به نام خالق هستی بخش

Breast Disease

Sima Zohari

BSc , MSN

Faculty Member of Shahid Beheshti MedicinUniversity

Breast Anatomy

• Breast contains 15-20 lobes

• Fat covers the lobes and shapes the breast

• Lobules fill each lobe

• Sacs at the end of

lobules produce milk

• Ducts deliver milk to the

nipple

Breast Clock and Quadrants

Breast Anatomy

• Four quadrants

• Parenchyma

– Alveoli Lobules Lobes

– Three tissue types

• Glandular epithelium

• Fibrous stroma and supporting structures

• Fat

– Cooper ligaments

• Fibrous continuations of the superficial fascia, which span the

parenchyma of the breast to the deep fascial layers

Breast Anatomy

• Nerves

– Long thoracic nerve

– Thoracodorsal nerve

– Medial pectoral nerve

– Lateral pectoral nerve

Breast Anatomy

• Vasculature

– Arterial supply

• Internal mammary artery(60%)

• Lateral thoracic artery(30%)

– Venous return

• Intercostals

• Axillary vein(primary)

• Internal mammary vein

– Lymphatics

Breast Anatomy

• Lymphatics

– Axillary chain

• Level 1 – lateral to pectoralis minor muscle

• Level 2 – along and under pectoralis minor

• Level 3 - medial to pectoralis minor

– Rotter’s nodes

• Between pectorial minor and major muscles

– Internal mammary chain (relatively minimal drainage)

• Parasternal

• medial

Regional Lymph Nodes for

Breast

• Infraclavicular (subclavicular) lymph nodes

– In the deltopectoral groove

• Supraclavicular lymph nodes

– Above the collarbone

Regional Lymph Nodes for

Breast

A: Pectoralis major

muscle

B: Axillary lymph nodes

level I

C: Axillary lymph nodes

level II

D: Axillary lymph nodes

level III

E: Supraclavicular lymph

nodes

F: Internal mammary

lymph nodes

Approach to Breast Problems

History

Age

Family history (Cancer)

Onset

Duration Discharge

Frequency

Lump , Nodules Trauma

Menstruation (menarche, menopause, contraceptives) Pain

Inspection

Symmetry

Skin / Nipple Change

Bulges / Retractions

Palpation

Breast

Axilla

Supraclavicular

Approach to Breast Problems

Breast Examination

Diagnostic Work Up

Ultrasound

Mammography

Biopsy

Cyst aspiration

MRI

• .

Classification Based On Histologic Types Non Proliferative Lesion

Simple Cyst

Complex cyst

Proliferative Lesions – Without Atypia

Ductal hyperplasia

Fibroadenoma

Intraductal papilloma

Sclerosing Adenoma

Radial Scars

Atypical Hyperplasia

Atypical ductal hyperplasia

Atypical lobular hyperplasia

Classification Based On Clinical Features

Mastalgia

Cyclic

Non Cyclic

Tumors and Masses

Nodularity or glandular

Cysts

Galactoceles

Fibroadenoma

Sclerosing Adenosis

Lipoma

Harmatoma

Diabetic Mastopathy

Cystosarcoma Phylloides

Nipple discharge

Galactorrhea

Abnormal nipple discharge

Breast infections and Inflammation

Intrinsic mastitis

Postpartum engorgement

Lactation mastitis

Lactation breast abscess

Chronic recurrent subareolar abscess

Acute mastitis associated with macrocystic breasts

Extrinsic infections

Mondor’s Disease

Hidradenitis suppurativa

Classification Based On Clinical Features

Benign Breast Disease

• Infectious and inflammatory

• Benign lesions

• Nipple Discharge

• Mastalgia

Infectious and Inflammatory Breast

Disease • Cellulitis, mastitis

– Usually associated with lactation

– Treat with 10-14 day course antibiotics to cover Staphylococcus and Streptococcus

• Abscess – Treated by surgical drainage

• Chronic subareolar abscess – Occurs at base of lactiferous duct, and squamous metaplasia of duct may

occur.

– Sinus tract to areola develops

– Treatment requires complete excision of sinus tract

– Recurrence is common

• Mondor’s disease – Phlebitis of the thoracoepigastric vein

– Palpable, visible, tender cord along upper quadrants

– Ultrasound may be helpful in confirming this diagnosis.

– Treatment self-limited, can use anti-inflammatories if necessary

Benign Lesions of the Breast

• Fibrocystic breasts – Broad spectrum of clinical and histologic findings

– Loose association of cyst formation, breast nodularity, stromal proliferation, and epithelial hyperplasia.

