Common Breast Disease
Dr. Chan Wing Cheong
Surgeon-in-charge
Breast Surgery, NTEC
Breast Anatomy and Location of
Disease Processes
Normal Breast Histology
Lymphatic Drainage
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Axillary nodes level 1,2,3
 most of the breast drain into axilla.
 pectoral nodes / breast and anterior chest wall
 sub scapular nodes / posterior chest wall and arm
 lateral nodes/ arm
 central (medial and apical) nodes/ drains all of the
above three groups of nodes
Infraclavicular
Supra-clavicular nodes
Internal mammary nodes
Abdominal nodes
Normal Breast Development and
Physiology
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At puberty the breast develops under the influence of the
hypothalamus, anterior pituitary, and ovaries and also requires
insulin and thyroid hormone
During each menstrual cycle 3 to 4 days before menses, increasing
levels of estrogen and progesterone cause cell proliferation and
water retention. After menstruation cellular proliferation regresses
and water is lost.
During pregnancy cellular proliferation occurs under the influence of
estrogen and progesterone, plus placental lactogen, prolactin and
chorionic gonadotropin. At delivery, there is a loss of estrogen and
progesterone, and milk production occurs under the influence of
prolactin.
At menopause involution of the breast occurs because of the
progressive loss of glandular tissue.
ANDI classification ( Hughes et al, 1992 )
Normal
Aberration
?? Disease
Reproductive phases
Periductal mastitis
Involution
cysts, duct ectasia, mild epithelial hyperplasia
Cyclical &
secretory
cyclical mastalgia & nodularity
Development
fibroadenoma, juvenile hypertrophy
Epithelial hyperplasia with
atypia
Giant fibroadenoma
(> 5cms)
Spectrum of breast changes
Multiple fibroadenomata
(> 5 per breast)
Aetiopathogenesis – Some Theories
Endocrine factors
1.
Disturbances in the Hypothalamo Pituitary Gonadal steroid axis
2.
Altered Prolactin profile – qualitative /quantitative change
Non endocrine factors
1.
Methyl xanthines, Stress
Genetic predisposition to catecholamine supersensitivity  Intra cellular
C - AMP mediated events 
2.
cellular proliferation
Diet rich in saturated fat
Altered plasma essential fatty acid profile  receptor supersensitivity to
normal levels of Oestrogen & Progesterone
3.
Iodine deficiency
Receptor supersensitivity to normal levels of Oestrogen & Progesterone
Carcinogenesis – Genetic Predisposition
Common Presenting Symptoms
Over 80 %
 Lump
 Painful lump or lumpiness
 Pain
Under 20 %
 Nipple discharge
 Nipple change
 Miscellaneous
Symptoms & Possible Diagnosis
1.Lump
Carcinoma
Fibroadenoma
Juvenile Fibroadenoma
Giant fibroadenoma
Phyllodes tumours
Cysts / Galactocele
2.Pain
Mastalgia : Cyclical &
Non cyclical
3.Nipple
discharge
Physiological
Bloodstained in
pregnancy
Intraductal papillomas
/ papillocarcinoma
Duct Ectasia
Galactorrhoea
4.Nipple
change
Developmental inversion of nipple
Acquired nipple retraction : duct
ectasia, periductal mastitis etc
Eczema
Paget’s disease etc.
Infections : Lactational & Non-lactational
5.Cosmetic
& other
problems
Comon cosmetic problems : size,
shape & symmetry of breast mound
Uncommon cosmetic problems :
developmental & acquired
Trauma
Rare problems
Benign vs. Malignant
Triple Assessment for
Breast Problem
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Clinical
Symptoms & signs
Assessment of risk factors
Imaging
Ultrasonography / Mammography
Other imaging tests
Pathological
Fine needle aspiration cytology
Core biopsy
Case Scenario
Case 1
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F/22
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Right breast swelling for 1 month
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No other symptoms
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What are the questions you want to ask?
Case 1
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USG breast:
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Compatible with a 1.5 cm fibroadenoma
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What would you offer her?
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What is the natural history of
fibroadenoma?
Case 2
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Same lady as case 1
No surgery after discussion
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However
Come back 7 months later
Size of lesion increases up to 5 cm
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What investigation do you want to do?
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Case 2
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USG
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Compatible with a giant fibroadenoma or
phylloides tumour
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Do you want to do FNA?
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What would you offer?
Case 2
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Wide local resection performed
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Pathology:
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Phylloides tumour of undetermined
malignant potential, margins appear to be
clear
How do you advice this patient?
