Fibrocystic breasts

Fibrocystic breasts are made of tissue that feels bumpy and nodular in texture.  It is a relatively common process.  More than 50% of women experience fibrocystic breast changes during their lives.  It used to be called Fibrocystic Breast Disease.  Now it’s more common to call it Fibrocystic Breast Changes – which are considered normal changes.  Symptoms may be pain and lumpiness and can be worse just before menstruation.

Treatment includes limiting caffeine, decreasing fat in the diet, and consider evening primrose oil which is a form of linoleic acid.

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.


Breast Masses in Children

Breast Masses in Children and Adolescence

Classification of the breast masses in children/adolescence

The process in parethesis below represents an example.

  • Physiological (Gynecomastia)
  • Inflammatory (Abscess)
  • Benign neoplastic (Fibroadenoma, Cystosarcoma phyllodes)
  • Primary malignant (Cystosarcoma phyllodes)
  • Secondary malignant (Lymphoma)

Neonatal breast nodules

Usually due to stimulation by maternal hormones

Cystosarcoma Phyllodes

  • Fibroadenomas and cystosarcoma phyllodes are the most common lesions of the breast in childhood.
  • Cystosarcoma phyllodes present as either benign or malignant but 95% in children are benign.

Best test for initial assessment in pediatric patients with breast mass?


Then what modality for diagnosis of the breast mass?

Fine needle aspiration.  FNA is preferred over core needle biopsy because of the possibility of deformity of the breast in the future with core needle biopsy.

What about excision biopsy in the pediatric breast?

Excisional biopsy should be avoided as an initial diagnostic procedure because the developing breast bud can be mistakenly removed, leading to deformity.

Pseudoangiomatous stromal hyperplasia

PASH = PseudoAngiomatous Stromal Hyperplasia

  • Presents as a distinct mass, area of thickening of breast tissue, or as an incidental finding
  • Biopsy is necessary to confirm diagnosis
  • Excision with negative margin (ie. 1 mm) is treatment – recurrence rate is low (7%) and no further treatment necessary
  • There are findings on mammogram and ultrasound by biopsy is needed for diagnosis.

Skin Sparing Mastectomy

What is skin sparing mastectomy?

Removal of breast tissue via a surgical technique which preserves as much of the breast skin as possible.  Skin sparking mastectomy can be done as a simple, total, or a modified radical mastectomy.  The goal is to preserve the skin needed for immediate reconstruction by a plastic surgeon.

What is removed during a skin sparing mastectomy?

Nipple, areola and the original biopsy scar is removed during a skin sparing mastectomy.

Who can have skin sparing mastectomy?

Most women can have skin-sparing mastectomies however, it’s mainly done with the plan of having immediate breast reconstruction with your plastic surgeon.

When is it not safe to have a skin sparing mastectomy?

When there is risk of having skin involvement with breast cancer (such as with inflammatory breast cancer.

Recurrence rates of skin sparing mastectomy vs. winder skin removal

For early breast cancer the local recurrence rate is from 0-7% which is similar to those with wider skin removal mastectomies.

What is inflammatory breast cancer?

Inflammatory breast cancer, or IBC, is considered the most deadly form of breast cancer.  While some IBC patients have a lump, the majority of patients do not have a lump in the breast.  The cancer cells are in the lymph vessels blocking normal flow of lymph fluid thus there is swelling and skin dimpling associated.  There may be flattening and turning inward of the nipple or crusted changes.  Itching might be a symptom on the skin as well.

What is the difference between simple and total mastectomy?

Simple and Total mastectomy are synonymous.  This procedure involves removing the entire breast tissue without touching the axillary contents.

What is a modified radical mastectomy?

The entire breast tissue is surgically removed along with the axillary contents.  The pectoral muscles are untouched.

What is Early Stage Breast Cancer

Early stage breast cancer is breast cancer which has not spread beyond the breast to nearby axillary lymph nodes.  Ductal carcinoma in-sity, stage I, IIA, IIB, and IIIA breast cancer are included as early stage breast cancer.  The five year overall survival for women with stage I breast cancer is around 88 percent.

Stage I breast cancer

Stage I breast cancer involves a tumor size less than 2 cm.  No outside spread of breast cancer

Stage II breast cancer

Stage II breast cancer has a tumor more advanced than stage 1.  It has one of the following characteristics

  • Tumor is 2-5 cm in diameter.  +/- spread to axillary lymph nodes.
  • Tumor is >5 cm.  No spread.  (Stage IIA)
  • Tumor is <2 cm.  Positive for spread to no more than 3 axillary lymph nodes.  (Stage IIB)
  • No tumor found in the breast.  Positive for spread to no more than 3 axillary lymph nodes.

Stage III breast cancer

Stage III breast cancer is known as locally or regionally advanced breast cancer.  Some 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.  Or tumor of anysize with fixation to skin or chest wall.
  • Inflammatory breast cancer is considered stage IIIB breast cancer.

Stage IV breast cancer = Metastatic breast cancer

Stage IV breast cancer is the most advanced form of breast cancer.  The cancer cells have spread to other areas of the body:   Lung, Liver, and Bone.

What is the T status for TNM staging of breast cancer?

T = tumor size.

  • T1 = less than 2 cm diameter for breast cancer
  • T2 = between 2-5cm

Smoking and flap necrosis with skin sparing mastectomies

Tissue flap necrosis is a possible complication related to a patient’s history of smoking as well as previous incisions for breast reduction.