Breast short note by S.Wichien (SNG KKU) Embryology Anatomy 5th,6th wk -15-20 lobes -2 ventral bands of ectoderm -Cooper suspensory lig ament (mammary ridge/milk line) -2nd/3rd rib--6th/7th rib (axilla to inguinal area) -lateral sternum--ant axillary line Polymastia -retromammary bursa -accessory breast -axillary tail of Spence Polythelia -upper outer--greater volume -accessory nipple -lactiferous sinus--stratified sq.epi -<1% of infant major duct--2 cuboidal cell -asso urinary/CVT abnormality minor duct--single columnar/cuboid Inverted nipple Nipple-areola complex -failure of pit to elevate above skin -pigment -4% infant -puberty--darker,elevate configuration Witch milk -sebaseous gl,sweat gl,accessory gl -maternal H.via placenta -smooth m--cir/long--erection Amastia -arrest milk line develop Alveolar epithelium -- 2 products Poland synd 1.prot.component of milk -hypoplasia/absence of breast -merocrine secretion -rib/costal cartilage defect -in endoplasmic reticulum -hypoplasia of subcu of chest wall 2.lipid component of milk -brachysyndactyly -apocrine secretion Symmastia -in cytoplasm -rare anomaly colostrum -webbing between breast across -first few day midline -low lipid--hi Ab(lympho,plasma cell) Supernumerary breast -along milkline Blood supply -common btw nipple and symphysis Artery -accessory axilla breast -perforating br of int mam.a. -lateral br of post ICS a. -br from axillary a. :highest thoracic :lateral thoracic :pectoral br of thoraco-acroomial a Vein -perforating br of int mam.v. -perforating br of post ICS v. -tributaries of axillary v. °Batson vertebral v.plexus :root of bone metas Nerve -3-6 ICS n. -cervical plexus--ant br of supraclavi n -intercostobrachial n--lat.br of 2 ICS n Breast short note by S.Wichien (SNG KKU) Lymph node Investigation Internal mammary node 25% MMG Axillary node 75% -detect early breast ca Level 1 -true positive 90% -axillary v.gr -screen at 40 yr -ext.mammary gr--ant -scapular gr--post Ultrasound Level 2 -in equivocal MMG finding ,cystic mass -central gr -uls guide bx -interpectoral gr--rotter Level 3 Ductogram -subclavicular gr--apical gr -nipple discharge -duct dilator-->small canular Skip metastasis -0.1-0.2 ml contrast is injected -25-29%--level 2,3 -filling defect-->intraductal papilloma -3%--level 3 **SLNB can miss 3% MRI -hi-sen, low spec than MRM Node metastasis 1.tumor cluster 1.ALN+ve, unknown 1° -isolated tumor cell <0.2cm 2.promblematic MMG 2.micrometas 3.rupture silicone -0.2-2 cm 3.macrometas ->2cm Nonpalpable lesion Bx -u/s localization--have mass Physiology -stereotactic technic --no mass Estrogen--duct development Progesterone--lobular development Palpable lesion Bx Prolactin--lactogenesis -FNA bx Pregnancy -CNB -inc ovarian/placental E&P -duct&lobular epi proliferate Indice of -prominent Montgomery gland Poliferation PCNA Milk production&relaese Apoptosis Bcl2 protein -stimulate nerve ending (NAC) bax:bcl2 ratio -prolactin secretion (dec ratio-poor prog) -oxytocin--contract myoepithelium Angiogenesis VGEF GF EGF ,HER2/neu Steroid H.R EP ,PR Dx study Hx,PE ca stage 1-4 CBC,LFT CXR,MMG ER,PR HER-2/neu Bone scan ca stage 2-4 U/s or CT abdo Breast short note by S.Wichien (SNG KKU) Gynecomastia ANDI -Male breast enlarge,elongate,inc epi Abberrant of Normal Development -often unilateral and Involution -12-15 yr -at least 2 cm in diameter Early reproductive yr (15-25yr) -usually not predispose ca Normal 1.lobular development Physiologic 2.stromal development 1.neonate 3.nipple eversion 2.adolescent Disorder 3.senescence--dec T,relative inc E 1.fibroadenoma (<3cm) 2.adolescent hypertrophy Klinefelter synd (XXY) 3.nipple inversion -hypoandrogenic state Disease -inc risk of ca breast 1.giant fibroadenoma (>3cm) 2.gigantomastia Classification 3.subareolar absecss gr1-mild enlarge,wo skin redundancy Mammary duct fistula gr2a-mod enlarge,wo skin redundancy gr2b-mod enlarge,w skin redundancy Later reproductive yr (25-40yr) gr3-mark enlarge,as female breast Normal 1.cyclic change of menstruation Cause 2.epi hyperplasia of preg Estrogen excess Disorder 1.testicular tumor 1.cyclic mastalgia and nodularity -germ cell tumor--seminoma 2.bloody nipple discharge -gonodal tumor--leydig,sertoli cell Disease 2.non testicular tumor 1.incapacitating mastalgia -adrenal cortical tumor 2.- -lung ca -hepatoma Involution 3.non alc/alc cirrhosis Normal 1.lobular involution Androgen deficiency 2.duct involution--dilatation/sclerosis 1.senescene 3.epi turnover 2.hypogonadism Disorder 1°testicular failure--klinefelter synd 1.macrocyst/sclerosing lesion 2°testicular failure 2.duct ectasia/nipple retraction :trauma,orchitis,cryptorchidism,XRT 3.epi hyperplasia Tx Disease -add testosterone 1.