Phyllodes Tumours
 Comprise less than 1% of all breast neoplasms
 May occur at any age but usually in 5th decade of life
 No clinical or histological features to predict recurrence
 16 - 30% may be malignant
 Common sites of metastasis : lungs, skeleton, heart and liver
Treatment of Phyllodes Tumours
1. Primary treatment
Local excision with
a rim of normal tissue
2. Recurrence
 Re excision
or
Mastectomy with or
without reconstruction
 Response to
chemotherapy and
radiotherapy for
recurrences and
metastases poor
Case 3
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F/52
Recently noticed a left breast lump
No pain
No other breast symptoms
Just menopause
What other questions regarding her problem
that you will ask ?
Risk Estimation for Breast Cancer
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RELATIVE RISK <2
Early menarche < 12 years
Late menopause > 55 years
Nulliparity
Proliferative benign disease
Obesity
Alcohol use
Hormone replacement therapy
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RELATIVE RISK 2–4
Age 35 first birth
First-degree relative with breast cancer
Radiation exposure
Prior breast cancer
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RELATIVE RISK >4
Gene mutation
Lobular carcinoma in situ
Atypical hyperplasia
Case 3
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P/E:
2.5 cm mass over upper outer aspect of
left breast
 Quite mobile
 No palpable axillary LN
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What would you do next ?
Case 3
Left
Case 3
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MMG / USG breast
2.5 cm mass
 No axillary nodes
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Core needle biopsy
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Invasive carcinoma
What would you offer?
Options
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Modified radical mastectomy
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MRM + reconstruction
 Autologus tissue flap
 Prosthesis
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Wide local excision + axillary dissection +
post-op RT
Any adjuvant therapy?
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Chemotherapy
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Radiotherapy
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? Indications
? Indications
Hormonal therapy
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? Indications
Case 4
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F/55
Good past health
Routine physical check-up
Screening mammogram
 Left breast microcalcification
What is your plan?
Options
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Stereostatic core biopsy
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Mammotome
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Contra-indicated in suspicious lesion ( BIRAD )
For small & likely benign microcalcification
Hook-wire guided excision biopsy
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For suspicious lesion
Aims to achieve a clear margin
Mammotome Biopsy
Hook-wire Guided Excision
If core biopsy confirms DCIS,
what’s next?
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If solitary, < 3cm, not high grade
 Wide local excision + RT
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Otherwise,
 Total mastectomy +/- reconstruction
 Axillary node dissection not required
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Hormonal therapy if ER / PR positive
Case 5
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F/ 43
Recent onset of left breast mastalgia
Clinically palpable thickening of breast
tissue over L3H
MMG not revealing
Needle biopsy: insufficient material
Thus open excision biopsy
Case 5
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Histopathology:
Lobular carcinoma in situ
 No invasive component
 All margins appear to be clear of tumour
cells
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What would you suggest to the patient?
Lobular Carcinoma (15-20%)
LCIS
Invasive LC
Case 6
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F/ 36
Mother of 2 children
Brownish stain on the inside of
undergarment
No pain
No nipple change
Differential Diagnosis?
How would you like to investigate furhter?
Ductogram
What can be offered to the patient ?
Case 7
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F / 67
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Not significant PMH
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Recent L breast pain
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What is the diagnosis ?
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What would you offer to
her ?
Management for
individual problem
Pain
Mastalgia
• Cyclical mastalgia
• Non cyclical mastalgia
•True (breast related)
• Musculoskeletal : costochondral or lateral chest wall
Infections
• Lactational infections
• Nonlactational infections
True breast pain
• Central : Periductal mastitis (inflammation, mass, abscess, mammary duct
fistula)
• Peripheral : associated with diabetes, rheumatoid arthritis, steroid usage,
trauma etc.
• Rare : Tuberculosis, Granulomatous mastitis, Diabetic (lymphocytic)
mastitis, etc.
• Skin associated : infected Sebaceous cyst, Hidradenitis suppurativa etc.
Mastalgia
Definition : Pain severe enough to interfere with daily life or lasting
over 2 weeks of menstrual cycle
True breast pain
True breast pain
Lateral chest
Costo
wall pain
Chondral pain
mild
Musculo skeletal pain
Management Protocol for True
Mastalgia
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Assess type of pain
Assess severity of pain ( Pain diary + Visual analogue scale )
Evaluation with Triple assessment
Treatment :
 Reassurance is the key to management
 Use of supportive undergarments
 Low fat, Methyl xanthine restricted diet
 Stop Oral contraceptives / HRT etc
Review patient. Successful in the majority ( 80 – 85 % ) of
patients
Use drugs in those not responding to non-pharmacological
treatment
Review and assess response
Drugs of Established Value in
Mastalgia
Drug
Dose
Clinical response
Side
Comments
effects
Evening
3 g / day
primrose oil
Danazol
Cyclical mastalgia 44 %
Low ( 2% )
Efficacy as medicine
Non cyclical mastalgia
questioned. Marketing
27%
authority withdrawn.
