003 Breast Pathology

BREAST SURGICAL
BREAST SURGICAL
PATHOLOGY
PATHOLOGY
Content
Content
1.
1.
The importance of breast pathology
2.
2.
Surgical anatomy
Surgical anatomy
3.
3.
Clinical examination of the breast
Clinical examination of the breast
4.
4.
Malformations
Malformations
5.
5.
Inflammations
Inflammations
6.
6.
Degenerative diseases
Degenerative diseases
7.
7.
Tumors
Tumors
a) a) Benign Benign
b) b) Malignant Malignant
8.
8.
Particular forms of breast cancer
Particular forms of breast cancer

The breast may be affected by a large variety of
The breast may be affected by a large variety of
pathology. Both benign and malignant type of pathology,
pathology. Both benign and malignant type of pathology,
affect with predilection women at any age but may affect
affect with predilection women at any age but may affect
men also.
men also.

Breast cancer, as well as cancer in general, remains a
Breast cancer, as well as cancer in general, remains a
particular health problem despite of world wide efforts of
particular health problem despite of world wide efforts of
researchers and physicians and huge funds allocated for
researchers and physicians and huge funds allocated for
prevention and treatment of this disease.
prevention and treatment of this disease.
FACTS
FACTS
1. 1.
Breast cancer is the most common cancer in women
worldwide.
worldwide.
2. 2.
Breast cancer is the third disease among the most
Breast cancer is the third disease among the most
common diseases in the world.
common diseases in the world.
3. 3.
One of eight women is likely to develop breast cancer
One of eight women is likely to develop breast cancer
in their lifetime.
in their lifetime.
4. 4.
In USA 2/3 of operated women for breast cancer do not
In USA 2/3 of operated women for breast cancer do not
have
have
axillary
axillary
lymph node metastases.
lymph node metastases.
5. 5.
In Romania 85% of women operated with breast cancer
In Romania 85% of women operated with breast cancer
are in advanced stages.
are in advanced stages.
Particular factors to be considered in breast
Particular factors to be considered in breast
pathology
pathology
:
:
1. 1.
The breast, in women
The breast, in women
,
,
beyond the role of breastfeeding
beyond the role of breastfeeding
(which is however limited to a short period of lifetime), has
(which is however limited to a short period of lifetime), has
mainly an
mainly an
erotic
erotic
and
and
esthetic
esthetic
role,
role,
and
and
therefore
therefore
, the
, the
breast pathology has a strong echo in the mental sphere
breast pathology has a strong echo in the mental sphere
of the woman.
of the woman.
2. Surgery, where is indicated, takes into account more and
more
the psycho
the psycho
-
-
affective aspect, tending to be
affective aspect, tending to be
less
less
mutilant
mutilant
possible, but
possible, but however it must also take into
account the invasive nature of the disease.
3. 3.
The breast is an
The breast is an
easily accessible
easily accessible
organ for examination,
organ for examination,
facilitating early detection of pathological changes.
facilitating early detection of pathological changes. The
sooner a breast lesion is discovered, the smaller will be
the unpleasant consequences of the possible surgery.

Knowing the breast anatomy is of particular importance
Knowing the breast anatomy is of particular importance
for clinician (and not only), especially in cancer cases,
for clinician (and not only), especially in cancer cases,
for several reasons:
for several reasons:
1.
1.
To be able to establish a correct diagnosis,
To be able to establish a correct diagnosis,
2.
2.
To be able to perform adequate surgery,
To be able to perform adequate surgery,
3.
3.
To perform the radiotherapy in indicated regions,
To perform the radiotherapy in indicated regions,
4.
4.
To be able to foresee eventually relapses of breast
To be able to foresee eventually relapses of breast
cancer.
cancer.
BREAST ANATOMY
BREAST ANATOMY
Embryology
Embryology

Mammary glands begin to develop from the
Mammary glands begin to develop from the
6
6
th th
week
week
of
of
intrauterine life from two
intrauterine life from two
ectodermal
ectodermal
thickening called
thickening called
mammary crests
mammary crests
. These crests are located along the
. These crests are located along the
lines described by
lines described by
Schultze
Schultze
(1892) as "
(1892) as "
milk lines
milk lines
" which
" which
join the
join the
axillary
axillary
region to
region to
homolateral
homolateral
groin.
groin.
Schultze line
milk line
Along these mammary crests there are
6-7 nodules, which in mammals will
develop more pairs of mammary glands.
In humans, the caudal portion of the
crests will disappear remaining only the
thoracic portion. This will determine, in
normal cases, the development of one
single pair of mammary glands in
pectoral region. There are cases when
supernumerary mammary glands, or
just components of the breast (eg.
nipples) may develop along the milk
lines.

In women, initially under the action of estrogen and
In women, initially under the action of estrogen and
subsequently in combination with progesterone,
subsequently in combination with progesterone,
mammary glands undergo significant
mammary glands undergo significant
changes
changes
till to the
till to the
stage of mature breast. This process generally takes 3
stage of mature breast. This process generally takes 3
-
-
4
4
years and is completed in general at the age of 16.
years and is completed in general at the age of 16.
Subsequent physiological changes occur during
Subsequent physiological changes occur during
pregnancy and lactation and menopause.
pregnancy and lactation and menopause.

In men, normally breasts remain almost unchanged, but
In men, normally breasts remain almost unchanged, but
size and structure changes may occur under certain
size and structure changes may occur under certain
conditions under the influence of various hormonal factors
conditions under the influence of various hormonal factors
(
(
gynecomastia
gynecomastia
).
).
The breast
The breast
Location
Location

Breasts are located in the
Breasts are located in the
antero
antero
-
-
superior region of the
superior region of the
chest. In women the classical breast area is extended
chest. In women the classical breast area is extended
cranio
cranio
-
-
caudal between the second and the sixth rib and
caudal between the second and the sixth rib and
in transverse direction between the margin of the
in transverse direction between the margin of the
sternum and the anterior
sternum and the anterior
axillary
axillary
line. In men this area is
line. In men this area is
limited solely to the breast areola region, being
limited solely to the breast areola region, being
rudimentary represented.
rudimentary represented.

The breast is enclosed between two thin sheets of
The breast is enclosed between two thin sheets of
superficial fascia of the pectorals.
superficial fascia of the pectorals.
Extension
Extension

The mammary gland area in women is extended in
The mammary gland area in women is extended in
cranio
cranio
-
-
caudal direction between the clavicle and the
caudal direction between the clavicle and the
superior margin of the rectus
superior margin of the rectus
abdominis
abdominis
and in
and in
transverse direction between the margin at the sternum
transverse direction between the margin at the sternum
and
and
latisimus
latisimus
dorsi
dorsi
muscle.
muscle.
Nippleareola
complex
between the 4th
and the 5th ribs
Extension of mammary gland
Breast limits

The mammary gland has a more extended area than the
The mammary gland has a more extended area than the
breast
breast
.
.
This aspect is very important because on this
This aspect is very important because on this
area pathological processes of the breast tissue may
area pathological processes of the breast tissue may
occur, and also for surgery because
occur, and also for surgery because
these are the limits
these are the limits
within which the surgeon must perform a radical
within which the surgeon must perform a radical
mastectomy for breast cancer.
mastectomy for breast cancer.

The axillary extension of the mammary gland (axillary
tail) is of special interest because it is often affected by
pathological processes. In some women this extension is
well represented and can be confused with a lipoma, an
axillary adenopathy, or a supernumerary breast. Usually
it becomes more evident during the premenstrual period
and lactation.

The internal surface of the gland is attached to the
pectoralis fascia by fibrous strips called Coopers
ligaments.
External appearance
External appearance

Two hemispherical shape masses, whose size and
Two hemispherical shape masses, whose size and
weight vary from person to person based on race, age,
weight vary from person to person based on race, age,
and the various physiological stages.
and the various physiological stages.
Generally the left
Generally the left
breast is bigger than the right one.
breast is bigger than the right one.

In the central zone there is the
In the central zone there is the
areola
areola
, a
, a
hyperpigmented
hyperpigmented
skin area, whose size also varies from person to person.
skin area, whose size also varies from person to person.

Under the areola
Under the areola
s skin there are many nervous fibers

s skin there are many nervous fibers
and smooth muscles arranged in circular and
and smooth muscles arranged in circular and
longitudinal layers, which by contraction decrease and
longitudinal layers, which by contraction decrease and
wrinkle the surface causing elongation and
wrinkle the surface causing elongation and
turgor
turgor
of the
of the
nipples.
nipples.

The areola has small prominences:
The areola has small prominences:
the Montgomery
the Montgomery
tubercles
tubercles
, which are large sebaceous glands which
, which are large sebaceous glands which
increase in volume during pregnancy and lactation.
increase in volume during pregnancy and lactation.
areola nipple
Montomery
The nipple
The nipple
, is a
, is a
cylindrical
cylindrical
-
-
conical
conical
prominence, of 10
prominence, of 10
-
-
12
12
mm length and 8
mm length and 8
-
-
10
10
mm in diameter. There
mm in diameter. There
are 15
are 15
-
-
20
20
galactophorous
galactophorous
pores
pores
of the
of the
lactiferous ducts
lactiferous ducts
.
.
Breast structure

For better guidance in locating various pathological
For better guidance in locating various pathological
processes, the breast was arbitrary divided into four
processes, the breast was arbitrary divided into four
quadrants by two lines, one vertical and the other
quadrants by two lines, one vertical and the other
perpendicular through the centre of the nipple.
perpendicular through the centre of the nipple.
1. 1. supero supero- -external (SE) external (SE) - - over 50% of breast cancers are located in over 50% of breast cancers are located in
this quadrant. this quadrant.
2. 2. infero infero- - external (IE) external (IE)
3. 3. supero supero- -internal (SI) internal (SI)
4. 4. infero infero- -internal (II) internal (II)

Two more quadrants are added:
Two more quadrants are added:
one
one
central (C)
central (C)
corresponding to
corresponding to
retroareolar
retroareolar
area and the
area and the
another which is the
another which is the
axillary
axillary
extension quadrant (AE
extension quadrant (AE
) of the
) of the
gland.
gland.
SI
II
IE
SE
PA
C
Breast quadrants
The structure of the breast
The structure of the breast

There are four types of tissues :
There are four types of tissues :
1. 1. Milk Milk- -producing mammary gland, producing mammary gland,
2. 2. Milk ducts, Milk ducts,
3. 3. Fatty tissue, and Fatty tissue, and
4. 4. Connective and fibrous tissue, and also blood vessels, Connective and fibrous tissue, and also blood vessels, lymphatics lymphatics and and
nerves nerves. .

The gland is composed of 15
The gland is composed of 15
-
-
20
20
lobes
lobes
. It is entirely
. It is entirely
enveloped by fatty tissue with the exception of the
enveloped by fatty tissue with the exception of the
retroareolar
retroareolar
region.
region.

The adipose layer under the skin is organized in
The adipose layer under the skin is organized in
lodges
lodges
separated by fibrous bands (Cooper
separated by fibrous bands (Cooper
s ligaments), which on
s ligaments), which on
palpation give the feeling of a granular surface.
palpation give the feeling of a granular surface.
Do not
Do not
confuse these fatty lodges with tumors.
confuse these fatty lodges with tumors.

The gland itself is fixed to the internal surface of the
The gland itself is fixed to the internal surface of the
derm
derm
by the
by the
Duret
Duret
crests which are of special importance
crests which are of special importance
because via these structures the malignant process can
because via these structures the malignant process can
spread to the skin
spread to the skin
. When these crests are invaded by the
. When these crests are invaded by the
tumoral process the skin becomes fixed to the gland and it
tumoral process the skin becomes fixed to the gland and it
can be retracted which is a clinical sign for cancer.
can be retracted which is a clinical sign for cancer.
Breast structure

The
The
retromammary
retromammary
layer
layer
is a space by which the
is a space by which the
mammary gland can slide on the surface of the large
mammary gland can slide on the surface of the large
pectoral muscle fascia. Invasion of this layer and
pectoral muscle fascia. Invasion of this layer and
penetration into the pectoral muscle, leads to fixation of
penetration into the pectoral muscle, leads to fixation of
the gland to the underlying muscle highlighted by the
the gland to the underlying muscle highlighted by the
Tillaux
Tillaux
maneuver
maneuver
.
.

In very rare cases, the glandular tissue may cross the
retrommary fatty layer penetrating into the pectoral
muscle. This was the justification for Halsted radical
mastectomy where pectoral muscles were removed
together with the breast.
Microscopic anatomy
Microscopic anatomy

The glandular parenchyma is divided into
The glandular parenchyma is divided into
lobes (
lobes (
15
15
-
-
20),
20),
lobules
lobules
and
and
acini
acini
. In their delimitation contributes the
. In their delimitation contributes the
stroma
stroma
represented by interlobular dense connective
represented by interlobular dense connective
tissue and
tissue and
intralobular
intralobular
loose tissue, forming
loose tissue, forming
septs
septs
along
along
which blood vessels and
which blood vessels and
lymphatics
lymphatics
are passing.
are passing.

The functional units of mammary gland are the
The functional units of mammary gland are the
acini
acini
.
.

Each lob has a milk duct which opens
Each lob has a milk duct which opens
separatelly
separatelly
at the
at the
surface of the nipple. The lobes are orientated
surface of the nipple. The lobes are orientated
radially
radially
around the areola.
around the areola.
Radial incisions in case of a mammary gland abscess
The lobes are orientated The lobes are orientated radially radially around the areola. around the areola.
Thats why

Each lactiferous (milk) ducts
Each lactiferous (milk) ducts
has a
has a
lactiferous sinus
lactiferous sinus
located at the base of the nipple. The diameter of these
located at the base of the nipple. The diameter of these
ducts is 2 to 4 mm. Inside there is a double layer
ducts is 2 to 4 mm. Inside there is a double layer
epithelium:
epithelium:
cuboid
cuboid
cells at the level of lobules and
cells at the level of lobules and
cylindrical shape cells in extra
cylindrical shape cells in extra
-
-
lobular space. The
lobular space. The
external layer has
external layer has
myoepithelial
myoepithelial
cells.
cells.

These ducts are responsible for the majority of breast
These ducts are responsible for the majority of breast
pathology. It is considered that neoplastic lesions have
pathology. It is considered that neoplastic lesions have
the starting point is these ducts and less in the acini.
the starting point is these ducts and less in the acini.

Also the breast fibrocystic disease has the starting point
Also the breast fibrocystic disease has the starting point
in these ducts.
in these ducts.
Vascularization
Vascularization
and
and
innervation
innervation
Arteries
Arteries

Internal mammary artery
Internal mammary artery
(from
(from
subclavian artery
subclavian artery
),
),

Lateral thoracic artery
Lateral thoracic artery
( from
( from
axillary artery)
axillary artery)

Intercostal artery branches
Intercostal artery branches
(from thoracic aorta).
(from thoracic aorta).

Other sources: thoracic
Other sources: thoracic
suprema
suprema
artery, arteries of
artery, arteries of
pectoral muscles,
pectoral muscles,
thoracoacromial
thoracoacromial
artery,
artery,
subscapular
subscapular
artery,
artery,
thoraco
thoraco
-
-
dorsal artery and superficial thoracic
dorsal artery and superficial thoracic
artery.
artery.
Arterial sources of the breast
Veins
Veins

The venous drainage of the breast is organized in two
The venous drainage of the breast is organized in two
networks: one
networks: one
superficial
superficial
and another one
and another one
deep
deep
.
.

The superficial network forms around the areola a
The superficial network forms around the areola a
venous plexus so called the
venous plexus so called the
Haller
Haller
s circle.
s circle.

Through the venous system cancerous cells are carried
Through the venous system cancerous cells are carried
to the first filtrating station: the lungs, and then towards
to the first filtrating station: the lungs, and then towards
other organs where metastases are relatively frequent:
other organs where metastases are relatively frequent:
liver, bones, brain.
liver, bones, brain.
Innervation
Innervation

Breast skin innervation is provided by
Breast skin innervation is provided by
brachial cutaneous
brachial cutaneous
nerve and branches from the
nerve and branches from the
intercostal nerves
intercostal nerves
4, 5, 6.
4, 5, 6.

Breast parenchyma receives sympathetic branches that
Breast parenchyma receives sympathetic branches that
reach the secretory units along the intercostal nerves 2,
reach the secretory units along the intercostal nerves 2,
3, 4, 5 and 6.
3, 4, 5 and 6.

The lymphatic system
The lymphatic system
is of particular interest in breast
is of particular interest in breast
surgery due to tumor extension mainly on this route with
surgery due to tumor extension mainly on this route with
particularly prognostic effect.
particularly prognostic effect.

There is a
There is a
superficial
superficial
network which collects lymph from
network which collects lymph from
skin and a
skin and a
deep
deep
parenchyma network.
parenchyma network.

Between those two lymphatic network there are two
Between those two lymphatic network there are two
areas of connection, one at the areola where there is a
areas of connection, one at the areola where there is a
superficial lymphatic plexus
superficial lymphatic plexus
and
and
one subaureolar
one subaureolar
(Sappey)
(Sappey)
and the other at the breast periphery.
and the other at the breast periphery.

Along these lymphatic routes, propagation of the cancer
Along these lymphatic routes, propagation of the cancer
is possible from depth to surface,
is possible from depth to surface,
which is the base for
which is the base for
indication to
indication to
remove the areola in mastectomies for
remove the areola in mastectomies for
breast cancer.
breast cancer.
There are two main lymphatic drainage routes:
There are two main lymphatic drainage routes:

External mammary route
External mammary route
(
(
axillary
axillary
route)
route)
-
-
it drains the
it drains the
lymph to the
lymph to the
ipsilateral
ipsilateral
axillary
axillary
lymph nodes. 75%
lymph nodes. 75%
-
-
97% of
97% of
cancer cells are carried through this route.
cancer cells are carried through this route.
On the trajectory
On the trajectory
of this route there is a lymph node (
of this route there is a lymph node (
Sorgius
Sorgius
) located at the
) located at the
edge of the great pectoralis muscle.
edge of the great pectoralis muscle.

Internal mammary route
Internal mammary route
,
,
which travels along the internal
which travels along the internal
mammary arteries towards the internal thoracic lymph nodes
mammary arteries towards the internal thoracic lymph nodes
(internal mammary lymph nodes), located
(internal mammary lymph nodes), located
retrosternal
retrosternal
in the
in the
intercostal spaces 1 to 5.
intercostal spaces 1 to 5.

From here the lymph goes to:
From here the lymph goes to:
Supraclavicular Supraclavicular lymph nodes lymph nodes
Cervical lymph nodes Cervical lymph nodes
On the left side to the thoracic duct and left lymphatic duct On the left side to the thoracic duct and left lymphatic duct
On the right side to the right lymphatic duct On the right side to the right lymphatic duct
To the To the Pirogoff Pirogoff jugulo jugulo- -subclavian subclavian confluence confluence
To the To the mediastinal mediastinal lymph nodes and lymph nodes and broncho broncho- -aortic nodes aortic nodes
Lymphatic routes
Besides these primary routes, there are other secondary
Besides these primary routes, there are other secondary
routes such as:
routes such as:
1. 1.
Transpectoral
Transpectoral
route
route

starts from the inner surface of
starts from the inner surface of
the breast, passes through the
the breast, passes through the
pectoralis
pectoralis
major to the
major to the
Rotter
Rotter
s
s
interpectoral
interpectoral
lymph nodes
lymph nodes
and then to the
and then to the
axillary
axillary
apical lymph nodes.
apical lymph nodes.
2. 2.
Retropectoral
Retropectoral
route
route

starts from the inner part of the
starts from the inner part of the
SE quadrant, passes behind the
SE quadrant, passes behind the
pactoralis
pactoralis
major towards
major towards
the apical lymph nodes.
the apical lymph nodes.
3. 3.
Intercostal route
Intercostal route
-
-
along the intercostal vessels direct
along the intercostal vessels direct
to the intercostal lymph nodes and from there to the
to the intercostal lymph nodes and from there to the
internal mammary lymph nodes.
internal mammary lymph nodes.
4. 4.
Contralateral
Contralateral
axillary
axillary
route
route
-
-
Although rare, it is still
Although rare, it is still
possible that
possible that
tumoral cells from breast to reach the lymph
tumoral cells from breast to reach the lymph
nodes from
nodes from
contralateral
contralateral
axila
axila
.
.
5. 5.
Inferior route
Inferior route
-
-
described by
described by
Gerota
Gerota
(
(
Romanian
Romanian
physician and anatomist)
physician and anatomist)
which drains the lymph to the
which drains the lymph to the
epigastric region and diaphragmatic nodules.
epigastric region and diaphragmatic nodules.
Lymphatic drainage of the breast
Anatomy of the
Anatomy of the
axilla
axilla

Axilla Axilla is a pyramidal shape structure with the tip facing the cervical is a pyramidal shape structure with the tip facing the cervical
region which is the junction between the arm and the chest. region which is the junction between the arm and the chest.

It has a tip, a base and 4 walls It has a tip, a base and 4 walls

The content of the The content of the axila axila is represented by: is represented by:
Arteries Arteries: :

Axillary Axillary artery, artery,

Lateral thoracic artery, Lateral thoracic artery,

Subscapular Subscapular artery, artery,

Thoracodorsal Thoracodorsal artery artery
Nerves Nerves: :

Brachial plexus, Brachial plexus,

Intercostobrachial Intercostobrachial nerve, nerve,

Thoracicus Thoracicus longus longus (Charles Bell (Charles Bell respiratory) nerve, respiratory) nerve,

Subscapular Subscapular nerve, nerve,

Thoracodorsal Thoracodorsal nerve, nerve,

Intercostal nerves Intercostal nerves
Fatty tissue Fatty tissue
Lymph nodes Lymph nodes
Veins Veins: :
The veins are The veins are omonim omonim
to the arteries to the arteries
Walls of the axilla
Berg Berg s s axillary axillary lymph nodes classification lymph nodes classification

Anglo
Anglo
-
-
American surgeons use
American surgeons use
Berg
Berg
s
s
axillary
axillary
lymph
lymph
nodes classification
nodes classification
that divides in three main categories
that divides in three main categories
based on prognostic and their relationship with
based on prognostic and their relationship with
pectoralis
pectoralis
minor muscle:
minor muscle:

Level 1 Level 1 - - are lymph nodes located under the lateral edge of the are lymph nodes located under the lateral edge of the
pectoralis pectoralis minor (lateral posterior and anterior) minor (lateral posterior and anterior)

Level 2 Level 2 - - are lymph nodes lying underneath the muscle between are lymph nodes lying underneath the muscle between
the medial and lateral edge the medial and lateral edge

Level 3 Level 3 - - lymph nodes located medial or above the medial edge lymph nodes located medial or above the medial edge
of the muscle (apical, of the muscle (apical, subclavian subclavian) )

In fact this classification is used in the TNM system for
In fact this classification is used in the TNM system for
malignant breast tumors. To this group, called regional lymph
malignant breast tumors. To this group, called regional lymph
nodes (N), in the TNM classification is added also the
nodes (N), in the TNM classification is added also the
ipsilateral
ipsilateral
internal mammary lymph
internal mammary lymph
group.
group.
Intramammary
Intramammary
lymph nodes are encoded as
lymph nodes are encoded as
axillary
axillary
lymph nodes in the
lymph nodes in the
TNM classification.
TNM classification.

