Breast Breast Disease II

Transcription

1 Handouts for Medical Students at SQU Handouts for Medical Students at SQU Breast Breast Disease II By: Dr. By: Adil Dr. Adil Al Ajmi Al Ajmi 1

2 Congenital abnormalities Extra nipples and breasts Between 1% and 5% of men and women have supernumerary or accessory nipples or, less frequently, supernumerary or accessory breasts. These usually develop along the milk line: the most common site for accessory nipples is just below the normal breast, and the most common site for accessory breast tissue is the lower axilla. Accessory breasts below the umbilicus are extremely rare. Extra breasts or nipples rarely require treatment unless unsightly, although they are subject to the same diseases as normal breasts and nipples. 2

3 Absence or hypoplasia of the breast One breast can be absent (Amazia) or hypoplastic, usually in association with defects in pectoral muscle(poland s syndrome). Some degree of breast asymmetry is usual, and the left breast is more commonly larger than is the right. True breast asymmetry can be treated by augmentation of the smaller breast, reduction or elevation of the larger breast, or a combination of procedures. Classification of Benign Breast Conditions 1) Normal 2) Aberrations 3) Disease 1) Normal: Lumpy Changes in relation to menstrual cycle Involution starts by 30y - microcyst formation - Fibrosis - adenosis + min/mod hyperplasia 3

4 2) Breast development and involution The breast is identical in boys and girls until puberty. Growth begins at about the age of 10 and may initially be asymmetrical: a unilateral breast lump in a 9-10 year old girl is invariably developing breast, and biopsy specimens should not be taken from girls of this age as they can damage the breast bud. The functional unit of the breast is the terminal duct lobular unit or lobule, which drains via a branching duct system to the nipple. The duct system does not run in a truly radial manner, and the breast is not separated into easily defined segments. The lobules and ducts - the glandular tissue - are supported by fibrous tissue and ligaments (suspensory ligaments) - the stroma. Most benign breast conditions and almost all breast cancers arise within the terminal duct lobular unit. After the breast has developed, it undergoes regular changes in relation to the menstrual cycle. Pregnancy results in a doubling of the breast weight at term, and the breast involutes after pregnancy. In nulliparous women breast involution begins at some time after the age of 30. During involution the breast stroma is replaced by fat so that the breast becomes less radiodense, softer, and ptotic (droopy). Changes in the glandular tissue include the development of areas of fibrosis, the formation of small cysts (microcysts), and an increase in the number of glandular elements (adenosis). The life cycle of the breast consists of three main periods: development (and early reproductive life), mature reproductive life, and involution. Most benign breast conditions occur during one specific period and are so common that they are best considered as aberrations rather than disease. 4

5 Aberrations of breast development Juvenile or virginal hypertrophy Prepubertal breast enlargement is common and only requires investigation if it is associated with other signs of sexual maturation. Uncontrolled overgrowth of breast tissue can occur in adolescent girls whose breasts develop normally during puberty but then continue to grow, often quite rapidly. No endocrine abnormality can be detected in these girls. Patients present with social embarrassment, pain, discomfort, and inability to perform regular daily tasks. Reduction mammoplasty considerably improves their quality of life and should be more widely available. Fibroadenoma Although classified in most textbooks as benign neoplasms, fibroadenomas are best considered as aberrations of normal development: they develop from a whole lobule and not from a single cell, they are very common, and they are under the same hormonal control as the remainder of the breast tissue. They account for about 13% of all palpable symptomatic breast masses, but in women aged 20 or less they account for almost 60% of such masses. There are three separate types of fibroadenoma: common fibroadenoma, giant fibroadenoma, juvenile fibroadenoma, and. There is no universally accepted definition of what constitutes a giant fibroadenoma, but most consider that it should measure over 5 cm in diameter. Juvenile fibroadenomas occur in adolescent girls and sometimes undergo rapid growth but are managed in the same way as the common fibroadenoma, as reassuring and conservative management. 5