200mg / day reduced to
Cyclical mastalgia 70%
High (22%)
More effective in Cyclical
100 mg on alternate
Non cyclical mastalgia
mastalgia.
days (low dose regime)
30%
Some side effects may be
permanent.
Bromocriptine
Tamoxifen
2.5 mg twice / day
Cyclical mastalgia 47%
(incremental dose
Non cyclical mastalgia
regime)
20%
10 mg / day
Cyclical mastalgia 94%
High (45%)
Not recommended due to
serious side effects
High (21%)
Not licensed for use in
Non cyclical mastalgia
Mastalgia.
56%
Used in Refractory
mastalgia & relapse
Goserelin
3.75 mg / month
Cyclical mastalgia 91%
High
Major loss of trabecular
intramuscular depot
Non cyclical mastalgia
bone limits use in Refractory
injection
67%
mastalgia & relapse
Nipple Discharge
Causes of nipple discharge
Benign (common)
Physiological causes
Intraductal pailloma
Blood stained nipple discharge of
pregnancy
Galactorrhoea
Periductal Mastitis
Duct Ectasia
Malignant (less common)
In situ carcinoma (DCIS)
Invasive carcinoma
Characteristics of Nipple Discharges
Non significant nipple discharge
Significant nipple discharge
Elicited
Spontaneous
Age < 40 years
Age > 60 years (new symtom)
Bilateral
Unilateral
Intermittent
Persistent
Thick
Watery
Non troublesome
Troublesome
Multiductal
Uniductal
Negative test for blood (reagent stick test for
Positive test for blood
blood)
Management of Spontaneous Nipple Discharge
Spontaneous nipple dischare
Triple assessment
Normal
Multi ductal
Distressing symptoms
Total duct excision
Abnormal
Uniductal
Surgery
Minor symptoms
Minor symptoms/
No suspicion of malignancy
Distressing symptoms/
No suspicion of malignancy
Distressing symptoms/
Suspicion of malignancy
Reassure
Reassure
Microdochectomy
Surgery
Galactorrhoea
Causes of galactorrhoea
Physiological causes
Drugs
Pathological causes
Extremes of age
Oestrogen therapy
Hypothalamic lesions
Stress
Anaesthesia
Pituitary tumors
Mechanical stimulation
Dopamine receptor blocking agents
Reflex causes : Chest wall injury, Herpes
Dopamine re-uptake blocker s
zoster neuritis, Upper abdominal surgery
Dopamine depleting agents
Hypothyroidism
Inhibitors of Dopamine turnover
Renal failure
Stimulation of serotoninergic system
Ectopic production : Bronchogenic and
Histamine H2-receptor antagonists
renal carcinoma
Management :
 Estimate Prolactin levels. If very high, evaluate for pituitary lesion
 Physiological - Reassurance, cessation of stimulation
 Drug induced - Stop or change drug if possible
 Pathological - Cabergoline / Bromocriptine, treat cause if possible ( e.g. Pituitary
surgery )
Breast Mass
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Just prominent glandular tissue
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Cyst
 Simple vs. complex
 Abscess if painful and inflammed
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Solid mass
 Benign tumors
 Fibrocystic disease
 Carcinoma
 Fat necrosis
Benign Lumps
Cysts
Common in the West ( 70 % of women )
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50% are solitary cysts
30% 2 - 5 cysts &
rest have > 5 cysts
Types
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Apocrine cysts
Lined by secretory epithelium
Cyst fluid has a Na : K ratio < 3
Likely to have multiple cysts
Likely to develop further cysts
Non-apocrine cysts
Cyst fluid has a Na : K ratio >3
Resembles plasma
Mixture of both
Management Algorithm for Cysts
Cyst
(Clinical diagnosis)
Fine needle aspiration
Non blood stained aspirate
No residual mass
No cyst recurrence
Residual mass
Cyst recurrence (X3)
No routine followup
Surgical biopsy
Blood stained aspirate
FNAC/Surgical biopsy
Fibroadenoma
Types
Solitary
Few
( < 5 / breast )
Multiple ( > 5 / breast )
Giant
( > 4 / 5 cm ) & Juvenile
Natural history
Majority remain small & static
50% involute spontaneously
No future risk of malignancy
Management Algorithm for
Fibroadenoma
Fibroadenoma
(clinical diagnosis)
Triple assessment
All results concurr
Age < 30 years
Results do not concurr
Age > 30 years
Multiple fibroadenomas
(Selective triple assessment)
Giant fibroadenoma/
Juvenile fibroadenoma
Clinical observation for 2 years
Excision
with rim of normal tissue
Excision of largest
Clinical observation of rest
Extracapsular Excision
No change/ shrinkage / disappearence
Increase in size/
At patient request
Discharge with advice on BSE
Extra capsular Excision
Chances of malignancy masquerading as Fibroadenoma
Age 20 – 25 yrs 1: 3000 possibility
Age 25 – 30 yrs 1: 300 possibility
Breast Carcinoma
Breast Cancer – No. 1 Cancer
Among Women in HK
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Most common cancer among women since 1994
No. 2 cancer killer among women in HK between
1981-1998
Due to decline in mortality rate, emerged as No.
