Breast Diseases

Published on 16/04/2015 by admin

Filed under Surgery

Last modified 22/04/2025

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4 Breast Diseases

Anatomy of the Breast

image

Mammary Gland

Basic Structure

• Adipose tissue and lactiferous glands lie between superficial and deep layers of superficial thoracic fascia.
• Cooper’s (suspensory) ligaments: partitions of fibrous connective tissue running from the deep fascia over the pectoralis major, external intercostals, and serratus anterior, through the breast parenchyma, to the dermis and superficial fascia
• Cooper’s ligaments form septa around glandular clusters and fat.
• Lactiferous ducts communicate with openings on nipple and areola.
• Accessory glands in areola: Montgomery’s tubercles
• Nipple contains skin, connective tissue, sebaceous glands, smooth muscle, vessels, and ducts.

Endocrinology

• Estrogen (e.g., in pregnancy) and tissue-based estrogen receptors control glandular proliferation and secretory states in concert with progesterone and other hormones and growth factors.
• Cyclic increases in estrogen level cause swelling and promote glandular growth.
• Cyclic increases in progesterone increase glandular maturation; decreases are associated with menses.

Sensory Innervation

• Cutaneous and deep, lateral cutaneous branches of T2-T6
• Nipple, T4, anterior and anterolateral (cutaneous) branches of 4th intercostal nerves
• Nerve compression by surrounding muscle can cause pain (e.g., Tietze’s syndrome, T4).

Development and Embryology

• Ducts and alveoli of glands are formed from invaginating ectoderm.
• Supporting connective tissue, blood vessels, and lymphatics are formed from mesenchyme.
• Embryonic mammary ridges extend from axilla to inguinal region; all but the most superior usually regress.
• Accessory or supernumerary nipples may be found along “this milk line.”
• Accessory axillary breast tissue is a developmental anomaly.

Vessels and Lymphatics

image

Vessels and Lymphatics of Breast

Arterial Supply

• Medial: internal thoracic (mammary) artery, branch of subclavian (first division)
• Superior: supreme thoracic artery, branch of axillary (first division)
• Lateral: thoracoacromial, lateral thoracic, circumflex scapular, subscapular, and thoracodorsal branches of the axillary artery (second and third divisions)
• Inferolateral: contributions from lateral (perforating) branches of intercostal arteries

Venous Drainage

• Drainage toward the axilla and axillary vein via named branches, including supreme thoracic, thoracoacromial, lateral thoracic, circumflex scapular, subscapular, and thoracodorsal
• Deep and medial drainage, including chest wall

image Anteriorly to intercostal veins and into the internal thoracic (mammary) veins
image Posteriorly through posterior intercostal veins into the azygos and hemiazygos vein systems

Lymphatic Drainage

• Drainage is extensive and multidirectional.
• Main flow is lateral, to axillary nodes.

image Level I : lateral and inferior to the lower border of the pectoralis minor
image Level II: deep, posterior to the pectoralis minor, including Rotter’s nodes between the pectoralis muscles
image Level III: above or medial to the upper border of the pectoralis major, including subclavicular and supraclavicular nodes

• Deep flow is along internal thoracic (mammary) vessel pathways to parasternal nodes, draining toward subclavian, supraclavicular, and deep cervical nodes.
• Metastasis spreads through groups of nodes in an unpredictable manner.
• Location of sentinel node (nearest, with metastasis) in axilla depends on the patient’s specific drainage pattern from the tumor site.
• Dye, tracer, or biopsy can miss real sentinel nodes (false negatives).

Clinical Correlates

Diagnostic Procedures

• X-ray mammography is the gold standard.

image ~90% sensitivity and specificity, overall
image Sensitivity low in young women due to greater density of parenchymal tissue

• Magnetic resonance imaging (MRI) is helpful in determining the extent of disease.
• Given clinical exam and positive mammography evidence, diagnosis of malignancy must be made by a pathologist: care is needed in biopsy procedures.

image Fine needle aspiration biopsy (FNAB)
image Core needle biopsy (CNB)
image Excisional biopsy: lesion plus margins; specimen should be anatomically oriented by labeling margins, so pathologist can identify margins that may be involved.

• Appropriate pathological analysis includes histological grading, estrogen and progesterone receptor levels, and Her-2/neu receptor status (if appropriate for systemic therapy).