Any other metastatic lymph nodes are coded as distant
Any other metastatic lymph nodes are coded as distant
metastases (M1) including
metastases (M1) including
subclavian
subclavian
, or
, or
contralateral
contralateral
cervical
cervical
lymph nodes.
lymph nodes.
CLINICAL EXAMINATION
CLINICAL EXAMINATION
OF THE BREAST
OF THE BREAST

The diagnosis is based on 3 elements:
The diagnosis is based on 3 elements:
1.
1.
History
History
2.
2.
Clinical examination
3.
3.
Paraclinic
Paraclinic
investigations
investigations

is the most important phase of the
is the most important phase of the
diagnosis because
diagnosis because
:
:
1.
1.
In most cases it is the first method of diagnosis
In most cases it is the first method of diagnosis
,
,
2.
2.
In advanced cases the method is sufficient, the
In advanced cases the method is sufficient, the
physical signs of
physical signs of
neoplasia
neoplasia
being obvious,
being obvious,
3.
3.
Local examination performed by woman itself (self
Local examination performed by woman itself (self
examination) is the most effective method of
examination) is the most effective method of
screening for early detection of breast cancer if other
screening for early detection of breast cancer if other
better methods are not available through a national
better methods are not available through a national
screening program.
screening program.

40% of tumors detected at
40% of tumors detected at
mammography
mammography
can not be
can not be
detected by palpation !
detected by palpation !

Clinical examination just of the breast is not enough!
Clinical examination just of the breast is not enough!
General
General
clinical examination
clinical examination
of the patient should be also
of the patient should be also
performed!
performed!
Local examination of the breast
Local examination of the breast

Not only the breast considered ill will be examined, but
Not only the breast considered ill will be examined, but
also:
also:
- - The The contralateral contralateral breast, breast,
- - The both The both axillae axillae, ,
- - The The supraclavicular supraclavicular and cervical lymph nodes and cervical lymph nodes

The examination can be performed both in orthostatic and
The examination can be performed both in orthostatic and
supine position. The standing position is preferred.
supine position. The standing position is preferred.
1. 1.Inspection Inspection
2. 2.Palpation Palpation
A.
A.
Inspection.
Inspection.
The patient in front of doctor with arms hanging
The patient in front of doctor with arms hanging
The following aspects will be noted:
The following aspects will be noted:

The position of the line between the two nipples.
The position of the line between the two nipples.
This
This
is supposed to be horizontal in normal cases. If there
is supposed to be horizontal in normal cases. If there
are changes in shape and volume of the breast the
are changes in shape and volume of the breast the
line becomes oblique.
line becomes oblique.

The breast volume.
The breast volume.
Any expansive process in the
Any expansive process in the
breast will lead to more or less increase of the breast
breast will lead to more or less increase of the breast
volume. This aspect is often observed in
volume. This aspect is often observed in
phyllodes
phyllodes
tumors
tumors
.
.

The shape of the breast.
The shape of the breast.
As long as the
As long as the
tumor
tumor
is small
is small
there won
there won
t be any changes in breast shape. As it

t be any changes in breast shape. As it
grows, alteration of breast shape will appear as
grows, alteration of breast shape will appear as
irregular elevations (bulges) or as
irregular elevations (bulges) or as
depressions (skin
depressions (skin
retraction).
retraction).
Tu Phyllodes
Tu Phyllodes

The aspect of the skin
The aspect of the skin
.
.

The colour
The colour
can be normal. In some advanced cases
can be normal. In some advanced cases
and in acute inflammatory breast cancer, the colour
and in acute inflammatory breast cancer, the colour
turns to reddish as in an inflammatory process making
turns to reddish as in an inflammatory process making
possible confusion with acute mastitis.
possible confusion with acute mastitis.

Skin surface
Skin surface
may look as an
may look as an
orange peel
orange peel
(
(
peau
peau
d
d
orange
orange
) very suggestive for breast cancer. It is caused
) very suggestive for breast cancer. It is caused
by lymphatic stasis in the
by lymphatic stasis in the
derm
derm
as the lymph ducts are
as the lymph ducts are
blocked by the tumoral process.
blocked by the tumoral process.

Exulceration
Exulceration
of the skin
of the skin
appears in advanced cases.
appears in advanced cases.

Venous network
Venous network
become visible being augmented in
become visible being augmented in
advanced cases, and also in
advanced cases, and also in
phyllodes
phyllodes
tumors
tumors
.
.

Nodules of permeation
Nodules of permeation
appear also in advanced
appear also in advanced
neglected cases.
neglected cases.
Venous network more visible
Tumoral nodules of permeation Tumoral nodules of permeation
Ulceration with necrosis
Skin of orange peel
Nipple retraction

The aspect of areola
The aspect of areola
.
.
The areola may be affected by
The areola may be affected by
tumoral processes like Paget
tumoral processes like Paget
s disease. The aspect is

s disease. The aspect is
similar to an
similar to an
exema
exema
.
.

The aspect of the nipple.
The aspect of the nipple.
Very suggestive for cancer is
Very suggestive for cancer is
the
the
unilateral retraction
unilateral retraction
of the nipple recently installed.
of the nipple recently installed.

Pathological discharge from the nipple.
Pathological discharge from the nipple.
It could be:
It could be:
serous, brownish,
serous, brownish,
lactescent
lactescent
, purulent,
, purulent,
haemorrhagic
haemorrhagic
.
.
The most suggestive for cancer is the unilateral
The most suggestive for cancer is the unilateral
spontaneous
spontaneous
haemorrhagic
haemorrhagic
discharge
discharge
which appears
which appears
especially in case of
especially in case of
intraductal
intraductal
papilloma
papilloma
.
.
Pagets disease of the breast
Breast lump with nipple retraction
The patient raises her upper limbs
The patient raises her upper limbs
above the head
above the head
.
.

By this maneuver, other aspects can
By this maneuver, other aspects can
stand out that do not occur in initial
stand out that do not occur in initial
position. This can produce changes in
position. This can produce changes in
the shape of the breast, nipple
the shape of the breast, nipple
retraction or modifications become
retraction or modifications become
more visible.
more visible.
The patient bent forward with hands on
The patient bent forward with hands on
hips.
hips.

In this position breasts are hanging,
In this position breasts are hanging,
pathological changes can be
pathological changes can be
obeserved in the breast bearing a
obeserved in the breast bearing a
malignant process. The breast hangs
malignant process. The breast hangs
less if the tumor is fixed to the pectoral
less if the tumor is fixed to the pectoral
muscles or chest wall.
muscles or chest wall.
B.
B.
Breast palpation
Breast palpation
Rules:
Rules:
1.
1.
The optimal period for breast palpation is between the
The optimal period for breast palpation is between the
5
5
th th
and the 7
and the 7
th th
day after the onset of menstruation.
day after the onset of menstruation.
2.
2.
Always start with the breast considered normal.
Always start with the breast considered normal.
3.
3.
Palpation is done with
Palpation is done with
palmar face of outstretched
palmar face of outstretched
fingers 2
fingers 2
-
-
5.
5.
4.
4.
Palpation must be gentle.
Palpation must be gentle.
5.
5.
Palpation must explore the
Palpation must explore the
entire breast area.
entire breast area.
6.
6.
Both axillae and cervical
Both axillae and cervical
lymph nodes should be
lymph nodes should be
palpated.
palpated.
fingertips 2-4 for breast palpation
There are four stages of palpation
There are four stages of palpation
1.
1.
Gross palpation
Gross palpation
described by Velpeau, trying to
described by Velpeau, trying to
capture any tumor formation. It is only an
capture any tumor formation. It is only an
orientative palpation.
orientative palpation.
2.
2.
Palpation of finesse
that must follow a certain
that must follow a certain
scheme not to omit any breast areas.
scheme not to omit any breast areas.
3.
3.
Tumor
Tumor
palpation
palpation
.
.
4.
4.
Palpation of the areola and the nipple.

Circular
Circular
-
-
concentric
concentric

Spiral
Spiral

Radial
Radial

No matter which method is chosen. The breast tissue
should be compressed against the chest wall and all
quadrants should be cheeked.
Palpation will notice the following features of the
Palpation will notice the following features of the
tumor
tumor
:
:
1. 1.
Number
Number
-
-
How many
How many
tumors
tumors
are found.
are found.
2. 2.
Location
Location
-
-
Most
Most
tumors
tumors
are located in the SE
are located in the SE
quadrant.
quadrant.
3. 3.
Dimensions
Dimensions
-
-
Generally, breast tumors found
Generally, breast tumors found
incidentally on palpation are of 2
incidentally on palpation are of 2
-
-
3 cm in diameter. If
3 cm in diameter. If
the breast is not too voluminous, tumors can be
the breast is not too voluminous, tumors can be
detected at a diameter of 1 cm.
detected at a diameter of 1 cm.
4. 4.
Form
Form
-
-
The form can be spherical or irregular.
The form can be spherical or irregular.
5. 5.
Consistency
Consistency
-
-
Generally they are of hard consistency.
Generally they are of hard consistency.
6. 6.
Sensitivity
Sensitivity
-
-
Malignant tumor is not painful on
Malignant tumor is not painful on
palpation (at least in the early stages and if there is no
palpation (at least in the early stages and if there is no
inflammatory process associated).
inflammatory process associated).
7.
7.
Tumor surface
Tumor surface
-
-
The surface is irregular in cancer but
The surface is irregular in cancer but
smooth in fribroadenoma.
smooth in fribroadenoma.
8.
8.
Tumor delimitation
Tumor delimitation
-
-
Cancer is poorly demarcated
Cancer is poorly demarcated
from the surrounding tissues.
from the surrounding tissues.
9.
9.
Tumor mobility
Tumor mobility

Breast cancer in first stages is
Breast cancer in first stages is
mobile, without having the mobility of a breast
mobile, without having the mobility of a breast
fibroadenoma. As it developes, it becomes more and
fibroadenoma. As it developes, it becomes more and
more fixed because of tissue invasion.
more fixed because of tissue invasion.
10.
10.
Adhesion
Adhesion
-
-
Adherence to the skin can be appreciated
Adherence to the skin can be appreciated
through two maneuvers:
through two maneuvers:
Ianisevsky Ianisevsky sign sign. . Wrinkling of the skin above the tumor is Wrinkling of the skin above the tumor is
impossible because of tumor infiltration and edema. impossible because of tumor infiltration and edema.
Dupuytrain Dupuytrain sign. sign. To lateral displacement maneuver of the To lateral displacement maneuver of the
tumor, behind it, the skin develops a depression. tumor, behind it, the skin develops a depression.
Adherence to the pectoral muscles can be demonstrated with Adherence to the pectoral muscles can be demonstrated with
the the Tillaux maneuver. Tillaux maneuver.
Dupuytrain Dupuytrain sign sign
Tillaux maneuver the doctor opposes to the adduction
movement of the patients arm (the pactorals muscles will
contract) and with the other hand palpating the breast he
will notice that the tumor becomes fixed as the pectorals
muscles contract.

The nipple is gently grasped between the index finger
The nipple is gently grasped between the index finger
and thumb and compressed.
and thumb and compressed.

In case of a breast cancer or an intracanalicular
In case of a breast cancer or an intracanalicular
papilloma, blood may leak through the nipple.
papilloma, blood may leak through the nipple.

In case of an intracanalicular papilloma, beneath the
In case of an intracanalicular papilloma, beneath the
nipple a tumor of about 1 to 1.5 cm can be felt
nipple a tumor of about 1 to 1.5 cm can be felt

Nipple retraction is caused by neoplastic infiltration
Nipple retraction is caused by neoplastic infiltration
and can not be reduced manually.
and can not be reduced manually.
Palpation of lymph nodes
Palpation of lymph nodes
A: Cervical nodes on the neck
B: Supraclavicular nodes just above the collarbone
C: Infraclavicular nodes just behind the collarbone
D: Axillary nodes in the armpit
A
B
C
D
BREAST MALFORMATIONS
BREAST MALFORMATIONS
Classification
Classification
Malformations
Malformations
Of number
Of number
Of volume
Of volume
Of shape
Of shape
Malformations
Malformations
congenital
congenital
acquired
acquired
Abnormalities of number
Abnormalities of number
1. 1.
Amastia
Amastia

Represents the congenital absence of one or Represents the congenital absence of one or
both breasts. both breasts.

It is sometimes associated with the absence of It is sometimes associated with the absence of
sternal sternal portion of the large portion of the large pectoralis pectoralis major major
(Poland Syndrome). (Poland Syndrome).

It may be associated with other malformations It may be associated with other malformations
such as the absence of internal genital organs, such as the absence of internal genital organs,
ribs 3 ribs 3- -4 or the upper limb. 4 or the upper limb.

It is more frequent in men. It is more frequent in men.

Amastia Amastia is complete if the areola and the nipple is complete if the areola and the nipple
are absent. are absent.
2. 2.
Athelia
Athelia

Is represented by the absence of the nipple Is represented by the absence of the nipple
associated or not with the absence of the associated or not with the absence of the
areola. areola.

It may occur at a normal located breast but are It may occur at a normal located breast but are
more frequent at supernumerary breast. more frequent at supernumerary breast.
3. 3.
Amazia
Amazia

refers to a condition where mammary gland is absent, either cong refers to a condition where mammary gland is absent, either congenital enital
or iatrogenic acquired. The nipple and areola are present. or iatrogenic acquired. The nipple and areola are present.
4. 4.
Polymastia
Polymastia

It is a frequent (1 It is a frequent (1- -5%) congenital malformation where more than two 5%) congenital malformation where more than two
breast are present. breast are present.

It can be It can be complete complete when all the anatomical structures of the breast are when all the anatomical structures of the breast are
present or present or incomplete incomplete when just the mammary gland is present. when just the mammary gland is present.

The The favorite favorite locations are along the milk crests of locations are along the milk crests of Schultze Schultze. The most . The most
frequent location is the frequent location is the axillary axillary region. There can be present up to 8 region. There can be present up to 8
supernumerary breasts. supernumerary breasts.

It may have a familial character, being transmitted It may have a familial character, being transmitted autosomal autosomal dominant dominant
from man to man in the same family, but can be sporadic also. from man to man in the same family, but can be sporadic also.

Supernumerary breasts may be affected by the same pathologies as Supernumerary breasts may be affected by the same pathologies as
the normal breasts. the normal breasts.
5. 5.
Polithelia
Polithelia

Is the condition represented by multiple nipples associated or n Is the condition represented by multiple nipples associated or not ot
with areola. with areola.

Frequency: 2% Frequency: 2%

Usually they appear symmetrically along the milk crests, but can Usually they appear symmetrically along the milk crests, but can
occur anywhere. They can be rudimentary or functional. occur anywhere. They can be rudimentary or functional.

Sometimes are associated with congenital urinary malformations. Sometimes are associated with congenital urinary malformations.
May serve as May serve as cutaneous cutaneous paraneoplastic paraneoplastic markers for markers for urogenital urogenital
malignancies. malignancies.

Not of particular clinical importance unless they are affected b Not of particular clinical importance unless they are affected by y
morbid processes. morbid processes.
Polithelia
Abnormalities of volume
Abnormalities of volume
1. 1. Anisomastia Anisomastia

Is due to uneven development of breasts and their asymmetrical Is due to uneven development of breasts and their asymmetrical
location. If the aesthetic defect is important it can be correct location. If the aesthetic defect is important it can be corrected by ed by
various operations of various operations of mammoplasty mammoplasty. .
2. 2. Atrophy of the breast ( Atrophy of the breast (micromastia micromastia) )

Is characterized by an insufficient development of the breast Is characterized by an insufficient development of the breast uni uni- - or or
bilaterally. bilaterally.

Is due to hormonal insufficiency or to general illnesses such as Is due to hormonal insufficiency or to general illnesses such as: :
tuberculosis, cirrhosis, syphilis, or other factors. tuberculosis, cirrhosis, syphilis, or other factors.

Treatment consists of treating the endocrine deficiency and also Treatment consists of treating the endocrine deficiency and also
silicone implant may solve de defect. silicone implant may solve de defect.
3. 3.
Breast hypertrophy (
Breast hypertrophy (
macromastia
macromastia
)
)

It is the consequence of hypertrophy based on proliferation of b It is the consequence of hypertrophy based on proliferation of breast reast
parenchyma ( parenchyma (acini acini, ducts) and the , ducts) and the stroma stroma is is oedematous oedematous infiltrated. infiltrated.

An obvious cause is unknown, hormonal factors being incriminated An obvious cause is unknown, hormonal factors being incriminated
and race (more common in black women). Another cause is the and race (more common in black women). Another cause is the
development of the mammary gland during pregnancy returning to development of the mammary gland during pregnancy returning to
the normal breast volume being incomplete. the normal breast volume being incomplete.

Breasts gradually increase reaching impressive dimensions and Breasts gradually increase reaching impressive dimensions and
weight (7 weight (7- -8 kg), most often in addition to a normal silhouette. 8 kg), most often in addition to a normal silhouette.
Increased breast weight will lead to deformation by stretching a Increased breast weight will lead to deformation by stretching and nd
ptosis ptosis. They become painful and exerted traction on the chest. Skin . They become painful and exerted traction on the chest. Skin
redness is often with visible superficial venous network and redness is often with visible superficial venous network and
frequently frequently intertrigo intertrigo appears in the appears in the submammary submammary groove. groove.

Treatment in less severe forms is represented only by support wi Treatment in less severe forms is represented only by support with th
suitable bras and anti suitable bras and anti- -estrogen therapy. In advanced forms the estrogen therapy. In advanced forms the
surgical treatment is recommended represented by surgical treatment is recommended represented by mammoplasty mammoplasty
reduction. reduction.
4.
4.
Gynecomastia
Gynecomastia

It is the development in excess of the breasts in men. It appear It is the development in excess of the breasts in men. It appears s
more frequently in teenagers. more frequently in teenagers.

Physiological Physiological gynecomastia gynecomastia occurs occurs in new born in new born, , prepubertal prepubertal and in and in
senescence due to an excess of estrogen. senescence due to an excess of estrogen.

The cause is the excess of estrogen or androgen hormone The cause is the excess of estrogen or androgen hormone
deficiency. deficiency.

Increased estrogen levels Increased estrogen levels may be due either to may be due either to hyperproduction hyperproduction
(testicular or adrenal tumors) or iatrogenic (administration of (testicular or adrenal tumors) or iatrogenic (administration of
estrogens), or liver failure (cirrhosis) to metabolize the estro estrogens), or liver failure (cirrhosis) to metabolize the estrogens. gens.

Testicular endocrine insufficiency Testicular endocrine insufficiency may have multiple causes: genetic may have multiple causes: genetic
( (Klinefelter Klinefelter syndrome), hereditary (disturbances in hormones syndrome), hereditary (disturbances in hormones
synthesis), congenital ( synthesis), congenital (anorhidia anorhidia, , cryptorchidism cryptorchidism), acquired (trauma, ), acquired (trauma,
orchitis orchitis, , hydrocele hydrocele, , varicocele varicocele, , tumors tumors) )

Initial treatment is conservative trying to resolve deficiencies Initial treatment is conservative trying to resolve deficiencies or by or by
administration of testosterone hormone or administration of testosterone hormone or tamoxifen tamoxifen to block the to block the
estrogen receptors. The estrogen receptors. The subcutaneous mastectomy subcutaneous mastectomy is indicated in is indicated in
rebel cases. rebel cases.
Gynecomastia
Abnormalities of shape
Abnormalities of shape
1.
1.
Inverted nipple
Inverted nipple

It is a relatively common abnormality and occurs mainly
It is a relatively common abnormality and occurs mainly
during puberty. It has an incidence of 2% in women. It is
during puberty. It has an incidence of 2% in women. It is
bilateral in 25% of cases.
bilateral in 25% of cases.

Nipple retraction may have different degrees of:
Nipple retraction may have different degrees of:
flattening,
flattening,
umbillication
umbillication
and
and
invagination
invagination
. Han and
. Han and
Hong (Han 1999) classified nipple retraction into 3
Hong (Han 1999) classified nipple retraction into 3
grades as follows:
grades as follows:
Grade 1 Grade 1 - - retracted nipple returns easily in the normal position retracted nipple returns easily in the normal position
and this position is maintained without the need for traction. and this position is maintained without the need for traction.
Slight compression or soft pinching of the skin around areola Slight compression or soft pinching of the skin around areola
causes the nipple to return to normal position. causes the nipple to return to normal position.
Grade 2 Grade 2 - - nipple can be brought to its normal position only by nipple can be brought to its normal position only by
traction and tends to retract after traction. traction and tends to retract after traction.
Grade 3 Grade 3 the nipple is strongly retracted, and it is difficult to the nipple is strongly retracted, and it is difficult to
reverse back into normal position even by forced traction reverse back into normal position even by forced traction. .
Inverted nipple
Inverted nipple

Breastfeeding is not contraindicated in inverted nipple,
Breastfeeding is not contraindicated in inverted nipple,
but it can raise problems that can be overcome by
but it can raise problems that can be overcome by
educating mothers on special techniques or by using of
educating mothers on special techniques or by using of
special suction devices.
special suction devices.

Inversion may promote nipple infection.
Inversion may promote nipple infection.

Surgical correction is possible, but is not indicated at
Surgical correction is possible, but is not indicated at
young ages because it may harm
young ages because it may harm
galactophorous
galactophorous
ducts.
ducts.

Appeared in mature woman, nipple retraction is an
Appeared in mature woman, nipple retraction is an
alarming sign that could mean:
alarming sign that could mean:
1.
1.
most often, a
most often, a
neoplastic
neoplastic
process, especially if the
process, especially if the
retraction is circumferential,
retraction is circumferential,
2.
2.
an inflammatory process underlying the nipple,
an inflammatory process underlying the nipple,
3.
3.
a
a
ductal
ductal
ectasia
ectasia
associated with
associated with
periductal
periductal
fibrosis
fibrosis
2. 2.
Breast
Breast
ptosis
ptosis

Breasts tend to descend over time due to their own weight. Breasts tend to descend over time due to their own weight.

Breasts only support is the skin and the Cooper Breasts only support is the skin and the Cooper s ligaments. s ligaments.

Ptosis Ptosis is mainly due to weakening of supportive fibrous breast is mainly due to weakening of supportive fibrous breast
elements (Cooper elements (Cooper s ligament) as a result of deficiencies in the s ligament) as a result of deficiencies in the
structure of collagen and elastic tissue, or idiopathic (frequen structure of collagen and elastic tissue, or idiopathic (frequently is tly is
associated with varicose veins, hemorrhoids, hernias, flat feet, associated with varicose veins, hemorrhoids, hernias, flat feet, stretch stretch
marks, etc.) or due to ovarian hormones and thyroid disorders, e marks, etc.) or due to ovarian hormones and thyroid disorders, either ither
due to aging processes. Another cause is breast hypertrophy. due to aging processes. Another cause is breast hypertrophy.

It occurs mainly in postmenopausal It occurs mainly in postmenopausal multiparous multiparous with repeated with repeated
lactations. lactations.

It has 4 phases of evolution: It has 4 phases of evolution: mild mild, , marked marked (the nipple in normal (the nipple in normal
position, breast lower pole down), position, breast lower pole down), complete complete (nipple is also lowered) (nipple is also lowered)
and and bulky bulky prolapse prolapse ( (ptosis ptosis is associated with marked hypertrophy). is associated with marked hypertrophy).

Treatment is surgical with aesthetic visa in most cases. The aim Treatment is surgical with aesthetic visa in most cases. The aim is to is to
restore the breast with the nipple in the normal position and to restore the breast with the nipple in the normal position and to restore restore
its normal shape and volume. The operation can involve the skin its normal shape and volume. The operation can involve the skin only only
in mild forms, but in forms with hypertrophy a glandular reducti in mild forms, but in forms with hypertrophy a glandular reduction is on is
also necessary. also necessary.
Level A = Normal breast
Level B = Mild breast ptosis
Level C = Moderate breast ptosis
Level D = Severe breast ptosis
Level E = Glandular or pseudo ptosis
Breast ptosis
INFLAMATORY AFECTIONS
INFLAMATORY AFECTIONS
OF THE BREAST
OF THE BREAST
Mastitis
Mastitis

Mastites
Mastites
are inflammatory diseases of the breast due to
are inflammatory diseases of the breast due to
infection, usually having the entrance gate the milk
infection, usually having the entrance gate the milk
pores of the nipple or the skin pores.
pores of the nipple or the skin pores.

