Breast Mass

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Functionally

part of reproductive system Respond to sexual

stimulation Feed babies

โอ้�วววววววววววววววววววววววววววว

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Structure & Anatomy

NippleNipple AreolaAreola Montgomery’s Montgomery’s

tuberclestubercles

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Structure & Anatomy

AlveolusAlveolus Milk ductMilk duct Lactiferous ductLactiferous duct Lactiferous sinusLactiferous sinus

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Arterial Supply to theBreast

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Veins draining the Breast

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Lymph Nodes of theBreast

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EvaluationEvaluation

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EVALUATION

A. Clinical Manifestation:

B. Physical Examination:

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Physical Examination

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C. Radiological Examination:1. Mammography (Screening):

• Uses low dose of radiation (0.1 rad)• Complementary study, can not replace biopsy• Microcalcification, architectural dislortion,duct

dilatation, fibronodular density– suggestive of CA• Early detection of an occult CA before

reaching 5 mm.• Recommended Program of Using

Mammography:1. Age 35-40 yr baseline mammography2. Age >40 yr annual mammography3. Age>50 yr mammography q 1-2 yrs depend on doctor

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Mammography

รู�ปแสดง malignant microcalcification และ architectural distortion

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mammographic findings

การ manage จะแบ่งเป็ น 6 Categories ตาม BIRAD S categories (Breast Imaging Recording And Data

System)

Category 0 . unfinished study : need additional imaging Category 1 . Normal : Suggest routine screening Category 2 . Benign looking : Suggest yearly Screening Category 3 . Probably benign : Suggest diagnostic mammogr

- aphy at 6 12 Month intervals Category 4 . Indeterminate or mild suspicion : Suggest Pathol

ogical tissue diagnosis Category 5 . Suspicious of malignancy : Suggest Pathological

tissue diagnosis

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EVALUATION

C. Radiological Examination:2. Computed Tomography or Magnetic Resonant Imaging:

• To expensive• For detection of vertebral metastasis

3. Ultrasonography• No radiation exposure• Can differentiate cystic lesions from solid mass• Can not detect less than 5mm.

4. Interventional Technique:Ductography:

– Inject radio-opaque contrast media into the mammary duct

D. Biopsy: positive result is diagnostic1. Excision biopsy2. Incision biopsy3. Core needle biopsy4. Fine needle biopsy

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BENIGN LESIONS OF THE BENIGN LESIONS OF THE BREASTBREAST

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BENIGN LESIONS OF THE BREAST

1.Fibroadenoma: Well circumscribed lesion, movable, smooth,

lobulated, encapsulated, painless, not associated w/ nipple discharge

Size does not regress after menstruation Etiology (?), could also be due to hormonal

imbalance Treatment:

– Excision biopsy (rule out malignancy)

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BENIGN LESIONS OF THE BREAST

2. Intra-ductal Papilloma: Proliferation of the ductal epithelium Commonly causes Bloody Nipple Discharge

• Palpable mass – 95% is intra-ductal papilloma

Treatment:• Excision of a palpable mass by biopsy

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BENIGN LESIONS OF THE BREAST

3. Phyllodes Tumor• Bulk of the mass is made up of connective tissue, with

mixed areas of gelatinous, edematous areas. Cystic areas are due to necrosis and infarct degenerations

• 80% are benign, usually large bulky lesions • Treatment:

– Excision biopsy:

» Benign – no further treatment, observe

» Malignant – total mastectomy / MRM

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BENIGN LESIONS OF THE BREAST

4. Mammary Duct Ectasia (Plasma cell mastitis, Comedomasttitis & Chronic mastitis)

Sub-acute inflammation of the ductal system usually beginning in the subareolar area w/ ductal obstruction

Usually present as a hard mass beneath or near areola w/ either nipple or skin retraction due to increase fibrosis

Appears during or after menopausal period Treatment:

– Excision biopsy

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BENIGN LESIONS OF THE BREAST

5. Gynecomastia: Development of female type of breast in male Usually unilateral or bilateral Causes :

a. Hepatic cirrhosis (for elderly alcoholic)

b. Estrogen medication for prostatic CA

c. Tumor producing estrogen/progesterone

Treatment:– tx primary cause– Subcutaneous mastectomy

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Malignant Lesions of the Breast

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Malignant Lesions of the Breast

Etiology: - multifactorial

1. Age

2. Age at menarche and menopause

3. Age at first pregnancy

4. HRT (Hormone replacement therapy)

5. Radiation

6. Diet

7. Genetic factor

8. Multiple Primary Neoplasms

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TNM Staging System

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TNM Staging System for Breast Carcinoma

Primary Tumor (T)TX – Primary tumor cannot be assessedT0 – No evidence of primary tumorTis – CA in situ (LCIS / DCIS), Paget’s dse of the nipple w/o tumorT1 – 2 cm or less

T1a – 0.5 cm. or lessT1b - > 0.5 cm. to 1 cm.T1c - > 1cm. to 2 cm.

