1. ‫به نام خالق هستی بخش‬

2. Breast Disease
Sima Zohari
BSc , MSN
Faculty Member of Shahid Beheshti MedicinUniversity

3. Breast Anatomy
• Breast contains 15-20 lobes
• Fat covers the lobes and shapes the
breast
• Lobules fill each lobe
• Sacs at the end of
lobules produce milk
• Ducts deliver milk to the
nipple

5. Breast Clock and Quadrants

6. Breast Anatomy
• Four quadrants
• Parenchyma
– Alveoli Lobules Lobes
– Three tissue types
• Glandular epithelium
• Fibrous stroma and supporting structures
• Fat
– Cooper ligaments
• Fibrous continuations of the superficial fascia, which span the
parenchyma of the breast to the deep fascial layers

8. Breast Anatomy
• Nerves
– Long thoracic nerve
– Thoracodorsal nerve
– Medial pectoral nerve
– Lateral pectoral nerve

9. Breast Anatomy
• Vasculature
– Arterial supply
• Internal mammary artery(60%)
• Lateral thoracic artery(30%)
– Venous return
• Intercostals
• Axillary vein(primary)
• Internal mammary vein
– Lymphatics

10. Breast Anatomy
• Lymphatics
– Axillary chain
• Level 1 – lateral to pectoralis minor muscle
• Level 2 – along and under pectoralis minor
• Level 3 - medial to pectoralis minor
– Rotter’s nodes
• Between pectorial minor and major muscles
– Internal mammary chain (relatively minimal drainage)
• Parasternal
• medial

11. Regional Lymph Nodes for
Breast
• Infraclavicular (subclavicular) lymph nodes
– In the deltopectoral groove
• Supraclavicular lymph nodes
– Above the collarbone

12. Regional Lymph Nodes for
Breast
A: Pectoralis major
muscle
B: Axillary lymph nodes
level I
C: Axillary lymph nodes
level II
D: Axillary lymph nodes
level III
E: Supraclavicular lymph
nodes
F: Internal mammary
lymph nodes

13. Approach to Breast Problems
 History
 Age
 Family history (Cancer)
 Onset
 Duration Discharge
 Frequency
 Lump , Nodules Trauma
 Menstruation (menarche, menopause, contraceptives) Pain
 Inspection
 Symmetry
 Skin / Nipple Change
 Bulges / Retractions

14. Approach to Breast Problems
 Palpation
Breast
Axilla
Supraclavicular

15. Breast Examination

19. Diagnostic Work Up
 Ultrasound
 Mammography
 Biopsy
 Cyst aspiration
 MRI

20. • .

21. Classification Based On Histologic Types
 Non Proliferative Lesion
 Simple Cyst
 Complex cyst
 Proliferative Lesions – Without Atypia
 Ductal hyperplasia
 Fibroadenoma
 Intraductal papilloma
 Sclerosing Adenoma
 Radial Scars
 Atypical Hyperplasia
 Atypical ductal hyperplasia
 Atypical lobular hyperplasia

22. Classification Based On Clinical Features
 Mastalgia
 Cyclic
 Non Cyclic
 Tumors and Masses
 Nodularity or glandular
 Cysts
 Galactoceles
 Fibroadenoma
 Sclerosing Adenosis
 Lipoma
 Harmatoma
 Diabetic Mastopathy
 Cystosarcoma Phylloides

23. Classification Based On Clinical Features
 Nipple discharge
 Galactorrhea
 Abnormal nipple discharge
 Breast infections and Inflammation
 Intrinsic mastitis
 Postpartum engorgement
 Lactation mastitis
 Lactation breast abscess
 Chronic recurrent subareolar abscess
 Acute mastitis associated with macrocystic breasts
 Extrinsic infections
 Mondor’s Disease
 Hidradenitis suppurativa

