1. Hypothetical Chief Complaint
“ I have left nipple swelling”

2. History of Present Illness
75 y.o. male was noted to have a painful left nipple swelling on 3/15/06. The nurse noted that it was an easily palpable lump, with tenderness upon palpation. A surgical consult was sought, and suggested to perform mammogram and ultrasound.

3. Past Medical History Past Surgical History Dementia HTN GERD
s/p cholecystectomy
s/p peg (12/05)

4. Medications Metoprolol 25 mg BID Senna 8.6 mg QHS
Ranatidine 150 mg BID
Seraquil 25 mg BID
Aricept 5 mg QHS
Tyenol 160mg/5mL Q 6 hours (PRN)
MVI

5. Allergies: NKDA
Social History: No smoking, drinking, or drugs
Family History: No history of cancers

6. VS: T: P: 80 RR: BP: 100/50
Gen: AAO x 3, NAD
HEENT: NC/AT, PERRLA, EOMI, no LAD, OP clear
Neck: supple, no thyromegaly
Chest: CTA b/l, + aw entry, + left breast mass, palpable at about 12 o’clock, + tenderness on palpation
CV: S1S2 nl, RRR
Abd: soft, NT/ND, + BS, no HSM
Extremities: WINL
Neuro: no focal neurological deficit, AAO x 3

7. Labs WBC: 7.9 Mg: 1.8 H/H: 11.7/39.8 Phosphorus: 2.8
Platelets: Coags: 11.2/25.4/.7
Na: CXR: NAPD
K: EKG: 100 BPM
Cl:107
HCO3: 29
BUN: 25
Cr: 0.9
Glucose: 78
Ca: 8.9

8. Radiographic Labs Mammogram
Right breast is fatty with some retroareolar densities probably representing mild gynecomastia
Density of left breast, which can represent gynecomastia, but mass can’t be excluded
U/S indicated and open excision
Impression:
Changes consistent with gynecomastia
R/O mass in left breast approximately at 2 o’clock
BI-RADS Score
Right breast: # 2
Left breast: #0

9. Radiographic Labs Ultrasound of Left Breast
In the periareolar region at 12 o’clock, 1-2, 3, 4-5 and 6 positions, hypoechoic density is seen, some borders have mass effect.
There is a slight vascularity within the lesion, which measures 1.5 x .69 cm in the radial plane and 1.49 cm in the anteradial plane
Some compression is seen consistent with gynecomastia
BI-RADS Score:
Left Breast: #3

10. Radiographic Labs Left Core Biopsy of Breast Mass
Breast tissue showing extensive foci of atypical ductal hyperplasia in the background of gynecomastia.

11. Breast Cancer

12. Breast Cancer
Breast cancer is the most common female cancer in the U.S.
It is the second most common cause of cancer death in women.
Lastly, it is the main cause of death in women ages 45 to 55.
However, male breast cancer is rare in contrast to female breast cancer.

13. Epidemiology
Breast cancer is 100 times more common in females than males.
In males, breast cancer accounts for <1% of all breast cancer cases in the U.S. and ~0.1% of cancer mortality in men.
The American Cancer Society estimated that 1,450 men would have been diagnosed with breast cancer in U.S. and 470 would die from this disease in year 2004.
The incidence of male breast cancer, once thought to be relatively stable, now seems substantially to be increasing, that has increased from 0.86 to 1.06 per 100,000 population over the last 26 years.
The median age of onset in males is years of age.
In females, it is estimated that approximately 211,240 American women would have been diagnosed with breast cancer in year 2005, and 40,410 women would have died.
Breast cancer rates increased by 1.2% per year between 1940 and 1980.
However, the median age of onset in females is years of age, around 10 years younger than males.

