Presentation on theme: "Primary care for women Major cause of lawsuits for ob/gyn"— Presentation transcript:
1 The Breast Basic Science Conference Cindy M Deutmeyer MUSC Department of Surgery May 25th, 2010 Primary care for womenMajor cause of lawsuits for ob/gynBreast cancer litigation is 2nd most common cause of lawsuit payments nationwide. Gynecologists named 47% of the time, radiologists 13%. Most common complaint is delay in diagnosis.
2 Anatomy Develop along paired mammary ridges Primary bud secondary buds epithelial cordsMajor (lactiferous) ducts empty into shallow mammary pit mesenchyme proliferates elevation above skin nipple4% Inverted nipples (pit not elevated above skin)Puberty: Estrogen & Progesterone proliferation of epithelial & connective tissue elementsPolymastia: accessory breastAmastia: absence of breastPoland’s Sx: hypoplasia or absence of breast w/rib, chest wall, & upper extremity defectsPolythelia: accessory nipples (1%)Breast made up of glandular, fatty, and connective tissue. Glandular portion arranged into 15 to 20 lobes with central duct, collecting ducts and secretory cells. Each lobe drains at nipple. Breast has rich blood supply and lymphatic system which makes metastasis of breast cancer easy. Tail of glandular tissue, axillary tail of Spence, which penetrates axilla. Important to examine this area.Blood supply mostly from internal mammary artery and lateral thoracic arteries. Major lymphatic drainage is axillary and internal mammary lymph nodes.
3 Anatomy 3 tissue types: fatty, fibrous, glandular 15-20 lobes composed of several LobulesEach lobe drains into Lactiferous Duct/Sinus, and eventually nippleCooper’s suspensory ligaments: fibrous connective tissue bands, perpendicular to dermis, structural support3 types of tissue- fatty tissue, fibrous tissue, and glandular structures. Each type can be source of pathologic change. Fibrocystic changes and fibroadenomas come from connective tissue. Necrosis or lipomas come from fatty tissue. Duct system can be come dilated, develop papillary neoplasms, or undergo malignant change.
4 Breast Boundaries Superior Clavicle, 2nd rib Inferior Inframammary Fold, 6th ribMedialSternum (lateral border)LateralAnterior axillary line, Latissimus dorsiPosteriorPectoral fascia* Axillary tail of Spence
5 Blood Supply & Lymphatics Internal Mammary a. perforatorsIntercostal a.Axillary a. branches* Lateral thoracic* Highest thoracicThoracoacromial a. branches3 principal groups of veins* Internal thoracic v. perforators* Intercostal v. perforators* Axillary v. tributariesBatson’s plexus: surrounds vertebral column6 axillary lymph node groupsReceive 75% lymph drainage3 axillary lymph node levels* Level I: lateral to Pec minor* Level II: deep to Pec minor* Level III: medial to Pec minor
7 Case 1: Breast Pain35 y.o. G1P1 presents with complaints of pain in breasts.Pain is bilateral, diffuse. Feels swollen.POBHx- SVD x 1PGYNHx- regular mensesPMHx/PSHx- negativeMEDS- noneFHx- noncontributory
8 Breast Pain Differential diagnosis Fibrocystic changes Mastalgia/mastodyniaCystDuct obstructionInflammation/infection- mastitisTrauma
9 Breast Pain Fibrocystic change Most common of benign breast conditionsReplaces “fibrocystic disease”Multiple tender breast massesMay be cyclic in natureMay be exaggerated response to hormonesUsually present as cyclic, bilateral pain and breast engorgementPain diffuse, often radiates to shoulders or upper armsProminent thickened plaques of breast tissue, often in upper outer quadrants
11 Breast Pain Infection/inflammation Presents with pain, erythema, feverLactational mastitis-Occurs postpartum, Staph aureus or MRSA colonizationManagement- ultrasound, antibiotics (PCN), continue breast feeding or pumping (if not MRSA); incision and drainage of abscess if virulent strain/nosocomialNonlactational abscess-Can be due to fistula, tuberculosis, fungi, carcinomaMammo & Ultrasound reqZuska’s Dz: recurrent retroareolar infections
