Juhi Asad, DO Sharon Rosenbaum Smith, MD Dept. of Breast Surgery Benign Breast Disease Juhi Asad, DO Sharon Rosenbaum Smith, MD Dept. of Breast Surgery

Outline Anatomy Benign disease Management Genetics

Anatomy Modified sweat gland between the superficial and deep layers of the chest wall Cooper’s Ligament Fibrous band of tissue

Anatomy Ducts Terminal ductules Milking forming glands Lobule

Question Axillary lymph nodes are classified accordingly to the relationship with the Axillary vein Pec.major Pec.minor Latissimus dorsi Serratus anterior

Anatomy Axillary lymph nodes defined by pectoralis minor muscle Level 1 – lateral Level 2 – posterior Level 3 – medial Long Thoracic Nerve Serratus anterior Thoracodorsal Nerve Latissimus Dorsi Intercostalbrachial Nerve Lateral cutaneous Sensory to medial arm & axilla

Anatomy Hormonal Effects Estrogen Progesterone Prolactin Development of the breast and lactiferous ducts Progesterone Secretory acinar tissue – lobules Prolactin Synergizes the effect of estrogen and progesterone

Benign Breast Diseases Glandular breast parenchyma Mass Asymmetric nodularity Pain Nipple-Areolar Complex Discharge Rash Retraction Surrounding breast skin Dimpling

Management History Clinical Breast Exam Breast imaging Tissue sampling Therapy

History Age Family History Prior biopsies Hormone therapy Menarche Pregnancy Breast feeding Menopause Family History Prior biopsies Hormone therapy

Question What are the risk factors that are part of the Gail Model? Race Age Age of 1st menses Age at 1st pregnancy # of 1st degree relatives # of biopsies

Clinical Exam Inspection Palpable Skin Symmetry Masses Gland Axilla, Supraclavicular spaces Nipple-areola complex

Question 22 yo female presents with a new right breast mass. Complains of mild tenderness. No other complaints. On physical exam, there is a 1 cm nodule at the 2:00 position. Your diagnostic test of choice is…. Mammogram Ultrasound Excisional biopsy Incisional biopsy

Breast Mass Breast Cysts Fluid-filled 1 out of every 14 women 50% multiple and recurrent Hormonally influenced Needle aspirated

Breast Cyst Anechoic, well marginated, well defined posterior shadowing

Breast Mass Fibroadenoma Stromal and epithelial elements Most common in women <30yo Firm, solitary tumors Multiple Increase in size Management Biopsy Excisional biopsy

Fibroadenoma Hypoechoic, no acoutic transmission

Breast Mass Phyllodes Tumor Proliferation of connective tissue with ductal elements Whorled and cellular stroma Firm, lobulated 2 to 40 cm in size 10% malignant Treatment Wide excision

Fibrocystic Disease Clinical, mammographic and histologic findings Exaggerated response from hormones and growth factors Cyclical pain Nodularity – upper outer quadrants

Fibrocystic Disease Histology Adenosis Apocrine metaplasia Fibrosis Duct ectasia Mild ductal hyperplasia

Fibrocystic Disease Risk Factors Dense breast Sclerosing adenosis Atypical ductal, papillary, or lobular hyperplasia

Question 34 yo female referred to you for evaluation of breast pain. The pain is burning and sharp in nature. Always present. On physical exam, dense glandular tissue bilaterally. Your working diagnosis is…. Cyclical breast pain Noncyclical breast pain cancer

Breast Pain Cyclical pain – hormonal Non-cyclical pain Dull, diffuse and bilateral Luteal phase Treatment Reassurance NSAIDS Evening primrose oil Non-cyclical pain Non-breast vs breast Imaging

Breast Infections Mastitis Generalized cellulitis of the breast Ascending infection subareolar ducts commonly occurs during lactation Staph. aureus Erythema, pain, tenderness

Mastitis Treatment Abx Continue to breast feed Close follow-up

Breast Abscess Abscess Breast tissue Treatment Abx Needle aspiration Incision and drainage

Question What is the difference between spontaneous vs non-spontaneous nipple discharge?

Nipple Discharge Physiologic Bilateral Involves multiple ducts Heme (-) Non-spontaneous Discharge – green, milky – galactorhea prolactin level.

