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 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.
What is an initial step to determine the tissue diagnosis of breast cancer?
Core needle biopsy (or fine needle aspiration) is preferred over excisional biopsy which may interfere with subsequent sentinel lymph node biopsy and may compromise the opportunity for induction chemotherapy.
Core needle biopsy can be done at any point during pregnancy.
10% of women under age 40 who develop breast cancer will be pregnant
Gravida is the number of pregnancies.
Para is the number that led to birth.
For example Gravida 3, Para 2 means that the patient has been pregnant 3 times and give birth 2 times. It might mean that the patient is currently pregnant.
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
- colon cancer
BRCA2 mutations may have additional risk of these cancers
- bile duct
Future research will discover more differences between BRCA1 and BRCA2.
More info about BRCA mutations and Angelina Jolie
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
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.
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
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
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 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.
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)
- 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.
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
- transiently during neonatal period due to motherly estrogrens
Causes of Gynecomastia
- Illicit drug use, especially marijuana
- Renal, Liver disease
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:
- Thyroid hormone
- Prolactin level
- FSAH, LH, DHEA
- 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
- 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