14. Back to Basics…ANATOMY
Basic Structure
Composed of glandular, fibrous, and adipose tissue.
Lies within layers of superficial pectoral fascia.
Each mammary gland consists of approximately 15 to 20 lobules, each of which has a lactiferous duct that opens on the areola.
The breast has ligaments that extends from the deep pectoral fascia to the superficial dermal fascia that provide structural support referred to as Cooper’s ligaments.
The skin dimpling in breast cancer is due to traction on Cooper’s ligaments.
The breast frequently extends into axilla as the axillary tail of Spence.
The breast is also partitioned into 4 quadrants by vertical and horizontal lines across the nipple:
Upper inner quadrant (UIQ)
Lower inner quadrant (LIQ)
Upper outer quadrant (UOQ)
Lower outer quadrant (LOQ)

15. Breast Anatomy

16. Quadrants of the Breast

17. Blood and Nerve Supply to the Breast
Blood Supply
Arterial
It is supplied by the axillary artery via the lateral thoracic and thoracoacromial branches
The internal mammary artery via its perforating branches
Adjacent intercostal arteries
Venous
It tends to follow the arterial supply; axillary, internal mammary, and intercostal veins
The axillary vein is responsible for the majority of venous drainage
The venous drainage is largely responsible for metastases to the spine through Batson’s plexus.
Nerve Supply
The breast is supplied by 4 main nerves:
Long thoracic nerve
Thoracodorsal nerve
Medial and lateral pectoral nerves
Intercostobrachial nerve

18. Lymphatic Drainage to the Breast
The lymphatic drainage of the breast is important because of its role in the metastasis of breast cancer.
Lymph tends to pass from the nipple, areola, and lobules of the gland to the subareolar lymphatic plexus.
Most lymph (more than 75%), especially from the lateral quadrants drain to the axillary lymph nodes.
The axillary lymph nodes are sub-divided into levels:
Level I (low): lateral border of pectoralis minor
Level II (middle): deep to pectoralis minor
Level III (high): medial border of pectoralis minor
Rotter’s node: these nodes lie between the pectoralis major and minor muscles.
Most of the remaining lymph, particularly from the medial quadrants, drains to the parasternal nodes or to the opposite breast, while lymph from the lower quadrants passes deeply to the inferior phrenic nodes.

19. Back to Basics….ANATOMY

20. Risk Factors for Breast Cancer
Females
Early menarche
Late menopause
Nulliparity or 1st pregnancy >30 y.o.a.
White race
Old age
Family history of breast cancer
Genetic predisposition (BRCA 1, BRCA 2, Li Fraumeni Syndrome)
Prior personal history of breast cancer
DCIS or LCIS
Atypical ductal or lobular hyperplasia
Males
Testicular Abnormalities
Undescended testes
Congenital inguinal hernia
Orchitis
Testicular injury
Infertility
Positive family history
Klinefelter Syndrome
Elevated endogenous estrogen
Previous irradiation
Trauma
Jewish ancestry

21. Screening for Breast Cancer
Breast screening is a method of detecting breast cancer at a very early age.
There are several methods for to screen for breast cancer, and it can begin at a very early age.
The simple ways to begin to screen for breast cancer are:
Breast Self Examination
Mammography
Ultrasound*

22. Breast Self Examination
All women should perform a self breast examination monthly after the menstrual period, when breast swelling and fibrocystic changes are less likely to interfere with the detection of a lump or mass.
This is also followed by a yearly clinical breast exam.
HOW TO DO THE EXAM
First, lift your right hand and place it behind your head.
Keep the first 3 fingers of your hand firmly together.
Press the outermost point of your right breast (near armpit) firmly in a little circular motion with the pads of your fingers. Then continue in a large circle all around your breast.
Move your finger an inch closer to the nipple and feel another circle around the breast. Continue circling until you have felt every part of the breast, including the nipple.
Squeeze the nipple gently to see if any fluid comes out.
Now change hands and repeat the procedure for the other breast.

23. Breast Self Exam (BSE)

24. Mammography 2. Mammogram
Mammograms are the most important tools doctors have to diagnose and evaluate women who have breast cancer.
It tends to identify 5 cancers/ 1,000 women
It is 85-90% sensitive
Gives false positives 10%, false negatives 6-8%
Mammograms are more useful in ages >30 secondary to the large proportion of fibrous tissue in younger women’s breast make more difficult to interpret.
Recommendation for annual mammograms start at the age of 40; however, women with risk factors for breast carcinoma should have ~ yearly mammograms at an earlier age.
The American College of Radiology Diagnostic Code interprets the mammograms from negative to highly suggestive of malignancy.