– Appears to represent an exaggerated response of breast stroma and epithelium to hormones and growth factors.

– Dense, firm breast tissue with palpable lumps and frequently gross cysts, commonly painful and tender to touch.

– No consistent association between fibrocystic complex and breast cancer.

Benign Lesions of the Breast

• Cysts – Fluid-filled, epithelium-lined cavities

– Influenced by ovarian hormones • Explains sudden appearance during the menstrual cycle, their rapid

growth, and their spontaneous regression with completion of the menses.

– Common after age 35, and rare before 25. Incidence declines after menopause.

– Three colors by needle aspiration • Simple cyst, clear or green fluid and is benign.

• Milk-filled cyst, called galactocele and is benign.

• Bloody cyst is a cause of concern for malignancy.

– Tx depends on whether the cyst completely resolves after aspiration

• Complete resolution, will follow up to ensure it does not recur.

• Incomplete resolution, Treat as breast mass and excise.Fluid-filled, epithelium-lined

Benign Lesions of the Breast

• Fibroadenoma – Well-defined, mobile benign tumor of breast

– Composed of both stromal and epithelial elements in the breast

– Common in younger women, and is most common tumor in women younger than age 30 years

– Can be diagnosed by FNA and followed if < 2-3 cm and age < 35

– Otherwise Dx by excision. At operation are well-encapsulated and detach easily.

• Phyllodes tumors (cystosarcoma phyllodes) – Giant fibroadenomas

– Rarely malignant

– Treat with wide local excision

Benign Lesions of the Breast

• Sclerosing adenosis – Proliferation of acini in the lobules, which may appear to have invaded

the surrounding breast stroma.

– Can simulate carcinoma both grossly and histologically.

• Epithelial and atypical hyperplasia – Involves ducts or lobules

– If greater than moderate hyperplasia then indicates higher risk of breast cancer

• Papilloma – Polyps of epithelium-lined breast ducts

– Located under the areola in most cases

– When under the nipple and areolar complex it often present with a bloody nipple discharge.

– Treatment is total excision through a circumareolar incision.

– Need to rule out invasive papillary carcinoma.

Benign Lesions of the Breast

• Mammary duct ectasia – Generally found in older women.

– Dilatation of the subareolar ducts can occur.

– A palpable retroareolar mass, nipple discharge, or retraction can be present.

– Tx involves excision of area.

• Fat necrosis – Associated with trauma or radiation therapy to breast.

– Can simulate cancer with mass or skin retraction.

– Bx is diagnostic and generally with lipid-laden macrophages, scar tissue, and chronic inflammatory cells.

Benign Breast Disease

• Nipple discharge – Pathologic nipple discharge is persistent and

spontaneous and is not associated with nursing. • Requires further evaluation

• Galactorrhea – Bilateral, milky discharge occurs

– Obtain prolactin levels, if highly elevated, suspect pituitary adenoma as one of causes.

• Bloody nipple discharge – Most common cause is intraductal papilloma

– Cancer present 10% of time.

– Cytologic exam on discharge

– Mammogram to rule out associated mass

– If drainage from isolated duct, then it should be excised.

Benign Breast Disease

• Mastalgia

– Cyclic pain

• Correlates with menstrual cycle.

• Can attempt to treat with danazol or bromocriptine

– Non-cyclic pain

• Drugs can be effective placebo

• NSAIDS may help

• Avoid caffeine and wear a supportive bra

– Cancer must be excluded through examination,

mammogram, and ultrasound if the pain is localized.

Evaluation & Management of Breast Pain

Mastalgia should be treated when:

It is severe enough to interfere with a woman’s life style

It occurs more than a few days every month.

History and Physical

Diagnostic work up

Mammogram

Micheal S sabel .Overview of benign breast disease. Uptodate 2008, November 14

Management of Breast Pain

Treatment Goals

Alleviate pain

Reduce or relieve irregularity

Rule out cancer of the breast

Management of Breast Pain

Diet and Lifestyle Modification

Elimination of Methylxanthines, Caffeine and

Chocolates

Reassurance

Supportive Bra

Low fat and high complex carbohydrate

Vitamin E supplementation

Evening Primrose oil

Micheal S sabel .Overview of benign breast disease. Uptodate 2008, November 14

Management of Breast Pain

Pharmacological Treatment NSAIDs

OCPs

Danazol 100- 400mg per day

75% of women with non cyclic pain will be symptom free

SE: Weight gain , menstrual irregularity , acne , hirsutism

Tamoxifen 10mg

Bromocriptine – prolactin antagonist

Surgery has no role in management of breast pain

Micheal S sabel .Overview of benign breast disease. Uptodate 2008, November 14

Evaluation & Management of Breast Pain

AAFP journal , April 15, 2000. Volume 61/ No. 8

Breast Masses

Normal glandular tissue of the breast is nodular

This is a general pattern or consistency of the breast

which include persistent lumpiness or nodularity which is

generally not abnormal when it is related to the

menstrual cycle.

