Category Archives: Breast Cancer

Giant fibroadenoma of the Breast

Giant Fibroadenoma of the Breast

  • Rare and generally occur in women age 15-20 years old.
  • Rapid growth
  • Can exceed 5 cm
  • Observation is not recommended for some patients because the rapid growth can lead to further problems (infarction, deformities)
  • Giant Fibroadenoma should be excised also to exclude a phyllodes tumor in addition to preventing futher problems of infarction and deformities.

When is a galactogram done?

Galactogram = Ductogram

Usually done for spontaneous unilateral bloody nipple discharge.  Sometimes it is done for serous (clear) discharge.

90% of the women with unilateral bloody nipple discharge = benign intraductal papilloma, a solitary discrete intraductal mass.  However if multiple masses are discovered in the duct, the more likely the diagnosis will be ductal carcinoma in situ (DCIS).

Regardless of single mass or multiple mass, a surgical biopsy (excisional biopsy) is required for diagnosis.  Methylene blue dye can assist the surgeon in removing the duct in the OR.

Pregnancy and Breast Cancer

Pregnancy affects breast cancer risk

Pregnancy stops monthly menstrual cycles and shifts the hormone balance to progesterone instead of estrogen; thus women who become pregnant while they are young and have many pregnancies may have slightly lower risk of breast cancer later on because they are exposed to less estrogen.

Breast Cancer diagnosis while pregnant

  • Mammograms are considered fairly safe during pregnancy.
  • Breast biopsy – ie core needle biopsy can be done during pregnancy.
  • MRI without contrast can be done while pregnant.
  • Chest X-Rays can be done.

Treating Breast Cancer while Pregnant

  • Surgeries can be done; however, SLN might be limited.
  • Radiation is usually given after delivery.
  • Chemo can start in the second trimester.  Induction chemotherapy can start (ie. for tumors fixed to the skin – stage III)
  • Hormone therapy should not be used during pregnancy.


Facts about Phyllodes tumors

Phyllodes tumors of the breast:

  • Not easily distinguished from fibroadenomas on physical exam and even challenging on radiological studies
  • Rarely involve the nipple-areolar complex
  • Most are in the upper outer quadrant
  • Central phyllodes tumors may present with bloody nipple discharge or nipple retraction
  • Few have been reported in men
  • Primary goal for treatment of phyllodes tumor is to achieve a wide negative margin with a rim of at least 1 cm of uninvolved tissue.
  • Total mastectomy may be required for lesions too big to achieve a 1 cm margin without markedly deforming the breast or for repeated local recurrences


Is there a difference between BRCA 1 and BRCA 2?

BRCA are breast cancer genes

When working properly these are tumor supressors.  They protect against breast cancer.

But when they are abnormal and genetically inherited – these are called the BRCA1 and BRCA2 genetic mutations.

Both BRCA mutations (1 and 2) increase risk of breast cancer

Normally women have a 12 % lifetime risk of developing breast cancer.  Having a BRCA mutation raises the risk to 50-85% with a high likelihood for a recurrence or a second tumor. Risk is the same for BRCA1 or BRCA2

The differences are the risks of associated other cancers.

Both have the increased risk of ovarian and pancreatic cancers

BRCA1 mutations may have additional risk of these cancers

  • cervical
  • uterine
  • pancreatic
  • colon cancer

BRCA2 mutations may have additional risk of these cancers

  • pancreatic
  • stomach
  • gallbladder
  • bile duct
  • melanoma

Future research will discover more differences between BRCA1 and BRCA2.

More info about BRCA mutations and Angelina Jolie

What is T4 in Breast Cancer

Staging of Breast Cancer

T stands for primary Tumor in the staging of Breast Cancer.

A T4 tumor is a tumor of any size with direct extesion to the chest wall (a) or skin (b).

  • T4a = extension to chest wall
  • T4b = Edema or ulceration of the skin of the breast.  Includes peau d’orange look of the skin.
  • T4c = both a and b above.
  • T4d = inflammatory carcinoma

For interest here’s the other T staging designations for Breast Cancer:

  • T1 = < 2 cm
  • T2 = 2-5 cm
  • T3 = > 5 cm


What are the side effects of tamoxifen?

Side effects and Risks of tamoxifen

Tamoxifen acts like an anti-estrogen in some tissues and acts like estrogen in other tissues.