12 Case 2: Nipple Discharge 35 y.o. G1P1 presents with complaints of spontaneous nipple discharge.Right breast, bloody dischargePOBHx- SVD x 1PGYNHx- benignPMHx/PSHx- negativeMEDS- OCPsFHx- noncontributory
14 Nipple discharge Workup Exam Labs- Prolactin, TSH Mammogram Cytologic evaluation of discharge- not very usefulDuctography
15 Nipple Discharge Intraductal papilloma Epithelial tumors arising in ducts of breastMain cause of nipple discharge in nonpregnant or nonlactating womenUsually women age 40-45Benign, extremely small increased cancer riskSize 2-5 mm, usually not palpablePresent with spontaneous, bloody, serous or cloudy nipple dischargeManagement- excisional biopsy
16 Nipple Discharge Ductal ectasia Second most common cause of nipple dischargeOlder patientsIncrease in glandular secretionDischarge thick, gray/black colorCan lead to nipple retraction and breast massManagement- medical, icepacks, anti-inflammatory agents, broad spectrum antibiotics, surgery if abscess or mass present
17 Nipple discharge *Bad signs Serous, serosanguinous, or watery dischargeAssociated with massUnilateralSingle ductPositive cytologyPositive mammographyAge >50 yrs old
18 Case 3: Breast Lump45 y.o. G2P2 presents with complaints of mass in left breast. Noticed on self exam.
19 Breast Lump History Length of time present Presence of pain Change in size or textureRelationship to menstrual cycleNipple dischargeFamily history of breast or ovarian cancer and agesAge at first live birth, menarche, menopause
21 Breast Lump Work up Exam Imaging- Biopsy- GET A TISSUE DIAGNOSIS!! Diagnostic mammogram- less sensitive in younger women due to breast densityUltrasound- can distinguish cystic lesions from solid masses (require further evaluation)Biopsy- GET A TISSUE DIAGNOSIS!!Fine needle aspiration, Core needle biopsy, Open biopsy
23 Breast Mass Fibroadenoma Second most common benign breast disease, most common benign solid tumorFirm, painless, mobile breast mass, 2-3 cm, commonly in upper outer quadrantsUsually women aged 20-40Multiple in 15-20% of patientsSlow growing, do not regress spontaneouslyCan be stimulated by exogenous estrogen, progesterone, lactation, pregnancyManagement- watch & wait, biopsy, or excision
24 Breast Mass Macrocysts Most often women age 35-50 Fluid-filled sac Often solitary but can be multipleCan have associated nipple dischargeAspiration for diagnosis and therapyGalactocoeleMilk-filled cystUsually follows lactationFirm, tender massUsually in upper quadrantsDiagnostic aspiration often curativeLipomaNontenderNo associated skin or nipple changesUsually postmenopausal womenManagement- biopsy or excision
25 Breast cancer >180,000 new cases per year (estimated from 2008) 80% in women >50 yrs old, 20% in women <50 yrs old>40,000 deaths per year (estimated from 2008)Second leading cause of cancer-related death in womenLifetime risk of breast cancer 12%One in eight women will develop breast cancerIncreasing incidence but decreasing mortalityLower incidence in Asian/Pacific Islanders, Hispanic/Latina, American Indian/Alaska nativesHigher mortality in African Americans (though lower lifetime risk)Incidence & Mortality lowest in Asia/Africa, underdeveloped nations, those who have not adopted the Westernized reproductive & dietary patterns
26 Breast cancer Risk factors (21% of cases) Factor Relative Risk + FHxMenstrual Hx (menarche <12, >40 yrs total)OCP use No effectEstrogen replacement <10 yrs No effectPregnancy (1st >35 y.o., nulliparous)Contralateral breast cancer 5.0Ovarian/uterine cancer 2.0
