By Luis Hamilton,2014-05-11 21:17
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    Mar 2007

    Anatomy and Physiology

    o Probably the most important thing to remember is simply the constituents of the


    o Constituents of a breast:

    o Ducts with single layer of columnar epithelium sitting on a myoepithelial

    layer (like the muscularis mucosa of the bowel)

    ; 10-15 ducts that have lobules at one end and exit at the nipple.

    o Fibrous stroma (including Cooper’s ligaments)

    o Fat

    o Lymphatic vessels

    o Blood vessels.

    o See Mastery of Surgery for details especially deep and lymphatic anatomy.

    Breast Tests

    o Mammography

    o How to look at mammograms

    ; Craniocaudal views (CC):

    ; Put them up with the bases of the breasts together.

    ; By convetion, the labels are on the lateral sides.

    ; MLO and ML views

    ; Put them up with the chest walls together

    ; The chest wall should be visible up to ? way down the

    breast base and there should be some soft tissue at the

    bottom of the film below the breast

    ; The nipple usually gets a beebee put on it.

    ; Metal rings are usually place on skin lesions

    o The idea that mammograms are not useful in patients <30 is hogwash.

    ; The denser breast tissue makes them not AS useful but they are

    still of value especially serial exams

    ; So don’t deny young women mammograms.

    o Divided into Screening and Diagnostic mammography

    o Screening Mammography

    ; Detects 8 breast cancers per 100 patients screened for the first time

    ; Detects 2 breast cancers per 100 patients screened each year.

    ; Current recommendations:

    ; Age 40-49 screening mammography at least every 2


    ; Age 50 + - screening mammography every year.

    ; See Sabiston p 878 for details of the studies showing benefits of

    screening mammography and why there was a big flap in 2001

    ; (a Lancet meta-analysis using only 2 of the 8 studies said

    that screening mammography was not useful it sucked

    though and repeat meta-analyses showed that it is useful)

    o Diagnostic Mammography

    ; Performed when there is an abnormality on clinical exam or

    screening mammogram

    ; Uses two additional techniques

    ; Magnification views

    o To further characterize calcifications

    ; Benign ones are monomorphic, round or

    sometimes tea cup shaped

    ; These are just within cysts.

    ; Compression views

    o If you have an opaque abnormality, it may just be

    an additive effect due to overlying benign fibrous

    tissue or it may be a mass

    o Squash the breast, and if the abnormality is due to a

    conglomerate of normal things then it will splay out.

    ; if it’s a mass, then it will stay opaque.

    o Mammograms are reported using the Breast Imaging Reporting and Data System (BI-RaDS)

    ; 0 = incomplete assessment (poor films)

    ; 1 = negative film no abnormalities

    o resume normal screening

    ; 2 = abnormality that is clearly benign

    o resume normal screening

    ; 3 = abnormality that is probably benign

    o earlier screening (6 months) or biopsy (pt specific)

    ; 4 = Suspicious abnormality

    o requires biopsy

    ; 5 = Highly suggestive of malignancy

    o FNA

    o 22-Ga needle

    o the real use of this is just to differentiate cysts from masses (which

    ultrasound can also do)

    o but it’s not a bad start

    o cannot differentiate DCIS from invasive Ca

    o Core Biopsy (aka large core needle biopsy)

    o The major way of biopsying non-palpable lesions

    o Radiologists in Edmonton will do this for anything that they are

    concerned about.

    o Can be U/S guided or stereotactic

    o Uses XR of the biopsy specimen to ensure that calcifications were

    included in the biopsy.

    o What to do with the results:

    ; If the results are inconclusive or if they are discordant with the

    mammographic findings then you must do an excisional biopsy

    (wire guided if not palpable)

    ; The real value of these is in finding cancer so that you can plan

    an appropriate oncologic procedure when it is necessary

    ; They have little negative predictive value!

    ; Examples

    ; Atypical cells is it DCIS or just atypia?

    ; Mammogram looks like Ca, biopsy looks benign

    ; Increased cellularity (fibroadenoma vs phyllodes)

    ; Calcifications not removed.

    ; In all of these cases, you have to excise the mass.