Dominant masses are characterized by persistence

throughout the menstrual cycle

Cystic Breast Mass

Common cause of dominant breast mass

May occur at any age, but uncommon in post menopausal

women

Fluctuates with menstrual cycle

Well demarcated from the surrounding tissue

Characteristically firm and mobile

May be tender

Difficult to differentiate from solid mass

Breast Masses: Cysts

Micheal S sabel .Overview of benign breast disease. Uptodate 2008, November 14

Fibrocystic Breast Disease

Most common of all benign breast disease

Most common between ages 20- 50

50% of women with Fibrocystic changes have clinical

symptoms

53% have histologic changes

Believed to be associated the Imbalance of progesterone

and estrogen.

May present with bilateral cyclic pain, breast swelling,

palpable mass and heaviness

Breast Masses: Cysts

Fibrocystic Breast Disease

Physical Examination

Tenderness

Increased engorgement and more dense breast

Increased lumpiness / glandular

Occasional spontaneous nipple discharge

Micheal Sabel .Overview of benign breast disease. Uptodate 2008, November 14

Breast Cysts: Diagnostics

Mammogram

Cystic outline

No calcification

No increased density

Ultra Sonogram

Cyst

Fine Needle Aspiration

Outpatient procedure

Non bloody fluid

Cyst disappears

If bloody fluid, surgical

biopsy of cyst is required

Reexamination 4-6 weeks

after aspiration

Management of Breast Cysts

AAFP journal , April 15, 2000. Volume 61/ No. 8

Breast Masses

Breast Mass: Fibroadenomas

Simple: Second most common benign breast lesion

Benign solid tumors containing glandular as well as fibrous tissue . Usually

present as well defined, mobile mass

Commonly found in women between the ages of 15 and 35 years

Cause is unknown, thought to be due to hormonal influence

May increase in size during pregnancy or with estrogen therapy

Giant: Fibroadenomas over 10cm in size

Excision is recommended

Juvenile

Variant of fibroadenomas

Found in young women between the ages of 10 -18.

Vary in size from 5 - 20cm in diameter. Usually painless, solitary, unilateral

masses

Excision is recommended

Breast Mass: Fibroadenomas

(Cont’d)

Complex

Complex fibroadenomas contain other proliferative changes

such as sclerosing adenosis, duct epithelial Hyperplasia,

epithelial calcification.

Associated with slightly increased risk of cancer

Dupont, WD page, DL, parl, FF, et al. Long term risk cancer in women with fIbroadenoma. NEJM 1994;331:10

Carty, NJ, Carter, c, Rubin, C et al management of fibroadenoma of the breast. Annals of royal college of surgeon England 1995:77:127

Micheal S sabel .Overview of benign breast disease. Uptodate 2008, November 14

Phylloides Tumors:

Rapidly growing

One in four malignant

One in Ten Metastasize

Create bulky tumors that distort the breast

May ulcerate through the skin due to pressure necrosis

Treatment consists of wide excision unless metastasis has occurred

Fat Necrosis:

Rare

Secondary to trauma- often not remembered

Tender, ill defined mass

Occasionally skin retraction

Treat with excisional biopsy

Breast Mass

Breast Mass

Galactocele

Milk filled cyst from over distension of a lactiferous duct.

Presents as a firm non tender mass in the breast,

Commonly in upper quadrants beyond areola.

Diagnostic aspiration is often curative.

Duct ectasia:

Generally found in older women.

Dilatation of the subareolar ducts can occur.

A palpable retroareolar mass, nipple discharge,

or retraction can be present.

