Breast Diseases

1. Breast Diseases Professor Hassan Nasrat Chairman Department of Obstetrics and Gynecology Faculty of Medicine King Abudluziz University

2. Why Gynecologist should know about breast diseases • Anatomy of the Breast • Common Breast Diseases • Breast Cancer: Epidemiology and Risk factors and screening • Approach to women with common breast problem

3. Why Gynecologist need to study Breast Disorders? For many women gynecologists are their primary health care physicians. increased awareness among women concerned about their own risk of developing breast cancer Desire to take hormonal therapy such as contraceptive pills or hormonal replacement.

4. Anatomy Of the Breast: The breast is subcutaneous gland (tubulo - alveolar gland). glandular tissue (20%), stroma f adipose and fibrous connective tissue (80%). The alveoli: Are the basic unit of the breast Each alveolus (0.2 mm in diameter). Lobule: Each contain 10-100. alveoli. Lobes: Each contain 20-40 lobule All are drained by a single lactiferous duct that opens to the exterior at the nipple. towards the areola they form the lactiferous sinuses (small reservoirs of milk: (Cooper's ligament): Separate the lobes, it extends from the skin to the underlying pectoralis fascia.

5. The alveoli (the basic unit) each 0.2 mm in diameter It is arranged in lobuli (10-100 alveoli per lobule) Twenty to 40 lobules form lobes each lobe is drained by a single lactiferous duct The lactiferous duct converges towards the areola to form the lactiferous sinuses Each lobe is separated by (Cooper's ligament) that extends from the skin to the underlying pectoralis fascia.

6. The areola; is a specialized pigmented skin that surrounds the nipple; it contains sweat glands and sebaceous glands (glands of Montgomery) that hypertrophy during pregnancy. It lubricates and protects the nipple during lactation. The innervation of the nipple and areola mediate the neurohumoral reflexes responsible for the removal of milk from the gland and the release of prolactin. Lymphatic drainage of the breast: Approximately 75% of the lymphatic drainage goes to the regional axillary lymph nodes.

7. The alveoli Lobule Lobes Anatomy of breast.

8. supernumerary nipples (polythelia) Accessory breasts or nipple giving rise to or beasts can occur along the breast lines. which run from the axilla to the groin. Underdevelopment of one breast in relation to the other is a common anomaly in approximately 3-5% of population. Breast tissue, the glandular and non-glandular elements are sensitive to the cyclic hormonal changes of menstrual cycles

9. Extensive polythelia along milk line

10. The Breast and The Menstrual cycle parenchymal proliferation of the ductal system Estrogen During the follicular phase dilatation of the ductal system and differentiation of the alveolar cells into secretory cells Progesterone During the luteal phase • Women often experience breast tenderness and fullness during the premenstrual period. • There is an actual increase in the volume of the breast by 25-30 ml as measured by water displacement technique, due to increased blood flow, vascular engorgement and water retention.

11. Systematic approach to evaluation of breast problems History : The duration of symptom. Whether there has been any change If it is unilateral or bilateral, multiple or single. Relation to menstruation The patient background risk factors: most importantly age, family history of breast cancer, hormonal therapy...Etc. Examination: Systematic and careful examination is essential and presents a good opportunity for patient education on the proper method of self examination

12. Common benign breast diseases • Fibrocystic changes: • Fibroadenoma: • Phyllodes Tumour: • Mastitis: • Superficial thrombophlebitis (Monro's disease): • Chronic Periareolar Abscess:

13. Fibrocystic changes: Is commonly observed throughout women reproductive life with increasing frequency from teenage to the premenopausal period. Incidence: Approximately 10% of women under the age of 20 and up to 60-70% in the premenopausal years. Is an exaggeration of the normal physiologic response of breast tissue to the cyclical levels of ovarian hormones. Usually not associated with increased risk of breast cancer unless there is epithelial cell turnover. It is unusual after the menopause unless associated with exogenous hormones.

