Blood supply to the breast (4)

Internal mammary

Intercostal arteries level 2-6

Thoracoacromial artery

Lateral thoracic artery

BI-RADS 1 – 5 for breast imaging. What are they and what do they need?

            1 or 2: 

Routine screening, don’t change management

            3

Repeat imaging at 6 months, decrease interval screening

            4-5 

further tissue biopsy

What kinds of discharge put you at higher risk for malignant pathology?

Bloody discharge

Spontaneous discharge

Persistent discharge

Unilateral discharge

Surgical Indications for Fibroadenoma

                        Large size at presentation (no firm cut-off, but typically > 3 cm)

                        Symptomatic (most commonly, pain)

                        Interval growth

                        Inability to exclude other premalignant or malignant lesions

                        Patient preference/anxiety

Phyllodes tumor on Bx

Tx?

What makes it a greater malignancy rate?

Does it go to the nodes? 

How does it spread?

 MC site of mets?

Histo?

WLE with 1 cm margins

Greater malignancy rate if mitoses > 5

Generally does NOT go to nodes, do not need nodal excision rare to metastases. 

Spread Hematogenously, rare metastasize.

         Liver

 Epithelial and stromal overgrowth

Radial scar, what is it? How do you manage it?

Sclerosing papillary proliferations or benign ductal proliferation's

– other names for radial scar

Small increased risk of cancer

Biopsy

Breast cancer

Hereditary disorders?

BRCA 1,2

Li fraumeni syndrome

Cowden syndrome

Peutz Jaeger syndrome 

CDH 1

Li fraumeni syndrome, Mutation?

Cowden syndrome, Mutation? 

Peutz Jaeger syndrome, Mutation? 

CDH 1, associated with?

Ductal carcinoma in situ DCIS

TX?

Hormonal therapy pre and post menopausal?

Pre menopausal? Postmenopausal?

Pre menopausal Tamoxifen–5 years 

Postmenopausal aromatase inhibitor

• If large lesion large
• Multiple quadrant Dz
• Any CI for post op radiation

Consider a lymph node Bx.

25% show invasive pathology

Usually do not have to evaluate lymph nodes unless doing mastectomy

Margins for DCIS?

DCIS - Different from ductal cancer how(spread)?

What does adding breast radiation do for breast conservation?  (DCIS)

LCIS Lobular carcinoma in situ

Premalignant?

Single or both breast cancer risk?

What do you need for Dx?

Tx?

Not a premalignant lesion

Increased cancer development in both breast

Positive core needle biopsy, needs resection

WLE to rule out invasive component or DCIS

You do a wide local excision, path has no invasive component or DCIS but positive margin on LCIS, how do you manage?

What risk do you need to talk with pt about?

Lifetime Risk?

How about hormone therapy?

Surgically complete, you do not need negative margin. 

Risk of developing a bilateral lesions and this would general be a ductal cancer.

Lifetime risk of 1/2% per year

Can benefit with hormonal therapy if hormone positive

T1 

T2 

T3 

T4 

N1: 

N2: 

N3:

Stage I: 

Stage II: 

Stage IIIa/b: 

Stage IIIc: 

Stage IV: 

Contraindication to radiation?

CI:

Pregnancy

Multicentric disease

Positive pathologic margins after re-resection

Relative CI:

              Previous radiation

              Scleroderma

              Mass > 5cm

Stage IIIa treatment: Locally advanced operable tumors

Stage IIIb-IIIc: locally advanced inoperable treatment

Surgery axillary staging, how do you want to approach this for invasive carcinomas

Positive nodes, what is the treatment?

Sentinel lymph node Bx/dissection for all invasive carcinomas      

Modified radical mastectomy

Cortical thickening 

Lack of a fatty hilum

Z-11 trial. What is it and why is it important?

Pt: >18yo, T1-2 tumors, fewer than 3 positive lymph nodel

No difference in recurrence, disease free survival and overall survival in median of 6.3yr. 

Who needs axillary node dissection?

Clinically positive nodes confirmed by FNA or core needle Bx

Sentinel nodes that were not identified

Cannot find your sentinel Nodes during dissection

Who gets chemotherapy with invasive breast cancer?

Chemotherapy REGIMENT for breast cancer?

Side effects: Taxanes

Side effects: Adriamycin

Side effects: Cyclophosphamide

Cyclophosphamide- hemorrhagic cystitis: TX?

What is the roll of radiation in the older pt? >70?

>70 with clinically negative nodes and ER+ T1 breast Ca

Hormonal therapy, lumpectomy with negative margins and NOT have to do radiation

Radiation after mastectomy? Who and where to you give radiation?

Chest wall and regional lymph nodes if they have positive lymph nodes 

Or > 5 cm mass 

Or positive margins

HER-2 positive treatment?

How long?

What test should you get before Tx?

