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Chapter 23

Breast

Karen A. Chojnacki Diane R. Gillum Kandace Peterson

Francis E. Rosato

I Introduction

A Anatomy

(Tear-drop shape)

Four quadrants

Upper inner quadrant

Upper outer quadrant (includes the axillary tail of Spence), most common site for breast cancer Lower inner quadrant

Lower outer quadrant

Parenchyma

Alveoli (10–100) form each lobule.

Lobules (20–40) form each lobe.

Lobes (15–20) are radially arranged segments that are each drained by a duct; all lobes converge at the nipple.

B Vasculature

Arterial supply

Internal mammary artery (60%)

Lateral thoracic artery (30%)

Venous return

Axillary vein (primary)

Intercostal vein

Internal mammary veins

Lymphatic drainage follows venous drainage.

The axillary chain is important drainage for neoplastic disease and is divided into three levels (Fig. 23 -1).

The axilla and supraclavicular region should be examined for adenopathy.

C Radiologic exam

Mammogram

A baseline mammogram is advised when the woman is 40 years of age and then yearly as long as the patient is in good health.

The mammogram is done sooner if the patient has a family history of early breast cancer. For these patients, the first mammogram should be done 5 years earlier than the age of the family member when diagnosed with breast cancer. For example, a patient whose sister developed breast cancer at age 39 should have her first mammogram at age 34.

Mammography can reveal the following: breast architecture, asymmetry, skin thickening, irregular masses, and microcalcifications.

Ultrasound

Ultrasound is not recommended for routine screening.

It is useful as a targeted exam for a symptomatic patient.

It can further characterize abnormalities seen on mammogram or found on physical exam (i.e., cyst vs. solid mass).

Magnetic resonance imaging (MRI)

Also not used for routine screening

Very sensitive but not specific evaluation of the breast

Especially useful in the evaluation of patients with mammographically dense breasts, patients with axillary disease, and negative mammogram

MRI can detect the extent of tumor within the breast and residual tumor within the breast after lumpectomy and can differentiate between tumor and postsurgical scar.

D

Biopsy is necessary to make a diagnosis.

Fine-needle aspiration (FNA) is useful in the evaluation of palpable lesions.

Cyst aspiration is both diagnostic and therapeutic.

Cyst must be drained completely.

Cyst fluid must be nonbloody. If fluid is bloody, excision is recommended to rule out malignancy.

If the lesion is solid , a fine -needle aspirate can extract cells, which can be examined cytologically. If cytology reveals atypia, excisional biopsy is recommended. If cytology reveals malignancy, further surgery is necessary.

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Core -needle biopsy is used to evaluate palpable solid lesions.

Incisional biopsy may be useful for diagnosis of inflammatory breast cancer.

Excisional biopsy

Completely removes the lesion

It may be the only surgical treatment of breast tissue if the margins are adequate.

It can be done using a local anesthetic with mild sedation.

Nonpalpable radiographic abnormalities

A needle -guided biopsy is performed by excising the lesion after the radiologist places a localizing wire in the breast to identify the site. The lesion must be visible on two mammographic views to allow accurate needle placement.

A stereotactic or mammotome biopsy uses computed mammographic equipment to deploy a core needle into mammographic abnormalities. This biopsy accurately samples nonpalpable lesions. This less invasive biopsy technique is indicated for patients with small nonpalpable radiodensities, single or multiple foci of calcifications, lesions seen on only one mammographic view, and lesions adjacent to breast implants.

III Benign Breast Disease

A Infectious and inflammatory breast diseases

Cellulitis, mastitis

Infection of the breast is usually associated with lactation.

Bacteria enter through the nipple (Staphylococcus or Streptococcus ). Treatment is a 10 - to 14 -day course of antibiotics to cover Staphylococcus and Streptococcus.

Patient can continue to breast feed during treatment. If breast feeding is too painful, a breast pump should be used.

Abscess is a collection of purulent fluid within breast parenchyma. It is treated by surgical drainage.

A chronic subareolar abscess occurs at the base of the lactiferous duct. Squamous metaplasia of the duct may occur.

A sinus tract to the areola develops.

Treatment requires complete excision of the sinus tract.

Recurrences are common, especially if the entire tract is not excised.

Mondor's disease is phlebitis of the thoracoepigastric vein.

A palpable, visible, tender cord runs along the upper quadrants of the breast along the course of the

vein.

Disease is self-limited, but anti -inflammatory agents and warm compresses improve patient comfort and shorten disease course.

B Benign lesions of the breast

Fibrocystic change (chronic cystic mastitis). This term is used for a broad spectrum of benign breast changes. It is characterized by nodularity with or without pain. Any dominant masses must be biopsied.

Fibroadenoma

Fibroadenoma is a well-defined tumor of the breast.

It consists of fibrous stromal tissue with an epithelial component.

Fibroadenoma is most common in younger women.

It is mobile and well circumscribed.

Usually, it is well visualized by ultrasound.

FNA, core biopsy, or excision is used to establish diagnosis.

Phyllodes tumors were previously referred to as cystosarcoma phyllodes.

These tumors are giant fibroadenomas that are rarely malignant.

They consist more of a cellular stroma than a fibroadenoma.

Malignancy is determined in part by an increased number of mitoses per high-power field compared with benign phyllodes tumors.

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Treatment is with a wide local excision. Inadequate local excision is associated with higher rates of local recurrence.

Sclerosing adenosis is a proliferation of acini in the lobules, which may appear to have invaded the surrounding breast stroma.

Atypical hyperplasia has three to six times higher the risk of breast cancer.

Fat necrosis is associated with trauma or radiation therapy to the breast but may simulate cancer with a mass or skin retraction. (The biopsy is diagnostic.)

Mammary duct ectasia

It can be found in older women.

Dilatation of the subareolar ducts can occur.

A palpable retroareolar mass, nipple discharge, or retraction can be present.

Family history for breast carcinoma produces a two to three times higher risk.

First -degree relatives (i.e., mother, daughter, sister) are affected. Risk is higher if the relative is premenopausal.

Hereditary breast cancer (HBC). The breast cancer gene (BRCA) has two forms:

BRCA-1: 60%–80% lifetime risk of developing breast cancer

BRCA-2: 30%–80% lifetime risk

Prior contralateral breast cancer doubles the patient's risk.

TABLE 23-1 Risk Factors for Breast Cancer

One to Two Times Relative Risk

Adapted with permission from Kelsey JL, Gannon MD. The epidemiology of breast cancer. CA Cancer J Clin 1991;41(3):157.

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High socioeconomic status

A nulliparous woman's risk is increased two to three times.

The risk is lowest in women who become pregnant before 23 years of age.

Exogenous estrogen has been shown to increase the risk of breast cancer in postmenopausal women.

C Symptoms

Masses are the presenting symptom in 85% of patients with carcinoma. Approximately 60% of breast masses are discovered by patients on SBE.

Pain is rarely a symptom but should be completely evaluated to eliminate the possibility of a malignancy.

Metastatic disease may also be the initial symptom.

Axillary nodes. Two percent of patients with breast cancer present with axillary node enlargement but no palpable primary breast tumor.

Hodgkin's disease; lung, ovarian, or pancreatic cancer; and squamous cell carcinoma of the skin must be ruled out.

If the results of all studies (including MRI) are negative, a blind mastectomy (i.e., removal of the breast without evidence of malignancy) is indicated.

Distant organ

Asymptomatic patients. High-risk patients (i.e., family or personal history of breast cancer) should be followed closely with mammography and physical examination. They should also be advised to practice