6 A definitive diagnosis of fibroadenoma can be made by a combination of clinical examination, ultrasonography, and histopathology usually with FNAC (Fine Needle Aspiration Cytology. They have characteristic mammographic features in older patients when they calcify, and a few patients have multiple fibroadenomas. Current evidence of the natural history of fibroadenomas suggests that less than 5% of them increase in size and about one quarter get smaller or completely disappear. Management fibroadenomas are managed conservatively. Indication for surgery: Patient request Size: Giant Fibroadenomas over 4 cm in diameter should be excised. Age: In women aged under fibroadenomas do not need excision unless this is requested by the patient. In women aged over a selective policy of excision should be used to ensure that breast cancers are not missed. Changes in the size over time. 6

7 Aberrations in early reproductive period Pain (mastalgia) Cyclical pain is very common in all ages, when is severe or prolonged is regarded as an aberration. Many women have breast tenderness and pain, also called mastalgia. It may come and go with monthly periods (cyclic) or may not follow any pattern (noncyclic). Cyclic pain is the most common type of breast pain. It may be caused by the normal monthly changes in hormones. This pain usually occurs in both breasts. It is generally described as a heaviness. The pain is usually most severe before a menstrual period and is often relieved when a period ends. Cyclic breast pain occurs more often in younger women. Most cyclic pain goes away without treatment and usually disappears at menopause. Noncyclic pain is most common in women 30 to 50 years of age. It may occur in only one breast. It is often described as a sharp, burning pain that occurs in one area of a breast that radiates to the axilla and arm. Noncyclic breast pain may also originate outside the breast in the chest wall, muscles, joints or heart, and radiate to the breast. The cause usually is pectorals muscle pain which is treated with NSAID. Treatment An imbalance of fatty acids within the cells may affect the sensitivity of breast tissue to circulating hormones. This theory provides the rationale for taking evening primrose oil capsules as a remedy for breast pain. Evening primrose oil contains gamma-linolenic acid (GLA), a type of fatty acid. GLA is thought to restore the fatty acid balance and decrease the sensitivity of breast tissue to circulating hormone levels.gamolinic, this is the gold standard to treat cyclical pain, Danazol, Bromocriptine, are used for the treatment of severe cyclic breast pain. These medicines are rarely used because they have significant side effects.. You may also be able to relieve breast pain by:. Taking magnesium. Magnesium supplements taken in the second half of the menstrual cycle (usually the 2 weeks before the next period) relieve cyclic breast pain as well as other premenstrual symptoms. Reducing dietary fat to 15% or less of your dietary intake is likely to reduce breast pain over time. Studies have not shown that avoiding caffeine relieves breast pain. But some women feel they have a decrease in breast pain when they decrease the amount of caffeine they consume. You may be able to prevent breast pain, tenderness, or discomfort by wearing a sports bra during exercise. It is important that the sports bra fit properly. It should keep the breasts almost motionless and allow them to move together with the chest, not separately.. A young woman with developing breasts may need to buy a new bra every 6 months. 7

8 Nodularity Cyclical nodularity are so common that they can be regarded as physiological and not pathological.. Focal breast nodularity is the most common cause of a breast lump and is seen in women of all ages. When excised most of these areas of nodularity show either no pathological abnormality or aberrations of the normal involutional process such as focal areas of fibrosis or sclerosis. The preferred pathological term is benign breast change, and terms such as fibroadenosis, fibrocystic disease, and mastitis should no longer be used by clinicians or pathologists. Aberrations of involution Cystic disease This term should be restricted to the clearly defined group of women with a palpable breast cyst. Cystic disease affects 7% of women in Western countries, and cysts constitute 15% of all discrete breast masses. Cysts are distended and involuted lobules and are seen most frequently in perimenopausal women. Most present as a smooth discrete breast lump that can be painful and is sometimes visible. Cysts have characteristic halos on mammography and are readily diagnosed by ultrasonography. The diagnosis is established by needle aspiration, and providing the fluid is not bloodstained it should not be sent for cytology. After aspiration the breast should be reexamined to check that the palpable mass has disappeared. Any residual mass requires full assessment by mammography and fine needle aspiration cytology as 1-3% of patients with cysts have carcinomas; few of these are associated with a cyst. Patients with multiple cysts have a slightly increased risk of developing breast cancer, but the magnitude of this risk is not considered of clinical significance. Mammogram of discrete breast lesion with surrounding halo characteristic of breast cyst. 8