25. Mammography American College of Radiology Diagnostic Code
BI-RADS SCORE
0: incomplete assessment, needs additional imaging
1: negative
2: benign finding
3: probably benign – recommend short term follow up
4: suspicion abnormality – consider biopsy
5: highly suggestive of malignancy

26. Ultrasonography
Ultrasound is frequently used to evaluate breast abnormalities that are found with screening mammography or during a physician performed breast examination.
Ultrasound allows significant freedom in obtaining images of the breast from almost any direction.
However, it is not FDA approved as a screening tool for breast cancer. Yet, it is used as a first tool in women under 30 years of age when a breast abnormality is found secondary to the large amount of fibrous tissue found in women of this age.
Advantages:
They are good for identifying cystic disease
Can assist in therapeutic aspiration
It has excellent contrast resolution
Disadvantages:
It lacks spatial resolution (fine detail)
It cannot detect most calcium deposits on breast tumors
It cannot document how much breast tissue has been imaged
Will not identify lesions <1cm

27. Diagnostic Tools for Breast Cancer
While physical breast exam, mammography, ultrasound, and other breast imaging methods can help detect a breast abnormality, biopsy followed by pathological analysis is the only definitive way to determine if cancer is present.
Depending on a number of factors, including how suspicious the abnormality appears; the size, the shape and the location of the abnormality many different methods of biopsy can be performed, such as:
Fine Needle Aspiration Biopsy (FNA)
Core Needle Biopsy
Vacuum-Assisted Biopsy (Mammatome or MIBB)
Large Core Surgical (ABBI)
Open Surgical (Excisional or Incisional)

28. Fine Needle Aspiration Biopsy
Fine Needle Aspiration Biopsy (FNA)
It is a percutaneous (“through the skin”) procedure that uses a fine gauge needle (22 or 25 gauge) and a syringe to sample fluid from a breast cyst or remove clusters of cells from a solid mass.
Advantages:
Fastest and easiest method of biopsy, where the results are easily available.
It is excellent for confirming breast cysts
Has a low morbidity
Only 1-2% false-positive rate
Disadvantages:
The procedure only removes very small samples of tissues or cells from breast
If the sample is benign fluid, then the procedure is ideal. However, if the tissue is solid or a cloudy sample, the small number of cells removed by FNA only allow for a cytologic (cell) diagnosis.
False negatives rate up to 10%
May miss deep masses

29. Core Needle Biopsy 2. Core Needle Biopsy
It is also a percutaneous procedure that involves removing small samples of breast tissue using a hollow “core” needle.
This procedure is usually for palpable lesions.
It differs from FNA in that is also uses a larger gauge needle (16,14 or 11).
Advantages:
Core needle biopsy usually allows for a more accurate assessment of a breast mass than FNA because the larger core needle usually removes enough tissue for the pathologist to evaluate abnormal cells.
Disadvantages:
Still a chance of sampling error
Again, like FNA it only removes a sample of the mass and not the entire area of concern.

30. Vacuum-Assisted Biopsy
3. Vacuum-Assisted Biopsy (Mammotome)
This is a relatively new biopsy that is percutaneous procedure that relies on stereotactic mammography or ultrasound imaging.
Stereotactic mammography involves using computers to pinpoint the exact location of a breast mass based on mammograms taken from two different angles.
Vacuum-assisted biopsy is minimally invasive procedure that allows for the removal of multiple tissue samples.
It has been becoming more common that open surgical biopsies due to its advantages.
Advantages:
Minimally invasive
Usually no significant scarring
Does not require stitches
No breast deformity
Procedure takes less than hour
Cost effective

31. Large Core Surgical 4. Large Core Surgical (ABBI)
It is a surgical technique that involves removing an entire intact breast lesion under image guidance.
It requires the use of a prone biopsy table and a stereotactic mammography.
It can remove 5 mm to 20 mm of breast tissue.
However, this technique is not widely accepted and has bought controversy secondary to that in large core biopsy it requires the removal of a significant portion of normal breast tissue just to reach the lesion.