Tx involves excision of area

Nipple Discharge

Majority of causes are benign

Most common cause is lactational

Overstimulation also common

Prolactin secreting tumors

Hypothyroidism

Drugs

Intraductal and other carcinomas

Unilateral, spontaneous, bloody discharge is

suspicious

Nipple Discharge

Intraductal Papilloma

Benign growth within ductal system

Presents as bloody nipple discharge

Excision is the only way to differentiate from

carcinoma

Galactorrhea

Bilateral milky discharge

Obtain prolactin level, TSH level

Nipple Discharge

Good history

Prolactin & TSH levels

Mammogram

Decrease stimulation

Breast Inflammation &

Infections

Mastitis Most common in lactating female

Dry, cracked fissured areola/nipple complex provides portal

for infection

Usually caused by Staph/Strep organisms

Rule out malignancy

Treat with heat, continued breast feeding,

Antibiotics for 10-14 days to cover staph and strept infections

Breast Inflammation &

Infections Abscess

May present with breast swelling, tenderness and fever

On PE, breast is tender , warm and fluctuant, may also have

purulent discharge

Treated by surgical drainage

Breast Inflammation &

Infections Mondor’s Disease

Phlebitis of the thoracoepigastric and lateral thoracic vein

Palpable, visible, skin retraction over tender extending to

chest wall

Spontaneous or related to trauma

Ultrasound may be helpful in confirming this diagnosis.

Treatment self-limited, can use NSAIDs

Mammogram if over 35yo to r/o malignancy

Breast Inflammation &

Infections Chronic Subareolar Abscess

Occurs at base of lactiferous duct, and squamous

metaplasia of duct may occur.

Sinus tract to areola develops

Treatment requires complete excision of sinus tract

Recurrence is common

Fibroadenoma Discussion

Features – Usually younger women

– Usually solitary mass, occasionally multiple

– May increase with pregnancy or involute post-menopause

Pathology – Benign tumor

– Circumscribed rubbery mass

– Overgrown fibrous stroma compressing epithelium

– May have some increased risk of breast cancer long term especially if associated with proliferative breast pathology*

Malignant Diseases of the

Breast

Breast Cancer

• A woman has a 1 in 8 chance of developing breast cancer at some point in her life.

• Risk factors – Increased age, family history, History of breast, ovary, or endometrial

cancer, >30 age at first pregnancy, high socioeconomic status, nulliparity, early menarche, and late menopause

• Symptoms – Lumps

• Presenting symptom in 85% of patients with carcinoma

– Pain • Must completely evaluate to rule out carcinoma

– Metastatic disease • Axillary nodes

• Distant organ symptoms, such as neurological

– Asymptomatic • Why we advise yearly SBE and yearly mammogram after age 50

Malignant Diseases of the

Breast • Non-invasive breast cancers

– 10% of all types of breast cancer

– Good prognosis

– Ductal carcinoma in situ, lubular carcinoma in situ, and paget’s disease

• Invasive breast cancers – Favorable histologic types (85% 5-year survival rate)

• Tubular carcinoma (grade 1 intraductal), colloid or mucinous carcinoma, and papillary carcinoma

– Less favorable types

• Medullary cancer, invasive lobular cancer, and invasive ductal cancer

– Least favorable type

• Inflammatory breast cancer

Breast Cancer Location

Ductal Carcinoma in Situ

• Seen as microcalcifications on mammogram

• Confined to ductal cells.

• No invasion of the underlying basement membrane.

• Chance of recurrence 25-50% in 5 years, of these 50% will be invasive

• Tx – Mastectomy an option if there is a substantial risk of

local/regional recurrence

– Wide local excision and radiation reduce local recurrence to 2%

– Wide excision alone suitable if <25mm, favorable histology, and the margins are clear

– Node dissection not necessary (nodal disease < 1%)

Lobular Carcinoma in Situ

• Not detectable on mammography

– Most commonly found incidentally

• Risk of invasive breast cancer in 20 years is 15-

20% bilaterally

• Tx

– Careful follow-up

– Bilateral masectomy may be considered if other risk

factors are present such as family history or prior

breast cancer, and also dependent on patient

preference.

Invasive Breast Cancers

• Favorable histologic types (85% 5-year survival rate)

• Tubular carcinoma (grade 1 intraductal), colloid or mucinous carcinoma, and papillary carcinoma

• Less favorable types • Medullary , invasive lobular, and invasive ductal

carcinoma

• Least favorable type • Inflammatory breast carcinoma

• Staging, prognosis, and treatment

Favorable histologic types

• Tubular carcinoma

– 2% of all invasive breast cancers

– Generally diagnosed by mammography

– Distinctive under microscope

– Long-term survival aproaches 100%

• Mucinous (colloid) carcinoma – 3% of all invasive breast cancers

– Generally confined to elderly population

– Bulky, mucinous tumor with characteristic microscopic features

– 5 and 10 year survival rates are 73 and 59 percent, respectively

• Papillary carcinoma – <2% of all invasive breast cancers

– Generally presents in seventh decade, and is a slowly progressive disease

– 5 and 10 year survival rates are 83 and 56 percent, respectively

Less Favorable Histologic

Types • Medullary carcinoma

– 4% of all invasive breast cancers

– Soft, hemorrhagic bulky presentation

– Diagnosed microscopically (lymphocytic infiltration)

– Metastases to axillary nodes in 44%

– 5 and 10 year survival rates are 63 and 50 percent respectively

• Invasive ductal carcinoma – Most common and occurs in 78% of all invasive breast cancers.