24. Benign Breast Disease
• Infectious and inflammatory
• Benign lesions
• Nipple Discharge
• Mastalgia

25. Infectious and Inflammatory Breast
Disease
• Cellulitis, mastitis
– Usually associated with lactation
– Treat with 10-14 day course antibiotics to cover Staphylococcus and
Streptococcus
• Abscess
– Treated by surgical drainage
• Chronic subareolar abscess
– Occurs at base of lactiferous duct, and squamous metaplasia of duct may
occur.
– Sinus tract to areola develops
– Treatment requires complete excision of sinus tract
– Recurrence is common
• Mondor’s disease
– Phlebitis of the thoracoepigastric vein
– Palpable, visible, tender cord along upper quadrants
– Ultrasound may be helpful in confirming this diagnosis.
– Treatment self-limited, can use anti-inflammatories if necessary

26. Benign Lesions of the Breast
• Fibrocystic breasts
– Broad spectrum of clinical and histologic findings
– Loose association of cyst formation, breast nodularity,
stromal proliferation, and epithelial hyperplasia.
– Appears to represent an exaggerated response of
breast stroma and epithelium to hormones and
growth factors.
– Dense, firm breast tissue with palpable lumps and
frequently gross cysts, commonly painful and tender
to touch.
– No consistent association between fibrocystic
complex and breast cancer.

27. Benign Lesions of the Breast
• Cysts
– Fluid-filled, epithelium-lined cavities
– Influenced by ovarian hormones
• Explains sudden appearance during the menstrual cycle, their rapid
growth, and their spontaneous regression with completion of the
menses.
– Common after age 35, and rare before 25. Incidence declines after
menopause.
– Three colors by needle aspiration
• Simple cyst, clear or green fluid and is benign.
• Milk-filled cyst, called galactocele and is benign.
• Bloody cyst is a cause of concern for malignancy.
– Tx depends on whether the cyst completely resolves after
aspiration
• Complete resolution, will follow up to ensure it does not recur.
• Incomplete resolution, Treat as breast mass and excise.Fluid-filled,
epithelium-lined

28. Benign Lesions of the Breast
• Fibroadenoma
– Well-defined, mobile benign tumor of breast
– Composed of both stromal and epithelial elements in the breast
– Common in younger women, and is most common tumor in
women younger than age 30 years
– Can be diagnosed by FNA and followed if < 2-3 cm and age < 35
– Otherwise Dx by excision. At operation are well-encapsulated
and detach easily.
• Phyllodes tumors (cystosarcoma phyllodes)
– Giant fibroadenomas
– Rarely malignant
– Treat with wide local excision

29. Benign Lesions of the Breast
• Sclerosing adenosis
– Proliferation of acini in the lobules, which may appear to have invaded
the surrounding breast stroma.
– Can simulate carcinoma both grossly and histologically.
• Epithelial and atypical hyperplasia
– Involves ducts or lobules
– If greater than moderate hyperplasia then indicates higher risk of breast
cancer
• Papilloma
– Polyps of epithelium-lined breast ducts
– Located under the areola in most cases
– When under the nipple and areolar complex it often present with a
bloody nipple discharge.
– Treatment is total excision through a circumareolar incision.
– Need to rule out invasive papillary carcinoma.

30. Benign Lesions of the Breast
• Mammary duct ectasia
– Generally found in older women.
– Dilatation of the subareolar ducts can occur.
– A palpable retroareolar mass, nipple discharge, or
retraction can be present.
– Tx involves excision of area.
• Fat necrosis
– Associated with trauma or radiation therapy to breast.
– Can simulate cancer with mass or skin retraction.
– Bx is diagnostic and generally with lipid-laden
macrophages, scar tissue, and chronic inflammatory
cells.

31. Benign Breast Disease
• Nipple discharge
– Pathologic nipple discharge is persistent and
spontaneous and is not associated with nursing.
• Requires further evaluation
• Galactorrhea
– Bilateral, milky discharge occurs
– Obtain prolactin levels, if highly elevated, suspect pituitary
adenoma as one of causes.
• Bloody nipple discharge
– Most common cause is intraductal papilloma
– Cancer present 10% of time.
– Cytologic exam on discharge
– Mammogram to rule out associated mass
– If drainage from isolated duct, then it should be excised.

32. Benign Breast Disease
• Mastalgia
– Cyclic pain
• Correlates with menstrual cycle.
• Can attempt to treat with danazol or bromocriptine
– Non-cyclic pain
• Drugs can be effective placebo
• NSAIDS may help
• Avoid caffeine and wear a supportive bra
– Cancer must be excluded through examination,
mammogram, and ultrasound if the pain is localized.

