Download - 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