9 Sclerosis Aberrations of stromal involution include the development of localised areas of excessive fibrosis or sclerosis. Pathologically, these lesions can be separated into three groups: sclerosing adenosis, radial scars, and complex sclerosing lesions (this term incorporates lesions previously called sclerosing papillomatosis or duct adenoma and includes infiltrating epitheliosis). These lesions are of clinical importance because of the diagnostic problems they cause during breast screening. Excision biopsy is often required to make a definitive diagnosis. Duct ectasia The major subareolar ducts dilate and shorten during involution, and, by the age of 70, 40% of women have substantial duct dilatation or duct ectasia. Some women with excessive dilatation and shortening present with nipple discharge, nipple retraction, or a palpable mass that may be hard or doughy. The discharge is usually cheesy, and the nipple retraction is classically slit-like. Surgery is indicated if the discharge is troublesome or the patient wishes the nipple to be everted. Slit-like nipple retraction due to duct ectasia (left) and nipple and nipple retraction due to breast cancer (right) 9

10 3) Disease Epithelial hyperplasia Epithelial hyperplasia is an increase in the number of cells lining the terminal duct lobular unit. This was previously called epitheliosis or papillomatosis, but these terms are now obsolete. The degree of hyperplasia can be graded as mild, moderate, or florid. If the hyperplastic cells also show cellular atypia the condition is called atypical hyperplasia. The absolute risk of breast cancer developing in a woman with atypical hyperplasia who does not have a first degree relative with breast cancer is 8% at 10 years: for a woman with a first degree relative with breast cancer, the risk is 20-25% at 15 years. 10

11 Breast Inflammation (Mastitis) Mastitis most commonly affects women while they are breast feeding. Cracking of the skin around the nipple allows bacteria from the skin surface to enter the breast duct where it grows and attracts inflammatory cells. Inflammatory cells release substances to fight the infection, but also cause breast tissue swelling and increased blood flow. Mastitis is treated with antibiotics. However, if a collection of pus (an abscess) from inflammatory cells and fluid results, the pus may have to be drained with aspiration. ORGANISM RESPONSIBLE FOR BREAST INFECTION TYPE OF INFECTION NEONATAL LACTATING NON LACTATING SKIN ASSOCIATED ORGANISM STAPHYLOCOCCUS AUREUS ESCHERICHIA COLI (RARE) STAPHYLOCOCCUS AUREUS STREPTOCOCCI (RARE) STAPHYLOCOCCUS AUREUS ENTEROCOCCI BACTEROIDES SPP STAPHYLOCOCCUS AUREUS FUNGI (RARE 11

12 Management of breast abscess Lactating mastitis is more commonly seen Skin Normal Needle Aspirate + Antibiotics Thinned or necrotic Needle aspiration or Mini I + D Br Med J 1994; 309: Non lactating mastitis Can be divided in two: 1) Centrally Periareolar region (periductal mastitis) Young mean age 30 years. Periareolar inflammation,(+ -) mass Active inflammation around non dilated duct, unlike ductectasia Confused with ductectasia. Smoking important in aetiology Treatment: Antibiotics and needle aspiration Exclude underlying neoplasm if mass is palpable Recurrence high because affected duct not excised (hence excision advised) 1/3 develop fistula 2) Peripheral Less common Associated with DM,,RA,,steroids treatment and trauma Pilonidal abscess been reported Associated with granulomatous lobular mastitis. Treatment: As central 12