Nipple Discharge Pathologic Unilateral Spontaneous Heme (+) Most common cause intraductal papilloma

Bloody Nipple Discharge

Intraductal Papilloma Single duct Benign 4% of intraductal ca

Imaging Mammography Ultrasound MRI

Mammography Screening tool Estimated reduction in mortality 15-25% Age of 40 Estimated reduction in mortality 15-25% 10% false positive rate Densities & calcifications

Calcification Macrocalcifications Microcalcifications Large white dots Almost always noncancerous and require no further follow-up. Microcalcifications Very fine white specks Usually noncancerous but can sometimes be a sign of cancer. Size, shape and pattern

BI-RADS Features Need additional imaging 1 Negative – routine in 1 yr BI-RADS Classification Features Need additional imaging 1 Negative – routine in 1 yr 2 Benign finding – routine in 1 yr 3 Probably benign, 6mo follow-up 4 Suspicious abnormality, biopsy recommended 5 Highly suggestive of malignancy; appropriate action should be taken

Ultrasound Not a screening tool Palpable vs cystic Mammographic detected lesion

Central anecho, well circumscribed margins, enhanced thru transmission

Ultrasound Benign Malignant Pure and intensely hyperechoic Elliptical shape (wider than tall) Lobulated Complete tine capsule Malignant Hypoechoic, spiculated Taller than wide Duct extension microlobulation

Ultrasound

Malignant or Benign

Malignant vs Benign

MRI High risk patients High sensitivity (95-100%) Personal history of breast ca LCIS, atypia 1st degree relative with breast cancer Very dense breast High sensitivity (95-100%) 10-20% will have a biopsy

MRI Pre Gad Post Gad Color Overlay

Diagnosis Fine needle aspiration Core biopsy Excisional biopsy Cytology Core biopsy Image guided Stereotactic Excisional biopsy Needle localization

FNA Fast, inexpensive 96% accuracy Institution dependent Unable to differentiate b/w in situ vs CA

Core Needle Biopsy 14-18 gauge spring loaded needle Tissue Multiple

Large Core Biopsy 6-14 gauge core Large samples Single insertion

Core biopsy Vacuum Assisted

Stereotactic Biopsy Suspicious mammographic abnormalities Patients lay prone

Stereo View

Excisional Biopsy Atypical lesions LCIS Radial scar Atypical papillary lesions Radiologic-pathologic discordance Phyllodes Inadequate tissue harvesting

High-Risk Prior breast cancer Family history of breast cancer Ovarian cancer BRCA-1 or BRC-2 gene Prior mantle radiation Biopsy proven of atypia or LCIS

Screening Prior breast cancer or atypia Family Hx BRCA Annual mammography 6 mo CBE Family Hx 10 yrs younger than relative’s diagnosis BRCA 25 yo – annual mammography

Genetics Early age of onset 2 breast primaries or breast and ovarian CA Clustering of breast CA with: Male breast CA, Thyroid CA, Sarcoma, Adrenocortical CA, Pancreatic CA leukemia/lymphoma on same side of family Family member with BRCA gene Male breast CA Ovarian CA

Genetics Hereditary Breast/Ovarian Syndrome Li-Fraumeni Syndrome BRCA 1 – chromosome 17 BRCA 2 – chromosome 13 Li-Fraumeni Syndrome P53 mutation – chromosome 17 Cowden Syndrome PTEN mutation – chromosome 10 Autosomal dominant pattern

BRCA Account to 25% of early-onset breast cancers 36%-85% lifetime risk of breast CA 16-60% lifetime risk of ovarian CA

BRCA BRCA 1 gene BRCA 2 gene Ovarian CA Male breast CA Prostate CA Pancreatic CA

BRCA Management Monthly BSE -- 18yo 6 mo CBE & annual mammo -- 25yo Discuss risk reducing options Prophylactic mastectomies Salpingo-oophorectomy – upon completion of child bearing 6 mo transvaginal US & CA125 – 35 yo

Li-Fraumeni Syndrome Mutation of p53 gene Premenopausal breast CA Tumor suppressor Premenopausal breast CA Childhood sarcoma Brain tumors Leukemia Adrenocortical CA Accounts for 1% of breast CA

Cowden Syndrome Major criteria Minor criteria Thyroid CA (follicular) Marcocephaly Cerebellar tumors Endometrial CA Breast CA – 25%-50% risk Skin and mucosal lesions Minor criteria Thyroid lesions GU tumors GI hamartomas Fibrocystic breast Mental retardation PTEN gene mutation on chromosome 10q23