33. Evaluation & Management of Breast Pain
 Mastalgia should be treated when:
 It is severe enough to interfere with a woman’s life style
 It occurs more than a few days every month.
 History and Physical
 Diagnostic work up
 Mammogram
Micheal S sabel .Overview of benign breast disease. Uptodate 2008, November 14

34. Management of Breast Pain
Treatment Goals
 Alleviate pain
 Reduce or relieve irregularity
 Rule out cancer of the breast

35. Management of Breast Pain
 Diet and Lifestyle Modification
 Elimination of Methylxanthines, Caffeine and
Chocolates
 Reassurance
 Supportive Bra
 Low fat and high complex carbohydrate
 Vitamin E supplementation
 Evening Primrose oil
Micheal S sabel .Overview of benign breast disease. Uptodate 2008, November 14

36. Management of Breast Pain
 Pharmacological Treatment
 NSAIDs
 OCPs
 Danazol 100- 400mg per day
 75% of women with non cyclic pain will be symptom free
 SE: Weight gain , menstrual irregularity , acne , hirsutism
 Tamoxifen 10mg
 Bromocriptine – prolactin antagonist
 Surgery has no role in management of breast pain
Micheal S sabel .Overview of benign breast disease. Uptodate 2008, November 14

37. Evaluation & Management of Breast Pain
AAFP journal , April 15, 2000. Volume 61/ No. 8

38. Breast Masses
 Normal glandular tissue of the breast is nodular
 This is a general pattern or consistency of the breast
which include persistent lumpiness or nodularity which is
generally not abnormal when it is related to the
menstrual cycle.
 Dominant masses are characterized by persistence
throughout the menstrual cycle

39. Breast Masses: Cysts
Cystic Breast Mass
 Common cause of dominant breast mass
 May occur at any age, but uncommon in post menopausal
women
 Fluctuates with menstrual cycle
 Well demarcated from the surrounding tissue
 Characteristically firm and mobile
 May be tender
 Difficult to differentiate from solid mass
Micheal S sabel .Overview of benign breast disease. Uptodate 2008, November 14

40. Breast Masses: Cysts
 Fibrocystic Breast Disease
 Most common of all benign breast disease
 Most common between ages 20- 50
 50% of women with Fibrocystic changes have clinical
symptoms
 53% have histologic changes
 Believed to be associated the Imbalance of progesterone
and estrogen.
 May present with bilateral cyclic pain, breast swelling,
palpable mass and heaviness

41. Fibrocystic Breast Disease
 Physical Examination
 Tenderness
 Increased engorgement and more dense breast
 Increased lumpiness / glandular
 Occasional spontaneous nipple discharge
Micheal Sabel .Overview of benign breast disease. Uptodate 2008, November 14

42. Breast Cysts: Diagnostics
 Mammogram  Fine Needle Aspiration
 Cystic outline  Outpatient procedure
 No calcification  Non bloody fluid
 No increased density  Cyst disappears
 Ultra Sonogram  If bloody fluid, surgical
 Cyst biopsy of cyst is required
 Reexamination 4-6 weeks
after aspiration

43. Management of Breast Cysts
AAFP journal , April 15, 2000. Volume 61/ No. 8

44. Breast Masses

45. Breast Mass: Fibroadenomas
 Simple: Second most common benign breast lesion
 Benign solid tumors containing glandular as well as fibrous tissue . Usually
present as well defined, mobile mass
 Commonly found in women between the ages of 15 and 35 years
 Cause is unknown, thought to be due to hormonal influence
 May increase in size during pregnancy or with estrogen therapy
 Giant: Fibroadenomas over 10cm in size
 Excision is recommended
 Juvenile
 Variant of fibroadenomas
 Found in young women between the ages of 10 -18.
 Vary in size from 5 - 20cm in diameter. Usually painless, solitary, unilateral
masses
 Excision is recommended

46. Breast Mass: Fibroadenomas
(Cont’d)
 Complex
 Complex fibroadenomas contain other proliferative changes
such as sclerosing adenosis, duct epithelial Hyperplasia,
epithelial calcification.
 Associated with slightly increased risk of cancer
Dupont, WD page, DL, parl, FF, et al. Long term risk cancer in women with fIbroadenoma. NEJM 1994;331:10
Carty, NJ, Carter, c, Rubin, C et al management of fibroadenoma of the breast. Annals of royal college of surgeon England 1995:77:127
Micheal S sabel .Overview of benign breast disease. Uptodate 2008, November 14