    Benign Disease

    1. Fibrocystic Change

    o A spectrum of mammographic, clinical and histological findings that occur in older women (present in some form in 90% of women in autopsy studies)

    o Dx:

    o Clinical: diffuse nodularity, tenderness, mild pain, often associated

    with cyclical mastalgia

    ; O/E anything from diffuse, sy

    ; mammetrical changes in texture (esp UO quadrant) to dense,

    firm breast tissue with lumps and cysts all over.

    o Mammographically: symmetrical, diffuse dense breast tissue

    o U/S cysts are common in women taking hormones or still


    o Histologically: macro and microcysts, adenosis, sclerosis, apocrine and

    squamous metaplasia along the duct lining (this makes the cheesy cyst

    contents th at look like dermoid contents)

    o Significance:

    o Without associated hyperplasia 1.5x RR of Ca later on

    o With associatd hyperplasia 1.9x RR of Ca later on.

    o Tx:

    o According to Sabiston - the ones with atypia can be offered Tamoxifen

    as chemoprevention (5 year course because after that, tamoxifen has

    an estrogen agonist effect).

    o In Edmonton, it is regarded as normal change in normal breasts with

    age so we don’t treat it.

    2. Breast Cysts

o Usually found as a mass by the patient

    o Influenced by ovarian hormones

    o So they often show up in the days leading to menses and resolve at the

    end of menses

    o Occur between the ages of 35 and menopause

    o Gross cysts in older women are either due to hormone therapy or cancer

    o Dx:

    o U/S

    o Aspiration

    o Incidental in OR these are often “blue dome cysts” (just because of

    their color)

o Significance:

    o risk of cancer in a cyst is very low!

    ; One study (Rosemond) looked at 3000 cyst aspirations and

    found only 3 cancers (0.1%)

    o Also, the presence of cysts alone doesn’t appear to increase patients’

    risk of Ca

o Management:

    o Simple cysts don’t need anything (not even aspiration) if it’s in a

    patient of the right age, changes with the menstrual cycle.

    o Aspirate if you are concerned about a mass associated with it

     Send for cytology if: o

    ; Bloody fluid (this is even debatable but Dr Dabbs does this)

    ; Cyst does not resolve with aspiration

    ; Cyst recurs more than twice

    o If you aspirate a cyst, decide what you are going to do with the result

    first and write the plan in the chart (eg “monitor if negative” or

    “excise no matter what”)

    o Recall: the goal of aspirating or biospying a mass that you’re going to

    take out anyway is to choose what operation you’re going to do.

    3. Fibroadenoma

o Aka adenofibroma

    o Stromal and epithelial elements (hence the name)

    o Basically just a tight conglomerate of glandular and fibrous tissue with

    no fat

    o Dx:

    o Appear in teenage girls (most common tumor of teenage girls)

    o After age of 25, the risk of the mass being malignant starts to climb so

    biopsy all of them even if they feel, sound, smell, look like


    ; Dr Dabbs

    o They do NOT occur after the age of 40

    o Clinically: firm, solitary tumors that may be lobulated

    ; They slip easily under the examining fingers.

    o U/S: differentiates them from cysts easily (besides, cysts don’t really

    occur in teenagers anyway)

    o FNA: normal tissue. So it’s not very useful (how would you know if

    you hit it?)

    o Significance:

    o No increased malignant potential!

    o However, they are made of breast tissue, so cancer can develop in one. o Having had a biopsy showing fibroadenoma carries a 2x RR of cancer

    ; Having had a biopsy at all carries a 1.8x RR of cancer though.

    o Management:

    o Age < 25 and classic nothing. You can just watch it. In fact, it’s ok

    just to tell her to come back if it changes.

    o Age 25+ - biopsy it. Core is the only way.

    o Excision:

    ; If the patient wants it

    ; If you know that it is a fibroadenoma, then a circumareolar

    incision is ok

    ; Remove it with a minimal amount of breast tissue

    o Juvenile/Giant Fibroadenoma

    o Occur in adolescents and are often giant (defined as > 5 cm)

    o Tx: Removal

    ; Don’t put a drain in

    ; Dr Dabbs “for some reason, they don’t get giant seromas, and

    the breast just returns to normal size and shape”

