1DDX: LECTURE 33 – FEBRUARY 7TH, 2007

BREAST AND AXILLA

CASE:
36 year old female presents with watery, thin, daily discharge from left breast. It has been going on for 4 months. Stains yellow, and much worse the
week prior to her period. Upper breast and back feel achy during this time.
What is going on? See notes at end of this lecture: look at this before next class.

DDX list
Galactorrhea
Galactocele (not normally associated with discharge)
Local breast disease: intraductal papilloma
Have to rule out cancer

Lab Dx: test for hormones, especially prolactin. HcG: have to rule out pregnancy. Thyroid? High TSH will increase prolactin.

What drugs is she on?

Rule out pituitary tumour? MRI or skull x-ray.
Mammogram.
Discharge: look at it. Test discharge for leukocytes. If there are fat cells in there, it is a milky discharge.

All of these tests were done, and all were negative. Just called it a “breast cyst” because they didn’t know what else it could be.
Endocrinologist was able to expel bloody discharge from left breast.

Intraductal papilloma: most likely cause of bloody discharge. Did not show up on mammogram, but this is what it ended up being. Did surgery although
they couldn’t find it in tests, and removed it in surgery.

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One other cause of non-cyclic breast pain that is not in notes: Tieze’s syndrome: inflammation where rib joins cartilage. Costo-chondritis. Causes
significant pain that feels like it is in the breast. If someone complains of this pain and tests don’t reveal pathology, consider this.

Fibroadenoma: occurs in teenagers, esp. 20s. 75% of breast lumps in women under 30.
Well-circumscribed border.
Called “breast mouse”: it moves around. May feel like marble in breast.
Solid mass: could insert needle and extract cells for testing.
May calcify around menopause: remove it because they don’t want it to transform.
Giant fibroadenoma: lemon-sized tumour. Usually benign, but one kind called cystosarcoma phylloides is a rare type of cancer. Doesn’t tend to recur.

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Breast cancer is most likely cancer to be diagnosed.
In other parts of the world, cervical cancer is an important cancer (morbidity and mortality). Less common in Canada d/t PAP.

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Breast cancer is second to lung cancer in cause of death from cancer.

MC area for cancer to occur is upper outer quadrant and areola. (50% and 18% respectively)

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Cumulative risk of developing breast cancer by age 80-90 is 1/8.

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Ductal carcinoma vs. ductal carcinoma in situ: m/c types diagnosed.
Lobular carcinoma in situ: occurs in the lobes of the breast instead of in the ducts.

On pathology report, will see different cell types:

Medullary: colour of brain
Tubular: look like tubes
Mucinous: make mucous
Papillary: look like fingers.
These types are associated with less serious kinds of cancer.

HEREDITARY BREAST CANCER

5-7% of all breast cancer is the result of a dominant gene being passed on from either parent (BRCA1, BRCA2).
Women with this have 80% risk by age 80. Look for patterns of ovarian or breast cancer in family history. If you have breast cancer, may go on to
develop ovarian cancer in the future (and vice versa).

DUCTAL CANCER IN SITU (DCIS)

May not present as a palpable mass: may only be detected as microcalcifications in mammogram.
Commonly localized to 1 quadrant.
Will the cells stay there or will they invade tissue? They have the potential to invade tissue.
Occurs in the ducts

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LOBULAR CARCINOMA IN SITU (LCIS)
Misnomer: it isn’t actually a cancer, more like a benign marker for increased risk of developing cancer later in life (8-9 times increase).
Occurs in the lobes
(Intraductal papilloma occurs in the lacteal sinus).
Looks very different from DCIS under microscope. Different type of cell.

INFLAMMATORY BREAST CANCER

Small percentage, but need to be able to recognize it.
Not good outcomes. Very invasive cancer.
Red, edematous skin. Often get “peau d’orange” effect on skin.
DDX between mastitis, IBC, give course of ABC, if no change, concern with IBC.
Tx: chemo, mastectomy.

PAGET’S DISEASE
Associated with moist, watery discharge, nipple erosion. If confined to nipple, areola, they can be removed

CYSTOSARCOMA PHYLLOIDES
Not aggressive, doesn’t tend to metastasize.