32. Open Surgical Biopsy 5. Open Surgical Biopsy
Traditional open surgical biopsy is the gold standard to which other methods of breast biopsies are compared.
It tends to require a 1.5 cm to 2 cm incision in the breast.
Excisional Biopsy: The surgeon will attempt to completely remove the area of concern, often along with the surrounding margin of normal breast tissue.
Incisional Biopsy: Similar to excisional biopsy except that the surgeon removes only part of the breast lesion, usually performed on large lesions.
Advantages:
Yields the largest breast tissue sample of all breast biopsy methods
Gold standard – the accuracy is close to 100% for a diagnosis
Disadvantages:
Requires stitches and leaves a scar
Chances of bleeding, infection, or problems with wound healing
Mortality risk associated with anesthesia

33. Staging of Breast Cancer
TNM Staging for Breast Cancer
Tx: Cannot assess primary tumor
T0: No evidence of primary tumor
T1: </= 2 cm
T2: </= 5 cm
T3: > 5cm
T4: any size, with direct extension into the chest wall or with skin edema or ulceration
Nx: Cannot assess lymph nodes
N0: No nodal metastasis
N1: Movable ipsilateral axillary nodes
N2: Fixed ipsilateral axillary nodes
N3: Ipsilateral internal mammary nodes
Mx: Cannot assess metastasis
M0: No metastasis
M1: Distant metastasis or supraclavicular nodes

34. Staging System for Breast Cancer
Stage
Tumor Size
Lymph Node Involvement
Metastasis 0*
DCIS or LCIS - I
Less than 2 cm
None II
Between 2-5 cm
No or in the same side of the breast No
III
More than 5 cm
Yes, on same side of breast IV
Not applicable
Yes

35. Treatment
The primary goal of local therapy is to provide optimal control of the disease in the breast and regional tissue while providing the best possible cosmetic result.
The different types of treatment may include surgery, radiation therapy, adjuvant chemotherapy, adjuvant endocrine therapy, or a combination of modalities.

36. Surgical Treatment
The optimal surgical approach is determined by the following factors:
Disease stage
Tumor size
Tumor location
Breast size and configuration
Number of tumors in the breast

37. Surgical Treatment
Radical mastectomy: Resection of all breast tissue, axillary nodes, and pectoralis major and minor muscles.
Modified radical mastectomy: Same as radical mastectomy except pectoralis muscles left intact.
Simple mastectomy: Resection of all the breast tissue, except pectoralis muscle left intact and no axillary node dissection.
Lumpectomy and axillary node dissection: Resection of mass with rim of normal tissue and axillary node dissection – good cosmetic result.
Sentinel node biopsy: Recently developed alternative to complete axillary node dissection.
Lymph nodes are identified on pre-operative scintigraphy and blue dye is injected in the periareolar area.
Axilla is opened and inspected for blue and/or “hot” nodes identified by a gamma probe.
When sentinel node is positive, an axillary dissection is completed.
When sentinel node is negative, axillary dissection is not performed unless axillary lymphadenopathy identified.

38. Breast Cancer
There are many different types of breast cancers, and they can be distinguished by the following:
Infectious/Inflammatory Disease
Mastitis
Fat Necrosis
Benign Disease
Fibroadenoma
Cystosarcoma Phyllodes
Intraductal Papilloma
Gynecomastia
Atypical Ductal Hyperplasia
Pre-Malignant Disease
Ductal Carcinoma In Situ (DCIS)
Lobular Carcinoma In Situ (LCIS)
Malignant Disease
Infiltrating Ductal Carcinoma
Infiltrating Lobular Carcinoma
Paget Disease (of the Nipple)

