Breast Clinical Correlation

1. Breast Clinical Correlation Anne T. Mancino MD

2. Breast Cancer Facts • An estimated 178,000 new cases of female invasive breast cancer will be diagnosed • An estimated 43,500 women will die from breast cancer • Approximately 37,000 cases of female in situ breast cancer will be diagnosed American Cancer Society 1999Cancer Facts & Figures

3. Risk Factors for Breast Cancer • Age • Personal history - 0.5-1% per year risk new cancer • Family history • First degree relative • Pre-menopausal  risk 3-4 fold • Germline mutation (BRCA1/2) 60-85% risk • Previous biopsy, especially with atypia • Early menses, late menopause, parity

4. ACS Screening Guidelines • Screening Mammography • Yearly starting at age 40 • Clinical Breast Exam • Every 3 years age 20-39 • Yearly after age 40 • Breast Self Exam • monthly after age 20

5. Breast Exam: Anatomy • Variety of sizes and shapes • Composed of fatty, fibrous and glandular tissue • Lymph nodes are important

6. Accessory Breast Tissue • Should always be examined as carefully as the other breast tissue.

7. Physical Findings Suspicious for Malignancy • Venous patterns • Skin edema • Nipple inversion • Retraction • Scaling or ulceration of the nipple • Inflammation

8. Venous Patterns • Increased prominence or engorgement of blood vessels in an asymmetric patterns • Suggestive of angiogenesis of tumor

9. Skin Edema • Produced by lymphatic blockade by tumor, lymph node removal • Appears as thickened skin with enlarged pores • aka “peau d’orange”

10. Nipple Inversion • Can be a normal variant • Unilateral or bilateral • Be suspicious for cancer in recently developed cases

11. Retraction • Can be caused by fibrosis formation in breast cancer • Fibrosis may produce retraction signs: • Dimpling of skin • Alteration in breast contour • Flattening or deviation of nipple

12. Retraction As Seen on Mammogram

13. Scaling or Ulceration • Seen in nipple and/or areola • “Paget’s disease”

14. Paget’s Disease • Tumor cells in epidermis

15. Inflammation - Breast Abscess • need to distinguish from inflammatory breast cancer • needs incision and drainage

16. Inflammatory Cancer • no discrete mass • erythema and warmth • cutaneous lymphedema • obstruction of dermal lymphatics by tumor

17. Inflammatory Cancer

18. Nipple Discharge • Spontaneous • Unilateral • One Duct • Clear, Serous, Bloody or Serosanguinous • Green • White or Milky

19. Nipple Discharge • Milky, clear, green, grey or black appearing discharge is usually physiologic • Referral not normally necessary, especially if bilateral or multiple ducts

20. Nipple Discharge • Bloody discharge • Could be a sign of benign intraductal papilloma • Should always be a referral to a breast specialist

21. Intraductal Papilloma • Most common cause of bloody nipple discharge • papilla have central fibrovascular core covered by myoepithelial and epithelial cell layers

22. Nipple Discharge • Serous drainage could be a sign of duct ectasia

23. Palpable mass • Ultrasound to see if solid or cystic • Guide aspiration or biopsy

24. Cysts • Derived from terminal duct lobular unit • endothelial lined • no risk of cancer

25. Fibroadenoma • Well circumscribed • occur in younger women

26. Fibroadenoma • Well circumscribed • benign stromal and epithelial elements • no increased risk of cancer

27. Biopsy Techniques • Fine Needle Aspiration • Cytology vs. Histology • Significant insufficient sampling • Unable to differentiate in-situ from invasive

28. Examples of Ductal Cells Under a Microscope BENIGN MALIGNANT

29. Tru-Cut • Histology • More definitive compared to FNA • Small fragmented samples • Multiple insertions/re-insertion's

30. Vacuum-Assisted Mammotome • Histology • Large, contiguous tissue samples • Single insertion • Can mark biopsy site • 2-3 mm skin incision – sutureless

31. Core biopsy samples

32. Screening Mammogram • Can identify abnormal mass or calcification • Biopsy under mammogram guidance • Stereotactic biopsy or excisional biopsy guided by wire placement

33. Stereotactic Breast Biopsy

34. Calcifications

35. Intraductal Hyperplasia • No atypia • proliferation of epithelial cells • varied size,shape • elongated secondary spaces • low risk cancer

36. Atypical Ductal Hyperplasia • Uniform cells with monotonous nuclei • lacks some features of DCIS -near periphery maintain orientation • three to five-fold increase risk of breast cancer

37. Lobular Carcinoma in Situ (LCIS) • Acini of lobules filled with uniform tumor cells • Multicentric and bilateral • 1% per year risk of invasive cancer in either breast

38. Ductal Carcinoma in Situ (DCIS) • Comedo type - central necrosis • Other types: • cribiform • micropapillary • papillary • solid

39. Infiltrating Ductal Cancer • most common type • well (gr I) to poorly (gr III) differentiated • Gr I tumor cells grow in glandular patterns • prognostic factors: • ER,PR, HER-2neu,p53 • S-phase, ploidy • angiogenesis

40. Open Surgical Excision • Performed in the OR • large skin incision • Local or General Anesthesia

41. History of Treatment • 1890’s - Halstead - Radical Mastectomy • 1948 - Dyson and Patey - Modified Radical Mastectomy • 1948 - McWhirter - Simple Mastectomy and radiation therapy • 1990’s - Lumpectomy/Axillary node dissection and radiation therapy

42. Radical Mastectomy • Remove breast, axillary contents, pectoralis muscles • lymphedema of left arm

43. Axillary Node Dissection • Level I - lower axilla around tail of breast • Level II - nodes up to the axillary vein • Level III - nodes above axillary vein and under pectoralis

44. Modified Radical Mastectomy • Excision of nipple and areola • breast and axillary nodes • leave pectoralis muscles

45. Modified Radical Mastectomy • Axilla dissected en bloc with the breast

46. Modified Radical Mastectomy • Long Thoracic Nerve • Winged Scapula • Thoracodorsal Nerve • Intercostal brachial • Numbness of the upper inner arm

47. Lymphatics • Routes of lymphatic flow • Used to devise less invasive techniques

48. Sentinel Node Biopsy • Technetium sulfur colloid • Isosulfan blue • injected at tumor • draining lymph node identified

49. Sentinel Node Biopsy • Node identified using gamma probe or by tracing blue lymphatic • excise “hot” and/or blue nodes and any palpable nodes

50. Sentinel Node Biopsy • Node sent to pathology • if no tumor, may avoid axillary dissection • false negative rate is 1-2%