The infection can affect the mammary gland and other
The infection can affect the mammary gland and other
anatomical structures (skin, subcutaneous tissue,
anatomical structures (skin, subcutaneous tissue,
muscle fascia)
muscle fascia)

paramastitis
paramastitis
.
.

Paramastitis
Paramastitis
can affect the
can affect the
pre(supra)mammary
pre(supra)mammary
tissues
tissues
(
(
suprammamary
suprammamary
mastitis
mastitis
) or the
) or the
retrommamary
retrommamary
tissues (
tissues (
retromammary
retromammary
mastitis
mastitis
or
or
inframastitis
inframastitis
).
).

When the infectious inflammatory process extends to
When the infectious inflammatory process extends to
the whole breast we talk about
the whole breast we talk about
panmastitis
panmastitis
.
.

Most commonly incriminated etiologic agent is
Most commonly incriminated etiologic agent is
Staphylococcus
Staphylococcus
aureus
aureus
and Streptococcus. There may
and Streptococcus. There may
be fungal infections also.
be fungal infections also.

It can be
It can be
acute
acute
or
or
chronic
chronic
mastitis. /
mastitis. /
Specific
Specific
or
or
nonspecific.
nonspecific.

Acute mastitis can occur at any age but usually during
Acute mastitis can occur at any age but usually during
lactation (
lactation (
puerperal mastitis
puerperal mastitis
).
).

Mastitis may be secondary to an infected hematoma or
Mastitis may be secondary to an infected hematoma or
may be a metastatic abscess during a general infectious
may be a metastatic abscess during a general infectious
disease.
disease.

Puerperal mastitis:
Puerperal mastitis:
is a nonspecific acute inflammation of
is a nonspecific acute inflammation of
the mammary gland that occurs in the period of pregnancy
the mammary gland that occurs in the period of pregnancy
and more frequently during lactation.
and more frequently during lactation.

The most often involved microorganism is S.
The most often involved microorganism is S.
Aureus
Aureus
.
.
through the nipple
through the nipple
s pores or through skin erosions, cracks

s pores or through skin erosions, cracks
or sores on the nipples. The favoring factor is the
or sores on the nipples. The favoring factor is the
stasis of
stasis of
the milk in the breast
the milk in the breast
. Infections play only a minor role in
. Infections play only a minor role in
the pathogenesis of both puerperal and
the pathogenesis of both puerperal and
nonpuerperal
nonpuerperal
mastitis in humans and many cases of mastitis are
mastitis in humans and many cases of mastitis are
completely aseptic under normal hygienic conditions.
completely aseptic under normal hygienic conditions.

Prophylactic measure are very important: complete
Prophylactic measure are very important: complete
emptying of the breast and rigorous local hygiene.
emptying of the breast and rigorous local hygiene.

There are two phases of evolution:
There are two phases of evolution:
1.
1.
Congestive phase (Acute
Congestive phase (Acute
galactophoritis
galactophoritis
)
)
2.
2.
Phase of collection (Breast abscesses)
Phase of collection (Breast abscesses)
Clinical picture
Clinical picture

In the congestive phase
In the congestive phase
, the patient experiences
, the patient experiences
intense pain in the breast, which becomes swollen.
intense pain in the breast, which becomes swollen.
Because of the pain the patient does not empty the
Because of the pain the patient does not empty the
breast milk leading to stasis and favor the infection.
breast milk leading to stasis and favor the infection.
Celsian
Celsian
signs appear. The breast is increased in volume,
signs appear. The breast is increased in volume,
firm, very painful with local temperature increased and
firm, very painful with local temperature increased and
diffuse skin redness. The nipple can be modified and with
diffuse skin redness. The nipple can be modified and with
purulent discharge. The patient is feverish and
purulent discharge. The patient is feverish and
inflammatory painful
inflammatory painful
axillary
axillary
adenopathy
adenopathy
may be present.
may be present.

In the collection phase
In the collection phase
, the inflammatory processes
, the inflammatory processes
usually focus on a particular region, where the touch may
usually focus on a particular region, where the touch may
feel
feel
fluctuence
fluctuence
. In untreated forms infection may extend
. In untreated forms infection may extend
to the entire breast (
to the entire breast (
panmastitis
panmastitis
) and may spontaneously
) and may spontaneously
fistulize
fistulize
to the skin.
to the skin.
Acute mastitis
Celsian signs

Breast abscesses
Breast abscesses
: are localized breast suppurations
: are localized breast suppurations
probably related to obstruction of lactiferous ducts.
probably related to obstruction of lactiferous ducts.

They can be located:
They can be located:
1.
1.
Subcutaneous
Subcutaneous
2.
2.
Sub
Sub
areolar
areolar
,
,
-
-
the most frequent
the most frequent
3.
3.
I
I
nterlobular (periductal
nterlobular (periductal
inflammation
inflammation
),
),
4.
4.
R
R
etromam
etromam
m
m
ar
ar
y
y
5.
5.
C
C
entral (simple
entral (simple
or
or
multiple)
multiple)

Symptoms and signs: pain, redness, local swelling,
Symptoms and signs: pain, redness, local swelling,
hyperthermia. Drained fluid from the nipple after
hyperthermia. Drained fluid from the nipple after
compression leaves a yellow stain (
compression leaves a yellow stain (
Budin
Budin
sign
sign
). There
). There
may be present
may be present
axillary
axillary
inflammatory
inflammatory
adenopathy
adenopathy
.
.
Different types of breast abscesses

Acute mastitis should be differentiated from other
Acute mastitis should be differentiated from other
diseases with similar symptoms such as :
diseases with similar symptoms such as :
1.
1.
Paramastitis
Paramastitis
2.
2.
Breast engorgement
Breast engorgement
(
(
due to expansion and
due to expansion and
pressure exerted by the synthesis and storage of
pressure exerted by the synthesis and storage of
breast milk
breast milk
.)
.)
3.
3.
Breast sarcoma
Breast sarcoma
4.
4.
Inflammatory breast cancer !
Inflammatory breast cancer !
Treatment
Treatment

Prophilaxy
Prophilaxy

Compliance with local hygiene measures
Compliance with local hygiene measures

Complete emptying of breast milk at each feeding
Complete emptying of breast milk at each feeding

Curative
Curative
In congestive phase In congestive phase

Broad Broad- -spectrum antibiotics spectrum antibiotics - - 96% of cases have favorable 96% of cases have favorable
evolution evolution

Evacuation of breast milk by milking or vacuum aspiration Evacuation of breast milk by milking or vacuum aspiration

Interruption of breast feeding from that breast Interruption of breast feeding from that breast - - even weaning even weaning

Local cold compresses Local cold compresses

Immobilization and breast suspension plus compression Immobilization and breast suspension plus compression
dressing. dressing.
In collection phase ( In collection phase (fluctuence fluctuence) )

In general In general anestehesia anestehesia

Incision, evacuation, debridement, drainage, dressing. In Incision, evacuation, debridement, drainage, dressing. In
superficial abscess the skin incision may be superficial abscess the skin incision may be arcuated arcuated parallel parallel
with Langer lines, for a better aesthetic effect, but in profoun with Langer lines, for a better aesthetic effect, but in profound d
abscesses radial incisions are indicated to avoid sectioning the abscesses radial incisions are indicated to avoid sectioning the
milk ducts. milk ducts.

Perform Perform antibiogram antibiogram ! !
Radial incisions in case of a mammary gland abscess
The lobes are orientated The lobes are orientated radially radially around the areola. around the areola.
Thats why
Debridement
Drainage
Chronic breast abscess
Chronic breast abscess

It
It
is the consequence of an unresolved acute mastitis.
is the consequence of an unresolved acute mastitis.

Signs
Signs
: a hard lump in the breast, infiltrating the surrounding
: a hard lump in the breast, infiltrating the surrounding
tissues, dimpling and puckering of the skin. Painful to touch
tissues, dimpling and puckering of the skin. Painful to touch
and on compression sometimes purulent nipple discharge.
and on compression sometimes purulent nipple discharge.
Peu
Peu
d'orange
d'orange
and retraction of the nipple may be present.
and retraction of the nipple may be present.

Axillary
Axillary
lymph nodes are enlarged.
lymph nodes are enlarged.

At incision: thick sterile pus surrounded by fibrous tissue.
At incision: thick sterile pus surrounded by fibrous tissue.

Because of local features it is difficult to make a differential
Because of local features it is difficult to make a differential
diagnosis with the breast cancer
diagnosis with the breast cancer
. A thorough history of the
. A thorough history of the
patient could reveal an acute mastitis treated years ago.
patient could reveal an acute mastitis treated years ago.
Also the skin scar present on the breast may help to make
Also the skin scar present on the breast may help to make
the difference.
the difference.

The treatment is incision or excision with
The treatment is incision or excision with
histopathological
histopathological
examination
examination
BENIGN TUMORS OF THE
BENIGN TUMORS OF THE
BREAST
BREAST
Breast
Breast
fibroadenoma
fibroadenoma

Breasts
Breasts
fibroadenoma
fibroadenoma
(or
(or
adenofibroma
adenofibroma
) are benign
) are benign
fibroepithelial
fibroepithelial
tumors of the mammary gland (contain
tumors of the mammary gland (contain
epithelial and
epithelial and
stromal
stromal
elements). The predominance of the
elements). The predominance of the
epithelial component determines the name of
epithelial component determines the name of
adeno
adeno
fibroma
fibroma
while the predominance of
while the predominance of
stromal
stromal
component determines the name of
component determines the name of
fibro
fibro
adenoma
adenoma
.
.

The notion of
The notion of
complex
complex
fibroadenoma
fibroadenoma
refers to the
refers to the
fibroadenomas
fibroadenomas
which have: cysts larger than 3 cm in
which have: cysts larger than 3 cm in
diameter,
diameter,
sclerosing
sclerosing
lesions, epithelial calcifications and
lesions, epithelial calcifications and
apocrine
apocrine
papillary modifications.
papillary modifications.

The pure adenoma
The pure adenoma
is very rare being a proliferation of
is very rare being a proliferation of
only the epithelial elements. It has 2 forms:
only the epithelial elements. It has 2 forms:
Acinar Acinar form form : : normal or cystic normal or cystic acinar acinar proliferation proliferation
Tubular form Tubular form : : may appear during lactation (lactation adenoma) may appear during lactation (lactation adenoma)

There are two forms of
There are two forms of
fibroadenomas
fibroadenomas
:
:
1.
1.
J uvenile
J uvenile
fibroadenomas
fibroadenomas
, which appear in young
, which appear in young
women and teenagers, and
women and teenagers, and
2.
2.
Myxoid
Myxoid
fibroadenomas
fibroadenomas
,
,
in
in
Carney
Carney
s Syndrome,
s Syndrome,
which
which
is a dominant
is a dominant
autosomal
autosomal
neoplastic
neoplastic
syndrome which
syndrome which
includes
includes
myxomas
myxomas
of the skin and mucosa and
of the skin and mucosa and
endocrine dysfunctions.
endocrine dysfunctions.

Fibroadenoma
Fibroadenoma
is the most frequent benign
is the most frequent benign
tumor
tumor
of the
of the
breast. Young females under 40 years age are
breast. Young females under 40 years age are
predominantly affected. In 10
predominantly affected. In 10
-
-
15% of cases they are
15% of cases they are
multiple.
multiple.

Even they are considered benign, yet they have a
Even they are considered benign, yet they have a
potential of malignant transformation (mostly
potential of malignant transformation (mostly
sarcomatous
sarcomatous
) in percentage of 3
) in percentage of 3
-
-
4%. Patients with
4%. Patients with
multiple
multiple
fibroadenomas
fibroadenomas
or complex types have a higher
or complex types have a higher
risk (twice) of breast cancer.
risk (twice) of breast cancer.

Fibroadenomas
Fibroadenomas
represent a hyperplasic or proliferative
represent a hyperplasic or proliferative
process started from a terminal milk duct. The cause is
process started from a terminal milk duct. The cause is
unknown.
unknown.

Aproximativelly
Aproximativelly
10% of them disappear in a year and the
10% of them disappear in a year and the
grate majority stop their evolution after they reach 2
grate majority stop their evolution after they reach 2
-
-
3 cm
3 cm
in diameter. They can regress in postmenopausal period
in diameter. They can regress in postmenopausal period
or they calcify. On the other hand they can rapidly grow
or they calcify. On the other hand they can rapidly grow
during pregnancy, during treatment with substitutive
during pregnancy, during treatment with substitutive
feminine hormones or during immunosuppressant
feminine hormones or during immunosuppressant
treatment, when they can simulate a breast cancer.
treatment, when they can simulate a breast cancer.

There is no racial predilection
There is no racial predilection

Fibroadenomas
Fibroadenomas
may be located anywhere in the breast.
may be located anywhere in the breast.
Clinical picture
Clinical picture

On inspection nothing can be noticed when they are
On inspection nothing can be noticed when they are
small. As they grow a bulge under the skin can be
small. As they grow a bulge under the skin can be
observed. In giant forms (
observed. In giant forms (
phyllodes
phyllodes
tumors
tumors
) the breast is
) the breast is
highly modified with distended skin, with marble like
highly modified with distended skin, with marble like
appearance, with visible vascular network.
appearance, with visible vascular network.

On palpation, the
On palpation, the
fibroadenoma
fibroadenoma
has some characteristic
has some characteristic
features that makes it easy to diagnose and differentiate
features that makes it easy to diagnose and differentiate
from other
from other
tumors
tumors
. There is a tumour of about 1
. There is a tumour of about 1
-
-
5 cm
5 cm
diameter, of hard
diameter, of hard
-
-
elastic consistency, with smooth
elastic consistency, with smooth
surface, well delimited from surrounding tissues, painless,
surface, well delimited from surrounding tissues, painless,
and the most important feature: very mobile.
and the most important feature: very mobile.

In the
In the
axilla
axilla
there are no pathological enlarged lymph
there are no pathological enlarged lymph
nodes.
nodes.

Paraclinical
Paraclinical
investigations for diagnosis are: ultrasound
investigations for diagnosis are: ultrasound
examination, mammography,
examination, mammography,
tru
tru
-
-
cut biopsy and
cut biopsy and
excisional
excisional
biopsy.
biopsy.

When the diagnosis is very clear, based on clinical
When the diagnosis is very clear, based on clinical
features, a
features, a
lumpectomy
lumpectomy
may be performed, followed by
may be performed, followed by
histopahological
histopahological
examination.
examination.

When the diagnosis is not very clear, a biopsy from the
When the diagnosis is not very clear, a biopsy from the
tumor (
tumor (
tru
tru
-
-
cut biopsy under ultrasound guidance) is
cut biopsy under ultrasound guidance) is
indicated.
indicated.

Clinical features of the
Clinical features of the
fibroadenoma
fibroadenoma
help to differentiate
help to differentiate
it from
it from
breast cancer
breast cancer
which has the following features:
which has the following features:
it
it
has a very weak delimitation from surrounding tissues, it
has a very weak delimitation from surrounding tissues, it
is not so mobile as
is not so mobile as
fibroadenoma
fibroadenoma
or is quite fixed in
or is quite fixed in
advanced stages, its surface is irregular and frequently it
advanced stages, its surface is irregular and frequently it
is associated with enlarged
is associated with enlarged
axillary
axillary
lymph nodes.
lymph nodes.
Other affections for differential diagnosis are:
Other affections for differential diagnosis are:
1. 1. Breast cysts Breast cysts elastic consistency, also mobile but on ultrasound elastic consistency, also mobile but on ultrasound
examination the content is fluid in contrast with examination the content is fluid in contrast with fibroadenoma fibroadenoma
which is solid. At fine needle aspiration fluid can be obtained. which is solid. At fine needle aspiration fluid can be obtained.
2. 2. Sclerocystic Sclerocystic mastopathy mastopathy feeling like feeling like lead shots" under the lead shots" under the
skin on palpation, ultrasound shows multiple small cystic skin on palpation, ultrasound shows multiple small cystic
formations of various sizes, usually symmetrical, often painful, formations of various sizes, usually symmetrical, often painful,
sometimes with greenish nipple discharge. sometimes with greenish nipple discharge.
3. 3. Breast Breast lipogranulomas lipogranulomas poorly delimitated mass with reduced poorly delimitated mass with reduced
mobility due to chronic inflammatory process, possibly mobility due to chronic inflammatory process, possibly
associated with axillary inflammatory associated with axillary inflammatory adenopathy. adenopathy.
4. 4. Lipomas Lipomas have softer consistency and are more superficial have softer consistency and are more superficial
5. 5. Other tumors of the breast Other tumors of the breast
Treatment
Treatment

Simple
Simple
fibroadenomas
fibroadenomas
are tumors well
are tumors well
incapsulated
incapsulated
which
which
can be easily
can be easily
enucleated
enucleated
. The operation of election is a
. The operation of election is a
lumpectomy
lumpectomy
with a margin of security of 1 cm around the
with a margin of security of 1 cm around the
tumor, and in cases of multiple or diffuse
tumor, and in cases of multiple or diffuse
fibroadenomas
fibroadenomas
a
a
quadrantectomy
quadrantectomy
can be performed. In complex cases a
can be performed. In complex cases a
skin sparing
skin sparing
mastectomy
mastectomy
can be performed.
can be performed.

The surface section of the
The surface section of the
fibroadenoma
fibroadenoma
has a pearly
has a pearly
white color which is bulging under the effect of elastic
white color which is bulging under the effect of elastic
fibers while in malignant tumor the section area is flat
fibers while in malignant tumor the section area is flat
sometimes with yellow spots and hard calcified areas.
sometimes with yellow spots and hard calcified areas.

Prognosis is favorable but keep in mind that the risk of
Prognosis is favorable but keep in mind that the risk of
breast cancer is twice as higher in women with history of
breast cancer is twice as higher in women with history of
operated
operated
fibroadenoma
fibroadenoma
and the risk of
and the risk of
sarcomatous
sarcomatous
transformation is about 3%.
transformation is about 3%.
Cancer
Fibroadenoma
Fibrocystic
Fibrocystic
mastopathy
mastopathy
mastoses
mastoses
( Reclus
( Reclus
disease
disease
)
)

Proliferative lesion that occurs in women around age 30,
Proliferative lesion that occurs in women around age 30,
but can be seen at any age.
but can be seen at any age.

Endocrine factors are involved:
Endocrine factors are involved:
hyperfoliculinemia
hyperfoliculinemia
,
,
hyperthyroidism, genital or thyroid dysfunctions.
hyperthyroidism, genital or thyroid dysfunctions.

Gross
Gross
appearance
appearance
:
:
multiple cysts of various sizes, filled
multiple cysts of various sizes, filled
with clear or cloudy yellow
with clear or cloudy yellow
-
-
brown liquid, surrounded by
brown liquid, surrounded by
sclerous
sclerous
tissue. Predominant one of the two components.
tissue. Predominant one of the two components.

Microscopic
Microscopic
appearance
appearance
: micro
: micro
cysts surrounded by fibrotic
cysts surrounded by fibrotic
walls
walls
,
,
with
with
cylindrical secretory epithelium
cylindrical secretory epithelium
with
with
mitochondria
mitochondria
and
and
multiple granules, hypo or atrophic
multiple granules, hypo or atrophic
breast tissue
breast tissue
;
;
epithelial changes may
epithelial changes may
transform into
transform into
maligna
maligna
ncy
ncy
.
.

Clinical
Clinical
:
:
embarrassment
embarrassment
or local
or local
pain
pain
, spontaneous or
, spontaneous or
provoked, especially during
provoked, especially during
menstruation
menstruation
. Palpation
. Palpation
reveals tumor
reveals tumor
s
s
(sizes
(sizes
from
from
mm
mm
to
to
2
2
-
-
3 cm) disseminated or
3 cm) disseminated or
grouped, uni or bilateral (usually), mobile, firm, slightly
grouped, uni or bilateral (usually), mobile, firm, slightly
painful, increase in menstrual period. Axillary adenopathy
painful, increase in menstrual period. Axillary adenopathy
usually is absent
usually is absent
.
.
Fibrocystic Fibrocystic mastopathy mastopathy
Only in 5% of cases, changes can be considered at risk
Only in 5% of cases, changes can be considered at risk
of developing cancer.
of developing cancer.
Treatment
Treatment
1. 1.
In early or localized forms in women under 35 years
In early or localized forms in women under 35 years
-
-
conservative treatment
conservative treatment

hormones, local applications
hormones, local applications
(
(
Mastoprofen
Mastoprofen
)
)
-
-
after pregnancy and lactation the
after pregnancy and lactation the
disease may regress.
disease may regress.
2. 2.
In rapidly growing forms or in case of ineffective
In rapidly growing forms or in case of ineffective
medication treatment
medication treatment
-
-
quadrantectomy
quadrantectomy
.
.
3. 3.
For diffuse forms that include all the gland
For diffuse forms that include all the gland
-
-
subcutaneous mastectomy
subcutaneous mastectomy
Breast cysts
Breast cysts

Cysts are
Cysts are
the most common "tumors" of the breast
the most common "tumors" of the breast
.
.

Cysts are rare in women over 50 years and generally do
Cysts are rare in women over 50 years and generally do
not have any relationship with breast cancer.
not have any relationship with breast cancer.

On palpation they are mobile with smooth surface and of
On palpation they are mobile with smooth surface and of
elastic consistency. Can be or not painful.
elastic consistency. Can be or not painful.

They are related to
They are related to
papillomas
papillomas
tumor type. The
tumor type. The
histologic
histologic
features are of
features are of
apocrine
apocrine
metaplasia
metaplasia
(the inner lining layer
(the inner lining layer
of large cysts is composed of
of large cysts is composed of
apocrine
apocrine
cells).
cells).

Intraoperative
Intraoperative
they look dark ("blue dome cysts")
they look dark ("blue dome cysts")

Can be treated by simple evacuation through
Can be treated by simple evacuation through
fine needle
fine needle
aspiration or excision.
aspiration or excision.
Needle aspiration in most cases is
Needle aspiration in most cases is
guided by ultrasound. When extracted fluid does not
guided by ultrasound. When extracted fluid does not
contain blood,
contain blood,
cytotlogical
cytotlogical
examination is nod needed
examination is nod needed
because there is no suspicion of cancer but when blood is
because there is no suspicion of cancer but when blood is
present in fluid it must be examined
present in fluid it must be examined
cytologically
cytologically
.
.

In most cases cyst evacuation by aspiration is the
In most cases cyst evacuation by aspiration is the
definitive treatment method.
definitive treatment method.
Breast cyst on ultrasound examination
FNA guided by ultrasound
Cyst excision
Galactocele
Galactocele

A cystic tumor that contains milky substance
which appears usually during breast feeding
period. Once lactation has ended, the cyst will
disappear on its own without intervention
. It is
. It is
usually located beneath areola, and due to
usually located beneath areola, and due to
abrupt suppression of lactation
abrupt suppression of lactation
Intracanalicular
Intracanalicular
papilloma
papilloma

Intracanalicular
Intracanalicular
papillomas
papillomas
are cell proliferation in the
are cell proliferation in the
mammary ducts
mammary ducts
.
.

Gross appearance
Gross appearance
:
:
Intraductal
Intraductal
vegetations of a few
vegetations of a few
mm, red multi ramified, epithelium developed in the
mm, red multi ramified, epithelium developed in the
ducts, located in the center of the gland and
ducts, located in the center of the gland and
subareolar
subareolar
region. The ducts are enlarged but with thin walls and
region. The ducts are enlarged but with thin walls and
contain a brownish fluid.
contain a brownish fluid.