39. Infectious/Inflammatory Breast Disease
Mastitis:
It is usually caused by S. aureus or Streptococcus spp.
It commonly occurs during early weeks of breast feeding, in which there is focal tenderness with erythema and warmth of overlapping skin.
Diagnosis: Ultrasound can be used to localize an abscess
Treatment: Continue breast feeding and recommend breast pump as an alternative.
If cellulitis would perform wound care and IV antibiotics, and if abscess would do incision and drainage followed by IV antibiotics.
Fat Necrosis
It usually presents as a firm, irregular mass of varying tenderness, with a history of a local trauma elicited in 50% of patients.
The exam represents irregular mass with no discrete borders that may or may not be tender.
Diagnosis and Treatment: Excisional biopsy with pathologic evaluation for carcinoma.

40. Mastitis Fat Necrosis

41. Benign Breast Disease Fibroadenoma
It is a fibrous stroma surrounds duct-like epithelium and forms a benign tumor that is grossly smooth, white, and well-circumscribed.
It typically more common in blacks, and occurs in the late teens to early 30’s.
This disease is also estrogen-sensitive, which has increased tenderness during pregnancy.
The breast exam shows smooth, discrete, circular and mobile mass
Diagnosis: FNA
Treatment: Observation

42. Benign Breast Disease Cystosarcoma Phyllodes
It is a variant of fibroadenoma, in which the majority are benign
The patients tend to present later than those with fibroadenoma
They tend to be indistinguishable from fibroadenoma by ultrasound or mammogram, but can only be distinguished on their histologic features (phyllodes has more mitotic activity).
The breast exam shows large, freely movable mass with overlying skin changes.
Diagnosis: Biopsy with pathologic evaluation
Treatment:
Small Tumors: Wide local excision with a least a 1 cm margin
Larger Tumors: Simple mastectomy

43. Cystosarcoma Phyllodes

44. Benign Breast Disease Intraductal Papilloma
It is a benign local proliferation of ductal epithelial cells, that has unilateral serosanguineous or bloody nipple discharge.
Patients usually present with subareolar mass and/or spontaneous nipple discharge.
In examination one must radially compress breast to determine which lactiferous duct express fluid
Diagnosis: Definitive diagnosis by pathologic evaluation of resected specimen.
Treatment: Excise affected duct

45. Benign Breast Disease Gynecomastia
It is the development of female-like breast tissue in males, which can either be physiologic or pathologic.
There is at least a 2 cm of excess subareolar breast tissue present to make the diagnosis.
The causes can be medications, illicit drugs, liver failure, increased estrogen, and/or decreased testosterone.
Treatment: Treat underlying cause if specific cause identified; if normal physiology is responsible, only surgical excision.

46. Benign Breast Disease Atypical Ductal Hyperplasia (ADH)
It is the name given to a condition that can occur in the lining of the milk ducts in the breast.
This typically is benign in both males and females but can be at risk for developing cancer; hence, further studies are needed.
In women, this disease rarely proceeds on towards cancer, and it is not cancer.
In men however, when ADH is diagnosed with a background of gynecomastia there is a 4-5 times increased risk for the development of invasive breast carcinoma.
Diagnosis: Biopsy
Treatment: Observation, or surgical resection

47. Atypical Ductal Hyperplasia

48. Pre-Malignant Disease
Ductal Carcinoma In Situ (DCIS)
It is the proliferation of ductal cells that spread through the ductal system but lack the ability to invade the basement membrane. It arises from the inner layer of epithelial cells in major ducts.
More than ½ the cases occur after menopause, in which there is a palpable mass some of the times.
Diagnosis: Clustered microcalcifications on mammogram, malignant epithelial cells in breast duct on biopsy.
Risk of invasive cancer: There is increased risk in ipsilateral breast, usually same quadrant; where infiltrating ductal carcinoma is most common histologic type.
Treatment:
If small (< 2 cm): Lumpectomy with either close follow-up or radiation
If large (> 2 cm): Lumpectomy with 1 cm margins and radiation
If breast diffusely involved: Simple mastectomy

49. Ductal Carcinoma In Situ

50. Pre-Malignant Disease
Lobular Carcinoma In Situ (LCIS)
It is a multi-focal proliferation of acinar and terminal ductal cells, which arises from cells of the terminal duct-lobular unit.
The vast majority of the cases occur prior to menopause, and one usually does not feel a palpable mass.
Diagnosis: Typically a clinically occult lesion; undetectable by mammogram and incidental on biopsy.
Risk of invasive cancer: There is an equally increased risk in either breast, infiltrating ductal carcinoma; associated with simultaneous LCIS in the contralateral breast in over ½ the cases.
Treatment: None, bilateral mastectomy an option if patient is at high risk.

