Common Breast Disease

1. Common Breast Disease Dr. Chan Wing Cheong Surgeon-in-charge Breast Surgery, NTEC

2. Symptoms & Possible Diagnosis Infections : Lactational & Non-lactational

3. Common Presenting Symptoms Over 80 % • Lump • Painful lump or lumpiness • Pain Under 20 % • Nipple discharge • Nipple change • Miscellaneous

4. Benign vs. Malignant

5. Over 90% are benign conditions

6. Breast Anatomy and Location of Disease Processes

7. Normal Breast Histology

8. Lymphatic Drainage • Axillary nodes level 1,2,3 • most of the breast drain into axilla. • pectoral nodes /  breast and anterior chest wall • sub scapular nodes / posterior chest wall and arm • lateral nodes/ arm • central (medial and apical) nodes/ drains all of the above three groups of nodes • Infraclavicular • Supra-clavicular nodes • Internal mammary nodes • Abdominal nodes

9. Normal Breast Development and Physiology • At puberty the breast develops under the influence of the hypothalamus, anterior pituitary, and ovaries and also requires insulin and thyroid hormone • During each menstrual cycle 3 to 4 days before menses, increasing levels of estrogen and progesterone cause cell proliferation and water retention. After menstruation cellular proliferation regresses and water is lost. • During pregnancy cellular proliferation occurs under the influence of estrogen and progesterone, plus placental lactogen, prolactin and chorionic gonadotropin. At delivery, there is a loss of estrogen and progesterone, and milk production occurs under the influence of prolactin. • At menopause involution of the breast occurs because of the progressive loss of glandular tissue.

10. ANDI classification ( Hughes et al, 1992 ) Normal Aberration ?? Disease Reproductive phases cysts, duct ectasia, mild epithelial hyperplasia cyclical mastalgia & nodularity fibroadenoma, juvenile hypertrophy Periductal mastitis Epithelial hyperplasia with atypia Giant fibroadenoma (> 5cms) Multiple fibroadenomata (> 5 per breast) Involution Cyclical & secretory Development Spectrum of breast changes

11. Aetiopathogenesis – Some Theories • Endocrine factors 1. Disturbances in the Hypothalamo Pituitary Gonadal steroid axis 2. Altered Prolactin profile – qualitative /quantitative change Non endocrine factors • Methyl xanthines, Stress Genetic predisposition to catecholamine supersensitivity  Intra cellular C - AMP mediated events  cellular proliferation 2. Diet rich in saturated fat Altered plasma essential fatty acid profile  receptor supersensitivity to normal levels of Oestrogen & Progesterone 3. Iodine deficiency Receptor supersensitivity to normal levels of Oestrogen & Progesterone

12. Assessment : Breast Problem

13. Triple Assessment for Breast Problem • Clinical • Symptoms & signs • Assessment of risk factors • Imaging • Ultrasonography / Mammography • Other imaging tests • Pathological • Fine needle aspiration cytology • Core biopsy

14. Risk Estimation for Breast Cancer • RELATIVE RISK <2 Early menarche < 12 years Late menopause > 55 years Nulliparity Proliferative benign disease Obesity Alcohol use Hormone replacement therapy • RELATIVE RISK 2–4 Age 35 first birth First-degree relative with breast cancer Radiation exposure Prior breast cancer • RELATIVE RISK >4 Gene mutation Lobular carcinoma in situ Atypical hyperplasia

15. Breast Examination

16. Left Mammography

17. Breast Ultrasonography

18. Galactography / Ductogram Intraduct papilloma

19. Fine Needle Aspiration Cytology

20. Core Biopsy

21. Mammotome Biopsy

22. Hook-wire Guided Excision

23. Case Scenario

24. Case 1 • F/22 • Right breast swelling for 1 month • No other symptoms • What are the questions you want to ask?

25. Case 1 • USG breast: • Compatible with a 1.5 cm fibroadenoma • What would you offer her? • What is the natural history of fibroadenoma?