14. Fibrocystic changes - Histologically : • Stroma: Fibrosis • Alveoli: non proliferative cystic changes • Ducts: proliferative changes including hyperplastic ductal epithelium, • adenosis and occasional papilloma formation. The nature and type of predominate change scorrelates with age: In the Twenties: more intense proliferation of the stroma (fibrosis). May lead to fibroadenoma or juvenile hypertrophy may result. During the Thirties: both the glandular tissue and stroma respond to the cyclic changes of hormones. If excessive proliferation and hyperplasia of ducts, ductules and alveolar cells occurs, it results in cyclic pain and nodularity. In the Forties: the lobules and ducts involutes and there is no severe pain unless a cyst increase rapidly in size giving point tenderness and lumps. Periductal mastitis and duct ectasia may develop at this stage.

15. symptoms and signs of fibrocystic changes - Symptoms: cyclic premenstrual breast pain, commonly bilateral and mostly located in the upper outer quadrant of the breast. - Signs: On examination there is identifiable tenderness and nodularity which is usually described as ill-defined thickness or areas of "palpable lumpiness" that are rubbery in consistency. Larger cysts, if present, are felt as balloon filled with water. - Investigations: rarely required

16. Fibrocystic Changes The etiologic factors Unknown Hormonal: No hormonal abnormalities have been found, though the possibility of imbalance of estrogen and progesterone hormones as well as abnormal prolactin secretion have been suggested. Dietary factors with excessive consumption of methylxanthines containing foods (coffee, tea, chocolate and cola drinks) have been described

17. Fibrocystic Changes - The management • Reassurance: • Non pharmacological treatment: Breast Support, reduction of consumption of compounds that contain methylxanthines and tobacco, evening primrose oil administration, γ-linolenic acid a polyunsaturated fatty acid to replenish fatty acid deficiency. • Pharmacologic treatments: - Diuretics for 2-3 days in the premenstrual days. - Low estrogen contraceptive pills. - Progesterone administration: during the secretory phase. - Anti prolactin e.g. Bromocriptine (5 mg /day) -Tamoxifen. (antiestrogen competes with estrogen for the estrogen receptors in the breast) - Gonadotrophin releasing hormone (Gn-RH) analogs: - Danazol: 100-400 mg/day continuously • Surgical intervention: e.g. if a dominant mass, a cyst. More major surgery for cases of intractable pain or if biopsy showed a precancerous lesion.

18. Virginal hypertrophy, age 13.

19. Fibroadenoma: • The second most common benign breast lesion. • It affects women in their early twenties. • Is an aberrant growth of normal tissue rather than neoplasm. Clinically it is usually discovered accidentally as painless solid mass which is mobile, non tender and rubbery in consistency. Investigations: Ultrasound examination may be required in some cases to differentiate between a cyst and fibroadenoma.

20. Enormously enlarged right breast due to the presence of a giant fibroadenoma

21. Treatment: • Excision biopsy especially if it increases in size and in women above thirties years of age. • conservative treatment and assurance In young girls (<25 years) is appropriate. The frequency of carcinoma within a fibroadenoma is very low, with only 119 reported cases (Yoshida 1985). Approximately 30 % of fibroadenoma regresses spontaneously and in 10-20% it decrease in size.

22. Fat Necrosis: - clinically can be confused with breast carcinoma. - It usually follows trauma but the incident can not often be recalled by the patient. - Is felt as a tender, firm, irregular mass that may be associated with area of ecchymosis and even skin retraction. - The diagnosis is determined after excision biopsy.

23. Phyllodes Tumour • Is a Fibroepithelial breast tumour seen more frequently during the premenopausal age. • Histologically it has similarity to fibroadenomas but with distinct connective tissue hypercellularity with different type of connective tissue elements, pleomorphism and higher level of mitotic activity (Azzopard 1979). • The lesion is most frequently benign, in the same time it is the most frequent cause of breast sarcoma. • There have been reports of cases with benign histologic characteristics demonstrating unexpected metastases leading to subsequent patient demise. The lesion is treated by total excision with wide margin of healthy breast tissue.