47. Breast Mass
 Phylloides Tumors:
 Rapidly growing
 One in four malignant
 One in Ten Metastasize
 Create bulky tumors that distort the breast
 May ulcerate through the skin due to pressure necrosis
 Treatment consists of wide excision unless metastasis has occurred
 Fat Necrosis:
 Rare
 Secondary to trauma- often not remembered
 Tender, ill defined mass
 Occasionally skin retraction
 Treat with excisional biopsy

48. Breast Mass
 Galactocele
 Milk filled cyst from over distension of a lactiferous duct.
 Presents as a firm non tender mass in the breast,
 Commonly in upper quadrants beyond areola.
 Diagnostic aspiration is often curative.
 Duct ectasia:
 Generally found in older women.
 Dilatation of the subareolar ducts can occur.
 A palpable retroareolar mass, nipple discharge,
or retraction can be present.
 Tx involves excision of area

49. Nipple Discharge
 Majority of causes are benign
 Most common cause is lactational
 Overstimulation also common
 Prolactin secreting tumors
 Hypothyroidism
 Drugs
 Intraductal and other carcinomas
 Unilateral, spontaneous, bloody discharge is
suspicious

50. Nipple Discharge
 Intraductal Papilloma
 Benign growth within ductal system
 Presents as bloody nipple discharge
 Excision is the only way to differentiate from
carcinoma
 Galactorrhea
 Bilateral milky discharge
 Obtain prolactin level, TSH level

51. Nipple Discharge
 Good history
 Prolactin & TSH levels
 Mammogram
 Decrease stimulation

52. Breast Inflammation &
Infections
 Mastitis
 Most common in lactating female
 Dry, cracked fissured areola/nipple complex provides portal
for infection
 Usually caused by Staph/Strep organisms
 Rule out malignancy
 Treat with heat, continued breast feeding,
 Antibiotics for 10-14 days to cover staph and strept infections

53. Breast Inflammation &
Infections
 Abscess
 May present with breast swelling, tenderness and fever
 On PE, breast is tender , warm and fluctuant, may also have
purulent discharge
 Treated by surgical drainage

54. Breast Inflammation &
Infections
 Mondor’s Disease
 Phlebitis of the thoracoepigastric and lateral thoracic vein
 Palpable, visible, skin retraction over tender extending to
chest wall
 Spontaneous or related to trauma
 Ultrasound may be helpful in confirming this diagnosis.
 Treatment self-limited, can use NSAIDs
 Mammogram if over 35yo to r/o malignancy

55. Breast Inflammation &
Infections
 Chronic Subareolar Abscess
 Occurs at base of lactiferous duct, and squamous
metaplasia of duct may occur.
 Sinus tract to areola develops
 Treatment requires complete excision of sinus tract
 Recurrence is common

56. Fibroadenoma Discussion
 Features
– Usually younger women
– Usually solitary mass, occasionally multiple
– May increase with pregnancy or involute post-
menopause
 Pathology
– Benign tumor
– Circumscribed rubbery mass
– Overgrown fibrous stroma compressing epithelium
– May have some increased risk of breast cancer long
term especially if associated with proliferative breast
pathology*

57. Malignant Diseases of the
Breast

58. Breast Cancer

59. • A woman has a 1 in 8 chance of developing breast cancer at some
point in her life.
• Risk factors
– Increased age, family history, History of breast, ovary, or endometrial
cancer, >30 age at first pregnancy, high socioeconomic status,
nulliparity, early menarche, and late menopause
• Symptoms
– Lumps
• Presenting symptom in 85% of patients with carcinoma
– Pain
• Must completely evaluate to rule out carcinoma
– Metastatic disease
• Axillary nodes
• Distant organ symptoms, such as neurological
– Asymptomatic
• Why we advise yearly SBE and yearly mammogram after age 50