Trastuzumab (Herceptin)

1 year.                       

TTE - cardiotoxic

Inflammatory breast cancer, what is it? How do we manage it?

All stage 3b Tx?

Rapid diffuse involvement of breast with cutaneous involvement and orange breast

Dermal lymphatic invasion of cancer cells

Chemoradiation followed by modified radical mastectomy

Paget's disease in the breast, what is it? How do we manage it?

Histo?

Treatment?

Eczematous changes with scaling of skin and nipple

Marker of underlying malignancies

Hormone receptor negative and HER-2 positive

 Clear cytoplasm and large nuclei

Breast conservation therapy if qualifies

Radical mastectomy with nipple removal and sentinel lymph node removal

Breast cancer in men, what do we need to think about?

<1%

Klinefelter's

Strong family history

BRCA2 patient (15%)

Breast cancer in pregnancy, How do we manage it?

First trimester management?

Breast cancer in pregnancy, How do we manage it?

First trimester management?

Modified Radical mastectomy, Why is that?

Breast cancer in pregnancy, How do we manage it?

Second or third trimester management?

Breast conservation therapy, radiation therapy post baby

              Radioisotope in pregnancy for lymph nodes

Methylene blue contraindicated in pregnancy!

Chemotherapy OK in 2-3rd trimesters

Concerning lesion on mammography, core lesion biopsy normal, what is next?

Most common sites for breast metastasis

BRCA 1, what other cancer are they at risk for?

Breast and ovarian 65% breast ovarian 40%

More likely to be triple negative

BRCA2, what other cancer are they at risk for? 

Tamoxifen risk factors

Thrombo-embolism

Uterine cancer

Why is bone a common site for mets in breast cancer?

Tender palpable cord in the outter lateral quadrant cord, what is DX?

Treatment?

Mondors disease (superficial thrombophlebitis). 

NSAIDs

Gynecomastia

• Surgical excision can be discussed if: 

• Unilateral
• Fails to regress
• Painful
• Cosmetically unacceptable
• Any worrisome features (>5 cm, enlarging, lymphadenopathy)

Gynecomastia

• Causes?

• Drugs: Digoxin, Thiazides, Estrogens, Phenothiazines, Theophylline, Spironolactone
• Hepatic cirrhosis
• Renal failure
• Malnutrition
• Hypothyroidism
• Testicular tumors → must rule these out with exam. Ultrasound if any concerns  

Nipple Discharge/Papillomas that requires further diagnostic evaluation

Spontaneous

Recurrent

Unilateral

Involving a single duct

Bloody or clear 

Nipple Discharge/Papillomas

• Management:

• Diagnostic mammography + US
• Tissue biopsy
• Ductogram (cannulation of duct + injection of contrast, immediate mammography)
• Cannot reliably exclude malignancy 
• Excisional biopsy if mammography and US non-diagnostic
• Can also do subareolar ductal exploration with duct ligation + excision 

• Consider excision of papilloma if:

• Symptomatic/bleeding
• >1.5 cm
• Peripheral
• Multiple
• Associated with calcs
• Atypia 

Fibroadenoma

• Exam

• Well circumscribed, mobile, firm, rubbery masses, may increase in size
• Tenderness or pain, often worse with menstruation
• Hormonally sensitive 

Fibroadenoma

• Imaging

• Mammography is little help to differentiate cyst from fibroadenoma (US is better)

Fibroadenoma

Cancer in a fibroadenoma?

Exceedingl rare:

• 50% are LCIS
• 35% are invasive
• 15% intraductal carcinoma

• Giant fibroadenoma

• >5 cm

Fibroadenoma

• Management:

• US + US-guided biopsy
• Close observation with short-term interval imaging if small and asymptomatic
• Possible Excision 

Fibroadenoma

• Excision if:

• >2.5 cm
• Increasing size
• Pain
• Increased cellularity on biopsy
• Need to exclude phyllodes tumor
• Patient anxiety

Hamartomas/Adenomas

• Excision if:

• >2.5 cm
• Increasing size
• Pain
• Increased cellularity on biopsy
• Need to exclude phyllodes tumor
• Patient anxiety

• Benign proliferations of epithelium + stromal supporting tissue
• Indistinguishable from fibroadenoma on exam
• May increase in size during pregnancy/lactation
• Biopsy to establish a diagnosis
• Indications for excision are the same as fibroadenoma 

Hamartomas/Adenomas

• Adenomas may increase in size during pregnancy/lactation

• This is a complex sclerosing lesion that is proliferative and related to scarring (due to inflammation, ischemia, etc)
• Generally require excision to rule out underlying carcinoma 

Radial Scar

• Risk of BC?

• Modestly increased risk for breast cancer → an association, not a cause
• This is both a radiological and histological diagnosis. Usually seen on imaging and then biopsied