  • Hot flashes and night sweats
  • Cancer of the uterus (most were endometrial cancer, a few were uterine sarcoma).  The risk is not present in those patients who have had  a hysterectomy.
  • Blood clots (DVT, PE, and stroke)

Tamoxifen is contraindicated in patients who continue to smoke due to the increased risk of thromboembolic disease.

How is Digital Mammograms different from film mammograms?

Breast cancer is the second most common cancer in women in the US second only to skin cancer.

Regarding the different types of mammograms (digital vs. film) overall diagnostic accuracy for breast cancer screening was similar but digital mammo was more accurate in women under 50 – more radiographically dense breasts

Benefits of Digital Mammograms over Film mammograms

  • Lower average radiation dose.  They use 25% less radiation than film mammograms because smaller areas of the breast are imaged in each view.
  • More accurate readings in patients under 50 and those with radiographically dense breasts.

Drawbacks of Digital Mammograms

Costs more

What is a normal white blood cell count

Normal WBC (White blood cells)

Normal WBC ranges from 3.5-10.5 billion cells/L or cells per mm2

Thus anything above 11 could be considered elevated.  But there are levels considered such as mildly elevated or severely elevated.

Other normal values for part of the CBC (complete blood count)

Normal value for hematocrit

Hct = 35-50%

Normal Value for platelet count

Platelets = 150-450 billion/L

What are the different types of Breast Cancer?

Different Types of Breast Cancer

Non-invasive Breast Cancer

  • Ductal Carcinoma In Situ (DCIS) – preinvasive
  • Lobular Carcinoma In Situ

Invasive Breast Cancer

  • Invasive Ductal Carcinoma = Infiltrating Ductal Carcinoma – Most common breast cancer accounting for 50-75% of all breast cancers.
  • Invasive Lobular Carcinoma
  • Tubular Carcinoma
  • Mucinous (colloid) Carcinoma
  • Papillary Carcinoma
  • Medullary Carcinoma

Special forms of Breast Cancer

  • Inflammatory Breast Cancer (IBC)
  • Pagets disease of the Breast – those who present with a mass at time of diagnosis most often have more advanced breast cancer.
  • Metaplastic Breast Cancer



What is the most common type of Breast Cancer?

What is the most common Breast Cancer?

Ductal Carcinoma is the most common type of breast cancer.  There are two types:  Ductal Carcinoma In Situ (DCIS)which is considered a pre-malignancy of the breast and there is Invasive Ductal Carcinoma of the breast.

The ducts refer to milk ducts.  This type of cancer comes from the lining of a milk duct within the breast.  These ducts carry milk from the lobules where the milk is made.



Lobular Carcinoma In Situ, a incidental finding, consider Tamoxifen

Lobular Carcinoma In Situ

  • Usually incidental finding at biopsy
  • Younger premenopausal women
  • 1% risk of breast cancer per year
  • The future cancer can appear in either breast
  • If surgery is to be considered, the procedure of choice is bilateral mastectomy
  • Tamoxifen can reduce future risk of breast cancer by 50%

Increased probability of developing a carcinoma of the breast

  • This can happen in 20-30 years after diagnosis of LCIS (Lobular carcinoma in situ)
  • 1% risk increase of breast cancer per year in someone diagnosed with LCIS
  • No role for sentinel lymph node biopsy.
  • Treatment for Lobular Carcinoma In Situ (LCIS)
  • Close observation
  • Consider repeat mammogram in 6 months.
  • Informed of increased risk of breast cancer
  • No role for re-excision, SLN or irradiation.
  • Tamoxifen should be considered with a nearly 50% reduction in cancer formation in women with LCIS
  • For patients who insist on a surgical operation – a bilateral total mastectomy would be the procedure of choice because the risk of breast cancer is equal on both sides.
Tamoxifen mechanism of action.  Breast Cancer.
Tamoxifen mechanism

Advanced Infiltrating Ductal Carcinoma of the Breast

Locally Advanced Breast Cancer

10-30% of all primary breast cancers are diagnosed as locally advanced which prohibits breast conservation methods.  Stage III breast cancer is considered locally advanced.

Stage (grade) III Breast Cancer

An example would be a 6 cm breast mass diagnosed as infiltrating ductal carcinoma with spread to lymph nodes.  (T3 N1 Mx)

Other examples:

  • Tumor is larger than 5 cm with positive spread to axillary lymph nodes, but the lymph nodes aren’t attached to each other.  Stage IIIA.
  • Tumor is smaller than 5 cm with positive spread of lymph nodes growing into each other and surrounding tissue.  Stage IIIA.
  • Tumor is smaller than 5 cm, but the cancer has spread to lymph nodes above the collar bone.  Stage IIIB.
  • Inflammatory breast cancer is considered stage IIIB breast cancer.