60. Malignant Diseases of the
Breast
• Non-invasive breast cancers
– 10% of all types of breast cancer
– Good prognosis
– Ductal carcinoma in situ, lubular carcinoma in situ, and paget’s
disease
• Invasive breast cancers
– Favorable histologic types (85% 5-year survival rate)
• Tubular carcinoma (grade 1 intraductal), colloid or mucinous
carcinoma, and papillary carcinoma
– Less favorable types
• Medullary cancer, invasive lobular cancer, and invasive ductal
cancer
– Least favorable type
• Inflammatory breast cancer

61. Breast Cancer Location

62. Ductal Carcinoma in Situ
• Seen as microcalcifications on mammogram
• Confined to ductal cells.
• No invasion of the underlying basement membrane.
• Chance of recurrence 25-50% in 5 years, of these 50%
will be invasive
• Tx
– Mastectomy an option if there is a substantial risk of
local/regional recurrence
– Wide local excision and radiation reduce local recurrence to 2%
– Wide excision alone suitable if <25mm, favorable histology, and
the margins are clear
– Node dissection not necessary (nodal disease < 1%)

63. Lobular Carcinoma in Situ
• Not detectable on mammography
– Most commonly found incidentally
• Risk of invasive breast cancer in 20 years is 15-
20% bilaterally
• Tx
– Careful follow-up
– Bilateral masectomy may be considered if other risk
factors are present such as family history or prior
breast cancer, and also dependent on patient
preference.

64. Invasive Breast Cancers
• Favorable histologic types (85% 5-year
survival rate)
• Tubular carcinoma (grade 1 intraductal), colloid or
mucinous carcinoma, and papillary carcinoma
• Less favorable types
• Medullary , invasive lobular, and invasive ductal
carcinoma
• Least favorable type
• Inflammatory breast carcinoma
• Staging, prognosis, and treatment

65. Favorable histologic types
• Tubular carcinoma
– 2% of all invasive breast cancers
– Generally diagnosed by mammography
– Distinctive under microscope
– Long-term survival aproaches 100%
• Mucinous (colloid) carcinoma
– 3% of all invasive breast cancers
– Generally confined to elderly population
– Bulky, mucinous tumor with characteristic microscopic features
– 5 and 10 year survival rates are 73 and 59 percent, respectively
• Papillary carcinoma
– <2% of all invasive breast cancers
– Generally presents in seventh decade, and is a slowly progressive
disease
– 5 and 10 year survival rates are 83 and 56 percent, respectively

66. Less Favorable Histologic
Types
• Medullary carcinoma
– 4% of all invasive breast cancers
– Soft, hemorrhagic bulky presentation
– Diagnosed microscopically (lymphocytic infiltration)
– Metastases to axillary nodes in 44%
– 5 and 10 year survival rates are 63 and 50 percent respectively
• Invasive ductal carcinoma
– Most common and occurs in 78% of all invasive breast cancers.
– Metastases to axillary nodes in 60%
– 5 and 10 year survival rates are 54 and 38 percent respectively
• Invasive lobular carcinoma
– 9% of all invasive breast cancers
– Metastases to axillary nodes in 60%
– 5 and 10 year survival rates are 50 and 32 percent respectively
– Higher incidence of bilaterality

67. Inflammatory carcinoma
• 1.5-3% of breast cancers
• Characteristic clinical features of erythema, peau
d’orange, and skin ridging with or without a palpable
mass.
• Commonly mistaken for cellulitis.
– Will generally fail antibiotics before being diagnosed
• Disease progresses rapidly, and more than 75% of
patients present with palpable axillary nodes.
• Distant metastatic disease also at much higher
frequency than the more common breast cancers.
• 30% 5 year survival rate
• Requires chemotherapy treatment immediately

68. Diagnosis
• Fine-needle aspiration
– Sensitivity is 80-98%, specificity 100%
– False negatives are 2-10%
• Core-needle biopsy
– More tissue, however still possibility of false
“negative” and could represent sampling error
• Incisional biopsy
– For large (>4 cm) lesions for whom pre-op
chemotherapy or radiation will be desirable.
• Excisional biopsy
– Removal of entire lesion and a margin of normal
breast parenchyma