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Age: older women get more cancer
Postive family history: SLIGHT increase in risk. 7-8 out of 10 have no family history. (but much more if you have BRCA1-2 gene)
Birthing history: Have first child in early 20s (up to 25), decreases risk up to 50%. Seems to mature the breast tissue in a way that is protective.
Reference: Steve Austin: ND in States, wrote about breast cancer “What you should know (but may not be told) about breast cancer prevention,
diagnosis and treatment.”
Abortion and miscarriage increase risk (not sure if subsequent births would change this)
Pregnancy after 35 increases your risk.
Lactation: breast-feeding longer protects more.
Dates of menarch and menopause: Early menarch, late menopause: more exposure to estrogen
Diet! Grain fibres have significant effect in lowering estrogen levels in blood, removing it from body in stool.
Overcooked meat, increase saturated fats increases risk
Should eat more fish, olive, flax oil. But omega-6 oils are contraindicated in breast cancer (eg. Evening Primrose). Studies showed that it increased
growth of cancer.
Soy? Consuming at young age it is protective. Not as protective if you start eating it in 30s, 40s, 50s.
Alcohol: any amount increases risk. Interferes with DNA methylation. Folic acid counters this effect
Hypothyroidism? Maybe a link
Anovulation: will have unopposed estrogen (no progesterone produced from ovulation)
BCP/HRT: risk associated, but risk goes away when pill stopped.
Lots that we can do to ensure proper metabolism of estrogen: FIBRE!
Obesity: conversion of androstenodiol into estrone by peripheral adipocytes. More adipocytes = more estrone.
More incidence among Caucasians, educated, upper class: might be later time of first birth, more reporting
FCBD does NOT increase risk unless it is associated with atypical cells. BUT: fibrocystic lesion could hide a lesion. More dense breast tissue make
mammography less effective.

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20% of cancers are not stony or rock hard.
May be fixed, but maybe not.

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What do you do when you find cancer? Have to refer to someone who can do future tests: mammography. Density of breast tissue interferes with
accuracy: false negatives with dense tissue.
Mammography: recommended annually from age 50 onwards.
Could be discrete or diffuse lesion.
Shows approximate dimensions, where it is, comparison between sides.

Ultrasound: differentiate between solid and cystic mass.

Biopsies
Fine needle aspiration: done in women who have multiple cysts in fibrocystic breast disease. If fluid, contents can be removed. Identify lesion, secure
lesion on top of rib, insert needle, draw out fluid. Fairly painless procedure. Range of normal colours of fluid extracted from breast cysts.
Looking for inflammatory cells in fluid.
Tru-cut or core biopsy: pulling out a small core of tissue. May require 1 stitch.
Incisional biopsy: part of all of tumour is excised.
Wire localization: wire put in so that surgeon can find tumour.
Medical infrared thermography: First line screening for breast cancer: adjunct to mammography. Measures the amount of heat given off by different
areas of the breast. Claim to be able to detect cancers 5-8 years before they can be detected on mammography. Completely painless, no radiation, no
squeezing. Can also pick up other pathologies. Not 100% accurate. Not covered by OHIP. $250: covered by some insurance companies (Great West
Life) Good option to consider for future?

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How to read a pathology report. Patient will have one after surgery: have them bring it to you.
TMN system of staging. T=size, M=metastases, N=lymph nodes
Stage 1: Size=0-2 cm, Nodes neg, no metastasis KNOW HIGHLIGHTED STAGES FOR TEST.
Stage 2: T1, N1, M0. OR T2, N0, M0 OR T3, N1, M0, (see chart, pg 20 for others)

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Stage 4, any sized tumour, any nodes, but if there is ANY metastasis, it is stage 4.
Grading: how similar is the cancer cell to a normal cell? Might be number system (1-3, 1-4 with 1 being well differentiated) High grade tumour: looks
least like normal cell, poorly differentiated, most aggressive)

Histopathology: different types of cells.

Receptor Status: look at cancer cells to determine if they have receptors for estrogen or progesterone. Estrogen can be absorbed: this is good.
Estrogen receptor breast cancer has much better prognosis: >50% better. Also helps determine treatment: Tamoxifen is helpful in estrogen receptor
breast cancer.

Ploidy Status: number of chromosomes: 70% of breast cancers have anploid.

S-Phase Fraction: Percentage of cells that are actively dividing at any one time: measure of how active the cells are

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Staging strongly predicts survival rates (especially later stages)

DISEASES OF THE AXILLA

Lymph nodes can be infected, can be related to the areas that drain into them.
Lymph node could also relate to a cancer: breast, lung, Hodgkin’s, lymphosarcoma

Glands of the skin:

Painful infections of sweat glands
Sebasceous gland can become cystic: this will be painless.

Subcutaneous tissue:
Cellulitis: diffuse strep (usually) infection. Red, tender, hot, edematous infection, very painful.

Skin:
Many women present with rashes in the axilla due to deodorant, but could be fungus

Ribs:
Could encounter cracked ribs, metastatic tumour in ribs

Painless conditions in the axilla: Hodgkin’s, metastatic cancers (breast, lung, lymphosarcoma), sebaceous cysts, lipoma
Painful: hydradenitis suppurativa, apocrine, lymphadenitis, cellulitis.

Christiane Northrup: Women’s bodies, women’s wisdom: the emotional components of female health conditions. Nurturing, mothering, may be linked to
pathologies of the breast.
Carolyn Myss: related to hurt, sorrow.

Study: stage 4 breast cancer: joined group once per week for 1-2 hours, life expectancy doubled from this intervention.

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