    4. Breast Abscess and Mastitis

    o Mastitis can occur in anyone

    o Breast abscess

    o A couple of types

    1. Along with mastitis (big, hot, edematous breast with an underlying


    o This occurs in lactating women especially

    2. A solitary abscess, usually just with overlying skin changes and no

    diffuse mastitis (these are usually subareolar)

    o This occurs in older women who smoke

    o Occurs with duct ectasia/cystic change

o Don’t forget – the differential is only two deep

    o Mastitis vs Inflammatory Breast Ca!

o Evaluation/tx:

    o Mastitis

    ; Give the patient some sedation and palpate the breast

    ; If you find an abscess (which you will if there is a rip-

    roaring mastitis going on), aspirate it with a HUGE needle

    (14 Ga angiocath for example)

    ; Then infuse a few cc’s of local + a few cc’s H2O into the

    cavity and withdraw just to irrigate it out.

    ; Warn the patient that you will probably have to do this

    again (maybe a couple of times)

    ; Give antibiotics

    ; Mastitis alone = Keflex (or Ancef if it’s really bad)

    o Always caused by S. aureus

    ; Mastitis + Abscess = Clindamycin

    o Once you have a nice blocked-off cavity

    anaerobes start growing.

    o Solitary abscess

    ; Aspirate and give clindamycin

    ; Warn them that you will probably have to aspirate it a

    couple of times

    ; Subareolar ones will often keep coming back until you do

    an I&D

o Zuska’s Disease

    o A fistula between the nipple and the edge of the areola because of

    recurrent abscesses

    o This is exactly like a perianal abscess and the treatment is the same

    o Under GA, put a lacrimal probe throught the fistula and deroof it


    o If you are concerned about inflammatory breast cancer then biopsy the skin

    (either a 3 mm punch biopsy or even just an FNA will do fine), treat with

    antibiotics in the interim and watch the patient closely.

    5. Papilloma

    o This is the most common cause of bloody nipple discharge. o True polyps of the ductal epithelium (you can see them clearly with

    ductoscopy even though this is useless and not done in Canada) o Can even get big enough to present as a mass.

o Usually 0.5 1 cm, but can be 5 cm

    o Presentation:

    o Bloody nipple discharge

    o Palpable subareolar mass

    o Tx:

    o Excise them

    o Identify the duct with the bloody discharge and MARK it with a

    marker before putting any local in

    ; The local will just squash the duct and make it impossible to

    put a probe in

    o Then put a lacrimal probe in the duct

    o Make a radial incision from the duct opening to the edge of the areola

    (that’s as far as you have to go)

    o Cut out the involved duct (don’t cut it open)

    o If it’s a mass rather than a leaking duct then you should do an

    oncologic type excision (incision over the mass and removal)

    6. Sclerosing Lesions

    1. Fat Necrosis

    o Do NOT use this diagnosis when a patient presents with a mass that

    she found after trauma (even though fat necrosis is caused by trauma

    and presents with a mass)

    o MOST masses found after trauma have nothing to do with

    the trauma!!!

    o Presents as a mass or as a mammographic abnormality (calcification,

    dense scar)

    o Dx:

    o Biopsy all of them (core)

    o Histology lipid laden macrophages, scar tissue, chronic

    inflammatory cells

    o Significance:

    o Has NO malignant potential but you may have to take it out to

    secure the dx.

    o Tx:

    o Watch it and reassure the patient.

    2. Radial Scar

    o Typically a mammographic finding

    o Just by convention, radiologists call a lesion <1cm a “radial

    scar” and once > 1cm a “sclerosing lesion”

    o Can also produce a mass, skin dimpling

    o Histologically these are a mess of cysts, ductal hyperplasia, adenosis

    and sclerosis.

    o Significance:

    o High risk of associated malignancy!

    o 20% of them have a neighbouring malignancy (usually DCIS)

    o Management:

    o Remove all of them! End of story

3. Sclerosing Adenosis

    o As the name suggests, there is adenosis (increased density of glandular

    tissue) and scarring

    o Looks like Ca in everyway (mammographically, histologically (to the

    untrained eye) and clinically)

    o Most common finding on core needle biopsy

    o The problem is that this problem just represents one of the fibrocystic

    changes so if you see it on a biopsy, then you haven’t accomplished

    anything. (ie you missed the mass)

    o Management:

    o If there is a mass, then you can either biopsy again or, better

    yet, just excise the mass.