69. Mammogram
Comparison CC View
Left Right

70. Thermograph
• Thermograph is one of the
newest ways to detect breast
cancer.
• Thermograph is a thermal image
of the breast tissue.
• It can also detect cancer before
the traditional mammogram can.
• www.breastthermography.com
• Picture from breastthermography.com

72. Staging and Prognosis
• Primary Tumor
– T1 = Tumor < 2 cm. in greatest dimension
– T2 = Tumor > 2 cm. but < 5 cm.
– T3 = Tumor > 5 cm. in greatest dimension
– T4 = Tumor of any size with direct extension to chest wall or skin
• Regional Lymph Nodes
– N0 = No palpable axillary nodes
– N1 = Metastases to movable axillary nodes
– N2 = Metastases to fixed, matted axillary nodes
• Distant Metastases
– M0 = No distant metastases
– M1 = Distant metastases including ipsilateral supraclavicular nodes
• Clinical Staging and prognosis
– Clinical Stage I T1 N0 M0 Stage Prognosis (5 year surv. Rate)
– Clinical Stage IIA T1 N1 M0 I 93%
– T2 N0 M0 II 72%
– Clinical Stage IIB T2 N1 M0 III 41%
– T3 N0 M0 IV 18%
– Clinical Stage IIIA T1 N2 M0
– T2 N2 M0
– T3 N1 M0
– T3 N2 M0
– Clinical Stage IIIB T4 any N M0
– Clinical Stage IV any T any N M1

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80. BREAST CANCER: Early Stage
Metastasis to ipsilateral axillary lymph node(s)
N1 = movable
N2 = fixed to one another or to other structures
M0 = no distant metastasis

81. BREAST CANCER
Spread to lymph nodes
Supraclavicular
Subclavicular
Mediastinal
Distal (upper)
axillary Internal mammary
Central (middle)
axillary
Interpectoral
(Rotter’s)
Proximal (lower)
axillary

82. Stage IV: Metastatic Breast Cancer

83. Prognostic Features
• Tumor size important prognostic factor
• Poor prognostic features of tumor:
– Presence of edema or ulceration of skin, mass fixed to chest wall or skin, satellite
skin nodules, peau d’orange (dermal lymphatic invasion), skin retraction and
dimpling, and involvement of medial portion of inner lower quadrant involved.
• Axillary node status:
– Best source of predicting survival or outcome
– N0 has 10 year survival rate of 60%
– N1 has 10 year survival rate of 50%
– N2 has 10 year survival rate of 20%
– If 10 or more nodes are diseased (N3) 10 yr surv. Rate is 14%
– Poor prognostic feature of nodes:
• Capsular invasion, extranodal spread, and edema of arm
• Distant metastases is very poor prognostic indicator
• Postive estrogen and progesterone receptor indicates likely response to
hormonal treatment and is a positive prognostic indicator

84. Treatment
• Modalities (palliative vs. curative)
– Surgery
• Local treatment
– Radiation
• Local treatment
– Chemotherapy and hormonal therapy
• Systemic treatment

85. Surgery
– Breast conservation therapy
• Stage I, stage II, and sometime stage III carcinomas
• Lumpectomy, axillary lymphadenectomy, and postoperative radiation therapy
• Contraindications: tumors > 5 cm , gross multifocal disease, and diffuse malignant
microcalcifications
• Local recurrence more than mastectomy so follow up important
– Modified radical mastectomy (most common mastectomy procedure for invasive
breast cancer)
• Entire breast and axillary contents are removed
• Pectoralis muscles remains
– Halsted radical mastectomy
• Removes breast, axillary contents, and pectoralis major muscle
• Cosmetically deforming
• Only indicated when pectoralis muscle involved
– Simple mastectomy
• All breast tissue is removed, axillary contents not removed
• Treatment for non-invasive breast cancer

86. Radiation
• Utilized for primary and metastatic disease
• Useful in breast conservation therapy to
reduce rate of recurrence.
– Radiate entire breast

87. Chemotherapy and Hormonal
Therapy
• Chemotherapy
– Eradicates risk of occult distant disease in stage I and stage II
patients.
– All patients with axillary node involvement are candidates along
with patients with negative axillary node involvement who are
high risk by other prognostic indicators.
– Example treatment is 6 months of cyclophosphamide,
methotrexate or adriamycin, and flourouracil along with
paclitaxel.
• Improvement in disease free interval and overall survival
• Hormonal therapy
– Tamoxifen
• Generally taken for five years in patientss with estrogen receptor
positive tumors.
– As effective as chemotherapy in post-menopausal patients with
estrogen receptor positive tumors

