breast pathology by peter bone

BREAST PATHOLOGY

Peter Bone

Objectives

Breast anatomy Pathologies Breast cancer Questions

Breast anatomy

1. Chest wall2. Pec muscles3. Lobe4. Nipple5. Areolar6. Duct7. Fatty tissue8. Skin

Quadrants

Breast pathology

Breast cancer Fibroadenoma Fibrocystic

breast changes

Duct ectasia Duct

papilloma Infective

mastitis

Breast cancer

Most common tumour in women- 1 in 9 Risk increases with age Risk factors:

Oestrogen therapy Nulliparity, early menarche, late

menopause PMHx and FHx High socioeconomic status Some benign conditions

Presentation

Local: Painless, irregular

increasing mass Skin tethering Nipple discharge Nipple inversion Skin dimpling

• Systemic:– Bone pain–Malaise–Weight loss– SOB

Screening

Mammography 50-70 y.o. Every 3 years

Investigations

Triple assessment: Clinical examination Imaging (USS or mammography) Cytology (Fine needle aspiration or core

biopsy)

Other: Receptor statuses- oestrogen, progesterone,

Her2 Staging (CXR, CT/MRI, PET, bone and liver

scans) Bloods and biochem testing

Staging

Stage 0 - Carcinoma in situ Stage I – 2cm, no lymph or mets Stage II – 2-5cm, axillary lymph Stage IIIA - >5cm or 4-9 lymph nodes Stage IIIB – spread to breast skin, chest

wall or intermal mammary lymph Stage IV – beyond breast, axilla and

internal mammary lymph nodes

Management

Surgical Wide local excision, segmental

mastectomy, simple mastectomy Sentinel node biopsy/axillary node

clearance Radiotherapy Chemotherapy +/- endocrine therapy Herceptin Long term follow up

Fibroadenoma

Common benign tumour in women below 40 y.o.

10% disappear each year, tend to regress after menopause

S/S: “breast mouse” round, firm, painless mass that can move when being palpated

Investigation: exam and ultrasound, cytology if needed

Management

Young- observe Older- remove Excise at any age if patient requests

Fibrocystic breast changes

Physiological swelling of the breast A.k.a. Mammary dysplasia, fibroadenosis,

etc Peak incidence 35-50 y.o. Related to hormones S/S- pain, tenderness, lumpiness Comes on week before period, then goes

when periods start

Diagnosis

Can be clinical from Hx and Ex- reassess in a few weeks

Imaging often used to help (mammography)

Cytology (FNA) if needed

Management

No treatment needed if asymptomatic Progesterone supplements can be used NSAIDs

Duct ectasia

Benign breast disease Dilation of ducts in the subareolar region Calcification of secretions Middle aged and elderly women (esp

smokers!)

Presentation

Microcalcification on routine mammogram

Nipple discharge (blood?) Palpable subareolar mass Non-cyclic mastalgia Nipple inversion or retraction

Diagnosis

Imaging required- some specific tests Ultrasound Mammography Ductography (galactogram)- contrast

dye into milk duct Ductal lavage and cytology

Management

Persistent/recurrent cases Surgical excision of ducts below nipple Seroma formation, nipple numbness,

nipple inversion

Duct papilloma

Benign, warty lesion in 2-3% Can be central or peripheral Peripheral have higher risk of

malignancy

Presentation, investigation

Presentation Small lump Bloody discharge

Investigation Mammogram? Galactogram FNA or core biopsy

Management

Observational Excision if wanted

Infective mastitis

Usually occurs with lactation (rarely without)

Breast ducts become blocked, bacteria enter

Staph aureus, staph epidermidis, streptococci

10-33% of breast feeding women Usually first few weeks post-partum

Risk factors

Nipple fissures, cracks and sores are predisposing factor

Age >30 y.o. PMHx of mastitis Gestational age >41 weeks Poor technique, causing incomplete

emptying

Presentation

One breast affected, only one quadrant or lobule affected

Erythema, oedema, tenderness Pus on aspiration Axillary lymph nodes

DDx- congestive mastitis (engorgement): swollen and tender, bilateral, no fever or erythema