3 cancer killer since 1999
According to 2002 figures, an average of 1 in 23
women would develop cancer
An average of 1 in around 100 women would die
from breast cancer
In 2002, 2,059 new cases and 425 deaths were
registered
Risk Factors
Cause of breast cancer is undetermined. However,
the following risk factors are identified:
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History of breast cancer
Family history of breast cancer, especially in
first degree relatives
Benign breast lesions – ADH, ALH etc.
Early menarche, late menopause
Late first pregnancy / no pregnancy
Exogenous estrogen (HRT)
Radiation
How is Breast Cancer Treated ?
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The type of treatment recommended will depend on
the size and location of the tumor in the breast, the
results of lab. tests done on the cancer cells and the
stage or extent of the disease.
Treatment can be divided into local treatment or
systemic treatment.
Local treatments are used to remove, destroy or
control the cancer cells in a specific area, such as
the breast.
Surgery and radiation treatment are local treatments.
Systemic treatments are used to destroy or control
cancer cells all over the body.
Chemotherapy and hormone therapy are systemic
treatments.
A patient may have just on form of treatment or a
combination, depending on her needs.
The Importance of Staging
TNM Classification
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TX
T0
Tis
Primary tumour cannot be assessed
No evidence of primary tumour
Carcinoma in situ or Paget’s disease of the
nipple with no tumour.
T1
2cm or less in greatest dimension
 T1a
0.5cm or less in greatest dimension
 T1b
More than 0.5cm, but not more than 1cm in
greatest dimension
 T1c
More than 1cm but not more than 2cm in
greatest dimension
T2 Tumour more than 2cm but not more than 5cm in
greatest dimension
TNM Classification
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T3 tumour more than 5cm in greatest dimension
T4 tumour of any size with direct extension to chest
wall or skin
 T4a
Extension to chest wall
 T4b
Oedema (including peau d orange) or
ulceration of the skin of breast or satellite
skin nodules confined to same breast
 T4c
Both T4a and T4b
 T4d
Inflammatory carcinoma
Regional Lymph Nodes (TNM)
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NX
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N0
N1
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N2
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N3
Regional lymph nodes cannot be assessed
(e.g. Previously removed or removed for
pathologic study)
No regional lymph node metastasis
Metastasis to movable ipsilateral axillary
lymph node(s)
Metastasis to ipsilateral axillary lymph
nodes that are fixed to one another or to
other structures
Metastasis to ipsilateral internal mammary
lymph nodes(s)
Distant Metastasis (TNM)
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MX
Presence of distant metastasis
cannot be assessed
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M0
No distant metastasis
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M1
Distant metastasis (includes
metastasis to ipsilateral
supraclavicular lymph node)
AJCC/UICC Stage Grouping
Tis
T1
T0
T1
T2
T2
T3
Stage 0
N0
M0
Stage I
N0
M0
Stage IIA
N1
M0
N1
M0
N0
M0
Stage IIB
N1
M0
N0
M0
Stage IIIA
T0
N2
M0
T1
N2
M0
T2
N2
M0
T3
N1
M0
T3
N2
M0
Stage IIIB
T4
Any N M0
Any T N3
M0
Stage IV
Any T Any N M1
Local-regional Control
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Surgery
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Toileting mastectomy
Modified radical mastectomy (MRM)
Wide local excision + axilla dissection
Wide local excision + sentinel node biopsy
Radiotherapy
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Must be given if breast conservative treatment is
applied
Otherwise depends on staging or resection
margin
Axillary Dissection
Therapeutic vs. staging
 SLNB
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Systemic Control
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Chemotherapy
 AC or Taxol
 Indications:
 Positive axilla nodes
 Node negative
 Young age
 High grade tumor
 Size > 1 cm
 Hormonal receptors negative
 C-erb 2 positive ( Herceptin )
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Hormonal therapy
 Mainly for tumors expressing hormonal receptors
 No age limit now
 Usually 5 years
 Tamoxifen, AI
Cosmetic Consideration
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BCT
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Reconstruction
Prosthesis
 Flap
 Prosthesis + flap
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Breast Conservation Treatment
Must be accompanied with post-op RT
Prosthesis
Silicone gel saline bag
Latissmus Dorsi Flap
TRAM Flap
TRAM Flap
Questions & Answers
Dr. Chan Wing Cheong
Surgeon-in-charge
Breast Surgery, NTEC