27 Breast cancer Classification Ductal carcinoma (>80% of cancers) In situ: progresses to invasive cancer; cribiform, solid, comedo types; classified by nuclear grade & necrosis; calcifications on mammoMedullary carcinoma: soft, hemorrhagic, BRCA1Colloid/Mucinous carcinoma: elderly, bulky, gelatinousTubular: peri- early menopausal, rarely metastasizesPapillary: 7th decade, nonwhite women, small, rarely metastasizeInflammatory: dermal lymphatics invaded, erythema & warmthPaget’s disease: eczematous lesion on nipple, usu assoc w/underlying malignancy,Apocrine duct
28 Breast Cancer Lobular carcinoma In situ: only in female breast; calcifications on mammo in adjacent tissue; 12x more common in white women; not premalignant lesion, but marker for future development of invasive cancerInfiltrative- multifocal, multicentric, bilateral; no distinct mass; signet-ring cell variantRare variantsJuvenile, epidermoid, carcinoid, squamous cell, spindle cellSarcoma and carcinosarcomaCystosarcoma phyllodes, angiosarcoma, malignant lymphoma
29 Breast cancer Symptoms 33% discovered by self-exam Breast enlargement or asymmetryNipple changes, retraction, or dischargeUlceration or erythema of skinAxillary massMusculoskeletal complaintsEarly- mammo abnormality, painless, mobile tumor
30 Breast cancer Screening Mammogram Annually every year >age 40, before age 40 in selected high-risk patients, w/annual clinical breast examStart 5-10 yrs before age of affected family memberDecreases mortality by up to 33% (not proven in women age 40-49)10% False-positive rate7% False-negative rateClustered microcalcifications, fine/stippled calcium around a lesion, solid mass, & asymmetric tissue thickening are suspicious for cancerIf equivocal findings on mammo, get ultrasound
31 Hereditary breast cancers Hereditary breast cancers 5-10% of breast cancersAppropriate counseling must be provided to patient and family before testing for BRCA mutationsBRCA1 mutation (Breast & Ovary; some colon & prostate)AD inheritance, chromosome 17q21, thought to be tumor suppressor genelifetime risk of breast cancer 90%, lifetime risk of ovarian cancer 40%Early age onset breast cancerBilateralUsu invasive ductal CA, poorly differentiated, hormone receptor (-)BRCA2 mutation (Breast, less Ovary; some GI, Prostate, Melanoma, & Pancreas)chromosome 13q12, early age of onset, male breast cancerlifetime risk of breast cancer is 85%, lifetime risk of ovarian cancer 20%Well differentiated, hormone receptor (+)Ashkenazi Jews, Icelandic & Finnish populationsClinical breast exam Q6 mo, w/yearly mammo (MRI) & transvaginal ultrasound w/CA-125 level starting at age 25 (if options below not excercised)Prophylactic mastectomy after child-bearingProphylactic oophorectomy after age 40
32 Breast Cancer Staging Clinical staging based on physical exam Pathological staging more accurateTNM Staging systemT1:<2cm, T2:>2cm, T3:>5, T4: any size + involvement of chest wall or skinN0:0 nodes, N1:movable, N2:fixed, N3:infraclavicular, supraclavicular, internal mammaryM0:no mets, M1:metsMost important predictor of survival is…
33 Breast Cancer Treatment In Situ (Stage 0)LCIS:observation, chemoprevention w/Tamoxifen, & bilateral total mastectomyDCIS: >4 cm disease or disease in >1quadrant = mastectomyLow-grade DCIS <0.5cm: Needle-localized Lumpectomy alone if margins are widely free of diseaseHigh-grade DCIS or larger size: Lumpectomy w/Adjuvant radiation tx, or MastectomyRecurrence rate greater (9%) w/Lumpectomy + Rad, but mortality rate similar to mastectomyRisk for recurrence increases with: >2.5 cm size, comedo type, close margins