Investigations

Breast milk culture Not always useful Abscess suspected (tender hard breast

mass, fluctuant with oedema) -> Refer! -> Ultrasound

Management

Conservative- technique, manual expression, fluids, analgesia, ice packs, etc

Medical- early prescription- flucloxacillin or erythromycin

Surgical- incision and drainage or needle aspiration

Investigate persisting mass

A 29 year old woman comes to see you, the GP, about a lump she has felt in her breast. On examination, it is small, firm, and mobile. An ultrasound shows a small, round mass

What is the most likely diagnosis?a) Fibrocystic change of the breastb) Duct ectasiac) Fibroadenomad) Breast cancere) Cannot tell without cytology

Answer: c) Fibroadenoma The examination points towards a

fibroadenoma over any of the other causes of breast lumps

Cytology is useful to help confirm this, but the history, exam and ultrasound make this the most likely diagnosis

3 days after birth, a breastfeeding lady complains of swollen, tender breasts. This is bilateral. She is not pyrexial, and there is no erythema

What is the most likely diagnosis?a) Infective mastitisb) Congestive mastitis (breast engorgement)c) Fibrocystic changesd) Breast cancere) Duct ectasia

Answer: b) Congestive mastitis (breast engorgement) Infective mastitis is more common after a

week or two, not a few days post-partum The lack of fever, redness, and the fact that

it is bilateral suggest congestive mastitis

A 39 woman presents to the GP with bloody discharge from the nipple.

What is the most common cause of bloody discharge in a woman at this age?a) Breast cancerb) Fibrocystic changesc) Paget’s disease of the breastd) Duct papillomae) Duct ectasia

Answer: d) Duct papilloma All answers other than fibrocystic

changes can give bloody nipple discharge, but duct papilloma is the most common in younger women

Pagets disease of the breast is an uncommon type of breast cancer. It typically affects the nipple (can also affect the areolar)

A 54 y.o. woman has recently been diagnosed with breast cancer. The tumour is large, and has spread to the axillary lymph nodes. She is Her2 receptor positive.

What is the most appropriate management?a) Radiotherapy, chemotherapy and

Herceptinb) Breast conserving surgery, radiotherapy,

chemotherapy and Herceptinc) Wide local excision, axillary clearance,

radiotherapy, chemotherapy, Herceptind) Total mastectomy, axillary clearance,

radiotherapye) Total mastectomy, axillary clearance,

radiotherapy, chemotherapy and Herceptin

• Answer: e) Total mastectomy, axillary clearance, radiotherapy, chemotherapy and Herceptin

• There tumour is large, thus breast conserving surgery and wide local excision are less likely to be used

• Axillary clearance is needed as it has spread to local nodes

• Radio and chemo are helpful to reduce recurrence

• As the patient is Her2+, Herceptin is recommended

GOODLUCK!

Sources

Principles of Anatomy and Physiology (Tortora and Derrickson), 13th ed.

Medicine at a Glance (Davey) 3rd ed Clinical Medicine (Kumar and Clark) 7th ed http://en.wikipedia.org/wiki/Lobe_(anato

my) http://www.patient.co.uk/doctor/benign-b

reast-disease http://radiopaedia.org/articles/fibroadeno

ma-of-the-breast-1

http://www.gpnotebook.co.uk/simplepage.cfm?ID=-2120613862

http://www.patient.co.uk/health/breast-lumps

http://en.wikipedia.org/wiki/Fibrocystic_breast_changes

http://en.wikipedia.org/wiki/Mastodynia#Treatments_for_cyclical_breast_pain

http://www.patient.co.uk/doctor/Mammary-Duct-Ectasia.htm

http://www.cancerscreening.nhs.uk/breastscreen/index.html

http://www.patient.co.uk/doctor/puerperal-mastitis

http://www.cancer.ca/en/cancer-information/cancer-type/breast/risks/?region=bc#High_SES

http://www.cancer.gov/cancertopics/factsheet/Risk/BRCA

http://www.surgical-tutor.org.uk/default-home.htm?core/neoplasia/fibroadenoma.htm~right

http://www.patient.co.uk/doctor/pagets-disease-of-breast