- 2.periductal mastitis Drugs 3.epi hyperplasia w atypia reserpine,theophylline verapamil TCA,furosemide Tx -stop drugs Idiopathic -tamoxifen 40 mg/d 1-4 m Breast short note by S.Wichien (SNG KKU) Benign breast disease Benign breast Tx 1.Non-proiferative disorder cyst ¤no inc risk ca -cyst aspiration -fibrocystic disease (cyst & apocrine metaplasia) Fibrocystic dz -duct ectasia -reassure/symp Tx -mild ductal epi hyperplasia -danazol,nsaid,tamoxifen,bromocrip -calcification -fibroadenoma and related lesion fibroadenoma giant fibroadenoma >5cm 2.proliferative disorder wo atypia -should r/o phyllodes tumor ¤no inc risk ca Sx I/C -sclerosing adenosis ->40yr -radial & complex sclerosing lesion -rapid growth>20% -ductal epi hyperplasia ->5cm -intraductal papilloma sclerosing disorder 3.atypical proliferative lesion -excision bx are needed to r/o ca ¤inc risk ca 4x -stereotactic guide bx -atypical lobular hyperplasia -atypical ductal hyperplasia periductal mastitis -ATB--metro+cloxa -abscess--drainage Recurrent abscess w fistula Fistulectomy Total d excision -small abscess large>50%areolar -same lesion different lesion -no N.inversion mark N.inversion -young pt old pt -no d/c pus d/c -no fistulec recur after fistulec nipple inversion -shortening subareolar duct -sx correction--cosmetic reason -c/p--nipple sensation/necrosis, fibrosis-->nipple retraction intraductal papilloma -microdochectomy Breast short note by S.Wichien (SNG KKU) Infection LCIS & DCIS 1.bact infection -Staph--localized,deep abscess LCIS DCIS Strep--diffuse superficial involve 1. age 44-47 54-58 yr -breast feeding 2.i ncidence 2-5 5-10% -subareolar,periduct,retromam space 3.c linical no mass,pain,dc Tx 4.MMG no microcalci -local w care--warm comp 5.p remen o 2/3 1/3 -iv ATB 6.s ynchro 5 2-46% -I&D--should Bx abscess cavity 7. multicentric 60-90 40-80% 8. bilat 50-70 10-20% Zuska disease 9. axilla metas 1 1-2% (recurrent periductal mastitis) 10.male - 5% -recurrent retroarolar infect/abscess 11. subsequent ca Tx interval to dx 15-20 5-10 yr -ATB+I&D histo ductal ductal incidence 25-35% 25-70% 2.mycotic infection laterality bilat ipsilat -blastomycosis or sporotrichosis -intra oral fungi--sucking infant LCIS -abscess close to NAC -only in female breast Tx -Terminal Duct Lobular Unit-- TDLU -antifungal agent -distort/distend TDLU -+/-drainage -maintain normal N:C ratio -calcify in adjacent tissue 3.hiradenitis supparativa -incidental finding -axilla--sebaceous gl NAC--Montgoney gl DCIS -mimic chronic inflam,paget,ca -can seen in male breast ca -proliferation of epi in duct 4.mondor s dz -papillary growth -variant of thrombophlebritis -intraductal ca -superficial v of ant chest wall 1.cribiform pattern -lateral thoracic v,thoracoepigastric v 2.solid growth pattern superficial epigastric v 3.comedo growth pattern -tender,cord like structure -benign, self limited dz--4-6 wk Classification of DCIS Tx Histo nu.gr necrosis DCIS grade -anti-inflam comedo hi extensive high -warm compression IM IM focal/no IM -restrict of motion of ipsilat ext noncomedo low absent low -braissiere support -not improve-->excision ¤IM--intermediate Breast short note by S.Wichien (SNG KKU) Ca breast 2.invasive ductal ca 1.sporadic 65-75% 2.1 adenoca c productive fibrosis 2.familial 20-30% (scirrhous,simple,NST)--80% 3.hereditary 5-10% -60% axillary LN metas BRCA1 45% -perimenopausal,menopause BRCA2 35% -poor margin p53(Li fraumeni) 1% -solitary,firm mass STK11/LKB1(Peutz J egh ) <1% -cut surface--stellate,chalky white or PTEN(cowden) <1% yellow streak into surrounding tissue 2.2 medullary ca--4% BRCA1 BRCA2 -special type 1.chro 17q21 13q12 -BRCA-1 hereditary breast ca 2.fxn Tumor suppression -soft,hemorhage DNA damage repair -often deep in breast 3.risk ca 60-80% -50%asso DCIS 4.age young 50 yr -5yr better than NST,invasive lobular 5.fam hx 52% 32% Microscopic 6.ovary ca 80% 20% -dense lymphoreticular infiltrate 7.male <20% 76% lymp/plasma cell predominate 8.ca prostate,colon,pancreas -poorly diff,active mitosis 9.diff poorly diff well diff -sheet like growth pattern 10.HR -ve +ve 2.3 mucinous (colloid)--2% 11.bilat yes yes -elderly -bulky tumor Hereditary risk of ca breast -extracellular pool of mucin ->=2 fam hx of ca breast/ovary -glistening and gelatinous -ca breast < 50yr -firm consistency -ca breast+ovary in same pt -5yr--73%, 10yr--59% -male breast 2.4 papillary--2% -small Cancer prevention for BRCA mutation -fibrovascular stalk 1.prophylactic mastectomy & recons -multilayer epithelium 2.prophylactic oophorectomy & HRT -prognosis as mucinous 3.intensive survei for ca breast&ovary 2.5 tubular--2% 4.chemoprevention -perimenopausal,menopause Screening recommendation -tubular arranged -early screen at 25 yr -long term survival approach 100% -clinical breast exam q 6 m -MMG q 12 m 3.invasive lobular ca--10% -TVS, ca-125 q 1yr -histo--small cell c round nuclei, scant cytoplasm