Breast Tumors (dr. mosad)
Types of breast mass lesions
Benign
Traumatic fat necrosis
Galactocele
Duct Ectasia
Fibrocystic diseases
Fibroadenoma
Duct papilloma
Phyllodes tumor
Papillary cystadenoma
Malignant
Carcinoma
Sarcoma
Fibroadenoma
- The most common tumor female breast.
- It is composed of both glandular and fibrous tissue
- etiology: unknown, It can be AND (aberration of normal development
- May be seen along with Fibroadenosis (ANI)
- Pathology:
• Increased sensitivity to estrogen or increased secretion unopposed by
progesterone for long time
• Mostly spherical; may be multinodular
• They typically stop growing after 2 to 3 cm size
• May harbor lobular carcinoma in situ
• It has 2 Types according to amount of fibrous tissue relative to
glandular tissue, both variants can co-exist
- Clinical features
• More common in blacks
• The peri-canalicular occurs in younger females (15 to 30 yrs), The
intracanalicular affects older age group (30 to 50 yrs)
• Painless, slow growing solitary lump (pain when associated fibro
adenosis or fibro cystic disease)
• Mostly seen in the lower part of the breast
• Multiple may be present; 10% cases
• Intracanalicular can grow large causing pain due to stretching skin &
more liable to malignant transformation esp.in older age
• No discharge per nipple
Pathology
Hard fibroadenoma
-firmer
-smaller
-moves well within the breast
tissue so called “breast
mouse”
-two capsules & in between
there is a line of cleavage:
1.True: fibrous
2.False: formed by
compressed breast
tissue
Microscopic picture -small acini impeded in a large
amount of fibrous tissue
-Peri-canalicular, ducts are
surrounded by fibrous tissue,
rounded
glands+
dense
fibrous tissue
Clinical picture
Age
Malignancy
Excision
Soft fibroadenoma
-relatively less firm
-grows larger with
profuse
connective
tissue “INTRADUCTAL
MYXOMA”
-few large amount acini
impeded in soft-firm
fibrous tissue
-Intra-canalicular, ducts
are compressed by
fibrous
tissue
so
glands show multiple
small projections
can grow large causing
pain due to stretching
skin
More common
younger females (15 to 30 older age group (30 to
yrs.)
50 yrs.)
Less liable
More Liable
It is well capsulated so Small projections may
enucleation is easy
be not seen & remain
leading to recurrence
so it needs safety
margin
On examination:
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No visible swelling ( large intra-canalicular may be visible)
Palpation: Freely mobile; more in young girls*
Firm consistency
No axillary lymph nodes, ( associated with axillary lymph nodes in cases of
accompanied mastalgia or inflammatory processes)
Treatment:
o Present trend: women under 25 yrs of age, routine excision is avoided
(the mass is small so Follow up & excision & biopsy if there is gradual
increase in size).
• The fibroadenoma grows up to 3 cm in 5 yrs
• Thereafter gradually become smaller
o In case of suspected pathology: excision & biopsy is the treatment of
choice
• Enucleation of the peri-canlicular variety : as it is well-capsulated
• Excision of the intra-canalicular variety : Small projections may be
not seen & remain leading to recurrence so it needs safety margin.
o Types of incisions:
• Circum-areolar/Peri-areolar or Sub mammary incision (Gaillard
Thomas’s incision) for cosmetic surgery
• If not possible then radial or curved incision over Langer’s lines.
