Breast Disorders

Wirsma Arif Harahap

Surgical Oncologist
Surgery Department
• Inflamation

• Neoplasm

• Congenital

• Metabolic

• Trauma
Breast Development
• Contains mainly fat
tissue, connective
tissue and glands
• 15-25 ducts
• Breast tissue
extends into axilla
(“tail”)
• Smallest, day 4-7
Quadrants
• Breast is divided into
quadrants
• Upper-Outer
quadrant has the
greatest mass
• UOQ is the site of
about half of all
breast cancers
Supernumerary Breasts
• Relatively common
• Found along “milk
line”
• Most identified
during
pregnancy/lactation
• Most common in
axilla
• Not dangerous
Supernumerary Nipples
• More common than
supernumerary
breasts
• Found along milk
line
• May darken during
pregnancy
• Not dangerous
Inverted Nipples
• Often will evert with
stimulation
• Mostly a cosmetic
issue
• Successful
breastfeeding is
usually possible.
Adolescent Breast Problems
• Assymetric growth is the rule
rather than the exception.
• Mammary hypertrophy:
Postpone surgical intervention
until all growth has occurred
• Breast masses are ~100%
benign and surgery or FNA is
almost never warranted
(disturbs breast architecture and
may be disfiguring
 Pregnancy Changes

• 1st TM: Tender breasts and nipples

• 2nd TM: Non-tender breasts enlarge
• 2nd-3rd TM: Steady darkening of nipples
and prominent Montgomery’s glands
Puerperal Mastitis
• Rapid onset of red,
hot, swollen, tender
breast
• High fever
• Prompt treatment
(Amox, Diclox,
Erythromycin,
Azithromycin
• Abscess needs
drainage
• Keep breast-feeding
Microbiology
 Microbiology
• Detection of pathogens difficult
– Usually nasal/skin flora
– Difficult to avoid contamination
• Milk culture
– Encouraged in hospital acquired, recurrent
mastitis, or no response in 2 days
 Microbiology
• Staph Aureus
• Coag neg staph
• Also, Group A and B βhemolytic Strep, E
Coli, H. flu
• MRSA
• Fungal infections
• TB where endemic – 1% of cases
 Fungal infections
• Based on case reports that anti-fungal cream
improves sx
• Case reports of cyptococcal infection
• Most common: Candida Albicans
– Genital tract  Newborn oral colonization
• May lead to nipple fissure
• Thought to be associated with deep, shooting
pains and nipple discomfort
• Most commonly treated with fluconozole to ♀,
oral nystatin to infant
Breast abscess
Profilaksis Mastitis
 Nipple Laceration

• Keep clean and dry.

• Stop breastfeeding that side and allow to heal
• Antibiotics usually not necessary
Cyclic Breast Pain
• Worst just before menses
• Thick, tender, nodular
breasts
• Not dangerous but
annoying
• Rx: OCPs (cyclic or
continuous)
• Rx: Danazol (extreme
cases)
• Reduce caffeine? Vitamin
E?
Non-Cyclic Breast Pain
• Often due to trauma
(breast or chest wall)
• May be due to muscle
strain
• May be due to increased
levels of estrogen
• Usually not due to
cancer
• Examine and refer if
cause is not obvious.
Nipple Discharge
• Normal nipple discharge
is clear, milky or green-
tinged.
• If bloody, needs surgical
evaluation
• If it stains the inside of
the bra each day, that is
galactorrhea and will
need thyroid and
pituitary evaluation.
Fat Necrosis
• Tender, thickened,
bruised area of breast
• Follows trauma
• Benign
• Resolves spontaneously
over weeks to months
• Atypical cases should
have FNA
Breast Cyst
• Smooth, unilateral mass
• Feels like a cyst
• Infrequently associated
with malignancy
• Aspirate
• Watch for reforming of
cyst
• Recurring cysts are
more worrisome
Paget’s Disease
• Crusty, flaking
lesion
• Gradual onset over
months or years
• Associated with
underlying breast
malignancy
• Diagnosis
confirmed by
needle biopsy
Breast Mass
• Dominant mass
• Unilateral
• Persists through the
menstrual cycle
• Usually biopsied
(FNA or excisional)
• Can wait weeks but
not months
Fibroadenoma
• Common
• Benign
• Solid, rubbery, non-tender
• Round or oval
• Rarely grow > 2-3 cm
• FNA or excisional Bx
• Observe in adolescents
Breast Cancer
• 30% of all cancers in
women
• Treatment is
successful in 3/4
• Rare before age 25
• Steadily increasing
frequency with
increasing age
• Affects 1/9 women
reaching age 90.
IBC-patient
Clinical Presentations of IBC
 Latency Period, 20 years or more