24. Mastitis: • Is the most common inflammatory condition of the breasts. It is seen most commonly, but not always, among nursing mothers. • The causative organisms are Staphylococcus aureus and Streptococcus species. • Clinically: fever, erythema, induration and tenderness. If neglected it may progress to form a breast abscess. • Treatment with broad spectrum antibiotics or penicillin such as e.g. dicloxacillin can abort the progression of the infection. • lactation may continue from the unaffected breast while expressing the affected one in order to prevent milk engorgement.

25. Superficial thrombophlebitis (Monor's disease): • This is an uncommon inflammatory condition (Haagensen et all 1986). • It presents as acute pain or erythema in the upper lateral portion of the breast usually caused by an inflammation of the superficial veins. • It may be associated with pregnancy, breast trauma, or surgical plastic breast procedures. • The treatment is conservative with symptomatic treatment similar to superficial thrombophlebitis in any other location.

26. Chronic Periareolar Abscess: • Is an uncommon condition. More commonly seen in premenopausal women. • It presents as recurring tender erythematous nodule that develop just at the edge of the areola. • Due to chronic ductal infection secondary to obstruction of the duct by keratin and other ductal debris. • It is treated by expression but may require incision draining to prevent recurrence.

27. Breast Cancer: • Breast cancer is the most common malignant neoplasm in women and comprises 18% of all female cancers • The incidence is increasing particularly among women aged 50-64, probably because of breast screening in this age group. • It is estimated that one in eight women will develop breast cancer during her lifetime. • Gynecologist should be able to provide basic counsel to women about screening and prevention methods for breast cancer also advise regarding potential risks of hormonal therapy e.g. HRT, or contraceptive pills in relation to the development of breast cancer.

28. Risk By Age: A Woman's Risk of Developing Breast Cancer

29. Risk factors for breast Cancer: • Reproductive factors (Age at Menarche and Menopause, Age at first pregnancy) • Particular histological diagnosis of breast biopsies: namely atypical hyperplasia, lobular carcinoma in situ • Family history • Particular life style factors

31. Genetic risk of breast: • Approximately 5-10% of breast cancers occur in families in which there are many women with the disease. • Two highly penetrance breast-ovarian cancer genes have been identified BRCA1 and BRCA2, Both are tumour suppressor genes inherited as an autosomal dominant • It can be transmitted through either sex and that some family members may transmit the abnormal gene without developing the cancer themselves. • Together they account for about 5% to 7% of all cases of breast and ovarian cancer and for 50% to 70% of hereditary cases of breast cancer. • The remaining cases are considered as "familial clusters" of breast cancer in the absence of gene mutation, or due to a mutation in a gene which is as yet unidentified.

32. Breast and ovarian cancer when linked to BRCA1 and BRCA2 mutation it tends to strikes early in • Inheritance of BRCA1 and BRCA2 mutation increase women lifetime risk of developing breast cancer between 50% and 85% (a seven fold increase). • In addition BRAC1 mutation increases the risk of ovarian cancer by as much as 28 fold, from 1.8% to 50% by the age 70

33. Screening for breast cancer: Aim: To decrease mortality by detecting the disease at an early stage. Methods: Monthly breast self examination and mammographic examination. • Genetic Counseling and testing: For individuals with an increased likelihood of carrying a mutation. The interpretation of tests results whether negative or positive is a complex matter. The decision to undergo testing should be left to the individual woman herself after understanding the significance of the matter.

34. Mammography being performed with appropriate compression applied.

35. Normal mammogram and the process of aging. (A) the normal breast parenchyma is seen as ill-defined white densities located predominantly behind the nipple. In young women, the breast tissue can be extremely dense with only a small amount of interspersed fat, making tumors hard to see. (B) mammogram on the same patient several years later shows fatty replacement of most of the breast tissue.

