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 Lymphatic vessels
o Blood vessels.
o See Mastery of Surgery for details especially deep and lymphatic anatomy.
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
; 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 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
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!
; 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.
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 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 Without associated hyperplasia – 1.5x RR of Ca later on
o With associatd hyperplasia – 1.9x RR of Ca later on.
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 Incidental in OR – these are often “blue dome cysts” (just because of
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 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.
o Aka adenofibroma
o Stromal and epithelial elements (hence the name)
o Basically just a tight conglomerate of glandular and fibrous tissue with
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 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 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.
; 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!
; 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
o Zuska’s Disease
o A fistula between the nipple and the edge of the areola because of
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.
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 Bloody nipple discharge
o Palpable subareolar mass
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
o Presents as a mass or as a mammographic abnormality (calcification,
o Biopsy all of them (core)
o Histology – lipid laden macrophages, scar tissue, chronic
o Has NO malignant potential but you may have to take it out to
secure the dx.
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
o High risk of associated malignancy!
o 20% of them have a neighbouring malignancy (usually DCIS)
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 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 Single duct
; Papilloma (vast majority)
; Duct ectasia (typically toothpaste like – essentially this is
sebum from squamous and apocrine metaplasia within ecstatic
o Multiple Ducts
; Galactorrhea (ie milk)
; Something is telling the breast to make milk
o Hyperprolactinemia (very rare, but a serum
prolactin level will resolve the question if you
; Fibrocystic change
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 New Medications?
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.
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
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
; 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
; Muscular (especially post irradiation)
; Fibrocystic change
; Breast Ca (especially inflammatory breast cancer)
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
; 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
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