7. Breast disorders and breast cancer *

firstaid pg 667

cooper's ligaments

suspensory ligaments; fibrous bands extending from the inner breast surface to the chest wall muscles

-retractions in cancer

axillary nodes (75%)

• _{^{Especially from lateral quadrants}}

primary lymphatic drainage of breasts

_{Internal mammary (parasternal) nodes}

• _{^{Especially medial breast}}

• _{^{Can communicate with the contralateral breast}}

_lesser:

• _{Supraclavicular nodes}

• _{^{posterior intercostal nodes}}

secondary lymphatic drainage of the breasts

Breast → pectoral (anterior) axillary nodes → central nodes → apical nodes → subclavian lymphatic trunk

general flow of lymphatics from the breast

upper outer quadrant

(more tissue +axillary drainage)

• Most common first site of breast cancer lymphatic metastasis = axillary nodes, particularly the sentinel lymph node.

^{Lateral breast → Axillary
Medial breast → Internal mammary/parasternal}

breast quadrant with the highest incidence of cancer

Estrogen

• _{binds estrogen receptors (ER) in breast tissue}

• _{Activates gene transcription and growth-factor signaling}

• _{→ Ductal epithelial proliferation}

• _{→ Elongation + branching of ducts}

• _{Also promotes stromal growth and fat deposition}

hormone promoting ductal growth?

Progesterone = Breast Growth

• _{Binds progesterone receptors in breast tissue}

• _{→ proliferation of lobular/alveolar epithelial cells}

• _{→ formation and maturation of lobules and alveoli}

• _{Prepares the breast for milk secretion during pregnancy}

• _{Works synergistically with estrogen}

hormone promoting lobular & alveolar development?

Prolactin → milk production

Oxytocin → milk ejection

hormones promoting milk production and ejection

stage II

tanner stage of breast budding

stage V

tanner stage of mature breast

Lobular hypertrophy

Increased vascularity

breast changes associated with pregnancy and lactation

↑ estrogen / ↓ androgen

hormone imbalance associated with gynecomastia

Hard, irregular, non-mobile mass

Skin dimpling, nipple retraction

Possible lymphadenopathy

physical exam findings associated with breast cancer

Young women (<30)

Mobile, rubbery, well-circumscribed

physical exam findings associated with fibroadenoma

breast cyst

Fluctuant, may be painful

Often cyclic

fibrocystic changes

Bilateral, cyclic pain

"Lumpy" breasts

bloody nipple discharge

physical exam finding associated with intraductal papilloma

core needle biopsy

preferred breast biopsy technique

Cyst vs solid mass

Young women (<30)

best uses of breast ultrasound

High-risk screening (e.g., BRCA)

Evaluating extent of cancer

best uses for breast MRI

Start mammography at age 40

Every 1–2 years

breast cancer screening recommendations for average risk pts

Start earlier (~age 30)

Annual MRI + mammogram

breast cancer screening plan for high risk patients

papilloma until proven otherwise

bloody nipple discharge =

BRCA1 or BRCA2 mutation

Strong family history of breast/ovarian/pancreatic/prostate cancer

Prior chest radiation at a young age

Certain hereditary cancer syndromes

Atypical hyperplasia / LCIS

describe who is considered "high risk" breast patients

Gail model

A breast cancer risk prediction tool used mainly in primary care to estimate:

5-year risk

Lifetime risk

BRCA1

high risk breast and ovarian cancer tumor marker

more often associated with triple-negative breast cancer

BRCA2

high risk breast cancer tumor marker

also ovarian, pancreatic, prostate, male breast cancer

BRCA1

tumor marker more often associated with triple negative breast cancer

TP53

gene associated with Li-Fraumeni

observation if classic and stable

excision if large, symptomatic, growing, or uncertain diagnosis

treatment of fibroadenoma

reassurance

supportive bra

analgesics

reduce symptom triggers if helpful

treatments for fibrocystic changes of breast

fat necrosis of breast

Often after trauma or surgery

Can mimic cancer clinically and on imaging

Diagnosis often requires imaging ± biopsy

localized

reproducible with palpation or movement

musculoskeletal

costochondritis, muscle strain, trauma, rib pain

define presentation of chest wall pain (not breast pain)

spontaneous

unilateral

from a single duct

bloody or serous/clear

signs of pathologic nipple discharge

Intraductal papilloma

Duct ectasia

Carcinoma

concering causes of nipple discharge

Tumor (size)

Nodes

Metastasis

components of TNM staging

invasive ductal carcinoma

most common invasive breast cancer

invasive lobular carcinoma

Invasive carcinoma that characteristically grows in a single-file pattern

ductal carcinoma in situ

Noninvasive

Often associated with microcalcifications

lobular carcinoma in situ

Marker of increased bilateral breast cancer risk

Not a true invasive cancer

inflammatory breast cancer

Peau d'orange, erythema, edema

Aggressive

paget disease of breast

Eczematous nipple changes

Often associated with underlying malignancy

lumpectomy + radiation

breast cancer therapy with the most conservation

mastectomy

Removal of the breast, with variations in skin/nipple preservation depending on case.

Implant-based

Autologous tissue flap

options for post-mastectomy reconstruction

ER+

PR+

HER2-

Lower proliferation

tumor markers of luminal A breast cancer

luminal A

breast cancer type with the best prognosis

ER+

lower PR and/or higher proliferation

may be HER2+ or HER2-

More aggressive than luminal A

tumor markers of luminal B breast cancer

Endocrine therapy helps

tamoxifen

aromatase inhibitors in appropriate patients

treatment recommendations for ER/PR positive cancers

trastuzumab-based regimens

treatment of HER2 positive cancer

No endocrine or HER2 target

chemotherapy often central

treatment of triple negative breast cancer

60%

life time risk of breast cancer in BRCA women

tamoxifen, raloxifene, or, in some settings, aromatase inhibitors

meds used as chemoprevention in BRCA patients

adjuvant chemotherapy

treatment given after surgery to reduce recurrence risk

adjuvant radiation therapy

typically indicated after breast-conserving surgery

excision of the involved duct/fistula tract

definitive management of chronic subareolar breast abscesses

paget disease of the breast

rare breast cancer involving the nipple and usually the areola, accounting for about 1%–3% of breast cancers. It often presents with itching, erythema, crusting, scaling, thickening, nipple flattening, or bloody/yellow discharge, and it can mimic eczema

older age, chest radiation, family history, BRCA1/2 mutations, Klinefelter syndrome, cirrhosis, and testicular disorders

risk factors for breast cancer in men

invasive, ductal in origin

more likely breast cancers in men