Microscopic appearance
Microscopic appearance
: vascular axis covered by
: vascular axis covered by
cylindrical epithelium (
cylindrical epithelium (
papilloma
papilloma
). At the periphery
). At the periphery
hyperplastic
hyperplastic
alterations are present. Focal areas of
alterations are present. Focal areas of
hemorrhage and necrosis are also present. Can
hemorrhage and necrosis are also present. Can
accommodate
accommodate
atypical hyperplasia
atypical hyperplasia
and
and
ductal
ductal
carcinoma in situ
carcinoma in situ
. If the epithelium is double layer
. If the epithelium is double layer
columnar cell, it becomes
columnar cell, it becomes
noninvasive papillary
noninvasive papillary
carcinoma.
carcinoma.
Clinical picture
Clinical picture
:
:

Common in women aged between 30
Common in women aged between 30
-
-
50 years, with:
50 years, with:
1. 1. Serous or Serous or sero sero- -sanguinous sanguinous discharge for long periods of time, discharge for long periods of time,
2. 2. Small, round tumor under the nipple, that does not adhere to the Small, round tumor under the nipple, that does not adhere to the
skin, skin,
3. 3. Traction of the nipple mobilizes the tumor (related to milk duct Traction of the nipple mobilizes the tumor (related to milk duct), ),
4. 4. Serous or Serous or sero sero- -sanguinous sanguinous discharge on nipple compression, discharge on nipple compression,
5. 5. No No axillary axillary adenopathy adenopathy. .

Multiple
Multiple
intraductal
intraductal
papillomas
papillomas
occur in approximately
occur in approximately
10% of cases, tend to occur in the younger patients and
10% of cases, tend to occur in the younger patients and
are less often associated with nipple discharge.
are less often associated with nipple discharge.
Paraclinical diagnosis:
Ultrasound examination Ultrasound examination
Mamography Mamography
Galactography Galactography
Mammary Mammary ductoscopy ductoscopy
Cytological examination of nipple discharge Cytological examination of nipple discharge
Tratament
Tratament
:
:

Deciding on the appropriate surgery is problematic due to
the difficulty in discriminating between intraductal
papilloma and breast cancer.

When the lesion is located to a single duct,
microdochectomy gives satisfactory results in younger
patients with a minimal interference with the breast. In
older patients where breast-feeding is not required, major
duct excision may be preferable.

When a specific duct cannot be identified then blind
excision of the retro-areolar ductal system is usually
performed (central quadrantectomy) followed by
histological examination.
Prognosis: the incidence of malignancy (invasive or in situ)
associated to papilloma varies between 1 and 23% A
solitary papilloma is not thought to be a pre-malignant
lesion and is considered by some to be an aberration
rather than a true disease process.

Multiple intraductal papillomas are more susceptible to
develop carcinoma.
Ultrasound examination
intracanalicular papilloma
Galactography Galactography
Intracanalicular papilloma - dilated
duct (3 mm ) at a distance of 1.5 cm
from the nipple
Ductoscopy
Ductoscopy
NIPPLE DISCHARGE
NIPPLE DISCHARGE
Nipple discharge is an event that causes discomfort and
Nipple discharge is an event that causes discomfort and
anxiety to women.
anxiety to women.
In this area significant progress have been made
In this area significant progress have been made
in
in
recent years through the development of diagnostic
recent years through the development of diagnostic
procedures.
procedures.
Physiopathology:

The causes that lead to discharge from the nipple are not yet
fully elucidated. In most cases it is associated with endocrine
disorders and/or certain drug treatments. They are often
associated to ductal ectasy and/or fibrocystic changes in the
mammary gland. Changes are often bilateral.

A less common noncancerous etiology is the ductal ectasy
associated with periductal inflammatory process
(galactophoritis)

The most common cause is the intraductal proliferation of
ductal epithelium as a result of a hyperplastic process,
micropapillar proliferation, papillomas and/or ductal
carcinomas.

The vast majority of intraductal changes that produce nipple
discharge are located in the first 1-4 cm of the lactiferous
duct from the nipple.
Nipple discharge- causes

Frequency
Frequency
:
:
-
-
3
3
-
-
8%
8%
.
.

Mortality and morbidity
Mortality and morbidity
:
:
the vast majority of patients heal
the vast majority of patients heal
after surgery. If the etiology is the cancer, mortality rate is
after surgery. If the etiology is the cancer, mortality rate is
the same as in case of other breast cancers. Of course, in
the same as in case of other breast cancers. Of course, in
case of early diagnosis (occult) the prognosis is even
case of early diagnosis (occult) the prognosis is even
better.
better.

Race
Race
:
:
there are no differences between races.
there are no differences between races.

Sex
Sex
: Nipple discharge can occur in both sexes but is more
: Nipple discharge can occur in both sexes but is more
common in women. When it occurs in young men is due to
common in women. When it occurs in young men is due to
a
a
ductal
ductal
ectasy
ectasy
similar to that of
similar to that of
gynecomastia
gynecomastia
without
without
hormone
hormone
-
-
related disorders. But, breast cancer is more
related disorders. But, breast cancer is more
common in men with nipple discharge.
common in men with nipple discharge.

Age
Age
: disease can occur at any age.
: disease can occur at any age.

Subclinical nipple discharge occurs more frequently in
Subclinical nipple discharge occurs more frequently in
women who use birth control pills and substitutive hormone
women who use birth control pills and substitutive hormone
therapy.
therapy.
Clinical picture
Clinical picture

In most cases, nipple discharge are bilateral
In most cases, nipple discharge are bilateral

The aspect of the discharge may be:
The aspect of the discharge may be:

Clear (aqueous)
Clear (aqueous)

Serous (yellowish)
Serous (yellowish)

Lactescente
Lactescente
(white)
(white)

Sero
Sero
-
-
sanguinolent
sanguinolent

Sanguinolent
Sanguinolent

To be considered nipple discharge, discharges must take
To be considered nipple discharge, discharges must take
place outside the period of lactation, to be spontaneous and
place outside the period of lactation, to be spontaneous and
persistent.
persistent.

Suspicion of cancer increases if the discharge is located
Suspicion of cancer increases if the discharge is located
only at one breast, from a single pore and is
only at one breast, from a single pore and is
sanguinolent
sanguinolent
.
.
Also if a tumor can be felt on palpation and if the patient is
Also if a tumor can be felt on palpation and if the patient is
over 50 years old.
over 50 years old.

After investigations, when suspected lesions are not
After investigations, when suspected lesions are not
malignant, in 73% of cases, nipple discharge regress
malignant, in 73% of cases, nipple discharge regress
spontaneously within 5 years.
spontaneously within 5 years.
Investigations
Investigations
1. 1.
Mammography
Mammography

not always relevant
not always relevant
2. 2.
Galactography
Galactography
(
(
ductography
ductography
)
)
is performed by injecting
is performed by injecting
a contrast iodine solution through a pore and making
a contrast iodine solution through a pore and making
mammograms. After nipple disinfection a
mammograms. After nipple disinfection a
ductogram
ductogram
cannula
cannula
is gently insert in the incriminated pore and
is gently insert in the incriminated pore and
slowly injected approximately 0.2 to 0.8 ml of iodine
slowly injected approximately 0.2 to 0.8 ml of iodine
solution. Then
solution. Then
cranio
cranio
-
-
caudal and
caudal and
latero
latero
-
-
lateral
lateral
mammograms are performed.
mammograms are performed.
Galactography
Galactography
is not indicated when:
is not indicated when:
Nipple discharge is bilateral Nipple discharge is bilateral
Secretion is not spontaneous or it cannot be obtained by Secretion is not spontaneous or it cannot be obtained by
compression of the nipple and so neither the pore can be compression of the nipple and so neither the pore can be
observed observed
Secretion occurs from many pores Secretion occurs from many pores
3. 3.
Other tests:
Other tests:

Breast ultrasonography

Cytological examination of nipple discharge
Cytological examination of nipple discharge
-
-
may reveal
may reveal
neoplastic
neoplastic
cells but the rate of false
cells but the rate of false
negative results (17.8%) and false positive (2.6%) is
negative results (17.8%) and false positive (2.6%) is
quite high.
quite high.

Hemocult
Hemocult
test
test
can be performed to detect minimal
can be performed to detect minimal
bleeding from the nipple.
bleeding from the nipple.

Ductoscopy
Ductoscopy
Galactorrhea
Galactorrhea
is usually not associated with breast cancer
is usually not associated with breast cancer
and the more, when it is bilateral.
and the more, when it is bilateral.

Galactorrhea
Galactorrhea
may occur due to:
may occur due to:
1.
1.
local stimulation of the nipple
local stimulation of the nipple
2.
2.
chest wall trauma
chest wall trauma
3.
3.
consumption of various drugs (contraceptives
consumption of various drugs (contraceptives
fenotiazide
fenotiazide
, antihypertensive, etc)
, antihypertensive, etc)
4.
4.
hypoparathyroidism
hypoparathyroidism
5.
5.
pituitary adenomas
pituitary adenomas
6.
6.
amenorrhea
amenorrhea
Treatment
Treatment
Surgery is indicated in the following cases:
Surgery is indicated in the following cases:
1. 1.
Discharge from a single pore, unilateral
Discharge from a single pore, unilateral
. Additional
. Additional
argument for surgery is
argument for surgery is
palpable tumors
palpable tumors
,
,
lesions
lesions
found
found
after
after
paraclinical
paraclinical
investigations, and
investigations, and
age over 40
age over 40
years
years
.
.
2. 2.
Indication of surgical treatment is supported by the
Indication of surgical treatment is supported by the
suspicion of an existing cancer.
suspicion of an existing cancer.
3. 3.
Recommended operation is the
Recommended operation is the
quadrantectomy
quadrantectomy
. The
. The
breast sector (quadrant) corresponding to the
breast sector (quadrant) corresponding to the
incriminated duct and pore is excised followed by
incriminated duct and pore is excised followed by
frozen section histopathology examination
frozen section histopathology examination
and
and
eventually conversion to mastectomy.
eventually conversion to mastectomy.
BREAST CANCER
BREAST CANCER
Unfortunately, we not know yet the cause of breast
Unfortunately, we not know yet the cause of breast
cancer and yet we can not prevent it, but history
cancer and yet we can not prevent it, but history
does not stop there.
does not stop there.
Features of breast cancer
Features of breast cancer
1. 1.
It affects a woman's organ that besides the biological
It affects a woman's organ that besides the biological
role of breastfeeding has a very important aesthetic and
role of breastfeeding has a very important aesthetic and
erotic role with deep implications on women
erotic role with deep implications on women
s psyche
s psyche
and personality.
and personality.
2. 2.
It is easy to detect by palpation or minimally invasive
It is easy to detect by palpation or minimally invasive
examination at low
examination at low
-
-
costs.
costs.
3. 3.
Particularly it affects older women (over 50 years). It is
Particularly it affects older women (over 50 years). It is
very rare in young.
very rare in young.
4. 4.
It is one of the forms of cancer, which if early diagnosed
It is one of the forms of cancer, which if early diagnosed
has one of the highest rates of post
has one of the highest rates of post
-
-
therapy survival.
therapy survival.
5. 5.
Breast cancer is one of the slowest developing
Breast cancer is one of the slowest developing
tumor
tumor
.
.
Since the beginning of the process until a
Since the beginning of the process until a
tumor
tumor
of 1 cm
of 1 cm
in diameter could pass even 10 years.
in diameter could pass even 10 years.
Epidemiology

worldwide,
worldwide,
comprising 16% of all female cancers
comprising 16% of all female cancers
. It is
. It is
thought to be a disease of the developed world because a
thought to be a disease of the developed world because a
majority (69%) of all breast cancer deaths occurs in
majority (69%) of all breast cancer deaths occurs in
developing countries (
developing countries (
WHO Global Burden of Disease,
WHO Global Burden of Disease,
2004
2004
).
).

Incidence rates vary greatly worldwide, with age
Incidence rates vary greatly worldwide, with age
standardized rates as high as 99.4 per 100 000 in North
standardized rates as high as 99.4 per 100 000 in North
America. Eastern Europe, South America, Southern Africa,
America. Eastern Europe, South America, Southern Africa,
and western Asia have moderate incidence rates, but
and western Asia have moderate incidence rates, but
these are increasing.
these are increasing.
The lowest incidence rates are found
The lowest incidence rates are found
in most African countries
in most African countries
but here breast cancer incidence
but here breast cancer incidence
rates are also increasing.
rates are also increasing.
Five Year Survival Rate By Age
Younger than 45 81%
Ages 45-64 85%
Ages 65 and older 86%
Source: American Cancer Society
Morbidity
Morbidity
Breast cancer ranks among the most common 3
diseases in the world
A new case at every 30 seconds
Mortality
One death every in 1.5 minutes.
It is the second cause of mortality after lung cancer
In Romania
In Romania

Breast cancer mortality has increased from 15.60/000 as
Breast cancer mortality has increased from 15.60/000 as
it was in 1978 to 23.27/ 000 in 1996. WHO estimated for
it was in 1978 to 23.27/ 000 in 1996. WHO estimated for
Romania, after 2000, that breast cancer mortality
Romania, after 2000, that breast cancer mortality
increased by 7%. Annual mortality is around 2,500
increased by 7%. Annual mortality is around 2,500
cases.
cases.

1% of women get breast cancer each year, which is
1% of women get breast cancer each year, which is
about 4200 new cases per year.
about 4200 new cases per year.

Two thirds of patients are first diagnosed in advanced
Two thirds of patients are first diagnosed in advanced
stages of disease (stages III and IV), in most cases a
stages of disease (stages III and IV), in most cases a
total mastectomy being the only surgical alternative.
total mastectomy being the only surgical alternative.
Etiopathogeny
Etiopathogeny
Risk factors
Risk factors
A. A. Factors that can not be modified Factors that can not be modified
B. B. Factors that can be modified (depend on our willing) Factors that can be modified (depend on our willing)

Gender
Gender
. The most important factor. It is known that in
. The most important factor. It is known that in
male breast cancer appears in a very small percentage:
male breast cancer appears in a very small percentage:
1
1
-
-
5%.
5%.

Race
Race
. White women have a slightly increased tendency
. White women have a slightly increased tendency
to develop breast cancer compared to black women. But
to develop breast cancer compared to black women. But
the latter are usually diagnosed in more advanced stages
the latter are usually diagnosed in more advanced stages
with lower survival rate. Also Hispanic women and Asian
with lower survival rate. Also Hispanic women and Asian
have a lower risk.
have a lower risk.

Age
Age
. The breast cancer incidence increases with age
. The breast cancer incidence increases with age
being the highest in the sixth decade.
being the highest in the sixth decade.

Genetic factors
Genetic factors
. About 5%
. About 5%
-
-
10% of cases can be
10% of cases can be
considered hereditary due to genetic mutations.
considered hereditary due to genetic mutations.
Incidence Rates by Race
Race/Ethnicity Female
All Races 127.8 per 100,000 women
White 132.5 per 100,000 women
Black 118.3 per 100,000 women
Asian/Pacific Islander 89.0 per 100,000 women
American Indian/Alaska Native 69.8 per 100,000 women
Hispanic 89.3 per 100,000 women
Source: National Cancer
Institute, SEER Cancer
Statistics Review, 2007.
Statistics
Probability of Developing Breast Cancer Within the
Next 10 years
By age 20 1 out of 1,760
By age 30 1 out of 229
Lifetime 1 out of 8
Source: Among those
cancer free at age
interval. Based on cases
diagnosed 2000-2002. "1
in" are approximates.
Source: American Cancer
Society Breast Cancer
Facts & Figures, 2008-
2009.

BRCA1 (breast cancer 1), BRCA2 (breast cancer 2)
BRCA1 (breast cancer 1), BRCA2 (breast cancer 2)

BRCA1 is located on the long arm of chromosome 17
BRCA1 is located on the long arm of chromosome 17
(17q), BRCA2 on chromosome 13q and BRCA3 gene
(17q), BRCA2 on chromosome 13q and BRCA3 gene
on chromosome 13q21
on chromosome 13q21

Women who have inherited mutations by deletion in
BRCA1 and BRCA2 have an increased risk of
developing breast cancer by 56
developing breast cancer by 56
-
-
85% rate and also
85% rate and also
ovarian.
ovarian.

BRCA1 is found in 3% of
BRCA1 is found in 3% of
of
of
breast cancer in general
breast cancer in general
and 70% in women with hereditary of breast cancer.
and 70% in women with hereditary of breast cancer.

BRCA2 mutation is identified in 10
BRCA2 mutation is identified in 10
-
-
20% of families with
20% of families with
breast and ovarian cancer risk and only in 2.7% of
women with early breast cancer. The risk of breast
cancer for women carrying BRCA2 is 25
cancer for women carrying BRCA2 is 25
-
-
30%.
30%.

HER2 (sau
HER2 (sau
HER2/neu
HER2/neu
)
)
(
(
human epidermal growth factor
human epidermal growth factor
receptor 2
receptor 2
)
)
is a surface gene that plays a key role in
is a surface gene that plays a key role in
regulating cell growth. When HER2 is altered more
regulating cell growth. When HER2 is altered more
HER2 receptors will be produced which leads to
HER2 receptors will be produced which leads to
increased cell multiplication. HER2 is found in 25
increased cell multiplication. HER2 is found in 25
-
-
30% of
30% of
women with breast cancer. They can be detected in
women with breast cancer. They can be detected in
tissues sample collected by biopsy or surgery.
tissues sample collected by biopsy or surgery.

Personal history of breast cancer
.
.
A woman who was
A woman who was
treated for breast cancer has a 3
treated for breast cancer has a 3
-
-
4 times higher risk of
4 times higher risk of
developing
developing
contralateral
contralateral
breast cancer and on a remnant
breast cancer and on a remnant
mammary gland after surgery, which is different from
mammary gland after surgery, which is different from
tumor recurrence.
tumor recurrence.

Radiotherapy
Radiotherapy
in breast area in history. If women,
in breast area in history. If women,
especially in childhood, have received chest radiation
especially in childhood, have received chest radiation
therapy in other diseases such as
therapy in other diseases such as
Hogkin
Hogkin
, or other types
, or other types
of cancers, have an increased risk (after some 12 times
of cancers, have an increased risk (after some 12 times
greater) of developing breast cancer
greater) of developing breast cancer

Personal history of epithelial hyperplasia
Personal history of epithelial hyperplasia
. In these
. In these
cases the risk increase depending on the type of
cases the risk increase depending on the type of
hyperplasia as follows:
hyperplasia as follows:
Typical epithelial hyperplasia Typical epithelial hyperplasia - - the risk is 1.5 the risk is 1.5- -2 times higher 2 times higher
Atypical epithelial hyperplasia Atypical epithelial hyperplasia - - the risk is 4 the risk is 4- -5 times higher 5 times higher
Atypical Atypical ductal ductal hyperplasia hyperplasia - - risk increases 10 times over the risk increases 10 times over the
next 10 years from diagnosis next 10 years from diagnosis
Nonproliferative Nonproliferative disease of the breast ( disease of the breast (adenosis adenosis, cysts, , cysts, ductal ductal
ectasy ectasy, , fibroadenoma fibroadenoma, fibrosis, mastitis, , fibrosis, mastitis, apocrine apocrine metaplasia metaplasia
and moderate and moderate squamous squamous hyperplasia) are not associated with hyperplasia) are not associated with
risk of breast cancer. risk of breast cancer.

Early menarche
Early menarche
(under 12) and
(under 12) and
late menopause
late menopause
(over
(over
55 years) are considered factors that may increase
55 years) are considered factors that may increase
cancer risk.
cancer risk.

Anthropometric factors
Anthropometric factors
. Anthropometric studies on
. Anthropometric studies on
patients with breast cancer revealed an interesting
patients with breast cancer revealed an interesting
fact, namely that the rapid growth in childhood and the
fact, namely that the rapid growth in childhood and the
adult height higher are associated with an increased
adult height higher are associated with an increased
risk of breast cancer.
risk of breast cancer.
B.
B.
Factors that can be modified
Factors that can be modified
and are related to
and are related to
way of life. It was found that the habits practiced in
way of life. It was found that the habits practiced in
adolescence may influence the risk of breast cancer
adolescence may influence the risk of breast cancer
later in life.
later in life.

Substitutive hormonal therapy
Substitutive hormonal therapy
. It's a proven fact that
. It's a proven fact that
using substitutive hormones (estrogen, progesterone)
using substitutive hormones (estrogen, progesterone)
after menopause increases the risk of breast cancer.
after menopause increases the risk of breast cancer.
These hormones are usually prescribed by doctors to
These hormones are usually prescribed by doctors to
prevent undesirable effects of postmenopausal
prevent undesirable effects of postmenopausal
hormone decline. Estrogens are indicated for
hormone decline. Estrogens are indicated for
prevention of osteoporosis, but they can cause uterine
prevention of osteoporosis, but they can cause uterine
cancer also.
cancer also.

Oral contraceptives
Oral contraceptives
. Use of oral contraceptives has a
. Use of oral contraceptives has a
low risk in determining breast cancer, and this usually
low risk in determining breast cancer, and this usually
occurs after a usage of over 10 years. But the risk
occurs after a usage of over 10 years. But the risk
disappears after discontinuation.
disappears after discontinuation.

Pregnancy
Pregnancy
. Women who gave birth the first time after the
. Women who gave birth the first time after the
age of 30, just as those who have never given birth,
age of 30, just as those who have never given birth,
have a higher risk of developing breast cancer.
have a higher risk of developing breast cancer.

Breastfeeding
Breastfeeding
. Some studies have suggested that
. Some studies have suggested that
breastfeeding, especially continued for 1.5
breastfeeding, especially continued for 1.5
-
-
2 years would
2 years would
had a protective role against breast cancer but there is
had a protective role against breast cancer but there is
no unanimity of opinion in this regard.
no unanimity of opinion in this regard.

Obesity
Obesity
. Is associated with an increased risk of breast
. Is associated with an increased risk of breast
cancer in postmenopausal women. Fat tissue has the
cancer in postmenopausal women. Fat tissue has the
ability to turn other hormones into estrogen. The risk of
ability to turn other hormones into estrogen. The risk of
breast cancer is higher due to higher amount of
breast cancer is higher due to higher amount of
estrogens.
estrogens.

All these factors listed above, although not have the
All these factors listed above, although not have the
same risk weight, have in common an element, namely:
same risk weight, have in common an element, namely:
the endogenous or exogenous
the endogenous or exogenous
hormones
hormones
.
.

Diet and vitamins.
Diet and vitamins.

Fats
Fats
-
-
high
high
-
-
fat diet, unlike in other types of cancer, in
fat diet, unlike in other types of cancer, in
case of breast cancer is not associated with a higher
case of breast cancer is not associated with a higher
risk of carcinogenesis.
risk of carcinogenesis.

Vegetables
Vegetables
and fruits also do not seem to influence
and fruits also do not seem to influence
the risk of breast cancer.
the risk of breast cancer.

Microlelements
Microlelements
(trace elements)
(trace elements)
and vitamins may
and vitamins may
have a role but there is no clear data in this regard.
have a role but there is no clear data in this regard.

Alcohol
Alcohol
. Women who consume alcohol have a higher
. Women who consume alcohol have a higher
risk of breast cancer but this risk is relatively small for
risk of breast cancer but this risk is relatively small for
small amounts of alcohol. This relative risk increased
small amounts of alcohol. This relative risk increased
with 7% for every 10 grams of alcohol consumed.
with 7% for every 10 grams of alcohol consumed.

Smoking
Smoking
-
-
while smoking does not appear to induce
while smoking does not appear to induce
breast cancer, women who smoke have a mortality rate
breast cancer, women who smoke have a mortality rate
higher by 25%.
higher by 25%.

Ionizing radiation
Ionizing radiation
increases the risk of breast cancer
increases the risk of breast cancer
especially if used at a young age. Radiological chest
especially if used at a young age. Radiological chest
exploration should be avoided wherever possible at a
exploration should be avoided wherever possible at a
young age.
young age.

Chemicals
Chemicals
. Although numerous experimental studies in
. Although numerous experimental studies in
animals have found mammary carcinogenic substances,
animals have found mammary carcinogenic substances,
none with this effect was found in humans.
none with this effect was found in humans.