13 Peripheral mastitis Central (periductal) mastitis Granulomatous Lobular Mastitis Young multiparous women Unknown aetiology Present with Mass +/- erythema High Recurrent + troublesome Conservative management Avoid surgical excision as its associated with complications (fistula) Steroids no proven value Treat 2 o infection - drain abscesses and treat with antibiotics Augmentin and Metronidazole for long period 13

14 Nipple discharge Nipple discharge is the third most common breast complaint after lumps and breast pain. A woman's breasts have some degree of fluid secretion activity throughout most of the adult life. In non-lactating women, small plugs of tissue block the nipple ducts and keep the nipple from discharging fluid. nipple discharged can be single or multi ducts and of different colours. During breast self examination breast, fluid may be expressed from the breasts of 50% to 60% of Caucasian and African-American women and 40% of Asian-American women. The majority of nipple discharges are associated with non-malignant changes in the breast such as hormonal imbalances. However, any woman with a suspicious or worrisome nipple discharge should be assessed with triple assessment. When nipple discharged is of concern: Blood stained or watery (serous) with a red, pink, colour Sticky and clear in colour (opalescent) Appears spontaneously without squeezing the nipple Persistent On one side only (unilateral) Bloody discharge during pregnancy and lactation is fairly common and usually not related to papilloma. During pregnancy and lactation, breast tissue grows rapidly and this can lead to duct irritation that causes bloody nipple discharge. This discharge should not interfere with nursing. If the discharge persists after lactation has stopped, it should be evaluated further Causes of nipple discharged \: Carcinoma invasive or non invasive (DCIS) Papilloma Periductal mastitis Ductectasia 14

15 Gynaecomastia Gynaecomastia (the growth of breast tissue in males to any extent in all ages) is entirely benign and usually reversible. It commonly occurs in neonate, puberty and old age. It is seen in 30-60% of boys aged years and usually requires no treatment as 80% resolve spontaneously within two years. Embarrassment or persistent enlargements are indications for surgical referral. Gynaecomastia is seen increasingly in body builders who take anabolic steroids; some have learnt that by taking tamoxifen they can combat this. Danazol produces symptomatic improvement in some patients with gynaecomastia. Patient with left sided gynaecomastia 15

16 Causes of Gynaecomastia 1) Physiological : Neonatal, Puberty, and Senile New born (neonate) gynaecomastia can effect new born because oestrogen passes through the placenta from the mother to the baby, this is temporary and will disappear soon. Puberty during puberty, boys hormone levels vary. if the level of testosterone drops, oestrogen can cause breast tissue to grow, this usually clears up as boys get older. Old age (Senile) As men get older, they produce less testosterone, also men tend to have more body fat, and this can cause more oestrogen to be produced. this can lead to excess of breast tissue growth., 2) Pathological: Primary Testicular Failure Klinefelter's Syndrome Acquired Testicular Failure: Mumps, Irradiation Tumours: Testicular, Adrenal, Pituitary Non-Endocrine Tumours: Bronchial carcinoma, Lymphoma, Hypernephroma Hepatic Disease: Cirrhosis, Haemochromatosis. 3) Drugs: Oestrogens and oestrogen agonists ( digoxin, spironolactone, methyldopa, phenothiazines ). Testosterone target cell inhibitors (cimetidine, cyproterone Acetate) Treatment Physiological gynaecomastia is managed conservatively and is benign and often reversible, surgery is only done for cosmetic reason. 16