Treatment of locally advanced breast cancer

Neoadjuvant therapy is a historical term.  Now called primary systemic therapy.  This is giving chemotherapy prior to operation.

Workup includes bone scan and abdominal CT prior to initiating chemotherapy.

Sentinel Lymph Node Surgery for Breast Cancer

Sentinel Lymph Node Dissection

  • First applied to breast cancer patients in 1991
  • first widespread use was for cutaneous melanoma
  • SLN decreases axillary morbidity.  Lymphedema is 1%-3%.  Decreased risk of parethesias.
  • The axillary recurrence rate was 0% with the negative sentinel lymph node group in one of the studies.
  • Frozen section examinations of the lymph nodes in the OR has a false negative rate of 10-15%.

Axillary Lymph Node status in Breast Cancer

  • Axillary lymph node status is the strongest prognostic indicator for breast cancer patients.
  • Axillary lymph node status most likely doesn’t need identification with DCIS (Ductal Carcinoma In Situ) disease.  There is less than a 1% chance of a positive lymph node status in the axilla with DCIS.
  • If there is a suspicion of an invasive component of breast cancer than consider sentinel lymph node procedure for diagnosing Axillary lymph node status.


Gynecomastia of the male breast

  • Gynecomastia is the benign hypertrophy of the male breast
  • asymptomatic or painful
  • unilateral or bilateral
  • just below the areolar region

Age distribution

3 peaks

  • transiently during neonatal period due to motherly estrogrens
  • puberty
  • adulthood

Causes of Gynecomastia

  • Illicit drug use, especially marijuana
  • Renal, Liver disease
  • Neoplasms
  • Hyperparathyroidism

Gynecomastia’s association with cancer

  • Testicular cancer
  • BRCA2 genetic multation may lead to male breast cancer

Diagnostics for Gynecomastia

For the older patient with no obvious etiology consider:

  • LFT
  • BUN
  • Creatinine
  • Thyroid hormone
  • Prolactin level
  • Testosterone
  • Bilateral mammorgram
  • FNA (fine needle aspiration) can be diagnostic or core needle biopsy, usually not a need for excisional biopsy.  Thus an excisional biopsy wouldn’t be a first line diagnostic tool in gynecomastia.

Paget’s Disease of the Breast

Paget’s Disease of the Breast

  • Diagnosis can be confirmed with a punch biopsy the nipple areolar complex.
  • Classically present with eczematous changes of the nipple which can progress to bleeding and ulceration.
  • More than 90% of patients have underlying carcinoma (in situ or invasive)
  • Cancer involving skin and nipple.
  • Treatment: mastectomy traditionally.  But could be nipple areolar excision with central lumpectomy with radiation therapy (breast conservation therapy) – similar results.
  • 50% of patients with Paget’s disease will present with palpable mass.
  • May be a role for MRI – deeper breast tissue disease may be missed radiographically and MRI can help detect.

What is breast conservation therapy?

A lesser amount of surgery than mastectomy.  Lumpectomy

Paget’s diease of the breast is also known as?

  • Paget’s disease of the nipple
  • Mammary paget disease


Nipple Discharge

Unilateral Nipple Discharge – spontaneous and persistent

  • Associated with a increased risk of carcinoma.
  • Can be clear, serous, serosanguinous or bloody
  • Nipple aspirate cytology isn’t popular as a diagnostic
  • Most common etiologies are intraductal papilloma and mammary duct ectasia
  • Doesn’t matter what’s found on radiology, open surgical biopsy is preferred
  • Directed duct excision plus excision of the surround area after ductogram.  Rule out papillary carcinoma of the breast.
  • Central duct excision (non-directed duct excision) is not as accurate.
  • If the lesion is deep, radiologist may help with needle localization with excision
  • DCIS = Ductal Carcinoma In Situ is the malignancy most commolny found in intraductal lesions with pathological nipple discharge.
  • Papillary carcinoma of the breast is a subset of DCIS.

Intraductal Papilloma

  • Benign
  • Most common cause of bloody nipple discharge
  • A single intraductal papilloma doesn’t increase the risk of breast cancer, but multiple papillomas does increase the risk slightly.

Mammary duct ectasia

  • Milk ducts beneath the nipple become dilated, thickened, and filled with fluid and thus have some discharge
  • Benign
  • Often improves without treatment.