Environmental and occupational factors
Environmental and occupational factors
. It seems that the
. It seems that the
polluted environment of large urban agglomerations and
polluted environment of large urban agglomerations and
the stress are negative risk factors.
the stress are negative risk factors.

There is an increased incidence of breast cancer among
There is an increased incidence of breast cancer among
airplane stewardess, incriminated factor being the more
airplane stewardess, incriminated factor being the more
intense
intense
cosmic radiation
cosmic radiation
at higher altitudes.
at higher altitudes.

Other factors
Other factors

Breast implants
Breast implants
.
.
-
-
there is no clear evidence that implants
there is no clear evidence that implants
would lead to increased incidence of breast cancer, but
would lead to increased incidence of breast cancer, but
implants make mammography difficult.
implants make mammography difficult.
Classification of risk factors according to their
Classification of risk factors according to their
importance
importance

High risk:
High risk:
1.
1.
The existence of genetic markers of susceptibility
The existence of genetic markers of susceptibility
(BRCA 1, BRCA 2)
(BRCA 1, BRCA 2)
2.
2.
Family history of breast cancer unilateral or
Family history of breast cancer unilateral or
bilateral, especially in first degree relatives
bilateral, especially in first degree relatives
3.
3.
4.
4.
History of
History of
hyperplastic
hyperplastic
mastopathies
mastopathies
5.
5.
Hormone replacement therapy (to treat
Hormone replacement therapy (to treat
postmenopausal symptoms),
postmenopausal symptoms),
6.
6.
History of ovarian or endometrial cancer
History of ovarian or endometrial cancer

Moderate risk:
Moderate risk:
1. 1. Age Age
2. 2. Family history of breast cancer occurred before menopause Family history of breast cancer occurred before menopause
3. 3. Radiation of the chest Radiation of the chest
4. 4. Small and repeated breast trauma Small and repeated breast trauma

Low risk:
Low risk:
1. 1. History of breast cancer occurred after menopause History of breast cancer occurred after menopause
2. 2. Nuliparity Nuliparity
3. 3. First birth at an older age than 30 First birth at an older age than 30
4. 4. Early menarche before age 12 Early menarche before age 12
5. 5. Late menopause, occurring over the age of 55 Late menopause, occurring over the age of 55
6. 6. Obesity occurred after menopause (increases risk by 80%) Obesity occurred after menopause (increases risk by 80%)
7. 7. Daily consumption of alcohol Daily consumption of alcohol
8. 8. Diet rich in fat and carbohydrates Diet rich in fat and carbohydrates
9. 9. Oral contraceptive used more than 10 years Oral contraceptive used more than 10 years
Primary prevention of breast cancer
Primary prevention of breast cancer
1.
1.
Avoiding exposure to radiation
Avoiding exposure to radiation
(avoiding unnecessary
(avoiding unnecessary
radiological examinations, avoid prolonged exposure
radiological examinations, avoid prolonged exposure
to ultraviolet radiation)
to ultraviolet radiation)
2.
2.
Physical activity
Physical activity
has beneficial effects through several
has beneficial effects through several
mechanisms.
mechanisms.
3.
3.
Limitation or exclusion of alcohol consumption.
Limitation or exclusion of alcohol consumption.
4.
4.
Maintaining an ideal weight
Maintaining an ideal weight
through diet and exercise
through diet and exercise
especially after menopause.
especially after menopause.
5.
5.
Hypocaloric
Hypocaloric
diet
diet
with a low
with a low
-
-
fat but high in vegetables,
fat but high in vegetables,
fruits, trace elements and vitamins, especially in
fruits, trace elements and vitamins, especially in
adolescence.
adolescence.
6.
6.
Avoid
Avoid
as much as possible
as much as possible
hormone replacement
hormone replacement
therapy and
therapy and
birth control pills.
birth control pills.
7.
7.
Giving birth and breastfeeding
Giving birth and breastfeeding
at a young age would
at a young age would
be beneficial.
be beneficial.
American Cancer Society recommends the following
American Cancer Society recommends the following
steps to detect early breast tumors:
steps to detect early breast tumors:
1.
1.
Women aged over 20 years
-
-
breasts self
breasts self
-
-
examination
examination
should be performed every month.
should be performed every month.
2.
2.
Women between 20 and 39 years
Women between 20 and 39 years
-
-
should be clinically
examined at least once every three years.
examined at least once every three years.
3.
3.
-
-
examined at least once a year, in addition self
examined at least once a year, in addition self
-
-
examination monthly and annual one mammography
examination monthly and annual one mammography
exam.
exam.
Evolution and symptoms
Evolution and symptoms

An adult body normally produces as many new cells as
An adult body normally produces as many new cells as
are needed to replace those lost, maintaining constant the
are needed to replace those lost, maintaining constant the
cell mass. Tumor cells multiplication instead does not
cell mass. Tumor cells multiplication instead does not
keep this balance. They are growing at a rate faster than
keep this balance. They are growing at a rate faster than
normal cells causing tumor masses.
normal cells causing tumor masses.

Tumor cells, unlike normal ones, are no longer so strictly
Tumor cells, unlike normal ones, are no longer so strictly
linked together to form tissues. Tumor cells have the
linked together to form tissues. Tumor cells have the
ability to spread in various ways in any region of the body.
ability to spread in various ways in any region of the body.
The immune system can not cope with this invasion and
The immune system can not cope with this invasion and
tumor cell metastases appear.
tumor cell metastases appear.

The underground breast cancer life is very long. Tumor
The underground breast cancer life is very long. Tumor
growth is measured in doubling time. A doubling time is
growth is measured in doubling time. A doubling time is
the length of time required for tumor cell mass to double
the length of time required for tumor cell mass to double
in volume.
in volume.

It takes about 23 doubling times starting from a tumor cell
It takes about 23 doubling times starting from a tumor cell
to reach a tumor mass large enough to be seen at
to reach a tumor mass large enough to be seen at
mammography and approximately 30 times (1 billion
mammography and approximately 30 times (1 billion
cells) to be palpable.
cells) to be palpable.

Doubling period can be short, sometimes for only 10
Doubling period can be short, sometimes for only 10
days, or longer, for years. An average period is of 4
days, or longer, for years. An average period is of 4
months.
months.

For example, if a first tumor cell occurred in the age of 40
For example, if a first tumor cell occurred in the age of 40
and if we believe it is a fast growing tumor with a
and if we believe it is a fast growing tumor with a
doubling period of two months, four years must pass until
doubling period of two months, four years must pass until
the tumor can be detected on mammography, so at the
the tumor can be detected on mammography, so at the
age of 44 years. As the tumor can be detected by
age of 44 years. As the tumor can be detected by
palpation have to pass about 5 years, so when the
palpation have to pass about 5 years, so when the
patient will have 49 years, that is after 9 years from first
patient will have 49 years, that is after 9 years from first
appearance of tumor cells.
appearance of tumor cells.
Clinical picture
Clinical picture

There is no unique clinical picture of breast cancer since
There is no unique clinical picture of breast cancer since
there are many clinical forms.
there are many clinical forms.
Symptoms are closely
Symptoms are closely
related to stage of the tumor.
related to stage of the tumor.

Initially, breast cancer does not have any symptoms.
Initially, breast cancer does not have any symptoms.
0.5% of breast cancer are asymptomatic. Pain occurs
0.5% of breast cancer are asymptomatic. Pain occurs
rarely, in 10% of patients (continuous or intermittent,
rarely, in 10% of patients (continuous or intermittent,
localized or irradiated pain).
localized or irradiated pain).

The tumor is usually detected by the patient itself during
The tumor is usually detected by the patient itself during
toilet.
toilet.

Local evolution
Local evolution
of breast cancer is by direct extension to
of breast cancer is by direct extension to
the surrounding tissues along the connective tracts, along
the surrounding tissues along the connective tracts, along
ducts and invasion of lymphatic and blood vessels.
ducts and invasion of lymphatic and blood vessels.
Local extension
Local extension

Extension in skin surface
Extension in skin surface
by invasion of
by invasion of
Duret
Duret
crests
crests
and Cooper ligaments.
and Cooper ligaments.

In this stage the skin becomes fixed, infiltrated and can
In this stage the skin becomes fixed, infiltrated and can
not be folded (
not be folded (
Ianisevski
Ianisevski
s
s
sign
sign
) and to side
) and to side
displacement maneuver of the tumor a depression
displacement maneuver of the tumor a depression
appears behind it (
appears behind it (
Dupuytrain
Dupuytrain
s
s
sign
sign
).
).
In a later stage the tumor infiltrates the deep skin, blocking
In a later stage the tumor infiltrates the deep skin, blocking
the local lymphatic circulation. Skin pores expands and
the local lymphatic circulation. Skin pores expands and
appears the aspect of orange peel (
appears the aspect of orange peel (
peau
peau
d
d
orange
orange
)
)
peau peau d d orange orange
Then, invading the skin, tumor leads to
Then, invading the skin, tumor leads to
ulceration
ulceration
which
which
has irregular borders, purple color, endured margins and
has irregular borders, purple color, endured margins and
necrotic tissue in the bottom.
necrotic tissue in the bottom.
Bleeding and infectious complications are common in this
Bleeding and infectious complications are common in this
stage.
stage.
Ulcerated breast cancer

Dermal tumor nodules
Dermal tumor nodules
may appear at some distance
may appear at some distance
from the tumor due to local lymphatic spread.
from the tumor due to local lymphatic spread.

If the tumor is located in the central quadrant it may
If the tumor is located in the central quadrant it may
produce
produce
nipple retraction
nipple retraction
through invasion of milk
through invasion of milk
ducts and connective tracts ( important diagnostic sign).
ducts and connective tracts ( important diagnostic sign).

Retraction is fixed, irreducible, unilateral and acquired.
Retraction is fixed, irreducible, unilateral and acquired.

Ducts invasion also causes
Ducts invasion also causes
nipple discharge
nipple discharge
(serous,
(serous,
sanguinolent
sanguinolent
or
or
lactescent
lactescent
either spontaneously or on
either spontaneously or on
compression)
compression)

Extension in depth
Extension in depth
to the pectoral muscles.
to the pectoral muscles.
Tillaux
Tillaux
maneuver
maneuver
(during pectoral muscle contraction in forced
(during pectoral muscle contraction in forced
adduction the tumor becomes fixed to the chest wall)
adduction the tumor becomes fixed to the chest wall)

Invasion may progress to the chest wall structures
Invasion may progress to the chest wall structures
(muscles, ribs) and then to pleura and lungs.
(muscles, ribs) and then to pleura and lungs.
Tillaux maneuver

The section surface of tumor has a characteristic
The section surface of tumor has a characteristic
aspect: flat,
aspect: flat,
stellate
stellate
, with irregular edges, of hard
, with irregular edges, of hard
consistency with yellow spots or areas of calcification or
consistency with yellow spots or areas of calcification or
areas of necrosis.
areas of necrosis.
Skin retraction
Regional extension
Regional extension

It takes place along the main and secondary lymphatic
It takes place along the main and secondary lymphatic
routes.
routes.

Along the lymphatic route there is a lymph node which
Along the lymphatic route there is a lymph node which
is most likely to retain first the cancer cells:
is most likely to retain first the cancer cells:
the
the
sentinel lymph node
sentinel lymph node
.
.

This node can be find and removed for examination by
This node can be find and removed for examination by
methods using radiotracers and dyes tracers. Biopsy of
methods using radiotracers and dyes tracers. Biopsy of
this lymph node can be performed to find if it is invaded
this lymph node can be performed to find if it is invaded
or not by the cancerous cells.
or not by the cancerous cells.
Histopathological
Histopathological
findings are very important in choosing the type of
findings are very important in choosing the type of
surgery which will be applied (with or without
surgery which will be applied (with or without
axillary
axillary
lymphadenectomy
lymphadenectomy
).
).
Noduli
axilari
Noduli
supraclaviculari
N
o
d
u
l
i

m
a
m
a
r
i

i
n
t
e
r
n
i
Noduli
axilari
contralaterali
Noduli
epigastrici,
diafragmatici
Lymphatic spread of tumor

Axillary
Axillary
lymph nodes affected by metastases gradually
lymph nodes affected by metastases gradually
increase in volume so they begin to compress and invade
increase in volume so they begin to compress and invade
the
the
axillary
axillary
vessels and nerves causing
vessels and nerves causing
pain in upper
pain in upper
limb
limb
.
.

Lymphatic invasion extends to the
Lymphatic invasion extends to the
subclavian
subclavian
and
and
supraclavicular
supraclavicular
lymph nodes group with the consequence
lymph nodes group with the consequence
of
of
lymphedema
lymphedema
of the upper limb but also open
of the upper limb but also open
secondary lymphatic channels to
secondary lymphatic channels to
contralateral
contralateral
armpit.
armpit.

Lymph node invasion is the most important prognostic
Lymph node invasion is the most important prognostic
factor, efforts in this area currently being targeted to
factor, efforts in this area currently being targeted to
detect breast cancer before this stage.
detect breast cancer before this stage.

Tumors located in the internal quadrants spread most
Tumors located in the internal quadrants spread most
commonly to internal mammary lymph nodes which can
commonly to internal mammary lymph nodes which can
not be detected by clinical examination.
not be detected by clinical examination.
Remote extension
Remote extension

is achieved by both lymphatic and venous routes.
is achieved by both lymphatic and venous routes.

Tumoral cells invade the microcirculation and are taken
Tumoral cells invade the microcirculation and are taken
by venous torrent towards superior vena cava. From here
by venous torrent towards superior vena cava. From here
they follow the natural path to the right heart and then to
they follow the natural path to the right heart and then to
the lung which represents the first major systemic filter.
the lung which represents the first major systemic filter.
The second filter is represented by liver.
The second filter is represented by liver.

The vast majority of tumoral cells remain stuck in the first
The vast majority of tumoral cells remain stuck in the first
filter (the lung) filter and start to develop
filter (the lung) filter and start to develop
lung
lung
metastases.
metastases.

Lung metastases are manifested initially by decreasing
Lung metastases are manifested initially by decreasing
exercise capacity,
exercise capacity,
dyspnea
dyspnea
at effort, and then even at
at effort, and then even at
rest.
rest.

In advanced forms irritating
In advanced forms irritating
cough
cough
and
and
dyspnea
dyspnea
is
is
increasing more and more going to
increasing more and more going to
exitus
exitus
, both by
, both by
reducing the lungs
reducing the lungs
hematosis
hematosis
surface to and
surface to and
paraneoplastic
paraneoplastic
pleurisy
pleurisy
.
.

Much of tumor cells can escape this filter and enter the
Much of tumor cells can escape this filter and enter the
pulmonary artery bloodstream from where the path is open
pulmonary artery bloodstream from where the path is open
to any region of the body.
to any region of the body.

Other most common sites of metastases are the
Other most common sites of metastases are the
liver
liver
and
and
bone
bone
.
.

Liver metastases
Liver metastases
determs
determs
symptoms like:
symptoms like:
weight loss
weight loss
, loss
, loss
of
of
appetite
appetite
, digestive problems and eventually
, digestive problems and eventually
jaundice
jaundice
.
.
There may be a dull
There may be a dull
pain
pain
under right costal margin
under right costal margin
produced by
produced by
Glisson
Glisson
s
s
capsule distension. Liver
capsule distension. Liver
metastases can be detected by ultrasound examination of
metastases can be detected by ultrasound examination of
the liver or by CT scan.
the liver or by CT scan.

Bone metastases
Bone metastases
appear to be the most common
appear to be the most common
sites of metastasis in breast cancer. They are present
sites of metastasis in breast cancer. They are present
in approximately 25% of cases. These metastases are
in approximately 25% of cases. These metastases are
manifested mainly by early
manifested mainly by early
pain
pain
. Most frequent
. Most frequent
complication of bone metastases is
complication of bone metastases is
pathological
pathological
fractures
fractures
.
.

Bone metastasis can be observed on bone radiograms
Bone metastasis can be observed on bone radiograms
which reveal bone circumscribed demineralization
which reveal bone circumscribed demineralization
and/or at
and/or at
radioscintigraphy
radioscintigraphy
or CT scan or PET scan.
or CT scan or PET scan.

Other regions of metastasis: the brain, spine, spinal
Other regions of metastasis: the brain, spine, spinal
cord, etc.
cord, etc.
but not Kidneys
but not Kidneys

In conclusion, although in early stages the breast
In conclusion, although in early stages the breast
cancer does not cause pain, there are other symptoms
cancer does not cause pain, there are other symptoms
that should be
that should be
warning signs
warning signs
for women and to
for women and to
determine them to contact a doctor.
determine them to contact a doctor.
1.
1.
The appearance of a breast tumor and/or
The appearance of a breast tumor and/or
axillary
axillary
enlarged lymph nodes
enlarged lymph nodes
2.
2.
Changes in breast shape and size, and nipple
Changes in breast shape and size, and nipple
symmetry
symmetry
3.
3.
Changes of skin surface (orange peel, tumor
Changes of skin surface (orange peel, tumor
nodules, ulceration, increased vascular drawing)
nodules, ulceration, increased vascular drawing)
4.
4.
Nipple discharge, especially
Nipple discharge, especially
sanguinolent
sanguinolent
5.
5.
Recent nipple retraction
Recent nipple retraction
Paraclinical
Paraclinical
and laboratory examinations
and laboratory examinations
in breast cancer
in breast cancer

To treat a breast cancer, first the doctor must answer
To treat a breast cancer, first the doctor must answer
to 2 questions:
to 2 questions:
1. 1. Has the woman a breast cancer ? Has the woman a breast cancer ?
2. 2. What is the exact location and extension of the tumor ? What is the exact location and extension of the tumor ?
Imaging examinations
Imaging examinations

Mammography and breast ultrasound are the most
Mammography and breast ultrasound are the most
frequent investigations used in this field.
frequent investigations used in this field.
Mammography
Mammography

It can find breast tumors in an early stage, about 2
It can find breast tumors in an early stage, about 2
years before they can be detected by palpation.
years before they can be detected by palpation.

Mammography does not prevent breast cancer!
Mammography does not prevent breast cancer!

Mammography uses X rays. Radiation level is very low
Mammography uses X rays. Radiation level is very low
(0.1
(0.1
Gy
Gy
).
).

There are two types of
There are two types of
mammograhy
mammograhy
:
:
1.
1.
Screening mammography
which is performed in
which is performed in
women with no complaints in the breast area.
women with no complaints in the breast area.
2.
2.
Diagnostic mammography

for women who has
for women who has
some complaints or modification in breast area
some complaints or modification in breast area
Each breast is compressed horizontally and then obliquely and x-
rays are taken in each position.
Screening versus Diagnostic Mammography
Screening versus Diagnostic Mammography

1. 1. It is applied to asymptomatic women It is applied to asymptomatic women
2. 2. Purpose is detection of possible abnormalities Purpose is detection of possible abnormalities
3. 3. Standard two views of each breast ( Standard two views of each breast (mediolateral mediolateral oblique and oblique and
craniocaudal craniocaudal) are taken ) are taken
4. 4. Images are read by radiologist Images are read by radiologist

1. 1. Applied to symptomatic (palpable finding, pain, spontaneous Applied to symptomatic (palpable finding, pain, spontaneous
nipple discharge, etc) nipple discharge, etc)
2. 2. Call back of a patient with an abnormal screening mammogram Call back of a patient with an abnormal screening mammogram
3. 3. Views are tailored to the patient's problem (may include spot or Views are tailored to the patient's problem (may include spot or
magnification views, additional projections, and ultrasound). magnification views, additional projections, and ultrasound).
4. 4. Usually performed in the presence of the radiologist and Usually performed in the presence of the radiologist and
interpreted at the time of the examination. interpreted at the time of the examination.

An improvement in this field is the
An improvement in this field is the
digital mammography
digital mammography
which stores and analyze the information on a computer.
which stores and analyze the information on a computer.

Detectable tumor size on mammography is an average
Detectable tumor size on mammography is an average
of 1 cm. diameter. In the table below are given for
of 1 cm. diameter. In the table below are given for
comparison of approximate sizes mammary tumors
comparison of approximate sizes mammary tumors
detected by mammography and by palpation.
detected by mammography and by palpation.
1 cm.
1,5 cm.
2 cm.
3,5 cm.

Mammographic features of a malignant tumor are:
Mammographic features of a malignant tumor are:
1. 1. Irregular whitish mass with marginal Irregular whitish mass with marginal spicule spicule
2. 2. Clusters of Clusters of microcalcification microcalcification
3. 3. Calcification less than 0.5 mm diameter Calcification less than 0.5 mm diameter
4. 4. Deformation of local architecture Deformation of local architecture
5. 5. Density asymmetry Density asymmetry
6. 6. Skin retraction Skin retraction
7. 7. Peritumoral Peritumoral edema edema

Mammographic features of a benign tumor are:
Mammographic features of a benign tumor are:
1. 1. Circumscribed mass Circumscribed mass
2. 2. Fat Fat- -containing lesion containing lesion
3. 3. Microcalcifications Microcalcifications
4. 4. Round, uniform density, large, coarse Round, uniform density, large, coarse
5. 5. Widely scattered Widely scattered
Mammograms
Interpretation of mammograms
Interpretation of mammograms

Standardization system BI
Standardization system BI
-
-
RADSTM (Breast Imaging
RADSTM (Breast Imaging
Reporting and Database System) to characterize the
Reporting and Database System) to characterize the
mammographic images:
mammographic images:
1.
1.
Category 0
Category 0
-
-
image inconclusive, it is necessary to
image inconclusive, it is necessary to
carry out other imaging
carry out other imaging
2.
2.
Category 1
Category 1
-
-
negative
negative
3.
3.
Category 2
Category 2
-
-
benign character changes
benign character changes
4.
4.
Category 3
Category 3
-
-
probably benign but require tracking
probably benign but require tracking
changes
changes
5.
5.
Category 4
Category 4
-
-
suspicious for cancer changes
suspicious for cancer changes
-
-
requires biopsy
requires biopsy
6.
6.
Category 5
Category 5
-
-
highly suggestive of cancer changes
highly suggestive of cancer changes
Indications:
Indications:
1. 1.
To investigate tumors detected by mammography or
To investigate tumors detected by mammography or
palpation and for biopsy guidance.
palpation and for biopsy guidance.
2. 2.
To differentiate the cystic from solid tumors.
To differentiate the cystic from solid tumors.
3. 3.
To explore the breast tumors that can not be evaluated
To explore the breast tumors that can not be evaluated
by mammography (or are not visible, either because of
by mammography (or are not visible, either because of
location, either due to dense breast tissue in young
location, either due to dense breast tissue in young
women)
women)
4. 4.
To explore the
To explore the
axillary
axillary
lymph nodes.
lymph nodes.
5. 5.
To explore the breast tissue in mastitis
To explore the breast tissue in mastitis

abscess
abscess
formation
formation
6. 6.
To guide the
To guide the
biobpsy
biobpsy
7. 7.
In pregnant women because there is no radiation
In pregnant women because there is no radiation
exposure.
exposure.

Limits of the method:
Limits of the method:
It takes longer time to investigate the patient It takes longer time to investigate the patient
Can not detect microcalcifications Can not detect microcalcifications
Isn Isn t so accurate than biopsy, there are frequently false negative t so accurate than biopsy, there are frequently false negative
and false positive conclusions and false positive conclusions
Examiner's experience is an important related factor Examiner's experience is an important related factor

Advantages of the method:
Advantages of the method:
Does not use radiation Does not use radiation
Can differentiate between a solid and a cystic structure Can differentiate between a solid and a cystic structure
Offers the possibility to explore in multiple levels Offers the possibility to explore in multiple levels
It is cheap It is cheap

Malignant features of the tumor:
Malignant features of the tumor:
Lesion is taller than it is wide Lesion is taller than it is wide
Decreased Decreased hyperechogenicity hyperechogenicity
Marked acoustical shadowing Marked acoustical shadowing
Spiculation Spiculation
Nuclear magnetic resonance imaging (MRI)
Nuclear magnetic resonance imaging (MRI)

It provides valuable information about tumor extension.
It provides valuable information about tumor extension.
The main drawback is the price far above the
The main drawback is the price far above the
mammography examination.
mammography examination.