51. Lobular Carcinoma In Situ

52. Malignant Disease Infiltrating Ductal Carcinoma
This is the most common invasive cancer in both males and females (80% of cases).
It is the most common in perimenopausal and postmenopausal women.
Presentation: A hard, fixed mass, “peau d’ orange” overlying the skin, ulceration of overlying skin, bloody nipple discharge, inverted or retracted nipple.
The ductal cells tend to invade stroma in various histologic forms described as scirrhous, medullary, comedo, colloid, papillary, or tubular.
Medullary: Invasive breast cancer that forms a distinct boundary between tumor tissue and normal tissue.
Colloid: Formed by mucus producing cancer cells
Can have metastasis to axilla, bones, lungs, liver and brain.

53. Infiltrating Ductal Carcinoma

54. Malignant Disease Infiltrating Lobular Carcinoma
It is the second most common type of invasive breast cancer (10% of cases).
It originates from terminal ducts cells and, like LCIS, has a high likelihood of being bilateral.
20% of infiltrating lobular carcinoma have simultaneous contralateral breast cancer.
Tends to present as an ill-defined thickening of the breast.
Like LCIS, lacks microcalcifications and is often multi-centric
Tends to metastasize to the axilla, meninges, and serosal surfaces.

55. Infiltrating Lobular Carcinoma

56. Malignant Disease Paget Disease (of the Nipple)
It is usually 2% of invasive breast cancers
They are usually associated with underlying LCIS or ductal carcinoma extending within the epithelium of the main excretory ducts to skin of nipple and areola.
Presentation: Tender, itchy nipple with or without a bloody discharge with or without a subareolar palpable mass
Treatment: Usually requires a modified radical mastectomy.

57. Paget Disease of the Nipple

58. Metastasis Breast cancer tends to metastasize to the following places:
Lymph nodes (most common)
Lung/pleura
Liver
Bones
Brain

59. Prognosis
Approximately 50% of patients with operable breast cancer develop recurrent disease unless they receive adjuvant chemotherapy or hormone therapy. Prognostic factors include:
Tumor size: Tumors larger than 5 cm are associated with a decreased survival rate and increased recurrence rate.
Axillary node status
Histopathology
Hormone receptor status
Oncogenic expression

60. 5 Year Survival Rate According to Stage
92% II
87%
III
75% IV
13%

61. Summary
Breast cancer is the most common female cancer, in contrast to male where it is rare, with a ratio of 100:1.
When performing an initial evaluation of patients with possible breast disease:
Remember to have a complete medical history, including risk factors, such as:
Ask when first menarche, first child, any history of breast cancer, when did menopause happen, how old is the patient, any previous breast biopsy, etc.
Be sure to inquire about any history of nipple discharge, or any changes in the size, shape, symmetry, or contour of the breasts.
Remember to inspect and palpate all four quadrants of the breast, the axillary lymph nodes, and the nipple-areolar complex for any discharge.
Screening test of choice: Mammogram
Diagnostic Test: Biopsies
Treatments: Surgical, Hormonal, Adjuvant Therapy [Chemotherapy, Radiation Therapy]

65. Surgical Specimen of Left Mastectomy
Gynecomastia with atypical ductal hyperplasia
Note:
The breast shows duct hyperplasia with periductal edema
Some ducts show atypical micropapillary hyperplasia
Few ducts show disorderly proliferation of epithelial cells nearly fills the duct
Focal duct dilation and apocrine metaplasia are also present