88. Classification
 Lesions with Increased Risk of Ca
 Ductal hyperplasia
 Sclerosing adenosis
 Complex fibroadenomas
 Atypical hyperplasia
 Radial scars
Micheal S sabel .Overview of benign breast disease. Uptodate 2008, November 14

89. Classification
 Lesions with no Increased risk of Ca
 Fibrocystic disease
 Duct ectasia
 Solitary papillomas
 Simple fibroadenomas
 Mastitis or breast abscess
 Galactocele
 Fat necrosis
 Lipoma

90. Alternative medicine
• There are also several alternative medicines that can help to reduce or
eliminate breast cancer.
• Vitamin A, Betacarotine, Vitamin C, and Vitamin E all increase the effect of
chemotherapy.
• CO-Q10 reduces the toxicity of chemotherapy
• Vitamin D, and Cholecalciferol helps inhibits growth in cancer cells
• Melitonin (which is a natural chemical produced in our brain) blocks the
estrogen receptors to the cancer

91. Alternative medicine
• Also Astragalus acts as an anti-viral and enhances the natural killer cells
• Cur cumin turmeric (is an anti tumor) increases you leukocyte production
• And Caud’ Arco is a mild herb that acts as an anti tumor
Therapeutic massage, acupuncture, and stress relieving techniques are also
used.
Treat the whole person not just the illness

92. Bone marrow transplant
• Getting a bone marrow transplant is one of the newest options for cancer.
• It is used when you receive high doses of radiation and chemotherapy.
Because chemotherapy kills all the cells both good, and bad it replaces
what was destroyed by the treatments.
• Bone marrow is donated from another person and then frozen and placed in
the cancer patients body by injection.
• A word of caution though this is still in the preliminary stages of trials &
testing for breast cancer.

93. Nutrition
• Perhaps one of the best ways to
help prevent cancer is an easy one
but often overlooked.
• Diets high in meat, fast foods,
refined carbohydrates, simple
sugars, low in fruit and veggies are
at high risk of developing cancer.
• Diets need to be well balanced in
that you need to eat your 5 servings
of fruits and veggies a day. Don’t
forget the whole grain foods as well.
• Picture from usda.gov

94. Nutrition
• Alcohol is associated with increasing the chances of many types of cancer, including
breast cancer.
• “An average alcohol intake of three drinks per day is associated with doubling the risk
of breast cancer”
• (chapter 16 core concepts in health, Insel)
• One should also avoid smoking because it increases the risk also.
• Fiber is also an interregnal part of our daily diets. Many foods that contain fiber also
contain many other vitamins that are considered “potential cancer fighting agents”.
• Fruits and veggies also contain anti carcinogens, carotenoids, antioxidants, and free
radicals that help protect our DNA.

95. Exercise
• Another aspect is to maintain a healthy body weight.
• That means to get off the couch an do something, walk the dog, ride a bike
or just exercise in you own home.
• If you stay away from fatty foods, (i.e.; fast foods) and eat a well balanced
diet. Then you will greatly reduce your chances of getting cancer.
• Don’t forget to take care of your self!!

96. Age as a Risk Factor
RISK
By age 30 1 out of 2,000
By age 40 1 out of 233
By age 50 1 out of 53
By age 60 1 out of 22
By age 70 1 out of 13
By age 80 1 out of 9
Lifetime risk 1 out of 8
NCI SEER Program, 1995-1997

97. Risk Factors
Controllable Uncontrollable
• Alcohol drinking • Getting older
• Being overweight • First degree
• Never having relative with breast
children cancer
• 1st child >30yrs of • A previous breast
age biopsy showing
• Hormone atypical changes
Replacement
• Birth control pills

98. Risk Factors
• Controllable • Uncontrollable
• Being exposed to • Being young (<12) at the
large amounts of time of menses
radiation • Starting menopause after
age 55
• Having an inherited
mutation in the breast
cancer genes (BRCA 1 or
2)
ACS Breast Cancer Facts 2001-02