Indications:
Indications:
1.
1.
Preoperative staging in breast cancer for possible or
Preoperative staging in breast cancer for possible or
multi
multi
-
-
focal disease,
focal disease,
2.
2.
Detection of implant rupture,
Detection of implant rupture,
3.
3.
Patient with metastatic breast cancer,
Patient with metastatic breast cancer,
4.
4.
Occult breast cancer,
Occult breast cancer,
5.
5.
Differentiation between scar and tumor recurrence,
Differentiation between scar and tumor recurrence,
6.
6.
Screening of high
Screening of high
-
-
risk patients.
risk patients.

Recommendations for Breast MRI Screening as an Adjunct to Recommendations for Breast MRI Screening as an Adjunct to
Mammography Mammography Cancer Screening Guidelines for Breast Screening Cancer Screening Guidelines for Breast Screening
with MRI as an Adjunct to Mammography with MRI as an Adjunct to Mammography by ACS by ACS

Recommend Annual MRI Screening (Based on Evidence*) Recommend Annual MRI Screening (Based on Evidence*)
BRCA mutation BRCA mutation
First First- -degree relative of BRCA carrier, but untested degree relative of BRCA carrier, but untested
Lifetime risk 20 Lifetime risk 20 25% or greater, as defined by BRCAPRO or other models that 25% or greater, as defined by BRCAPRO or other models that
are largely dependent on family history are largely dependent on family history

Recommend Annual MRI Screening (Based on Expert Consensus Opinio Recommend Annual MRI Screening (Based on Expert Consensus Opinion ) n )
Radiation to chest between age 10 and 30 years Radiation to chest between age 10 and 30 years
Li Li- -Fraumeni Fraumeni syndrome and first syndrome and first- -degree relatives degree relatives
Cowden and Cowden and Bannayan Bannayan- -Riley Riley- -Ruvalcaba Ruvalcaba syndromes and first syndromes and first- -degree relatives degree relatives
Insufficient Evidence to Recommend for or Against MRI Screening Insufficient Evidence to Recommend for or Against MRI Screening
Lifetime risk 15 Lifetime risk 15 20%, as defined by BRCAPRO or other models that are largely 20%, as defined by BRCAPRO or other models that are largely
dependent on family history dependent on family history
Lobular carcinoma in situ (LCIS) or atypical lobular hyperplasia Lobular carcinoma in situ (LCIS) or atypical lobular hyperplasia (ALH) (ALH)
Atypical Atypical ductal ductal hyperplasia (ADH) hyperplasia (ADH)
Heterogeneously or extremely dense breast on mammography Heterogeneously or extremely dense breast on mammography
Women with a personal history of breast cancer, including Women with a personal history of breast cancer, including ductal ductal carcinoma in carcinoma in
situ (DCIS) situ (DCIS)

Recommend Against MRI Screening (Based on Expert Consensus Opini Recommend Against MRI Screening (Based on Expert Consensus Opinion) on)
Women at <15% lifetime risk Women at <15% lifetime risk
Transverse high-resolution MR
mammography of breast and
implants.
Note the implant twisting on the
upper (left) image and the implant
valve on the lower (left) image
Breast cancer
CT scan
CT scan

This method of investigation is not routinely used to
This method of investigation is not routinely used to
diagnose breast tumors due to exposure to radiation. It
diagnose breast tumors due to exposure to radiation. It
is however very useful in advanced stages of disease
is however very useful in advanced stages of disease
to assess the extension of
to assess the extension of
neoplastic
neoplastic
process in the
process in the
chest wall structures or distant metastases detection.
chest wall structures or distant metastases detection.
CTLM (Computed Tomography Laser
CTLM (Computed Tomography Laser
Mammography)
Mammography)

Uses laser technology to produce three
Uses laser technology to produce three
-
-
dimensional
dimensional
images of the breast. It does not create any discomfort.
images of the breast. It does not create any discomfort.
CTLM
CTLM
is a method of looking at the blood flow to the
is a method of looking at the blood flow to the
breast and thereby should visualize tumor
breast and thereby should visualize tumor
angiogenesis. It can images through implants and
angiogenesis. It can images through implants and
dense breast tissue easily, unlike mammography.
dense breast tissue easily, unlike mammography.
Mammogram
CTLM
Scintimammography
Scintimammography
(
(
Sestamibi
Sestamibi
)
)

It is based on the fact that the radiant substance is
It is based on the fact that the radiant substance is
captured at a greater extent by tumors than normal
captured at a greater extent by tumors than normal
tissue due to their increased metabolism.
tissue due to their increased metabolism.
It is used in selected cases as:
It is used in selected cases as:
1. 1.
For patients with dense breast tissue difficult to
For patients with dense breast tissue difficult to
investigate with other imaging methods.
investigate with other imaging methods.
2. 2.
When a breast tumor can be felt but it can not be
When a breast tumor can be felt but it can not be
detected by mammography or ultrasound.
detected by mammography or ultrasound.
3. 3.
Breast implants
Breast implants
4. 4.
When multiple, multifocal tumors are suspected.
When multiple, multifocal tumors are suspected.
5. 5.
When after mastectomy tumors appear at the level of
When after mastectomy tumors appear at the level of
postoperative scar.
postoperative scar.
6. 6.
To explore the
To explore the
axilla
axilla
in detecting metastatic lymph
in detecting metastatic lymph
nodes or for sentinel node biopsy.
nodes or for sentinel node biopsy.
Sestamibi Sestamibi
P.E.T.
P.E.T.
-
-
Positron Emission Tomography
Positron Emission Tomography

The principle is the same as in
The principle is the same as in
Sestamibi
Sestamibi
.
.

Post
Post
-
-
therapy is particularly useful for detecting any
therapy is particularly useful for detecting any
remaining cancer and active areas and to detect lymph
remaining cancer and active areas and to detect lymph
node or distant metastases.
node or distant metastases.
Other imaging investigations:
Other imaging investigations:

Chest radiograph Chest radiograph

Bone radiography Bone radiography

Bone Bone scintigraphy scintigraphy

Thermography Thermography - -The area around the cancer tissue has a higher The area around the cancer tissue has a higher
temperature because of rich blood supply and more intense temperature because of rich blood supply and more intense
metabolism metabolism

Electrical impedance scanning (EIS Electrical impedance scanning (EIS) )
Thermography Thermography
Investigation methods of milk ducts
Investigation methods of milk ducts
1. 1.
Ductography
Ductography
(
(
Galactography
Galactography
)
)
-
-
is an x
is an x
-
-
ray
ray
examination that uses mammography, a low
examination that uses mammography, a low
-
-
dose x
dose x
-
-
ray
ray
system for examining breasts, and a contrast material to
system for examining breasts, and a contrast material to
obtain pictures, called
obtain pictures, called
galactograms
galactograms
, of the inside of the
, of the inside of the
breast's milk ducts.
breast's milk ducts.

Indications:
Indications:
Unilateral persistent Unilateral persistent sanguinolent sanguinolent nipple discharge nipple discharge

Contraindications:
Contraindications:
Allergy to contrast substance Allergy to contrast substance
Difficult to achieve in the following conditions: Difficult to achieve in the following conditions:

Previous operations on the nipple Previous operations on the nipple

Inverted nipple Inverted nipple
2. 2.
Ductal
Ductal
lavage
lavage
-
- Examines the cells in wash liquid. Examines the cells in wash liquid.
3. 3.
Ductoscopy
Ductoscopy - - It is capable of detecting smaller abnormalities It is capable of detecting smaller abnormalities
than mammograms, MRI or ultrasound tests. than mammograms, MRI or ultrasound tests.
Ductogram. Magnification view demonstrates filling
defects approximately 1.5 cm from the nipple
Ductoscopy
Normal Papilloma
TUMORAL MARKERS IN BREATS CANCER
TUMORAL MARKERS IN BREATS CANCER

Tumoral markers are substances that can be detected
in small amounts in blood, urine and various tissues.
Measurement of these markers is useful in detection
and diagnosis of various cancers.

Usefulness:
1. Determination of cancer risk in some people
2. Detect cancer in the body
3. Reflecting the stage of the disease
4. Monitoring the effectiveness of cancer treatment
5. Early tumor recurrence detection
6. Prognosis estimation of the case
marker
ER/PR
(estrogen/
progesteron
receptor)
Estrogen receptors bind to cancer cells stimulating
their proliferation and differentiation. Progesterone
is also a mitogenic factor stimulating the mammary
epithelium.
Determination of ER and PR receptors by
immunohistochemistry has become an important
standard for clinical labor as the presence of these
receptors influence therapeutic measures and
prognosis of patients.
The patients with breast cancer who have both types of
receptors (70% cases) have the best remission to
treatment with Tamoxifen, while those with only one
type of receptor (30%) have poor results, and those
with low levels of receptors (less than 10%) had
poor results also.
BRCA1
(breast cancer 1)
Chromozom 17q
BRCA2
(breast cancer 2)
Chromozom 13q,
developing breast cancer by 56-85% rate and also
ovarian.
BRCA1 is found in 3% of of breast cancer in general and
70% in women with hereditary of breast cancer.
BRCA2 mutation is identified in 10-20% of families with
cancer for women carrying BRCA2 is 25-30%.
HER-2/neu
(human epidermal
growth factor
receptor 2)
Gene ERBB2 localised
on chromozom
17q21.1
Is a surface gene that plays a key role in regulating cell
growth. When HER2 is altered more HER2 receptors
will be produced which leads to increased cell
multiplication. HER2 is found in 25-30% of women with
breast cancer. They can be detected in tissues sample
collected by biopsy or surgery.
In women with metastatic HER2 positive is indicated
Herceptin (Trastuzumab) - a monoclonal antibody
produced by biotechnology.
CA 15-3
(Carbohydrate Antigen
15-3) (Cancer Antigen
15-3) Antigen oncofetal
(from blood)
It is a marker used to monitor treatment
effectiveness in advanced breast
cancer.
Rarely is increased in the early stages of
the disease.
CA-125 also known as mucin 16
For following the response to treatment
and predicting prognosis after
treatment. It is especially useful for
detecting the recurrence of ovarian
cancer.
CA 27-29 It is found in the blood of the vast majority
of the patients with breast cancer.
It is used together with other tests to
monitor the treated of breast cancer in
stage II and III
It is an independent factor for predicting
tumor recurrence
Invasive methods of diagnosis
Invasive methods of diagnosis
Breast biopsy
Breast biopsy

The only examination that can make with certainty the
The only examination that can make with certainty the
diagnosis of cancer is histopathology which can be
diagnosis of cancer is histopathology which can be
obtained by biopsy.
obtained by biopsy.

Confirmation of breast cancer before surgery is useful
Confirmation of breast cancer before surgery is useful
because it influences the magnitude of this act, if it is
because it influences the magnitude of this act, if it is
necessary and subsequent treatments as well.
necessary and subsequent treatments as well.

Types of breast biopsies:
Types of breast biopsies:
1. 1.
Percutaneous
Percutaneous
Fine needle aspiration Fine needle aspiration
Tru Tru Cut biopsy Cut biopsy
Vacuum assisted biopsy Vacuum assisted biopsy
ABBI ABBI (advanced breast biopsy instrumentation) (advanced breast biopsy instrumentation)
2. 2.
Surgical
Surgical
Incisional Incisional
Excisional Excisional
1. 1.
Fine needle aspiration (FNA)
Fine needle aspiration (FNA)

Indications:
Indications:
Tor tumors of cystic nature Tor tumors of cystic nature
For solid lesions in stage T3 or T4, or For solid lesions in stage T3 or T4, or axillary axillary and local and loca l
recurrences recurrences
Due to possible false negative results, this type of
Due to possible false negative results, this type of
investigation is not very suitable for exploring tumors
investigation is not very suitable for exploring tumors
of less than 1 cm.
of less than 1 cm.

Cytological examination is required in the following
Cytological examination is required in the following
situations:
situations:
1. 1. Hemorrhagic fluid is extracted Hemorrhagic fluid is extracted
2. 2. After aspiration the tumor mass does not disappear completely After aspiration the tumor mass does not disappear completely
3. 3. It is a recurrent cyst It is a recurrent cyst
4. 4. There is a suspicion for cancer on mammogram There is a suspicion for cancer on mammogram
Breast FNA guided by ultrasound
2.
2.
Tru
Tru
cut biopsy
cut biopsy

It is also a
It is also a
percutaneous
percutaneous
method. The essential
method. The essential
differences from fine needle aspiration biopsy are:
differences from fine needle aspiration biopsy are:
1.
1.
It uses a thick needle, specially fitted with a cutting
It uses a thick needle, specially fitted with a cutting
mechanism
mechanism
2.
2.
The process of obtaining biopsy material is cutting
The process of obtaining biopsy material is cutting
not aspiration
not aspiration
3.
3.
The material obtained is a cylinder of tissue, enough
The material obtained is a cylinder of tissue, enough
to differentiate between invasive and noninvasive
to differentiate between invasive and noninvasive
type of cancer
type of cancer
4.
4.
Core needle biopsy is not suitable for cystic lesions
Core needle biopsy is not suitable for cystic lesions
The principle of Tru Cut biopsy
Biopsy gun
Tru Cut biopsy
Guided by ultrasound
Advantages:
Advantages:

Sample tissue with enough cellular material to detect
Sample tissue with enough cellular material to detect
breast cancer
breast cancer

Harvested fragments can demonstrate relationship with
Harvested fragments can demonstrate relationship with
the surrounding tissue ad can make the difference
the surrounding tissue ad can make the difference
between in situ and invasive cancer.
between in situ and invasive cancer.
Disadvantages:
Disadvantages:

As a biopsy, it harvests only fragments of tissue, not
As a biopsy, it harvests only fragments of tissue, not
the entire tumor. Even if the fragment does not contain
the entire tumor. Even if the fragment does not contain
cancer cells is not an absolute guarantee that the
cancer cells is not an absolute guarantee that the
patient is not suffering from breast cancer.
patient is not suffering from breast cancer.

The method cannot be applied to women with breast
The method cannot be applied to women with breast
implants as the risk for perforation the implant.
implants as the risk for perforation the implant.
3.
3.
Vacuum assisted biopsy
Vacuum assisted biopsy

The novelty of the method is that the biopsy needle is
The novelty of the method is that the biopsy needle is
adapted to a vacuum system. By using vacuum, breast
adapted to a vacuum system. By using vacuum, breast
tissue is absorbed into the needle slot ensuring a better
tissue is absorbed into the needle slot ensuring a better
sampling. 3
sampling. 3
-
-
6 specimens are extracted.
6 specimens are extracted.
Stereotactic breast
vacuum assisted biopsy
4.
4.
ABBI
ABBI
-
-
Advanced Breast Biopsy
Advanced Breast Biopsy
Instrumentation
Instrumentation

This type of biopsy uses a thicker needle of
This type of biopsy uses a thicker needle of
0.5 to 2 cm in diameter.
0.5 to 2 cm in diameter.

The intention of this type of biopsy is to
The intention of this type of biopsy is to
extract as much tissue as possible, even
extract as much tissue as possible, even
the entire tumor if the size permits.
the entire tumor if the size permits.

Is carried out only with stereotactic
Is carried out only with stereotactic
equipment. Rarely used in now days.
equipment. Rarely used in now days.
SURGICAL BIOPSIES
SURGICAL BIOPSIES
1. 1.
Excisional
Excisional
biopsy
biopsy

It is the most commonly used.
It is the most commonly used.

The surgeon will remove the tumor with a safety margin
The surgeon will remove the tumor with a safety margin
of normal tissue around it.
of normal tissue around it.
2. 2.
Incisional
Incisional
biopsy
biopsy

This applies when the breast tumor is larger (more than
This applies when the breast tumor is larger (more than
4 cm diameter) or diffuse, or when chemotherapy and
4 cm diameter) or diffuse, or when chemotherapy and
radiotherapy are the primary treatment.
radiotherapy are the primary treatment.

Surgeon excises only a portion that is suggestive for
Surgeon excises only a portion that is suggestive for
cancer
cancer
.
.
Advantages of surgical biopsies:
Advantages of surgical biopsies:

Ensures the diagnosis in almost 100% cases being the
Ensures the diagnosis in almost 100% cases being the
"gold standard" in this sense.
"gold standard" in this sense.

In case of small tumors it can be regarded as definitive
In case of small tumors it can be regarded as definitive
surgical therapy method (lumpectomy) if the tumor was
surgical therapy method (lumpectomy) if the tumor was
excised with negative margins.
excised with negative margins.
Summary of breast biopsy methods
Summary of breast biopsy methods
STAGING OF BREAST
STAGING OF BREAST
TUMORS
TUMORS
TNM classification
TNM classification
The T stages (tumor)

TX means that the tumor size cannot be assessed

T1 The tumor is no more than 2 centimeters (cm)
across
T1 is further divided into 4 groups
T1mic under a microscope the cancer cells can be
seen to spread less than 0.1cm into surrounding tissue
(microinvasion)
T1a the tumor is more than 0.1 cm but not more
than 0.5 cm
T1b the tumor is more than 0.5 cm but not more
than 1 cm
T1c the tumor is more than 1 cm but not more than
2 cm

T2 The tumour is more than 2 centimeters, but no
more than 5 centimeters across

T3 The tumour is bigger than 5 centimeters across

T4 is divided into 4 groups
T4a The tumor has spread into the chest wall
T4b The tumor has spread into the skin
T4c The tumor is fixed to both the skin and the
chest wall
T4d Inflammatory carcinoma this is a cancer in
which the overlying skin is red, swollen and painful to
the touch
T stage
The N stages (nodes)
The N stages (nodes)

NX means that the lymph nodes cannot be assessed (for example, i NX means that the lymph nodes cannot be assessed (for example, if f
they were previously removed) they were previously removed)

N0 N0 No cancer cells found in any nearby nodes No cancer cells found in any nearby nodes

N1 N1 Cancer cells are in the upper levels of lymph nodes in the armp Cancer cells are in the upper levels of lymph nodes in the armpit it
but the nodes are not stuck to surrounding tissues but the nodes are not stuck to surrounding tissues

N2 is divided into 2 groups N2 is divided into 2 groups
N2a N2a there are cancer cells in the lymph nodes in the armpit, which there are cancer cells in the lymph nodes in the armpit, which are are
stuck to each other and to other structures stuck to each other and to other structures
N2b N2b there are cancer cells in the lymph nodes behind the breast bon there are cancer cells in the lymph nodes behind the breast bone e
(the internal mammary nodes, which have either been seen on a sc (the internal mammary nodes, which have either been seen on a scan or an or
felt by the doctor. There is no evidence of cancer in lymph node felt by the doctor. There is no evidence of cancer in lymph nodes in the s in the
armpit armpit

N3 is divided into 3 groups N3 is divided into 3 groups
N3a N3a there are cancer cells in lymph nodes below the collarbone there are cancer cells in lymph nodes below the collarbone
N3b N3b there are cancer cells in lymph nodes in the armpit and under t there are cancer cells in lymph nodes in the armpit and under the he
breast bone breast bone
N3c N3c there are cancer cells in lymph nodes above the collarbone there are cancer cells in lymph nodes above the collarbone
The M stages (metastases)
The M stages (metastases)

M0 M0 No sign of cancer spread No sign of cancer spread

M1 M1 Cancer has spread to another part of the body, apart from the Cancer has spread to another part of the body, apart from the
breast and lymph nodes under the arm breast and lymph nodes under the arm
AJCC stage grouping
AJCC stage grouping
(
(
American J oint Committee on
American J oint Committee on
Cancer)
Cancer)
Stage 0 Stage 0 Tis Tis N0 M0 N0 M0
Stage I Stage I T1* N0 M0 T1* N0 M0 (*T1 includes T1mic) (*T1 includes T1mic)
Stage IIA Stage IIA T0 N1 M0 T0 N1 M0 - - T1* N1** M0 T1* N1** M0 - - T2 N0 M0 T2 N0 M0
(*T1 includes T1mic **The prognosis of patients with pN1a diseas (*T1 includes T1mic **The prognosis of patients with pN1a disease is e is
similar to that of patients with pN0 disease.) similar to that of patients with pN0 disease.)
Stage IIB Stage IIB T2 N1 M0 T2 N1 M0 - - T3 N0 M0 T3 N0 M0
Stage IIIA Stage IIIA T0 N2 M0 T0 N2 M0 - - T1*N2 M0 T1*N2 M0 - - T2 N2 M0 T2 N2 M0 - - T3 N1 M0 T3 N1 M0 - - T3 T3
N2 M0 ( *T1 includes T1mic) N2 M0 ( *T1 includes T1mic)
Stage IIIB Stage IIIB T4 Any N M0 T4 Any N M0 - - Any T N3 M0 Any T N3 M0
Stage IV Stage IV Any T Any N M1 Any T Any N M1
Overall survival of breast cancer patients according to American J oint Commission on Cancer
(AJ CC) stage. The relative survival rates of 50,834 patients with breast cancer stratified for
stage at presentation between 1983 and 1987. Note that survival rates decrease with increasing
stage at initial presentation. Additionally, patients with invasive cancers continue to die of
disease beyond the 6-year period illustrated
TREATMENT OF BREAST
TREATMENT OF BREAST
CANCER
CANCER
The natural history of breast cancer. This graph
displays the overall survival of patients with
untreated breast cancer.
COMPLEX MULTIMODAL TREATMENT
COMPLEX MULTIMODAL TREATMENT
1.
1.
Surgical
Surgical
2.
2.
Adjuvant
Adjuvant

Radiotherapy
Radiotherapy

Chemotherapy
Chemotherapy

Hormonal therapy
Hormonal therapy

Immunotherapy
Immunotherapy

Others
Others

Selection of local and systemic treatment modalities and
Selection of local and systemic treatment modalities and
priorities of application depends on a number of factors
priorities of application depends on a number of factors
and prognostic predictors including:
and prognostic predictors including:
1.
1.
Tumor histology
Tumor histology
2.
2.
Clinical and pathological features of tumor
Clinical and pathological features of tumor
3.
3.
Lymph nodes status
Lymph nodes status
4.
4.
Tumor hormone receptor
Tumor hormone receptor
5.
5.
HER2 marker level
HER2 marker level
6.
6.
Distant metastases
Distant metastases
7.
7.
Existing
Existing
comorbidities
comorbidities
8.
8.
Age of patient
Age of patient
9.
9.
Menopausal status of the patient
Menopausal status of the patient
10.
10.
Patient preferences
Patient preferences

Breast cancer in men is treated in the same way as in
Breast cancer in men is treated in the same way as in
postmenopausal women
postmenopausal women
4 groups of breast cancer
4 groups of breast cancer
1. 1.
Non
Non
-
-
invasive carcinoma
invasive carcinoma (stage 0) (stage 0)
ductal ductal carcinoma (DCIS) carcinoma (DCIS)
lobular carcinoma (LCIS) lobular carcinoma (LCIS)
2. 2.
Operable invasive carcinomas
Operable invasive carcinomas
stage I stage I
stage II stage II
some of stage IIIA some of stage IIIA
3. 3.
Inoperable invasive cancers
Inoperable invasive cancers
stage IIIB stage IIIB
stage IIIC stage IIIC
some stage IIIA some stage IIIA
4. 4.
Cancers with distant metastases or recurrent
Cancers with distant metastases or recurrent (stage IV). (stage IV).

