage could be a sign of duct ectasia

  23. Palpable mass • Ultrasound to see if solid or cystic • Guide aspiration or biopsy

  24. Cysts • Derived from terminal duct lobular unit • endothelial lined • no risk of cancer

  25. Fibroadenoma • Well circumscribed • occur in younger women

  26. Fibroadenoma • Well circumscribed • benign stromal and epithelial elements • no increased risk of cancer

  27. Biopsy Techniques • Fine Needle Aspiration • Cytology vs. Histology • Significant insufficient sampling • Unable to differentiate in-situ from invasive

  28. Examples of Ductal Cells Under a Microscope BENIGN MALIGNANT

  29. Tru-Cut • Histology • More definitive compared to FNA • Small fragmented samples • Multiple insertions/re-insertion's

  30. Vacuum-Assisted Mammotome • Histology • Large, contiguous tissue samples • Single insertion • Can mark biopsy site • 2-3 mm skin incision – sutureless

  31. Core biopsy samples

  32. Screening Mammogram • Can identify abnormal mass or calcification • Biopsy under mammogram guidance • Stereotactic biopsy or excisional biopsy guided by wire placement

  33. Stereotactic Breast Biopsy

  34. Calcifications

  35. Intraductal Hyperplasia • No atypia • proliferation of epithelial cells • varied size,shape • elongated secondary spaces • low risk cancer

  36. Atypical Ductal Hyperplasia • Uniform cells with monotonous nuclei • lacks some features of DCIS -near periphery maintain orientation • three to five-fold increase risk of breast cancer

  37. Lobular Carcinoma in Situ (LCIS) • Acini of lobules filled with uniform tumor cells • Multicentric and bilateral • 1% per year risk of invasive cancer in either breast

  38. Ductal Carcinoma in Situ (DCIS) • Comedo type - central necrosis • Other types: • cribiform • micropapillary • papillary • solid

  39. Infiltrating Ductal Cancer • most common type • well (gr I) to poorly (gr III) differentiated • Gr I tumor cells grow in glandular patterns • prognostic factors: • ER,PR, HER-2neu,p53 • S-phase, ploidy • angiogenesis

  40. Open Surgical Excision • Performed in the OR • large skin incision • Local or General Anesthesia

  41. History of Treatment • 1890’s - Halstead - Radical Mastectomy • 1948 - Dyson and Patey - Modified Radical Mastectomy • 1948 - McWhirter - Simple Mastectomy and radiation therapy • 1990’s - Lumpectomy/Axillary node dissection and radiation therapy

  42. Radical Mastectomy • Remove breast, axillary contents, pectoralis muscles • lymphedema of left arm

  43. Axillary Node Dissection • Level I - lower axilla around tail of breast • Level II - nodes up to the axillary vein • Level III - nodes above axillary vein and under pectoralis

  44. Modified Radical Mastectomy • Excision of nipple and areola • breast and axillary nodes • leave pectoralis muscles

  45. Modified Radical Mastectomy • Axilla dissected en bloc with the breast

  46. Modified Radical Mastectomy • Long Thoracic Nerve • Winged Scapula • Thoracodorsal Nerve • Intercostal brachial • Numbness of the upper inner arm

  47. Lymphatics • Routes of lymphatic flow • Used to devise less invasive techniques

  48. Sentinel Node Biopsy • Technetium sulfur colloid • Isosulfan blue • injected at tumor • draining lymph node identified

  49. Sentinel Node Biopsy • Node identified using gamma probe or by tracing blue lymphatic • excise “hot” and/or blue nodes and any palpable nodes

  50. Sentinel Node Biopsy • Node sent to pathology • if no tumor, may avoid axillary dissection • false negative rate is 1-2%

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