Unspecialized Initiated Benign Malignant

Cell Cell Tumor Tumor

Initiation Promotion Progression

•Mutation •Proliferation •Mutation
•Cancer Gene •Independence •Invade & Spread

Stages of Cancer Formation

 TYPE OF BREAST CANCER

Epitelial : Insitu : DCIS, LCIS

Invasive : Carsinoma

Non Epitelial : Sarcoma

Limfoma

Mixed

Metastasis
STAGING

TNM
 RISK FACTORS

• Uncontrollable risk factors

• Controllable risk factors

 UNCONTROLLABLE RISK
FACTORS
• Being female
• Age
• Mutations of Breast cancer genes(BRCA
1 and BRCA 2)
• History of previous breast biopsy which
showed precancerous condition
• Gynecological history
 CONTROLLABLE RISK
FACTORS
• Obesity

• Use of oral contraceptives for five years

or longer or hormone replacement
therapy

• Having 1st child after 30

• More than one alcoholic drink a day

EAT HEALTHY
EXERCISE
Early detection is the best
protection
 EARLY DETECTION

1. Clinical Breast Examination

2. Mammogram
3. Monthly Breast Self Examination (BSE)
CLINICAL BREAST
EXAMINATION
 Clinical Breast Examination (CBE)

Age Frequency of CBE

20 – 39 Every 3 years
40 Every Year
 SELF BREAST
EXAMINATION

• Once every month starting at the

age of 20
BREAST SELF EXAMINATION

There are two parts to the BSE

–Looking
–Feeling
 Looking
Monthly BSE in Mirror

• Place arms at sides

LOOKING IN THE MIRROR
Lump

• Any new lump or

hard knot found in
the breast or
armpit.
• Any new lump or
thickening that
does not shrink or
lessen after your
next period.
Change in Skin Color, Size or Texture

• Any change in
size, shape or
symmetry of your
breast
• Any thickening or
swelling of the
breast
Skin Dimpling
• Any dimpling,
puckering or
indention in the
breast
• Dimpling, skin
irritation or other
change in the
breast skin or
nipple
Changes in Nipple

• Redness or scaliness
of the nipple or breast
skin
• Nipple tenderness or
pain
• Nipple retraction;
turning or drawing
inward or pointing in
a new direction
Nipple Discharge
• Any fluid coming
from your nipples
other than breast
milk, particularly if
the discharge is
bloody, clear and
sticky, dark or
occurs without
squeezing your
nipple
 Feeling

• Examine each breast separately

• Use pads of fingers not the tips

• Examine the armpits

Feeling
Finger Use
Use the pads of your
middle three fingers
to feel the texture of
your breast.

Your finger pads are

the top third of each
finger, not the tips.
FEELING
Patterns
SCREENING MAMMOGRAM

• X ray picture of breast performed in a

woman without any breast complaints
MAMMOGRAM TECHNIC
 Mammogram

Age Frequency of
Mammogram
40 1-2 year
50 Every year
<49 with family Consult health care providers
hx of breast about risks
cancer
MAMMOGRAHY RESULTS
ULTRASOUND
ULTRASOUND
BIOPSY TECHNIC
 BIOPSY RESULTS

• 80% of all breast biopsies turn out to be

benign
 WHAT IF IT IS CANCER?
• It is tough to prepare for the “C” word

• But remember that it is not a death

sentence

• With early diagnosis women’s chances

of surviving are very good
 TREATMENT OPTIONS
• Depend on
– Size of the tumor

– Invasive or in situ

– Lymph node status

– Whether it has spread to other parts of

the body
 TREATMENT

• Surgery

• Radiation Therapy

• Chemotherapy

• Hormonal Therapy
 SURGERY

• Breast conservation

• Mastectomy
 SURGERY
• Lumpectomy
 SURGERY

• Mastectomy
EVALUATION OF LYMPH
NODES
RECONSTRUCTION
RECONSTRUCTION
 RADIATION THERAPY
• Adjuvant

• High energy rays used to kill cancer

cells

• Usually effective in killing fast

growing cells such as breast cancer
cells
RADIATION THERAPY
 CHEMOTHERAPY
• Anticancer drug

• In early breast cancer after surgery to

reduce the risk of recurrence

• Large and locally advanced cancer to

reduce the size prior to surgery

• In metastatic cancer to reduce cancer

that has spread to relieve symptoms and
prolong life
 HORMONAL THERAPY

• Hormones in the blood stream can

attach to cancer cells and promote their
growth

• Hormonal therapy blocks the receptor or

production of hormones
 PROGNOSIS
• Early Breast Cancer ( Stage 1)

• 10 year survival - over 90%

• Advanced Breast Cancer ( Stage IV)

• 10 year survival - less than 10%

Though Early Detection and
Improved Treatments more
Women Than ever are
Surviving Breast Cancer
Thank You