Giant fibro adenoma
-
Grows more than 5 cm in size
Bimodal age of presentation (at puberty and peri-menopause)
More common in blacks
Epithelial hyperplasia and atypia, more liable for malignant
transformation
- Characterized by rapid growth
- Differentiate from phyllodes tumour, Benign virginal hypertrophy
On examination:
- Enlarged breast
- Displaced nipple position
- Stretched and shiny skin
- Dilated veins
- Skin necrosis may occur: if stretching existed for a long period + super
added infections or scratches or erosions
Treatment:
- Enucleation &biopsy
- In cases of older age or suspicious to malignancy: a fine needle
aspiration is obtained before surgery & assure the patient that there is
completion of surgery (mastectomy) in cases of malignancy or severe
atypia
Phyllodes Tumor
- Also called Cystosarcoma Phyllodes, Serocystic Disease Of Brodie or
Benign Cystosarcoma
- Mostly seen in premenopausal women (40yrs age)
- Show a wide range of histology
o From an almost benign condition resembling
fibroadenoma
o To the ones with high mitotic index
&premalignant condition
- Tumor has irregular projections: cause for
recurrences
Clinical features:
•
•
•
•
•
•
•
•
•
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Presents as massive tumour
Unevenly bosselated surface
Ulceration with long-term stretching
Pressure necrosis of overlying skin
Or warm, red, shiny skin with dilated veins
Normal nipple
Firm consistency
Smooth margins
Not fixed: the stretched skin can be picked up
No axillary lymph node involvement
Known for local recurrence due to prjections
N.B
Probe test:
- It is used to differentiate if necrosis occurring due to skin stretch or
infiltration
- A probe is inserted under the skin, if it passes smoothly then necrosis is
a result of skin stretching
Treatment:
• Younger women (Benign end of spectrum known by fine needle
aspiration): Simple enucleation
• Older patients (Malignant end of the spectrum): Wide excision with 1
cm margin or more
• Recurrences or malignancy: mastectomy with reconstruction
Duct papilloma
- Benign tumor, usually small
- Arising from their lining epithelium of lactiferous duct
- It may too small for clinical palpation, but may obstruct a duct for cyst
formation
- Not a pre-cancerous condition*
- Usually single and unilateral (60-70%)
- Papilloma has a stalk
- Papilloma vs papillomatosis (epithelial hyperplasia without a stalk)
Clinical features
- Age 30 to 50 yrs.
- Bloody discharge: commonest presentation & most annoying complain for
the patient
- In cases of obstruction & cystic formation: Small and soft lump palpable
beneath the areola or nipple; often difficult
- Discharge from the affected duct on pressing the lump
- May present with a cystic swelling; due to impalpable lump blocking the
duct
- No lymph nodes are affected, except in cases of superadded affection
Treatment
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Single duct is affected: Microdochectomy
complete excision of the affected duct
Wedge resection
If not palpable then gently probe the affected duct
Carry on the resection with 1mm distance from the probe
Papilloma is mostly situated 4-5 cm away from the nipple
Notes in Breast cancer
- Brca1&2 (tumor suppressor genes), so their mutations predispose tumors
- In all Hormonal risk factors: there is over exposure to estrogen unopposed
by progesterone
- In there is cancer in one side, risk increases for the other
- Ordinary eczema (compared to Paget’s eczema): bilateral, good response to
local ointment, no destruction of nipple& areola.
- Solid subtype of ductal carcinoma in situ =complete obstruction.
- Comedo subtype = solid subtype with central necrosis
- Breast lymphatic spread can be through supraclavicular &subclavian lymph
nodes
- Transperitoneal spread can also lead to blumer shelf tumor
- Mastitis carcinomatosis: mostly in pregnant & lactating women as pregnant
hormones accelerate process of tumor proliferation, it can be very
aggressive tumor in an early stage
So lactating & pregnant women that have symptoms of infection, edema,
redness & hotness in breast & don’t respond to medications must follow up
as it may be mastitis carcinomatosis
- Nipple discharge is mostly bloody
- Necrotic nipple discharge is a cheesy material
- Peau d orange occurs as a result to infiltration of lymph nodes around hair
follicles
- Satellite nodules occurs due to cancer cell deposition in lymphatic vessels
- Women<35 shouldn’t do mammography to avoid ionized radiation & not to
increase risk of malignancy
- MRI is done if a patient has a mass tumor excision to deffrentiate between
fibrosis & recurrence
- Mammogram
- Radiological examination for metastasis/metastatic workup: brain ct- chest xray- multislice ct for chest, abdomen & pelvis with contrast- bone scanning
‫نزودالحتة دي على الراديولوجوكال اكسامنيشن‬
- FNAC is done under local anesthesia
- Positive FNAC is diagnostic but negative cannot exclude malignancy
- Tru-cut needle is more accurate in diagnosis than FNAC
- T4= any size with superficial or deep infiltration
- Males usually have poor prognosis as it is detected in late stage
- The Pregnant have poor prognosis as pregnancy hormones make tumor very
aggressive & may lead inflammatory carcinoma
- The Obese have poor prognosis due late detection of mass in the big-sized
breast
- Breast conservative surgery: quadrantectomy+ lymph node clearance+
postoperative chemo or radiotherapy
- Immediate breast reconstruction= oncoplastic surgery
- Ductal infiltration is an indication of mastectomy
- Sentinel L.N biopsy: inject dye around areola, first L.N that pick up the dye is
excised & examined. Then, an intra-operative pathologist takes a section:
• if positive – do an axillary dissection
• negative – there is no lymph node affection
- sandwich technique: adjuvant chemotherapy, then surgery, then
postoperative chemotherapy
- hormonal treatment in case of post-operative positive estrogen receptors