26. Fibroadenoma Natural history Majority remain small & static 50% involute spontaneously No future risk of malignancy Types Solitary Few (< 5 / breast ) Multiple (> 5 / breast ) Giant (> 4 / 5 cm) & Juvenile

27. Management Algorithm for Fibroadenoma Chances of malignancy masquerading as Fibroadenoma Age 20 – 25 yrs 1: 3000 possibility Age 25 – 30 yrs 1: 300 possibility

28. Case 2 • Same lady as case 1 • No surgery after discussion • However • Come back 7 months later • Size of lesion increases up to 5 cm • What investigation do you want to do?

29. Case 2 • USG • Compatible with a giant fibroadenoma or phylloides tumour • Do you want to do FNA? • What would you offer?

30. Case 2 • Wide local resection performed • Pathology: • Phylloides tumour of undetermined malignant potential, margins appear to be clear • How do you advice this patient?

31. Phyllodes Tumours • Comprise less than 1% of all breast neoplasms • May occur at any age but usually in 5th decade of life • No clinical or histological features to predict recurrence • 16-30% may be malignant • Common sites of metastasis : lungs, skeleton, heart and liver

32. Treatment of Phyllodes Tumours • 1. Primary treatment • Local excision with • a rim of normal tissue • 2. Recurrence • Re excision or • Mastectomy with or without reconstruction • Response to chemotherapy and radiotherapy for recurrences and metastases poor

33. Case 3 • F/52 • Recently noticed a left breast lump • No pain • No other breast symptoms • Just menopause • What other questions regarding her problem that you will ask ?

34. Risk Estimation for Breast Cancer • RELATIVE RISK <2 Early menarche < 12 years Late menopause > 55 years Nulliparity Proliferative benign disease Obesity Alcohol use Hormone replacement therapy • RELATIVE RISK 2–4 Age 35 first birth First-degree relative with breast cancer Radiation exposure Prior breast cancer • RELATIVE RISK >4 Gene mutation Lobular carcinoma in situ Atypical hyperplasia

35. Case 3 • P/E: • 2.5 cm mass over upper outer aspect of left breast • Quite mobile • No palpable axillary LN

36. What would you do next ?

37. Left Case 3

38. Case 3 • MMG / USG breast • 2.5 cm mass • No axillary nodes • Core needle biopsy • Invasive carcinoma • What would you offer?

39. Options • Modified radical mastectomy • MRM + reconstruction • Autologus tissue flap • Prosthesis • Wide local excision + axillary dissection + post-op RT

40. Any adjuvant therapy? • Chemotherapy • ? Indications • Radiotherapy • ? Indications • Hormonal therapy • ? Indications

41. Case 4 • F/55 • Good past health • Routine physical check-up • Screening mammogram • Left breast microcalcification

42. What is your plan?

43. Options • Stereostatic core biopsy • Mammotome • Contra-indicated in suspicious lesion ( BIRAD ) • For small & likely benign microcalcification • Hook-wire guided excision biopsy • For suspicious lesion • Aims to achieve a clear margin

44. Mammotome Biopsy

45. Hook-wire Guided Excision

46. If core biopsy confirms DCIS, what’s next? • If solitary, < 3cm, not high grade • Wide local excision + RT • Otherwise, • Total mastectomy +/- reconstruction • Axillary node dissection not required • Hormonal therapy if ER / PR positive

47. Case 5 • F/ 43 • Recent onset of left breast mastalgia • Clinically palpable thickening of breast tissue over L3H • MMG not revealing • Needle biopsy: insufficient material • Thus open excision biopsy

48. Case 5 • Histopathology: • Lobular carcinoma in situ • No invasive component • All margins appear to be clear of tumour cells What would you suggest to the patient?

49. Lobular Carcinoma in situ • Lobular carcinoma in situ (LCIS) is not a cancer, but its presence means that there is a small increase in the risk of developing breast cancer later in life. • Management • Surveillance with Breast Examination / MMG • Chemoprevention • Prophylactic Subcutaneous Mastectomy +/- reconstruction

50. Case 6 • F/ 36 • Mother of 2 children • Brownish stain on the inside of undergarment • No pain • No nipple change