4. DCIS (see below)

    7. Nipple Discharge

    o Very common (even in non-lactating or older patients)

    o Very rarely due to cancer in all comers (5% risk even in the most suspicious


    o Causes

    o Single duct

    ; Papilloma (vast majority)

    ; Duct ectasia (typically toothpaste like essentially this is

    sebum from squamous and apocrine metaplasia within ecstatic


    ; Carcinoma

    o Multiple Ducts

    ; Galactorrhea (ie milk)

    ; Something is telling the breast to make milk

    ; DDx:

    o Breastfeeding

    o OCP

    o Hyperprolactinemia (very rare, but a serum

    prolactin level will resolve the question if you

    are concerned)

    ; Non-milky

    ; Fibrocystic change

    ; Medications

    o Thiazides

    o TCA’s

    o Maxeran

    o Cimetidine

    o Verapamil

    o Significance:

    o One study of 270 patients with single duct discharge found 16 (6%)

    had cancer. In every one, the fluid was bloody or positive hemoccult

    o So 1/20 with single duct discharge have cancer. o Questions to ask:

    o Unilateral vs Bilateral?

    o One duct or many?

    o Associated Mass?

    o Bloody?

    o Breastfeeding?

    o New Medications?

    o Management:

    o Single Duct excise the duct!! Regardless of what the fluid looks like

    ; This is why there is no point doing a hemoccult test your

    going to excise the duct regardless.

    ; As above

    ; Mark the duct with a marker

    ; THEN put local in

    ; Then put a lacrimal probe in the duct and make a

    RADIAL incision from the nipple to the edge of the

    areola and excise the duct

    o This type of incision heals VERY well

    o Associated Mass

    ; Excise the mass (that is where the money is)

    ; Do an oncologic resection (ie incision overtop of the mass)

    ; No axillary staging because you haven’t diagnosed a


    o Multi Duct

    ; Try to make a diagnosis based on Hx, P/E, labs.

    ; Very rarely will you have to do anything.

    8. Mastalgia

o Again very common and very benign

    o Only 5% of breast cancers present with pain

    o Breast pain (especially bilaterally with no associated mass is virtually

    always benign)

    o Questions to ask:

    o Mass or no mass?

    o Cyclical or Non-cyclical?

    o 3 basic presentations

    o Pain with a mass

    ; Fibrocystic change

    ; Abscess

    ; Fibroadenoma

    ; Breast cancer

    o Cyclical pain with no mass (usually dull, diffuse aching/tenderness)

    ; Functional (varies with menses)

    ; OCP/HRT (usually subsides after 3 cycles of the therapy)

    ; Fibrocystic change

    o Noncyclical pain with no mass (often sharp and unilateral)

    ; Usually not from the breast

    ; Costochondritis

    ; Muscular (especially post irradiation)

    ; GERD

    ; Angina

    ; Pulmonary

    ; Fibrocystic change

    ; Mastitis

    ; Mondor’s

    ; Breast Ca (especially inflammatory breast cancer)

    o Management:

    o Careful physical exam for all of them especially for signs of a mass

    or signs of inflammatory breast cancer

    ; Ie pale nipple, effaced nipple, peau d’orange, striae, erythma,

    firm/dense edematous breast tissue.

    o Use it as an excuse to get a mammogram

    o Pain with a mass:

    ; Workup the mass as for any other mass (don’t worry about the


    ; Biopsy it. +/- Ultrasound.

    ; Focus on the mass. The mass. The mass. The mass. The mass. o Cyclical pain

    ; Reassurance is all that is usually necessary o Non-cyclical pain

    ; Mammogram

    ; Breast exam

    ; If no mass, signs of inflammatory breast cancer or

    mammographic abnormality, then it is benign!

    ; Reassurance will cure 85% of them (or at least make them go


    ; Suggestions:

    o Wear a supportive bra

    o Ibuprofen 600 mg prn

    o Evening primrose oil (1.5 g qd)

    o Danazol DON’T DO THIS.

    o Bromocriptine DON’T DO THIS.

    o Tamoxifen DON’T DO THIS (not allowed in

    Canada anyway)

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