34 Breast Cancer Treatment Early Invasive (Stage I, IIA, or IIB)Mastectomy with assessment of axillary lymph node statusBreast conserving surgery with assessment of axillary lymph node status + radiation (standard of care)Sentinel lymph node bx is now standard care for women with clinically negative nodes; metastatic disease in an axillary or sentinel lymph node requires full axillary dissectionContraindications to sentinel node bx: T3/T4, Inflammatory CA, palpable axillary nodes, pregnancy, DCIS without mastectomy, prior axillary surgery, after neoadjuvant chemo, prior nononcologic breast surgeryRelative contraindications to breast conserving tx: prior radiation, positive surgical margins after re-excision, multicentric disease, scleroderma, lupusChemo tx: for all node (+), cancers >1cm,and cancers >0.5cm with adverse prognostic features (BV or lymph invasion, high nuclear or histological grade, HER-2-neu amplification, & (-) hormone receptorsTamoxifen: for hormone receptor (+), >1cm; 5yr tx if premenopausal; 1-2 yr tx then aromatase inhibitor if menopausalHerceptin: for HER-2-neu (+) cancers
35 Breast Cancer Treatment Advanced Local-Regional (Stage IIIA or IIIB)No clinically detected distant metsNeoadjuvant chemo to shrink tumor & allow for breast conservation tx w/radiation (doxorubicin or taxane regiminMost get Mastectomy with evaluation of axillary status followed by radiation, +/- chemoSLNBx acceptable after neoadjuvant tx if no clinical nodes prior to chemo (need axillary dissection then)Distant Metastases (Stage IV)Tx mostly aimed at enhancing quality of lifeHormonal therapy: bone or soft tissue mets only and receptor (+)Cytotoxic chemo: hormone receptor (-) or refractory, or symptomatic visceral metsBisphosphonates: bony mets
36 Radiation Therapy Can be used for all stages of Breast cancer Reduces risk of local recurrenceStandard in breast conservation txNot needed for low-grade DCIS of the solid, cribiform, or papillary subtypes that is <0.5 cm & excised widely w/negative marginsMastectomy radiation: positive margins, 4 or more lymph nodes positive (or 3 or more in premenopausal woman)Chest wall & supraclavicular lymph nodes are radiated
37 Surgical Approach- Breast Conservation Resection of primary cancer with a 2mm margin of normal-appearing tissue + assessment of regional node status + radiation txSegmental mastectomy, lumpectomy, partial mastectomy, wide local excisionUse areolar incision when possibleShould be able to encompass in mastectomy incision if completion mastectomy neededUpper breast lesion: follow lines of ZahnLower breast lesion: radial incisionOncoplastic techniques if possible
38 Surgical Approach- Mastectomy Skin sparing: removes all breast tissue, NAC, & prev biopsy scars (recurrence rate 6-8%)Total (simple): all breast tissue, NAC, skinModified radical: all breast tissue, NAC, skin & Level I & II axillary lymph nodesHalstead radical: same as modified, with pectoralis major & minor removed & Level III nodesPatey modification of MRM: removes pectoralis minor for dissection of Level III nodesSkin flap thickness usu 7-8 mmComplications: seroma (30%), hematoma, wound infection, skin flap necrosisLymphedema w/MRM: 10-20% (tx w/compression sleeve)
39 Breast Reconstruction Immediate for prophylactic mastectomy or early invasive cancerDelayed for advanced cancer (radiation needed)Immediate: Expander/Implant, or Autologous tissue (latissimus dorsi myocutaneous flap; abdominal TRAM or DIEP flap)If 2 or less ribs resected, no recon needed (scar tissue provides stabilization)
40 Special SituationsBreast CA in Pregnancy: usu present w/advanced disease; MRM in 1st & 2nd trimesters; lumpectomy w/axillary node dissection,radiation after delivery; chemo acceptable in 2nd & 3rd trimesters onlyMale Breast CA: <1% of all breast CA; usu invasive ductal; highest in Jewish & African-Americans; preceded by gynecomastia in 20%; similar survival rates as women; tx similar to womenPhyllodes tumor: benign, borderline, or malignant; mammo findings cannot distinguish type; sharp demarcation from normal breast tissue; Tx w/lumpectomy or mastectomy; no axillary dissection neededInflammatory Breast CA: induration, erythema, & edema; invasion of dermal lymphatics classic finding; 75% have palpable lymph nodes;Tx is neoadjuvant chemo w/MRM, radiation, +/- adjuvant chemo; poor prognosis
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