Breast Disease

Anatomy of breasts: large modified sebaceous glands within superficial fascia of the anterior chest wall.

Wt: 200-300g, 20% glandular tissue and 80% fat and connective tissue.

Composed of 12-20 lobes arranged radial fashion from the nipple.

Lymphatics: 75% regional axillary nodes (30-60 #), other route internal mammary, direct spread to mediastinum-intercostal glands, subpectoral and subdiaphragmatic. Lymphatic drainage usually flows toward the most adjacent group of nodes. Thus the concept represents basis for sentinel node mapping.

Benign breast disease                                                            

1. Fibrocystic changes- cysts within ducts and increased fibrous tissue, irregular, nodular and cyclically painful breasts. Exaggeration of normal psychological response of breast tissue to cyclic levels of ovarian hormones. Occurs 20-50 years old.

• Three clinical stages: mastoplasia (pt 20’s) pain upper, outer quadrants, due to proliferation of stoma. Adenosis (pt 30’s) less pain and cystic (pt 40’s) no breast pain.
• Management: support bra, diuretics, decrease consumption caffeine and tobacco.
• Drug of choice danazol (FDA approved rx mastalgia) 100, 200, 400 mg daily for 4-6 months but no more than 6 months. If no response, then trial of bromocryptine or tamoxifen (which completes with estrogen receptor in breast.)
• Cancer risk depends upon biopsy findings
  • Non-proliferative- no risk
  • Proliferative- 2x risk
  • Atypical- 5x risk
  • Atypical + family Hx- 11x risk

1. Fibroadenomas second most common. Usually adolescents and women in their 20’s. Don’t change size with meses, no pain or tenderness. Rx conservative 6 month follow-up vs. surgery. Fine needle aspiration should be performed to rule out any malignancy with either histologic or cytologic evaluation.
2. Cystosarcoma phyllodes- most frequent breast sarcoma rapidly growing fifth decade of life. 1:4 is malignant. Rx benign cystosarcoma is exision with wide margin of normal tissue.
3. Intraductal papilloma- bloody discharge from one nipple, perimenopausal women, and spontaneous and intermittent. Can be watery, serous or serosanguineous. Located under areola in 75%. With pressure, you should identify whether it’s a single duct or multiple ducts. With single duct, can be intraductal papilloma or cancer vs. multiple ducts most likely cancer. Rx biopsy of involved duct and surrounding tissue.
4. Nipple discharge- milky-galactorrhea, multicolored and sticky-ductal ectasia, purulent-mastitis, serous/serosanguineous. Can be either intraductal papilloma, fibrocystic, or cancer.
5. Fat necrosis- rare, related to trauma. Mammography stippled calcification and stellate contractions. Skin associated skin retraction similar to cancer. Rx- excisional biopsy.
6. Breast cyst- variant fibrocystic changes, present in 30-50 year olds, frequent pain and tenderness which worsens premenstrually then regresses.

• Management- office needle aspiration. Mass deflates and clear fluid. No further eval.
• Bloody fluid sent cytology and biopsy, mass remains diag mammo and US. If reoccurrence restrict caffeine, OC, if recurs twice then excision.

#1 cause of cancer in women. Increase diagnosis whites > blacks, death in blacks > whites

#2 cause of death after lung cancer.

Risk: 1/50 at 50 years old, 1/24 at 60 years old, and 1/10 at 80 years old

Hereditary breasts and ovarian cancer (HBOC) gene mutation explains 5-10% breast cancer. 80% due to BRCA 1-2 gene mutation. BRCA 1-2 is responsible for preventing DNA errors, but mutated BRCA genes allow DNA errors.

• 1/3 cases of 20-29 years old
• Of women with breast < 50 years old and one close relative with breast <50 years old, mutation is present in 18%
• 45% have BRCA1 (mapped chromosome 17), 35% have BRCA2 (chromosome 13), 20% other mutations.
• BRCA positive lifetime risks
• 50% by 50 years old
• 87% by 70 years old
• Ovarian cancer by 70 years old. BRCA1 150% (40-60%) BRCA2 15% (10-20%)

Risks of HBOC:

1. Personal history of early breast cancer, bilateral, in multiple sites, ovarian cancer (at any age)
2. Previously indentified BRCA 1-2 mutation in family
3. 1^st degree relative (mother/sister) with premenopausal breast cancer
4. More than 2 family members (maternal or paternal) with breast or ovarian cancer
5. Ashkenazi Jewish heritage with family history of breast cancer at any age
6. Family history: Cowden of Li-Fraumeni syndrome

No increased risk-adenosis, fibroadenoma, mastitis, mild hyperplasia

Slight increased risk- moderate hyperplasia, papilloma

Increased risk- atypical hyperplasia, high breast density

Mammographic breast density- 3-5 times greater risk of breast cancer in women with high breast density on mammo vs. women with low density

• Density decreased advancing age, menopause, heavier body weight, earlier childbearing
• Density increased with hormonal use
• Birad system breast density is rated category 1-4 (4 being the greatest density)

Breast cancer and endogenous hormones-

• Reproductive history- 1^st term pregnancy < 30 years protective, transient increase risk in 2-3 years after delivery, greater protection with a larger number of term pregnancies, lactation minimally positive or no effect
• Oophorectomy at under 35 years old: 75% reduction in risk

Breast cancer and exogenous hormones-

• OCP neither cause nor protect
• HT- estrogen only no risk, E+P increased risk more notable with longer duration of use and correlated with increased breast density. E+P may be weak promoters but not cause of breast cancer.

Prevention of breast cancer in high risk women-

• low fat diet, exercise, ideal body weight, limit alcohol and stop smoking, limit HT use for women to 2 years use
• Prophylactic mastectomy with reconstruction > 90% breast reduction
• Prophylactic oophorectomy 75% reduction ovarian cancer and breast cancer.
• Chemoprevention
• SERMS- tamoxifen-49% dec if high risk, 86% ductal hyperplasia. Raloxifene equal to tamoxifen (STAR trial) in reducing risk of invasive breast cancer, but more VTE
• Aromatase inhibitors- arimidex, Femara
• 70-80% ER + breast tumors prevented. Few side effects and better outcomes

Breast cancer screening in high risk women-

• Mother with breast cancer: begin 10 years before mother diagnosed
• Family history/BRCA+
• CBE and mammo every 6-12 months, starting 25-30 years
• Ovarian cancer screening 6-12 months, from 40 years old: CA 125, US and color Doppler

• Breast ultrasound- conjunction with mammo. Uses cystic vs. solid masses, small invasive cancers if dense breast, and vascular assessment
• MRI- Gadolinium contrast identifies neovascularity. Sensitivity 90%, performed early in menstrual cycle.
• Annual MRI- MBRCA mutatiob, 1^st degree relative of BRCA carrier, radiation to chest between age 10 and 30 years, Li-Fraumeni syndrome and first degree relatives, Cowden and Bannayan- Riley- Ruvalcaba syndromes