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Surgical Breast Pathology. Juan C. Cendan, MD Assistant Professor of Surgery. Objectives of Lecture. Categorize risk factors for cancer Highlight future cancer risk for a given benign lesion Describe diagnostic workup for breast masses and tools available to the clinician
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Surgical Breast Pathology Juan C. Cendan, MD Assistant Professor of Surgery
Objectives of Lecture • Categorize risk factors for cancer • Highlight future cancer risk for a given benign lesion • Describe diagnostic workup for breast masses and tools available to the clinician • Provide up-to-date guidelines in the screening and diagnosis of breast masses • Brief review of surgical options and implications in patients with breast cancer
Assessment of Risk/History • Four major risks (increase RR by 4x): • Family history • 1st degree relatives • Age at diagnosis, BRCA1/2 risk • Atypical hyperplasia on prior biopsies • Personal breast cancer history • LCIS
Assessment of Risk/History • Four Minor Risk Factors: 1-2x RR • Early menarche • Long interval from menarche to 1st child • Nulliparity • Ovarian or endometrial cancer • Estrogen therapy after menopause
Physical Exam • Be systematic • Inspection of breasts: sitting up, then recumbent • “Strip method” • Nipples • Lymph nodes
Clinical Examination of a Patient with Benign Breast Disease Santen, R. J. et al. N Engl J Med 2005;353:275-285
Common Benign Breast Disorders in Women Santen, R. J. et al. N Engl J Med 2005;353:275-285
Diagnostics • Standard screening mammogram • CC and MLO • Diagnostic mammogram • Above, plus compression/additional views • In either case, 5-10% false negative and 90-95% sensitivity
Cranio-caudal (CC) view and mediolateral oblique (MLO) mammographic view
Histopathological Appearance of Benign Breast Disease (Hematoxylin and Eosin) Panel A shows nonproliferative fibrocystic changes:the architecture of the terminal-duct lobular unit is distorted by the formation of microcysts,associated with interlobular fibrosis.Panel B shows proliferative hyperplasia without atypia. This is adenosis,a distinctive form of hyperplasia characterized by the proliferation of lobular acini,forming crowded gland-like structures.For comparison,a normal lobule is on the left side.Panel C also shows proliferative hyperplasia without atypia.This is moderate ductal hyperplasia,which is characterized by a duct that is partially distended by hyper- plastic epithelium within the lumen.Panel D again shows proliferative hyperplasia without atypia,but this is florid ductal hyperplasia:the involved duct is greatly expanded by a crowded,jumbled-appearing epithelial proliferation.Panel E shows atypical ductal hyperplasia:these proliferations are characterized by a combination of architectural complexity with partially formed secondary lumens and mild nuclear hyperchromasia in the epithelial-cell population.Panel F shows atypical lobular hyperplasia:monotonous cells fill the lumens of partially distended acini in this terminal-duct lob- ular unit. Hartmann, L. C. et al. N Engl J Med 2005;353:229-237
Diagnostics • Ultrasound • Useful in the young • Useful in pregnant women • Delineates solid vs cystic • MRI • Possibly the future of breast diagnostics, not there yet, limitations with biopsy
Biopsy techniques • Palpable solid mass • Needle or core biopsy • Incisional or excisional biopsy • Non-palpable mass • Stereotactic core • Stereotactic “mammotome” • Needle localized biopsy
Some Benign Conditions • Nipple Discharge • Incidence of malignancy when bloody (10-15%) and unilateral, though usually papilloma • More likely cystic or duct ectasia • Consider prolactin if bilateral
Benign, con’t • Fibroadenoma • Very common in young women • Freely mobile and smooth • Characteristic u/s appearance • Half of adenomas resolve if <3cm over 5yrs • Large adenomas should be biopsied to exclude rare phylloides tumor
Benign, con’t • Cysts • Due to relative excess estrogen, usually in 4-5th decades • Fluctuate with menses • Aspirate, if bloody then excise, send fluid for path the first time
Benign, con’t • Abscess, • Usually in lactating women • Painful and erythematous • Usually staph and strep • Drainage and antibiotics indicated • Rarely, can aspirate and treat with antibiotics • Caveats, in nonlactating (Ca), non-resolving (atypical infection), inflammatory cancer
Classification of Benign Breast Lesions on Histologic Examination, According to the Relative Risk of Breast Cancer Santen, R. J. et al. N Engl J Med 2005;353:275-285
Risk of Breast Cancer According to Breast Density in Premenopausal and Postmenopausal Women Santen, R. J. et al. N Engl J Med 2005;353:275-285
Risk of cancer of benign breast lesions, Hartmann et al, NEJM 2005
Examples of Outcomes among 100 Women Followed for an Average of 15 Years: Explaining Relative Risk Calculations to Patients… Start with known risk and “translate” it to an absolute risk Elmore, J. G. et al. N Engl J Med 2005;353:297-299
Cancer • Most women with breast cancer have no risk factors! • Role of dietary fat, estrogen • Breast cancer genes responsible for 3-5% only
Cancer • DCIS • Carcinoma in situ • Usually found on mammography as microcalcifications • Felt to progress to invasive in 30-50% if untreated • Subtypes: comedo highest risk
Cancer • DCIS, con’t • Treatment • Non-invasive, so risk of LN disease is minimal • Must treat the breast, options: • Excise with large enough margins (>1cm) in a small tumor • Or, Excise and radiate • Or, Mastectomy +/- reconstruction
Cancer • Invasive Ductal Cancer • “Garden variety breast cancer” • More often presents with mass than DCIS • Treatment: • BREAST: Excise and RT or mastectomy, Cannot just excise with margins (30-40% recur) • Lymph Nodes: Must be sampled for staging • Sentinel Node vs Axillary Dissection
Cancer • Chemotherapy • Recommended for tumors >1cm in most patients • Recommended if lymph nodes are positive • 8 recommended chemo protocols at this time!! • ER positivity and Tamoxifen
Cancer • Survival