T2 – 2 to 5 cm.T3 - > 5 cm.T4 – any size w/ direct extension to chest wall or skin

T4a – extension to chest wallT4b – edema / ulceration of the skin / satelite

noduleT4c – both T4a and T4bT4d – Inflammatory carcinoma

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TNM Staging System for Breast Carcinoma

Regional Lymph Nodes (N)NX – Not assessed (previously removed)

N0 – No regional LN metastasis

N1 – (+) movable ipsilateral axillary LN

N2 – (+) LN fixed to one another

N3 – (+) Ipsilateral INTERNAL MAMMARY LN

Distant Metastasis (M): MX – not assessed M0 – (-) M1 –(+) including metastasis to ipsilateral supraclavicular LN

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Metastasis site

Bone - 4960( %)Lung - (15 20%)

Pleura - 1015( %)

Soft tissue - (7 15%)Liver -510( %)

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TNM Staging System for Breast Carcinoma

Stage Grouping: 5- year survival rateStage 0 Tis N0 M0 100Stage I T1 N0 M0 100

Stage IIA T0 N1 M0 92T1 N1a M0T2 N0 M0

Stage IIB T2 N1 M0 81T3 N0 M0

Stage IIIA T0 – T2 N2 M0 67 T3 N1-2 M0

Stage IIIB T4 Any N M0 54

Any T N3 M0Stage IV Any T Any N M1 20

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Treatment

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Surgical Management

1. Radical Mastectomy (Willi Meyer, Halsted)2. Extended Radical Mastectomy

3. Modified Radical Mastectomy:4. Total mastectomy w/ or w/o radiation:

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Surgical Management:5. Subcutaneous Mastectomy:6. Quandrantectomy, axillary, radiotherapy

(QUART)7. Partial Mastectomy and Radiation:

Indications for Conservative Surgery:1. Small breast CA < 4cm

2. Clinically (-) axillary LN

3. Breast volume adequate size to allow uniform dosage of irradiation

4. Radiation therapist experience to avoid damage of retained breast

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Chemotherapy: Adjuvant chemotherapy Neoadjuvant chemotherapy (Primary

chemotherapy)Radiation

conserving breast surgery post MRM 2-3 wks of post operative or after finished

Chemotherapy

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Hormonal therapy hormonal dependent tumor

• estrogen• growth stimulating factor• epidermal growth factor• growth inhibitory factor

estrogen receptor, progesterone receptor

ชน�ดของการร�กษามะเร�งเต�านมด�วย hormone

1. 1. Ablation:Ablation:• Oophorectomy,

adrenalectomy,hypophysectomy

2. 2. Anti-estrogen:Anti-estrogen:• Tamoxifen – -a non

-steroidal anti estrogeni c.

• Aromasin,Aminogluthethimide

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Therapeutic Approach

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Therapeutic Approach for Breast Cancer

Stage 0 Non-infiltrating (In-situ)

Carcinoma of duct and lobules:• Increase diagnosis due to

mammography

1. LOBULAR CARCINOMA in SITU:

• เป็ นพยาธิ�สภาพซึ่"#งเช$#อวาเก�ดที่&# duct lobular apparatus

• การว�น�จฉั�ยสวนใหญ่ เป็ นการพบ่ โดยบ่�งเอ�ญ่ จ"งบ่อกอ,บ่�ต�การณ์.ได�

ยาก• Tx: 1.

Closed observation2.

Hormonal treatment (Tamoxifen/aromatase inhibitor) for 5 years

3. Surgery (bilateral mastectomy) w/ immediate reconstruction

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Therapeutic Approach for Breast Cancer

2. Ductal Carcinoma In Situ:

• Absence of invasion of surrounding stroma hence confined w/in the basement membrane

• Treatment: – Total mastectomy– Wide local excision +

Radiotherapy– Wide local excision

alone

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Therapeutic Approach for Breast Cancer

Paget’s Disease of the nipple

≈ - 074. % Chronic eczematoid lesion of the nipple Tenderness, itching, burning and intermittent bleeding Tx:

Mammogram เพ$#อหามะเร�งซึ่"#งพบ่รวมก�บ่ Paget ‘ s disease ถ้�าพบ่วาม&มะเร�งอ$#นรวมด�วย ให�ร�กษาตามชน�ดของมะเร�งเต�านมน�1นๆ

หากไมพบ่รอยโรครวมก�บ่มะเร�งชน�ดอ$#นอาจพ�จารณ์าที่4า wide excision หร$อที่4า Simple mastectomy รวมก�บ่ axillary dissection

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Therapeutic Approach for Breast Cancer

Breast Cancer in Men: Factors:

a. Klinefelter syndromeb. Estrogen therapyc. Irradiationd. Trauma

Age: 60-70y/o s/sx: breast mass, nipple retraction and/or

discharge, ulceration and pain. Commonly ER positive and well differentiated Prognosis is similar w/ female Treatment:

• MRM + radiation if with ulceration and high grade• Orchiectomy / chemotherapy

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Therapeutic Approach for Breast CancerStage I & II

Modified radical mastectomy

(+) LN (-) LN (-) LN Low risk High

risk

Hormonal / observe chemotherapy

chemotherapy

High Risk Patients A. Histologic criteria:B. Rapid growth rateC. Youth of the patientD. Estrogen receptor negative

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Therapeutic Approach for Breast Cancer

Advance Breast Cancer (III / IV):

Palliative Mastectomy

(+) Estrogen (-) Estrogen

Chemotherapy/Hormonal/Radiotherapy

Chemotherapy/Radiotherapy

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Thank you