99. Breast Cancer Screening Methods
For Healthy Women
1. Breast Self Exam — Status
– Guiding principal “Know your breasts —
they are not land mines”
2. Clinical Breast Exam
– Age 20-39: every 3 years
– Age after 40: every year
3. Mammography
– Age after 40: every year

105. Balloon and lumpectomy

107. A dose of 34 Gy was delivered at a depth of 1 cm over the
course of 5 days. CT scans were used to assess the
conformance of the resection cavity tissue to the
MammoSite® RTS balloon.
Balloon on CT

108. Coping with your Diagnosis
• Express your emotions
• Develop a fighting spirit
• Build a strong support group
• Trust your health care team

111. Revised Differential Diagnosis
1 Fibroadenoma
2 Cyst
3 Fibrocytic Mass
4 Breast Cancer

112. Components of Appropriate
Screening Program
• Professional Physical Examination
• Breast Self Examination (BSE)
• Mammography

113. Screening Recommendations
Professional Breast Exam
Age Physical Exam
20 – 40 yrs Every 3 years
> 40 yrs Annually

114. Carcinoma
Tabar L, Dean P.
Teaching atlas of
mammography. 2nd ed.
New York, New York:
Thieme Inc; 1985:91.

115. Comedo Carcinoma
Dean P. Teaching
atlas of
mammography. New
York, New York:
Thieme Inc; 1985:168

116. Ductal Carcinoma
Tabar L, Dean P. Teaching atlas of mammography. 2nd ed. New York, New
York: Thieme Inc. 1985:169

117. Sclerosing Duct Hyperplasia
Tabar L, Dean P.
Teaching atlas of
mammography. 2nd ed.
New York, New York:
Thieme Inc. 1985:106

118. Fibro-adeno-lipoma
Tabar L, Dean P.
Teaching atlas of
mammography. 2nd ed.
New York, New York:
Thieme Inc. 1985:25

119. Lipoma
Tabar L, Dean P.
Teaching atlas of
mammography. 2nd ed.
New York, New York:
Thieme Inc. 1985:21

120. Fibroadenoma
Tabar L, Dean P.
Teaching atlas of
mammography. 2nd ed.
New York, New York:
Thieme Inc. 1985:200

121. Cystosarcoma Phylloides
Tabar L, Dean P. Teaching atlas of mammography. 2nd ed. New York, New York:
Thieme Inc. 1985:63

122. Intraductal Papilomatosis
Tabar L, Dean P. Teaching atlas of mammography. 2nd ed. New York, New
York: Thieme Inc. 1985:192

123. Intraductal Papillomatosis
Tabar L, Dean P. Teaching atlas of mammography. 2nd ed. New York, New
York: Thieme Inc. 1985:48

125. Carcinoma
Tabar L, Dean P.
Teaching atlas
of
mammography.
2nd ed. New
York, New York:
Thieme Inc.
1985:95

126. Paget Disease , Mammary

127. Paget’s Disease
• Uncommon
• Usually involves the nipple
• Histologically, vacuolated cells are seen in the epidermis
of the nipple and result in an eczematous dermatitis of
the nipple.
• It is generally associated with an underlying intraductal
or invasive carcinoma.
– Mammography should be performed
• About 30% of patients have axillary node metastasis at
diagnosis.
• Mastectomy is the standard of treatment
– 80% have a 10 year survival rate if there is no mass present and
no axillary nodes are involved.

128. The Male Breast
• Gynecomastia
– Prepubertal gynecomastia
• Rare, adrenal carcinoma and testicular tumor can cause this.
– Pubertal gynecomastia
• Occurs in 60-70% of pubertal boys.
– Senescent gynecomastia
• 40% of aging men have this to some degree.
• Drugs, such as steroids, digitalis, hormones, spironolactone, and antidepressants can
cause this.
• Male breast carcinoma
– 0.7% of all breast cancers
– <1% of male cancers
– Average age of diagnosis is 63.6 years old
– Painless unilateral mass that is usually subareolar with skin fixation, chest wall
fixation,, and ulceration.
– Mostly ductal carcinoma
– Males generally present at later stage than woman
• Overall survival worse in men, however when compared stage for stage the survival
rates are similar.

129. ?