Benign Disease

Classification

• Nonproliferative with no increased risk of neoplasia
• Proliferative, relative risk 1.5-2.0
• Proliferative with atypia, relative risk 4.5-5.0
image

Fibrocystic Disease

Fibrocystic Disease

• Multiple types
• Symptoms: pain, nipple discharge, masses, lumps that vary with menstrual cycle
• Atypical ductal or lobular hyperplasia
• Sclerosing adenosis can appear as a cluster of calcifications without pain or apparent mass and might look like cancer on mammogram.
image

Fibroadenoma

Other Benign Breast Diseases

• Abscesses and infectious mastitis

image May be associated with breast-feeding
image Commonly caused by Staphylococcus aureus

• Fibroadenomas: most common in adolescents and young women
• Cysts: discrete, can feel hard before menses, are visible on ultrasound

image Simple: might disappear after aspiration
image Complex: might require excision, especially if solid components are imaged

• Ductal ectasia: ducts ending in areolar tissue, may become infected
• Papillomas

image Intraductal are the most common cause of blood discharge from nipple.
image Not premalignant, but studied for atypia
image Excision is often recommended.

• Phyllodes tumors

image Resemble fibroadenomas, but are pathologically distinguished by proliferation of stromal and epithelial cells compressing surrounding tissue
image High recurrence rate, excision recommended

• Cystosarcoma phyllodes: malignant variant of phyllodes tumor
• Sclerosing adenosis and radial scars: can give radiological appearance of infiltrating cancer
• Superficial venous thrombophlebitis (cordlike) may be associated with trauma and strenuous activity (e.g., Mondor’s disease).

Premalignant Lesions

Ductal Carcinoma in Situ (DCIS)

• Considered a premalignant lesion
• 50% ipsilateral cancer risk with unresected lesions
• 5%-10% progress to contralateral breast cancer.
• Not palpable, with cluster calcifications
• Characterized by malignant duct cells that do not invade the basement epithelium
• Treatment

image Lumpectomy with radiation or chemotherapy for small-focus lesions
image Simple mastectomy for high-grade (comedo-type or multicentric or multifocal) lesions

Lobular Carcinoma in Situ (LCIS)

• Considered a marker for the development of cancer
• 40% progress to cancer.
• Not palpable, no calcifications
• Patients whose lesions progress to cancer are more likely to develop ductal carcinoma.
• Primarily a premenopausal disease
• Often found incidentally

Breast Cancer

Carcinoma: Risk Factors

• Risk is 1/9 for white American women; rate for Latin American and black women has been lower but is catching up.
• Lobular carcinoma in situ may be a precursor of invasive lobular disease.
• 5%-10% of patients have a mutation in BRCA1 or BRCA2 genes.

image BRCA1 (chromosome 17q): hereditary breast and ovarian cancer syndrome
image BRCA2 (chromosome 13, q12-13 region): in families with heredity male breast, prostate, or pancreatic cancer

• Other factors: personal history of breast cancer, prior exposure to ionizing radiation (e.g., therapeutic), increasing age
• Early onset of menses is associated with increased risk
• Current evidence is equivocal on risk with contraceptives and hormone therapy.
• About 2% of all breast cancers occur in men.

Paget’s Disease of the Breast

• Epithelial neoplasia beginning in nipple and areola, extending through ducts to deeper tissues
• Invasive disease is treated like ductal or lobular cancer.

Clinical Signs

• Tumors involving Cooper’s ligaments cause skin dimpling.

image

Skin Dimpling

• Carcinoma involving the mammary ducts causes nipple retraction.

image

Nipple Retraction

• Carcinomatous invasion of subcutaneous lymphatics causes lymphedema, with orange peel (peau d’orange) appearance of the skin.

image

Clinical Signs of Breast Cancer

Staging and Treatment

• Treatment has long been based on principles of tumor cell biology, which practically require staging, assessing the anatomical progression of tumors.
• Staging

image Current tumor/node/metastasis (TNM) system is based on clinical and pathological classification.
image Primary tumor (T): scored by size and anatomical location, involvement of the chest wall
image Lymph node status (N): scored by number, size, and location of affected nodes
image Metastasis (M): scored based on evidence of spread to distant structures
image Stages 0 through IV are based on a matrix of TNM scores, with stage 0 being newly diagnosed in situ disease (Tis) and stage IV being any combination of T and N scores with distant metastasis (M1).
image With staging, indications for further treatment account for the specific location and extent of disease.

• Treatment

image Lumpectomy

image Breast-conserving therapy that excises identified lesions with surrounding clean margins.
image Usually combined with x-ray therapy (XRT) as an alternative to simple mastectomy

image Simple mastectomy (formerly total)

image Standard of care for T1 and T2 cancers
image Removal of entire breast, superficial and deep fascia, nipple and areola, level I and II axillary nodes
image Reconstruction

image Radical mastectomy

image For stage II and III, as appropriate: entire breast, superficial and deep fascia, pectoralis major, nipple, areola, axillary lymph node dissection (ANLD)
image Reconstruction, postoperative XRT, and systemic therapy

image ANLD must avoid damaging the long thoracic nerve (to serratus anterior), as it lies on the lateral thoracic wall (medial wall of axilla).
image Chemotherapeutic adjuncts, alternatives

image Breast cancer systemic therapy
image Adjuvant systemic therapy
image Neoadjuvant (induction chemotherapy)

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