17 Phyllodes Tumours From Greek (phullon leaf) are distinct pathological entities and cannot always be clinically differentiated from fibroadenomas are rare fibro-epithelial breast lesion. Most phyllodes tumors present as palpable, solitary, well-defined, mobile, and painless breast massesare typically large, fast growing masses that form from the periductal stromal cells of the breast. They account for less than 1% of all breast neoplasms. Palpable axillary lymph nodes are encountered in 20% of patients with phyllodes tumors, but histologic evidence of malignancy is encountered in fewer than 5% of axillary lymph node dissections for clinically positive nodes. Tumors are classified histologically as low, intermediate, or high grade on the basis of five criteria: 1) stromal cellularity, 2) stromal atypia, 3) the microscopic appearance of the tumor margin (infiltrating, effacing, or bulging), 4) mitoses per 10 high-power fields, and 5) the macroscopic size of the tumor. Structural and cytogenetic studies of constituent cells have demonstrated similarities between fibroadenomas and phyllodes tumors, and there is evidence that certain fibroadenomas develop into phyllodes tumors. The diagnosis of phyllodes tumor should be considered in all patients with a history of a firm, rounded, well-circumscribed, solid (i.e., noncystic) lesion in the breast. FNA is usually non diagnostic, primarily because of the difficulty of obtaining adequate numbers of stromal cells for cytogenic analysis. core biopsy or Simple excisional biopsy should be performed if aspiration fails to return cyst fluid or if ultrasonography demonstrates a solid lesion. Because phyllodes tumors mimic fibroadenomas, they are often enucleated or excised with a close margin Although most phyllodes tumors have minimal metastatic potential, the most common site of metastasis from malignant phyllodes tumors is the lungs (via the hematogenous route). They may be considered benign, borderline, or malignant (cystosarcoma phyllodes) depending on histological features including: stromal cellularity, infiltration at the tumor's edge, and mitotic activity. They have a proclivity for local recurrence and should be excised with at least a 1 cm margin. Local recurrence has been correlated with excision margins but not with tumor grade or size. If a simple excision cannot be accomplished without gross cosmetic deformity or if the tumor burden is too large, a simple mastectomy should be performed. Radiation therapy may have a role in the management of patients with chest wall invasion. Chemotherapy, which is reserved for patients with metastatic disease, is based on guidelines for the treatment of sarcomas. 17

18 References: Moore, K. L., 1982 The developing human. Clinicall oriented Embryology. W. B. Ssaunders Company, Philadelphia, London, Toronto, Mexico City, Rio de Janeiro, Sydney, Tokyo. Chetty, U., 1998 The breast In: Applied Surgical Anatomy. A guide for the surgical trainee. Editors: G;asby, M. A.. Owen, W. J. and Kristmundsdottir, F. Butter worth Heinemann, Oxford, Auckland, Boston, Johannesburg, Melbourne, New Delhi. Greenhall, M. J., Cancer of the Breast Oxford Textbook of Surgery Dixon J. M., 1993 Breast conservation Surgery. In recent Advances in Surgery. Editors: Taylor, Johnson, C. D. Churchill Livingstone. Edinburgh, London, Madrid, Melbourne, New York and Tokyo. Seltzer MH: Breast complaints, biopsies, and cancer correlated with age in 10,000 consecutive new surgical referrals. Breast J 10:111, 2004 Henderson IC: Risk factors for breast cancer development. Cancer 71(suppl):2127, 1993 Slattery ML, Kerber RA: A comprehensive evaluation of family history and breast cancer risk. JAMA 270:1563, 1993 Newcomb PA, Storer BE, Longnecker MP, et al: Lactation and a reduced risk of premenopausal breast cancer. N Engl J Med 330:81, 1994 Marchant DJ: Estrogen-replacement therapy after breast cancer: risk versus benefits. Cancer 71(suppl):2169, 1993 Wingo PA, Lee NC, Ory H, et al: Age specific differences in the relationship between oral contraceptive use and breast cancer. Obstet Gynecol 78:161, 1991 Belkacémi Y, Bousquet G, Marsiglia H, et al. (2007). "Phyllodes Tumor of the Breast". Int J Radiat Oncol Biol Phys 70 (2): 492. doi: /j.ijrobp PMID Barth RJ Jr, Wells WA, Mitchell SE, Cole BF (2009). "A prospective, multi-institutional study of adjuvant radiotherapy after resection of malignant phyllodes tumors.". Ann Surg Oncol. 16 (8): doi: /s PMID