The goal of treatment in carcinoma in situ is either
The goal of treatment in carcinoma in situ is either
to
to
prevent invasion
prevent invasion
or to diagnose invasive component as
or to diagnose invasive component as
long as it is still located at the breast.
long as it is still located at the breast.
A. lobular carcinoma (LCIS)
A. lobular carcinoma (LCIS)

Treatment is simple
Treatment is simple
surveillance
surveillance
because the risk of
because the risk of
invasive cancer in time is very low (about 21% to 15)
invasive cancer in time is very low (about 21% to 15)

Bilateral simple mastectomy
Bilateral simple mastectomy
with or without
with or without
reconstruction is another alternative.
reconstruction is another alternative.

Tamoxifen
Tamoxifen
therapy for 5 years significantly reduces
therapy for 5 years significantly reduces
(56%) the risk of invasive cancer.
(56%) the risk of invasive cancer.
1.
1.
NON
NON
-
-
INVASIVE CARCINOMAS
INVASIVE CARCINOMAS
B.
B.
Ductal
Ductal
carcinoma in situ (DCIS)
carcinoma in situ (DCIS)

In
In
patinets
patinets
with
with
extended
extended
DCIS,
DCIS,
simple mastectomy
simple mastectomy
is indicated without
is indicated without
axillary
axillary
lymphadenectomy
lymphadenectomy
.
.

In patients with
In patients with
limited
limited
DCIS
DCIS
conservative surgery
is
is
enough if margin resections are tumor free.
enough if margin resections are tumor free.
(
(
lumpectomy
lumpectomy
,
,
quadrantectomy
quadrantectomy
)
)

Radiotherapy
Radiotherapy
is indicated after excision in all tumors
is indicated after excision in all tumors
larger than 5 cm.
larger than 5 cm.

Tamoxifen
Tamoxifen
is indicated to reduce the risk of a primary
is indicated to reduce the risk of a primary
tumors in the
tumors in the
contralateral
contralateral
breast and local
breast and local
recurrence in those with conservative surgery
recurrence in those with conservative surgery
2.
2.
INVASIVE BREAST CANCER
STAGES I, IIA AND IIB
STAGES I, IIA AND IIB

Surgery is represented by
Surgery is represented by
total mastectomy
total mastectomy
with
with
axillary
axillary
lymphadenectomy
lymphadenectomy
or
or
with
with
axillary
axillary
lymphadenectomy
lymphadenectomy
.
.

Contraindications for breast
Contraindications for breast
-
-
conserving therapy requiring
conserving therapy requiring
radiation therapy include:
radiation therapy include:
Absolute: Absolute:

Prior RT to the breast or chest wall Prior RT to the breast or chest wall

RT during pregnancy RT during pregnancy

Diffuse suspicious or malignant appearing Diffuse suspicious or malignant appearing microcalcifications microcalcifications

MuIticentric MuIticentric disease disease
Relative: Relative:

Multifocal disease requiring two or more separate surgical incis Multifocal disease requiring two or more separate surgical incisions. ions.

Active connective tissue disease involving the skin (especially Active connective tissue disease involving the skin (especially
scleroderma and lupus) scleroderma and lupus)

Tumors > 5 cm (category 2B) Tumors > 5 cm (category 2B)

Axillary
Axillary
lymphadenectomy
lymphadenectomy

level I and II of lymph nodes must be removed.
level I and II of lymph nodes must be removed.

Sentinel node biopsy
Sentinel node biopsy
may be considered in the
may be considered in the
following cases:
following cases:
1.
1.
Nonpalpable
Nonpalpable
axillary
axillary
lymph nodes
lymph nodes
2.
2.
Tumor less than 5 cm diameter
Tumor less than 5 cm diameter
3.
3.
Without having had breast surgery on the same
Without having had breast surgery on the same
breast
breast
4.
4.
Without preoperative treatment with chemotherapy,
Without preoperative treatment with chemotherapy,
radiotherapy or hormone therapy
radiotherapy or hormone therapy

If the sentinel node can not be identified or on frozen
If the sentinel node can not be identified or on frozen
sections metastases are found,
sections metastases are found,
axillary
axillary
lympadenectomy
lympadenectomy
should be performed.
should be performed.
3.
3.

STAGE III
STAGE III
A. Locally advanced cancer but operable
A. Locally advanced cancer but operable
-
-
T3N1M0
T3N1M0

Surgical treatment consists of
Surgical treatment consists of
total mastectomy
total mastectomy
with
with
axillary
axillary
lymphadenectomy
lymphadenectomy

reconstruction
reconstruction

Treatment is the same as in stage II
Treatment is the same as in stage II
B. Locally advanced cancer
B. Locally advanced cancer

inoperable
inoperable
-
-
stages IIIB
stages IIIB
and IIIC
and IIIC
Stage IIIB Stage IIIB T4 T4, , any any N, M0 N, M0
Stage IIIC Stage IIIC any any T, T, N3 N3, M0 , M0

It begins with
It begins with
preoperative chemotherapy
preoperative chemotherapy
followed
followed
by mastectomy with
by mastectomy with
lymphadenectomy
lymphadenectomy
if remission is
if remission is
obtained.
obtained.
Time interval between surgery and radiation therapy
Breast irradiation should be started as soon as possible
after surgery and not later than 12 weeks after, except for
patients in whom radiation therapy is preceded by
chemotherapy. However, the optimal interval between
BCS and the start of irradiation has not been defined.
4.
4.
ADVANCED STAGE WITH METASTASES OR
ADVANCED STAGE WITH METASTASES OR
LOCAL RECURRENCE
LOCAL RECURRENCE
A. Recurrence
A. Recurrence

Recurrence
Recurrence
after conservative surgery
after conservative surgery
-
-
radical
radical
mastectomy with
mastectomy with
lymphadenectomy
lymphadenectomy
chemo
chemo
-
-
hormonal
hormonal
therapy (to keep in mind that the patient have already
therapy (to keep in mind that the patient have already
received radiation!)
received radiation!)

Relapse occurs after total mastectomy
Relapse occurs after total mastectomy
-
-
excision
excision
without "heroic operation" followed by local
without "heroic operation" followed by local
radiotherapy (if there was no previous irradiation).
radiotherapy (if there was no previous irradiation).

If relapse
If relapse
cannot be removed
cannot be removed
the patient will benefit
the patient will benefit
from local radiotherapy
from local radiotherapy
.
.
B. Metastases
B. Metastases

Palliative treatment
Palliative treatment
in this stage is trying to prolong the
in this stage is trying to prolong the
life.
life.

Surgery
Surgery
comes into discussion in the following
comes into discussion in the following
circumstances:
circumstances:
1.
1.
Mastectomy
Mastectomy
or excision of recurrences with the
or excision of recurrences with the
purpose of "cleaning" the ulcerated lesions which
purpose of "cleaning" the ulcerated lesions which
has become infected.
has become infected.
2.
2.
Oophrectomy
Oophrectomy
(
(
ovarectomy
ovarectomy
) in premenopausal
) in premenopausal
patients.
patients.
3.
3.
Bone marrow transplantation
Bone marrow transplantation
(
(
autologous
autologous
) or stem
) or stem
cell transplantation combined with high dose radio
cell transplantation combined with high dose radio
-
-
chemotherapy.
chemotherapy.
Surgical treatment
Surgical treatment
1.
1.
Tumor removal
Tumor removal
(+ /
(+ /
-
-
Lymphadenectomy
Lymphadenectomy
)
)

Conservative surgery
Conservative surgery
1. 1. Lumpectomy Lumpectomy
2. 2. Quadrantectomy Quadrantectomy
3. 3. Extended Extended quadrantectomy quadrantectomy

Mastectomy
Mastectomy
1. 1. Simple mastectomy Simple mastectomy
2. 2. Skin sparing mastectomy Skin sparing mastectomy
3. 3. Mastectomy with Mastectomy with axillary axillary lymphadenectomy lymphadenectomy
Maden Maden
Patey Patey
Halsted Halsted - - limited indications (tumor infiltration of the pectoral limited indications (tumor infiltration of the pectoral
muscles) muscles)
Heroic" operations
Heroic" operations ( (Ugon Ugon, , Dubau Dubau, etc.) have no indication in , etc.) have no indication in
now days now days
2. 2.
Surgery to remove the lymph nodes
Surgery to remove the lymph nodes

Sentinel node biopsy Sentinel node biopsy

Axillary Axillary lymphadenectomy lymphadenectomy

Internal mammary Internal mammary lymphadenectomy lymphadenectomy
3. 3.
Breast reconstruction surgery
Breast reconstruction surgery
4. 4.
Endocrine surgery
Endocrine surgery
(
(
oofrectomy
oofrectomy
)
)

Axillary
Axillary
lymph node metastases remain the most
lymph node metastases remain the most
important prognostic factor in breast cancer and also a
important prognostic factor in breast cancer and also a
basis that guides the adjuvant therapy.
basis that guides the adjuvant therapy.

Sentinel node is the first node on the lymphatic route
Sentinel node is the first node on the lymphatic route
where the probability of metastasis is high and early.
where the probability of metastasis is high and early.

Only about 30% of women who require
Only about 30% of women who require
axillary
axillary
node
node
sampling actually have metastasis to the lymph nodes.
sampling actually have metastasis to the lymph nodes.

Lymphatic mapping and sentinel lymph node biopsy can
Lymphatic mapping and sentinel lymph node biopsy can
identify the patients with positive nodes, thus saving the
identify the patients with positive nodes, thus saving the
majority of women from an
majority of women from an
axillary
axillary
dissection.
dissection.
Sentinel lymph node biopsy (SLNB)

In most cases the sentinel lymph nodes are located in
In most cases the sentinel lymph nodes are located in
the
the
axilla
axilla
but there are cases when the sentinel lymph
but there are cases when the sentinel lymph
node is located elsewhere, or there are more than a
node is located elsewhere, or there are more than a
single sentinel lymph node. This are the reasons why the
single sentinel lymph node. This are the reasons why the
lymphatic mapping prior operation is important.
lymphatic mapping prior operation is important.
I
II
III
Possible locations of sentinel
lymph node
Axillary level I, II and III
Internal mammary chain
Supraclavicular and cervical
Intramammary
Interpectoral (Rotter)
Other locations
Mapping using Technetium 99 shows intramammary sentinel lymph node

Mapping is useful also for guiding the radiation therapy.
Mapping is useful also for guiding the radiation therapy.

Contraindications of SLNB:
Contraindications of SLNB:

Contraindications related to tumor:
Contraindications related to tumor:

Tumors larger than 5 cm diameter or advanced local
Tumors larger than 5 cm diameter or advanced local
stage
stage

Patients with palpable
Patients with palpable
axillary
axillary
lymph nodes
lymph nodes

Patients with pure
Patients with pure
ductal
ductal
carcinoma in situ
carcinoma in situ

Contraindications related to the patient:
Contraindications related to the patient:

Previous breast surgery or armpit surgery
Previous breast surgery or armpit surgery

Preoperative chemo
Preoperative chemo
-
-
radiotherapy
radiotherapy

Patients with
Patients with
multicentric
multicentric
tumors in the same breast
tumors in the same breast
that are in different quadrants.
that are in different quadrants.

Pregnancy
Pregnancy

Allergy to technetium 99m
Allergy to technetium 99m
sulphur
sulphur
colloid
colloid

There are two methods used for sentinel lymph node
There are two methods used for sentinel lymph node
detection: one using radioisotopes (Technetium 99) and
detection: one using radioisotopes (Technetium 99) and
the other which is using a dye (
the other which is using a dye (
metilen
metilen
blue or
blue or
isosulphan
isosulphan
blue). In many cases, for better results the
blue). In many cases, for better results the
two methods are combined. The advantage of
two methods are combined. The advantage of
radioisotope method is that it allows the preoperative
radioisotope method is that it allows the preoperative
mapping guiding the surgeon and also the radiotherapy.
mapping guiding the surgeon and also the radiotherapy.
The dye method is cheaper.
The dye method is cheaper.

The tracer is injected around the tumor or areola. It flows
The tracer is injected around the tumor or areola. It flows
via the lymphatic network toward the first lymph node of
via the lymphatic network toward the first lymph node of
the lymphatic route that drains also the tumor. This first
the lymphatic route that drains also the tumor. This first
node can be detected in two ways depending on the
node can be detected in two ways depending on the
traces used. If technetium 99 was used a special gamma
traces used. If technetium 99 was used a special gamma
detection device and probe is necessary for detection. If
detection device and probe is necessary for detection. If
dye was used the lymph node will be detected by its blue
dye was used the lymph node will be detected by its blue
color.
color.
Blue dye is injected around the areola
A local massage is performed for a faster diffusion of the dye
After 10-15 minutes incision in the axilla may be performed for detection of node
Sentinel lymph node
Gamma detection device

The excised node will be sent to
The excised node will be sent to
histologic
histologic
examination.
examination.
In the result is negative the
In the result is negative the
axillary
axillary
lymphadenectomy
lymphadenectomy
is
is
not necessary but if tumoral cells were found the
not necessary but if tumoral cells were found the
axillary
axillary
dissection should be performed. Preventing unnecessary
dissection should be performed. Preventing unnecessary
axillary
axillary
dissection is important in preventing associated
dissection is important in preventing associated
complications (
complications (
seroma
seroma
, shoulder and upper limb pain,
, shoulder and upper limb pain,
lymphedema
lymphedema
, scars, etc)
, scars, etc)

Lumpectomy
Lumpectomy

It is a surgical method applied for early stages of cancer
It is a surgical method applied for early stages of cancer
which removes the tumor with surrounding healthy
which removes the tumor with surrounding healthy
tissue. Almost always is followed by six weeks of
tissue. Almost always is followed by six weeks of
radiotherapy. The specimen is examined by pathologist
radiotherapy. The specimen is examined by pathologist
and if the tumor is too close to the margin of resection
and if the tumor is too close to the margin of resection
the surgeon must perform a re
the surgeon must perform a re
-
-
resection at the same
resection at the same
site.
site.

Quadrantectomy
Quadrantectomy
(segmental mastectomy): removal
(segmental mastectomy): removal
of a quadrant of mammary gland.
of a quadrant of mammary gland.

Partial mastectomy
Partial mastectomy
(or extended
(or extended
quadrantectomy
quadrantectomy
):
):
removal of more than a quadrant of the breast.
removal of more than a quadrant of the breast.

Usually, after these operations external radiation therapy
Usually, after these operations external radiation therapy
is given for a period of six weeks.
is given for a period of six weeks.

Skin
Skin
-
-
Sparing Mastectomy
Sparing Mastectomy

removes the entirely
removes the entirely
mammary gland and the areola but sparing the skin.
mammary gland and the areola but sparing the skin. A
"keyhole"like or other types of incision are performed.
This type of operation is used when a breast
reconstruction is intended - an expander in introduced
under the pectoral muscle and after a while it is replaced
by silicone.

Simple or total mastectomy
Simple or total mastectomy
: removes the entire
: removes the entire
breast, but
breast, but
without
without
axillary
axillary
lymph nodes and underlying
lymph nodes and underlying
muscles. The skin incision is elliptical including the
muscles. The skin incision is elliptical including the
areola and nipple. It may be oblique or horizontal
areola and nipple. It may be oblique or horizontal
depending on breast volume and shape.
depending on breast volume and shape.

Modified radical mastectomy
Modified radical mastectomy

removes the
removes the
mammary gland between boundaries: sternum, clavicle,
mammary gland between boundaries: sternum, clavicle,
latisimus
latisimus
dorsi
dorsi
and the origin of rectus
and the origin of rectus
abdominis
abdominis
, and
, and
also removes the
also removes the
axillary
axillary
lymph nodes of level I and II.
lymph nodes of level I and II.
Level III lymph nodes are not dissected.
Level III lymph nodes are not dissected.

Madden mastectomy
Madden mastectomy

removes the entire breast +
removes the entire breast +
level I and II
level I and II
axillary
axillary
lymph nodes.
lymph nodes.

Patey
Patey
mastectomy
mastectomy

the same as in Madden
the same as in Madden
procedure but the
procedure but the
pectoraslis
pectoraslis
minor insertion is
minor insertion is
sectioned for a better access to the
sectioned for a better access to the
axilla
axilla
.
.

Radical mastectomy
Radical mastectomy
-
-
amputation of the breast
amputation of the breast
(Halsted operation) presumes mastectomy plus a wide
(Halsted operation) presumes mastectomy plus a wide
excision of the pectoral muscles and
excision of the pectoral muscles and
axillary
axillary
lymph
lymph
nodes. In now days this type of operation is no longer
nodes. In now days this type of operation is no longer
performed, just in cases when muscles are invaded by
performed, just in cases when muscles are invaded by
tumor.
tumor.
Modified radical mastectomy Modified radical mastectomy
Incision
Mastectomy
Axilla
Breast
Tumor
Advanced cases of breast cancer
Mastectomy was performed just for cleaning the area not with radical
intention
Recurrence operated large excision with omentoplasty
(when the wound cannot be closed and the pectoralis
muscle was excised remaining only the chest wall, the great
omentum may be used to cover the rib cage and promote
granulation) followed by skin grafting.
Postoperative complications
Postoperative complications

Post
Post
-
-
mastectomy
mastectomy

Subcutaneous hematoma
Subcutaneous hematoma

Wound infection
Wound infection

Skin necrosis
Skin necrosis

Chest
Chest
paresthesia
paresthesia

Postoperative local pain
Postoperative local pain

Seroma
Seroma

Lymphedema
Lymphedema

Keloid
Keloid
scars
scars

Granulomas
Granulomas

Tumor
Tumor
recurrence
recurrence

After
After
axillary
axillary
lymph node dissection:
lymph node dissection:

Lesions or thrombosis of the
Lesions or thrombosis of the
axillary
axillary
vein
vein

Seroma
Seroma

Lymphedema
Lymphedema
:
: The reported prevalence rate of The reported prevalence rate of lymphedema lymphedema is is
approximately 11%. Extensive surgery, RT, and advanced age are approximately 11%. Extensive surgery, RT, and advanced age are
recognized risk factors for arm recognized risk factors for arm edema edema. .

Impairment of shoulder movements.
Impairment of shoulder movements. Symptoms include Symptoms include
decreased range of motion of the shoulder, a problem that may be decreased range of motion of the shoulder, a problem that may be
improved with early participation in a physical therapy program. improved with early participation in a physical therapy program.

Damage to the brachial plexus,
Damage to the brachial plexus, with chronic pain and varying with chronic pain and varying
degrees of decreased grip strength occurring in up to 15% of degrees of decreased grip strength occurring in up to 15% of
patients and lasting for more than a year after surgery patients and lasting for more than a year after surgery

Chest wall pain
Chest wall pain
Lymphedema
Local recurrence
Post-therapy follow-up program for patients
with breast cancer
Year 1 Year 1 Year 2 Year 2 Years 3 Years 3- -5 5 > 5 Years > 5 Years
Clinical Clinical
examination examination
4 month 4 month 4 month 4 month 6 month 6 month 12 month 12 month
Chest radiography Chest radiography Initial Initial
If If
necessary necessary
If If
necessary necessary
If If
necessary necessary
Mammography Mammography 12 month 12 month 12 month 12 month 12 month 12 month 12 month 12 month
Bone Bone scintigraphy scintigraphy Initial Initial
If If
necessary necessary
If If
necessary necessary
If If
necessary necessary
INFLAMMATORY BREAST
INFLAMMATORY BREAST
CANCER
CANCER
IBC
IBC
Klotz
Klotz
-
-
Volkmann
Volkmann
s disease
s disease

Inflammatory breast cancer is particularly serious invasive
Inflammatory breast cancer is particularly serious invasive
form of primary breast cancer, characterized by rapid
form of primary breast cancer, characterized by rapid
evolution and clinical appearance of a breast inflammatory
evolution and clinical appearance of a breast inflammatory
process.
process.

The incidence is 1
The incidence is 1
-
-
6% being more common in African
6% being more common in African
-
-
American population (10.1%) than in Caucasian
American population (10.1%) than in Caucasian
population (6.2%). It tends to be diagnosed in younger
population (6.2%). It tends to be diagnosed in younger
women compared to non
women compared to non
-
-
IBC breast cancer.
IBC breast cancer.

The characteristic aspect of inflammation is given by the
The characteristic aspect of inflammation is given by the
obstruction of the skin lymphatic vessels due to lymphatic
obstruction of the skin lymphatic vessels due to lymphatic
invasion by tumor cells.
invasion by tumor cells.

Like other types of breast cancer, it can occur in men, but
Like other types of breast cancer, it can occur in men, but
usually at an older age than in women. Some studies have
usually at an older age than in women. Some studies have
shown an association between family history of breast
shown an association between family history of breast
cancer and IBC.
cancer and IBC.
Signs and symptoms

The onset is often sudden.

Women have breast pain and nipple discharge may occur.

On clinical examination the breast is swollen, deformed,
with skin erythema and edema, increased local
temperature. The aspect is that of peau dorange or
"orange peel".

Axillary lymph nodes are increased in volume and
sensitive.

In more advanced forms contralateral axillary lymph nodes
are also affected.

All this aspects are very similar to acute mastitis and
confusion is not rare. In this event, patients are treated for
a long time with antibiotics and antiinflammatory drugs but
as they do not heal, suspicion of a cancer arises.
Diagnosis
Diagnosis

The only investigation that could make the correct
The only investigation that could make the correct
diagnosis is biopsy.
diagnosis is biopsy.

Usually the first examination is breast ultrasound to
Usually the first examination is breast ultrasound to
reveal some collections. This is of no use for correct
reveal some collections. This is of no use for correct
diagnosis in this case.
diagnosis in this case.

Eventually cytology of nipple discharge could detect
Eventually cytology of nipple discharge could detect
cancerous cells.
cancerous cells.

Inflammatory cancer is characterized as a high
Inflammatory cancer is characterized as a high
histological grade invasive carcinoma, the presence of
histological grade invasive carcinoma, the presence of
molecular markers including high aggressiveness of S
molecular markers including high aggressiveness of S
phase,
phase,
aneuploidy
aneuploidy
, lack of ER receptors and a large
, lack of ER receptors and a large
increase in markers of p53 and epidermal growth factor.
increase in markers of p53 and epidermal growth factor.
Treatment
Treatment

The treatment is complex, aggressive, including
The treatment is complex, aggressive, including
chemotherapy, radiotherapy and mastectomy with
chemotherapy, radiotherapy and mastectomy with
axillary
axillary
lymphadenectomy
lymphadenectomy
if after chemotherapy the response is
if after chemotherapy the response is
favorable, plus hormone therapy if estrogen receptor are
favorable, plus hormone therapy if estrogen receptor are
present.
present.

With aggressive treatment using multimodal approach,
With aggressive treatment using multimodal approach,
the 5 year survival rate improved significantly from an
the 5 year survival rate improved significantly from an
average of 18 months to 50% at 5 years.
average of 18 months to 50% at 5 years.
PAGET
PAGET
S DISESE OF THE
S DISESE OF THE
BREAST
BREAST
Sir Sir James Paget James Paget

(1814 (1814- -1899) 1899)

Paget's disease has an incidence of 1
Paget's disease has an incidence of 1
-
-
3% of all breast
3% of all breast
cancers in women. It may occur rarely in males also.
cancers in women. It may occur rarely in males also.

The average age of patients with breast Paget's disease
The average age of patients with breast Paget's disease
is 53
is 53
-
-
59 years, 5
59 years, 5
-
-
10 years more than for the patients
10 years more than for the patients
with breast cancer. Age limits in which the disease was
with breast cancer. Age limits in which the disease was
found is between 24 and 84 years.
found is between 24 and 84 years.

The diagnosis of certainty is established only by
The diagnosis of certainty is established only by
histopathological
histopathological
examination that emphasizes the
examination that emphasizes the
unique features of Paget's cells.
unique features of Paget's cells.
Pathophysiology
Pathophysiology
:
:

Although the
Although the
pathophysiology
pathophysiology
of Paget's disease has
of Paget's disease has
long been controversial, most authors now agree that
long been controversial, most authors now agree that
the origin of the disease is the
the origin of the disease is the
neoplastic
neoplastic
cells of the
cells of the
intraductal
intraductal
breast cancer that invade the skin retrograde
breast cancer that invade the skin retrograde
through the nipple
through the nipple
s pores.
s pores.
Signs and symptoms
Signs and symptoms

An itchy rash on the nipple and areola, which then
An itchy rash on the nipple and areola, which then
ulcerates.
ulcerates.