36. An ultrasound examination of a young woman with a palpable lesion shows an echo-free simple cyst.

37. Preventive measure for women at genetic risk of breast and ovarian cancer: • Surveillance: intensive surveillance program. In addition chang in life still e.g. cessation of smoking, alcohol drinking and encourage exercise • Medical prophylaxis: e.g. OCP, Tamoxifen • Prophylactic surgery: Prophylactic oophorectomy:

38. Common Presentation of Breast Problems: • Breast pain or mastalgia. • Breast lumps. • Nipple discharge. • Presentation due to cosmetic complains e.g. too small or too large breasts…etc.

39. Breast Pain “Mastalgia” • Is defined as pain originating in the breasts. It may be localized in the breast or in a severe case may radiate to the axillae. • Should be differentiated from premenstrual breast discomfort which is not uncommon symptoms. But moderate to severe mastalgia estimated to occur in 11 % of cases. • Sometimes the symptoms are severe and can disturb daily activities, sex life and even sleep.

40. Etiology of breast pain • In the majority of cases no apparent cause can be found. • Important causes to exclude are pain originating from costochondritis junction. • mastitis or breast abscess. • The most common cause is fibrocystic changes • Cancer is infrequently present with pain. Pain is usually a late symptom of cancer..

41. Breast Pain Non Cyclic Pain Stretching of Cooper’s ligament Pressure from Bra Fat Necrosis Hydradenitis suppurative [Focal Mastitis Periductal Mastitis Cysts Mondor’s disease Cyclic Pain Hormonal stimulation Non Breast Pain Chest wall Tietze's syndrome Radicular pain from cervical arthritis Non Chest Wall Pain Gallbladder disease Ischemic heart disease

42. Management of Mastalgia • Careful history taking and examination. • Any risk factors for breast cancer should be identified (namely age, previous history, first degree relatives with breast cancer or previous biopsy with diagnosis of atypical ductal hyperplasia or lobular carcinoma in situ and long term users of HRT >10 years). Systemati Physical Breast examination. • In low risk patients usually no further investigations are required. • In high-risk women (>40 years) mammography and ultrasound • In most of cases management as in fibrocystic changes. • Patients with a breast lump or who fail to respond to medication or unilateral persistent pain in post-menopausal women should be referred for further evaluation in a center with facilities for imaging and cytology.

43. Nipple Discharge: • Spontaneous, persistent discharge in non lactating women can be due to a variety of causes: • Although in only approximately 3% nipple discharge is associated with breast carcinoma each case should be carefully evaluated. • The main objective is to rule out underlying malignancy. It is to be noted that the color of the discharge does not differentiate a benign from a malignant process. • Furthermore while cytology of the discharge is important it may yield false negative results in up to 20% of cases. • Therefore the diagnosis of the underlying cause of nipple discharge requires careful evaluation, mammographic examination and eventually excision biopsy.

46. Nipple Discharge No Galactorrhea Presence of Galactorrhea Hyperprolactinemia From one duct Bloody Serosanguineous Intraduct papilloma Ductal carcinoma in situ Paget’s disease of the breast From Multiple Ducts Fibrocystic changes Ductal ectasia

47. Breast Lump: • Breast Lump whether discrete or multiple is a common presentation and perhaps one of the most worrying for women. • The DD includes a variety of conditions. • The objective is to define cases that need further investigations or referral to breast specialist as opposed to cases with low index of suspicion for malignancy in which reassurance and watchful waiting may be appropriate.

48. Discrete Solitary Lump Age 30-50 yr Firm discrete lump Fibroadenoma, cyst, fibrocystic changes, ductal hyperplasia, atypical ductal hyperplasia, atypical lobular hyperplasia Age >50 yr Firm discrete lump Cyst, Ductal Carcinoma in situ, invasive cancer Age < 30 yr Firm rubbery Lump Fibroadenoma Diffuse Lumps (lumpy breast) Absence of Discrete lump Fibrocystic changes

49. Thank you

50. Lymphatics of breast.