Ulceration is regularly covered by crusts leaving a false
Ulceration is regularly covered by crusts leaving a false
impression of healing. Small vesicles may appear on the
impression of healing. Small vesicles may appear on the
affected skin area. Lesions do not heal with topical
affected skin area. Lesions do not heal with topical
treatments and tend to extend in surface.
treatments and tend to extend in surface.

Symptoms can last for many years until the patient
Symptoms can last for many years until the patient
decides to consult a doctor. The lesion is often
decides to consult a doctor. The lesion is often
interpreted as a dermatitis, eczema or psoriasis.
interpreted as a dermatitis, eczema or psoriasis.

The disease may be associated with nipple discharge of
The disease may be associated with nipple discharge of
various types, but the bleeding should be a warning sign
various types, but the bleeding should be a warning sign
for both patient and physician.
for both patient and physician.

Nipple retraction
Nipple retraction
is also a sign indicating the presence of
is also a sign indicating the presence of
a
a
retroareolar
retroareolar
cancer.
cancer.

Unlike
Unlike
exema
exema
, skin lesions in Paget's disease have
, skin lesions in Paget's disease have
relatively well defined edges and are infiltrated. The
relatively well defined edges and are infiltrated. The
diameter of these lesions can be between 3 and 15 cm.
diameter of these lesions can be between 3 and 15 cm.

In 30
In 30
-
-
50% of cases is usually associated a
50% of cases is usually associated a
palpable
palpable
tumor
tumor
which is located behind the nipple in most cases
which is located behind the nipple in most cases
(70% at a distance less than 2 cm from the nipple), but it
(70% at a distance less than 2 cm from the nipple), but it
can be located anywhere in the mammary gland (about
can be located anywhere in the mammary gland (about
30% are located away from the skin changes)
30% are located away from the skin changes)

Axillary
Axillary
adenopathy
adenopathy
in the early stages is present in
in the early stages is present in
approximately 25% of cases. The incidence of
approximately 25% of cases. The incidence of
axillary
axillary
lymph node metastases is 50
lymph node metastases is 50
-
-
60% in all cases, higher
60% in all cases, higher
when the tumor is already palpable.
when the tumor is already palpable.
Clinical forms:
Clinical forms:

Previously described is the typical form.
Previously described is the typical form.

There are approximately 20
There are approximately 20
-
-
30% of cases in which
30% of cases in which
just a breast tumor is present, without typical skin
just a breast tumor is present, without typical skin
manifestations associated.
manifestations associated.

When the single manifestation is
When the single manifestation is
nipple discharge
nipple discharge
, the
, the
risk of
risk of
axillary
axillary
lymph node metastases is 5%.
lymph node metastases is 5%.

There are also cases (7%
There are also cases (7%
-
-
26%) when the typical skin
26%) when the typical skin
manifestations of Paget's disease are not accompanied
manifestations of Paget's disease are not accompanied
by an associated breast cancer.
by an associated breast cancer.

Pigmented mammary Paget's
Pigmented mammary Paget's
disease is rare, being
disease is rare, being
described both in men and women with
described both in men and women with
intraductal
intraductal
breast cancer spread to the epidermis through a
breast cancer spread to the epidermis through a
ductal
ductal
pore.
pore.
Pigmented mammary Paget's disease Pigmented mammary Paget's disease
Differential diagnosis
Differential diagnosis
will be done between other
will be done between other
conditions with similar symptoms located at the areola
conditions with similar symptoms located at the areola
and nipple:
and nipple:
1. 1.
Bowen's disease
Bowen's disease
-
-
squamous
squamous
cell carcinoma in situ
cell carcinoma in situ
2. 2.
Contact dermatitis
Contact dermatitis
3. 3.
Nodular
Nodular
cutaneous
cutaneous
amyloidosis
amyloidosis
4. 4.
Malignant melanoma
Malignant melanoma
5. 5.
Ductal
Ductal
adenoma
adenoma
6. 6.
Adenomatosis
Adenomatosis
7. 7.
Nipple erosions
Nipple erosions
Diagnosis
Diagnosis

It may be easy, as long the consulting physician has
It may be easy, as long the consulting physician has
sufficient knowledge of breast pathology. Otherwise
sufficient knowledge of breast pathology. Otherwise
confusion with
confusion with
exema
exema
or other inflammatory skin
or other inflammatory skin
disease is possible.
disease is possible.

Investigation which has the highest chance of diagnosis
Investigation which has the highest chance of diagnosis
is biopsy of the skin lesion, followed by histology.
is biopsy of the skin lesion, followed by histology.

Mammography is the routine examination which may
Mammography is the routine examination which may
reveal, in some cases (50
reveal, in some cases (50
-
-
70%), the presence of
70%), the presence of
mammary tumor, located behind the nipple either
mammary tumor, located behind the nipple either
associated with another region or even the presence of
associated with another region or even the presence of
microcalcifications
microcalcifications
. A negative result does not exclude
. A negative result does not exclude
the possibility of cancer.
the possibility of cancer.
Treatment
Treatment

It is mainly surgical. Extension of breast excision is based on It is mainly surgical. Extension of breast excision is based on
disease stage and location of the tumor. disease stage and location of the tumor.
1. 1. If there is no palpable tumors If there is no palpable tumors and if the mammography is negative, and if the mammography is negative,
the operation is excision of areola and nipple followed by the operation is excision of areola and nipple followed by
radiotherapy. radiotherapy.
2. 2. If there is a If there is a retroareolar retroareolar palpable tumor palpable tumor, and nowhere else, and if , and nowhere else, and if
histopathology reveals a carcinoma in situ histopathology reveals a carcinoma in situ - - lumpectomy with lumpectomy with
excision of the nipple and areola will be performed. excision of the nipple and areola will be performed.
3. 3. If tumor is invasive If tumor is invasive, sentinel node biopsy is recommended followed , sentinel node biopsy is recommended followed
by by lymphadenectomy lymphadenectomy if metastases are present, and mastectomy. if metastases are present, and mastectomy.
4. 4. In advanced cases In advanced cases or if the tumor is located away from the skin or if the tumor is located away from the skin
lesions, mastectomy with lesions, mastectomy with axillary axillary lymphadenectomy lymphadenectomy is indicated. is indicated.
5. 5. Radiotherapy is usually used after mastectomy. Chemotherapy and Radiotherapy is usually used after mastectomy. Chemotherapy and
hormone therapy depend on tumor histological and hormone therapy depend on tumor histological and
immunohistological immunohistological features. features.
Prognosis
Prognosis

Patients with palpable breast tumors have a lower survival
Patients with palpable breast tumors have a lower survival
rate than those with
rate than those with
nonpalpable
nonpalpable
tumors, and also those
tumors, and also those
with invasive forms and
with invasive forms and
axillary
axillary
lymph node metastases
lymph node metastases
(between 100% and 0% survival rate at five years,
(between 100% and 0% survival rate at five years,
depending on evolution stage).
depending on evolution stage).
PHYLLODES TUMOR
PHYLLODES TUMOR

Phyllodes
Phyllodes
tumor is a rare tumor, more often benign than
tumor is a rare tumor, more often benign than
malignant, that appears exclusively in women.
malignant, that appears exclusively in women.

It occurs in any human race and any age with a majority in
It occurs in any human race and any age with a majority in
the 5
the 5
th th
decade.
decade.

It occurs more frequently on the left breast. It is a large (5
It occurs more frequently on the left breast. It is a large (5
-
-
30 cm) and mobile tumor. It represents less than 1% of all
30 cm) and mobile tumor. It represents less than 1% of all
breast cancers.
breast cancers.

It is the most common form of cancer derived from non
It is the most common form of cancer derived from non
-
-
epithelial cells, occurring only in the breast.
epithelial cells, occurring only in the breast.
Symptoms
Symptoms

The patient notices the occurrence of a firm consistency
The patient notices the occurrence of a firm consistency
tumor, mobile, well circumscribed, in the breast.
tumor, mobile, well circumscribed, in the breast.

Tumor tends to increase rapidly in volume. Rarely extends
Tumor tends to increase rapidly in volume. Rarely extends
to the areola and nipple and ulcerates.
to the areola and nipple and ulcerates.

The patients with metastases will have the symptoms of
The patients with metastases will have the symptoms of
those organs where metastases are.
those organs where metastases are.
On clinical examination:
On clinical examination:

The presence of a tumor of firm consistency, mobile, well
The presence of a tumor of firm consistency, mobile, well
circumscribed, non
circumscribed, non
-
-
adherent.
adherent.

Superjacent skin is stretched, shiny with visible vascular
Superjacent skin is stretched, shiny with visible vascular
design (marble like).
design (marble like).

The clinical appearance is very similar to breast
The clinical appearance is very similar to breast
fibroadenoma
fibroadenoma
and so mammographic images.
and so mammographic images.
Paraclinical
Paraclinical
investigations
investigations

The only way to correctly diagnose is surgical biopsy
The only way to correctly diagnose is surgical biopsy
because there is no marker for this type of tumor, and
because there is no marker for this type of tumor, and
mammographic images can not distinguish between
mammographic images can not distinguish between
malignant and benign form.
malignant and benign form.
Phyllodes tumor
Mammogram
Section surface
Phyllodes tumors
The differential diagnosis must be made
The differential diagnosis must be made
with:
with:
Angiosarcoma Angiosarcoma
Breast cancer Breast cancer
Giant Giant fibroadenoma fibroadenoma
Acute inflammatory cancer Acute inflammatory cancer
Sclerosing Sclerosing adenosis adenosis
Liponecrosis Liponecrosis
Fibrocystic mastitis Fibrocystic mastitis
Breast abscess Breast abscess
Acute mastitis Acute mastitis
Treatment
Treatment

It is only surgical:
It is only surgical:
mastectomy without axillary
mastectomy without axillary
lymphadenectomy
lymphadenectomy
.
.

For the benign forms the prognosis is very good.
For the benign forms the prognosis is very good.

In malignant forms recurrences are more
In malignant forms recurrences are more
aggressive as the primary tumor. Most frequentlly
aggressive as the primary tumor. Most frequentlly
the metastases are located in lungs followed by
the metastases are located in lungs followed by
bone, heart and liver. The vast majority of
bone, heart and liver. The vast majority of
patients with metastases die within 3 years of
patients with metastases die within 3 years of
treatment. Unfortunately there is no cure for
treatment. Unfortunately there is no cure for
systemic metastases.
systemic metastases.
OCCULT BREAST CANCER
OCCULT BREAST CANCER

Breast cancer is manifested from the beginning only by
Breast cancer is manifested from the beginning only by
axillary
axillary
lymph node metastases or rarely with distant
lymph node metastases or rarely with distant
metastases without mammary tumors that can be
metastases without mammary tumors that can be
detected on physical examination or mammography.
detected on physical examination or mammography.

Rare cases <1%
Rare cases <1%

The most frequent symptoms are: moderate pain in
The most frequent symptoms are: moderate pain in
armpit, more as a local embarrassment and eventually,
armpit, more as a local embarrassment and eventually,
found by self examination a tumor at this level without an
found by self examination a tumor at this level without an
obvious cause.
obvious cause.

If breast lesions which could explain the
If breast lesions which could explain the
axillary
axillary
adenopathy
adenopathy
are not found, a careful examination of all
are not found, a careful examination of all
areas that drain to the
areas that drain to the
axilla
axilla
must be performed. There
must be performed. There
are cases when minor skin lesions, sometimes
are cases when minor skin lesions, sometimes
apparently cured can be easily overlooked. History is
apparently cured can be easily overlooked. History is
important and may reveal recent injuries in this areas.
important and may reveal recent injuries in this areas.
The differential diagnosis should be made with other
diseases that can cause unilateral axillary lymph
nodes enlargement such as:
Benign Benign

Wounds (accidental wounds, scratching cat bites, insect bites, e Wounds (accidental wounds, scratching cat bites, insect bites, etc.). tc.).

Panaritium Panaritium

Folliculitis, and other infectious lesions Folliculitis, and other infectious lesions

Hidrosdenitis axillaris Hidrosdenitis axillaris

Acute and chronic mastitis Acute and chronic mastitis

Phlebitis spontaneous, traumatic or paratherapeutic of the upper Phlebitis spontaneous, traumatic or paratherapeutic of the upper
limb. limb.

Antiperspirants and deodorants Antiperspirants and deodorants
Malignant Malignant

Other skin cancers (melanoma) Other skin cancers (melanoma)

Pleuro Pleuro- -pulmonary tumors pulmonary tumors

Cancers of the lymphatic system Cancers of the lymphatic system
Investigations
Investigations

Mammography can reveal
Mammography can reveal
microcalcifications
microcalcifications
even before
even before
the tumor becomes palpable and ultrasound can be
the tumor becomes palpable and ultrasound can be
helpful in detecting small cystic lesions. All other
helpful in detecting small cystic lesions. All other
necessary investigations will be performed (chest
necessary investigations will be performed (chest
radiography, CT or better MRI scan, PET scan, tumoral
radiography, CT or better MRI scan, PET scan, tumoral
markers, etc)
markers, etc)

If all the investigation find nothing, usually follows a
If all the investigation find nothing, usually follows a
therapeutic test period, of about 10 to 15 days with anti
therapeutic test period, of about 10 to 15 days with anti
-
-
inflammatory drugs.
inflammatory drugs.

Axillary
Axillary
node biopsy is the next step in establishing the
node biopsy is the next step in establishing the
etiology when inflammatory treatment fails.
etiology when inflammatory treatment fails.
Treatment
Treatment

Do not forget that the presence of
Do not forget that the presence of
axillary
axillary
metastases
metastases
proven by histopathology, represents at least stage II of
proven by histopathology, represents at least stage II of
breast cancer.
breast cancer.

Radical mastectomy with
Radical mastectomy with
axillary
axillary
lymphadenectomy
lymphadenectomy
is
is
most frequent applied.
most frequent applied.

Radiotherapy on the entire breast gland of first intention,
Radiotherapy on the entire breast gland of first intention,
without mastectomy, after
without mastectomy, after
axillary
axillary
lymhadenectomy
lymhadenectomy
could be another choice.
could be another choice.

To these, chemotherapy and hormone therapy are
To these, chemotherapy and hormone therapy are
added depending on the type and stage of breast
added depending on the type and stage of breast
cancer.
cancer.
Prognosis
Prognosis

Many studies have shown that the prognosis for occult
Many studies have shown that the prognosis for occult
breast cancer is the same or even better than for
breast cancer is the same or even better than for
palpable tumors at the same stage (still more than stage
palpable tumors at the same stage (still more than stage
II).
II).

Most important prognostic factor in these cases is the
Most important prognostic factor in these cases is the
number of lymph nodes affected by metastases.
number of lymph nodes affected by metastases.

In one study, survival rate at 5 years was 87% when the
In one study, survival rate at 5 years was 87% when the
number of lymph nodes was between 1 and 3, and
number of lymph nodes was between 1 and 3, and
decreased to half (42%) when their number was 4 or
decreased to half (42%) when their number was 4 or
higher.
higher.
BREAST CANCER IN MEN
BREAST CANCER IN MEN

They represent only 1% of all breast cancers. In
They represent only 1% of all breast cancers. In
Western developed countries the incidence of breast
Western developed countries the incidence of breast
cancer in men is 1/100.000 men but in African countries
cancer in men is 1/100.000 men but in African countries
the incidence is much higher.
the incidence is much higher.

It can occur at any age but is most commonly
It can occur at any age but is most commonly
diagnosed after the age of 60 years.
diagnosed after the age of 60 years.

Determinant causes are not known.
Determinant causes are not known.

The following types of breast cancer usually occur in
The following types of breast cancer usually occur in
men:
men:
1.
1.
Infiltrating
Infiltrating
ductal
ductal
carcinoma
carcinoma
. The vast majority of
. The vast majority of
patients have this type of cancer.
patients have this type of cancer.
2.
2.
Ductal
Ductal
carcinoma in situ
carcinoma in situ
(
(
intraductal
intraductal
carcinoma)
carcinoma)
3.
3.
Inflammatory carcinoma
Inflammatory carcinoma
4.
4.
Paget's disease
Paget's disease
of the breast.
of the breast.
5.
5.
Lobular carcinoma in situ
Lobular carcinoma in situ
has not been found in
has not been found in
breast cancer in men.
breast cancer in men.
Breast liposarcoma
Cancer

Symptoms and signs are similar to those in women with
Symptoms and signs are similar to those in women with
breast cancer
breast cancer
Staging of breast cancer in men:
Staging of breast cancer in men:

Stage 1
Stage 1
-
- tumor diameter is tumor diameter is less than 2 cm. less than 2 cm. Lymph nodes are not Lymph nodes are not
affected and there are no signs of distant metastases affected and there are no signs of distant metastases
.
.

Stage 2
Stage 2
-
- the diameter of the tumor is the diameter of the tumor is between 2 and 5 cm between 2 and 5 cm. It may . It may
adhere to structures such as skin and pectoral muscle. Usually t adhere to structures such as skin and pectoral muscle. Usually there here
are enlarged axillary lymph nodes but no evidence of distant are enlarged axillary lymph nodes but no evidence of distant
metastases. metastases.

Stage 3
Stage 3
-
- Tumor Tumor more than 5 cm more than 5 cm in diameter, can adhere to in diameter, can adhere to
adjacent structures (skin, muscle). Usually there are enlarged a adjacent structures (skin, muscle). Usually there are enlarged axillary xillary
lymph nodes but no evidence of metastases. lymph nodes but no evidence of metastases.

Stage 4
Stage 4
-
- any size tumor, with enlarged to lymph nodes and distant any size tumor, with enlarged to lymph nodes and distant
metastases. metastases.
Diagnosis
Diagnosis
is the same as for women.
The treatment
The treatment

Tamoxifen hormone therapy is also indicated in men
Tamoxifen hormone therapy is also indicated in men
especially in forms of cancer with ER / PR positive
especially in forms of cancer with ER / PR positive
receptors.
receptors.

The survival rate is the same as for women in the same
The survival rate is the same as for women in the same
stage of evolution, but men breast cancer generally is
stage of evolution, but men breast cancer generally is
discovered in more advanced stages.
discovered in more advanced stages.

The prognosis depends on:
The prognosis depends on:

Stage of cancer
Stage of cancer

Histopathological type
Histopathological type

Some features of tumoral cells
Some features of tumoral cells

Bilaterality
Bilaterality

Age and health of the patient
Age and health of the patient
BREAST CANCER AND
BREAST CANCER AND
PREGNANCY
PREGNANCY

Tumors most commonly associated with pregnancy are:
Tumors most commonly associated with pregnancy are:
1. 1. Cervical cancer Cervical cancer
2. 2. Breast cancer Breast cancer
3. 3. Malignant melanoma Malignant melanoma
4. 4. Lymphomas Lymphomas
5. 5. Thyroid cancer Thyroid cancer

Fortunately the incidence of these cancers is quite low
Fortunately the incidence of these cancers is quite low
during pregnancy. For this reason there are no
during pregnancy. For this reason there are no
statistical studies on many cases, sporadic cases being
statistical studies on many cases, sporadic cases being
reported in the literature.
reported in the literature.

Cancer during pregnancy raises special ethical and
Cancer during pregnancy raises special ethical and
psychology problems.
psychology problems.

The patient must choose between maintaining the
The patient must choose between maintaining the
pregnancy and cancer treatment.
pregnancy and cancer treatment.

Breast cancer incidence is about 0.01 to 0.03% of
Breast cancer incidence is about 0.01 to 0.03% of
pregnant women and are most often found in women
pregnant women and are most often found in women
who delay pregnancy until the age between 30 and 40
who delay pregnancy until the age between 30 and 40
years.
years.

During pregnancy significant breasts changes occur
During pregnancy significant breasts changes occur
which make difficult early detection of small tumors.
which make difficult early detection of small tumors.

In pregnant women in general tumors are detected with
In pregnant women in general tumors are detected with
a delay of five months from the
a delay of five months from the
nonpregnant
nonpregnant
.
.

Also pregnant women have a 2.5 times higher chance of
Also pregnant women have a 2.5 times higher chance of
being diagnosed with metastatic breast cancer.
being diagnosed with metastatic breast cancer.

Mammographic examination is avoided during
Mammographic examination is avoided during
pregnancy due to exposure to radiation. Any breast
pregnancy due to exposure to radiation. Any breast
changes considered abnormal will be examined by
changes considered abnormal will be examined by
ultrasonography.
ultrasonography.

Biopsy is encumbered with the risk of suppurations,
Biopsy is encumbered with the risk of suppurations,
hematoma and bleeding in pregnant women. It is done
hematoma and bleeding in pregnant women. It is done
under the protection of antibiotics.
under the protection of antibiotics.
Abnormal breast changes during pregnancy
Abnormal breast changes during pregnancy
and breastfeeding
and breastfeeding

Breast cysts
Breast cysts

Galactocele (cysts filled with milk)
Galactocele (cysts filled with milk)

Breast fibroadenoma
Breast fibroadenoma

Nipple discharge
Nipple discharge

Breast inflammation
Breast inflammation
Breast cancer treatment during pregnancy
Breast cancer treatment during pregnancy

Treatment of breast cancer in pregnant women is mainly
Treatment of breast cancer in pregnant women is mainly
surgical: lumpectomy or mastectomy with or without
surgical: lumpectomy or mastectomy with or without
axillary
axillary
lymphadenectomy
lymphadenectomy
according to the presence of increased
according to the presence of increased
axillary
axillary
lymph nodes, and tumor stage.
lymph nodes, and tumor stage.

If the woman is in the last 2
If the woman is in the last 2
-
-
3 weeks of pregnancy, surgery
3 weeks of pregnancy, surgery
may be postponed until after birth.
may be postponed until after birth.

If the tumor was diagnosed during the first weeks of
If the tumor was diagnosed during the first weeks of
pregnancy, abortion and complex treatment of cancer
pregnancy, abortion and complex treatment of cancer
would be the best choice.
would be the best choice.

Radio
Radio
-
-
chemotherapy and
chemotherapy and
hormono
hormono
therapy the will not be
therapy the will not be
used during pregnancy.
used during pregnancy.

If breast cancer was found postpartum, the same principles
If breast cancer was found postpartum, the same principles
of treatment as provided in any woman will be applied, with
of treatment as provided in any woman will be applied, with
breastfeeding discontinuation.
breastfeeding discontinuation.

Prognosis of breast cancer during pregnancy is identical to
Prognosis of breast cancer during pregnancy is identical to
that of
that of
nonpregnant
nonpregnant
women in the same stages.
women in the same stages.
Pregnancy after breast cancer treated in
Pregnancy after breast cancer treated in
history
history

Women who have been treated previously for breast
Women who have been treated previously for breast
cancer could have a normal pregnancy in future.
cancer could have a normal pregnancy in future.
The
The
minimum duration of time from diagnosis and treatment
minimum duration of time from diagnosis and treatment
of breast cancer to pregnancy should be at least 2 years.
of breast cancer to pregnancy should be at least 2 years.
Breast cancer effects on fetus
Breast cancer effects on fetus

So far, no cases of metastases at the fetus from breast
So far, no cases of metastases at the fetus from breast
cancer have been cited, but there were several cases
cancer have been cited, but there were several cases
cited in the literature of metastases in the placenta.
cited in the literature of metastases in the placenta.

003 Breast Pathology

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003 Breast Pathology

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BREAST SURGICAL

s skin there are many nervous fibers

t be any changes in breast shape. As it

s disease. The aspect is

s pores or through skin erosions, cracks

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