– Metastases to axillary nodes in 60%

– 5 and 10 year survival rates are 54 and 38 percent respectively

• Invasive lobular carcinoma – 9% of all invasive breast cancers

– Metastases to axillary nodes in 60%

– 5 and 10 year survival rates are 50 and 32 percent respectively

– Higher incidence of bilaterality

Inflammatory carcinoma

• 1.5-3% of breast cancers

• Characteristic clinical features of erythema, peau d’orange, and skin ridging with or without a palpable mass.

• Commonly mistaken for cellulitis. – Will generally fail antibiotics before being diagnosed

• Disease progresses rapidly, and more than 75% of patients present with palpable axillary nodes.

• Distant metastatic disease also at much higher frequency than the more common breast cancers.

• 30% 5 year survival rate

• Requires chemotherapy treatment immediately

Diagnosis

• Fine-needle aspiration – Sensitivity is 80-98%, specificity 100%

– False negatives are 2-10%

• Core-needle biopsy – More tissue, however still possibility of false

“negative” and could represent sampling error

• Incisional biopsy – For large (>4 cm) lesions for whom pre-op

chemotherapy or radiation will be desirable.

• Excisional biopsy – Removal of entire lesion and a margin of normal

breast parenchyma

Mammogram Comparison CC View

Left Right

Thermograph

• Thermograph is one of the

newest ways to detect breast

cancer.

• Thermograph is a thermal image

of the breast tissue.

• It can also detect cancer before

the traditional mammogram can.

• www.breastthermography.com

• Picture from breastthermography.com

Staging and Prognosis • Primary Tumor

– T1 = Tumor < 2 cm. in greatest dimension

– T2 = Tumor > 2 cm. but < 5 cm.

– T3 = Tumor > 5 cm. in greatest dimension

– T4 = Tumor of any size with direct extension to chest wall or skin

• Regional Lymph Nodes – N0 = No palpable axillary nodes

– N1 = Metastases to movable axillary nodes

– N2 = Metastases to fixed, matted axillary nodes

• Distant Metastases – M0 = No distant metastases

– M1 = Distant metastases including ipsilateral supraclavicular nodes

• Clinical Staging and prognosis – Clinical Stage I T1 N0 M0 Stage Prognosis (5 year surv. Rate)

– Clinical Stage IIA T1 N1 M0 I 93%

– T2 N0 M0 II 72%

– Clinical Stage IIB T2 N1 M0 III 41%

– T3 N0 M0 IV 18%

– Clinical Stage IIIA T1 N2 M0

– T2 N2 M0

– T3 N1 M0

– T3 N2 M0

– Clinical Stage IIIB T4 any N M0

– Clinical Stage IV any T any N M1

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BREAST CANCER: Early Stage Metastasis to ipsilateral axillary lymph node(s)

N1 = movable

N2 = fixed to one another or to other structures

M0 = no distant metastasis

BREAST CANCER Spread to lymph nodes

Supraclavicular

Subclavicular

Distal (upper)

axillary

Central (middle)

axillary

Proximal (lower)

axillary

Mediastinal

Internal mammary

Interpectoral

(Rotter’s)

Stage IV: Metastatic Breast Cancer

Prognostic Features

• Tumor size important prognostic factor

• Poor prognostic features of tumor: – Presence of edema or ulceration of skin, mass fixed to chest wall or skin, satellite

skin nodules, peau d’orange (dermal lymphatic invasion), skin retraction and dimpling, and involvement of medial portion of inner lower quadrant involved.

• Axillary node status: – Best source of predicting survival or outcome

– N0 has 10 year survival rate of 60%

– N1 has 10 year survival rate of 50%

– N2 has 10 year survival rate of 20%

– If 10 or more nodes are diseased (N3) 10 yr surv. Rate is 14%

– Poor prognostic feature of nodes: • Capsular invasion, extranodal spread, and edema of arm

• Distant metastases is very poor prognostic indicator

• Postive estrogen and progesterone receptor indicates likely response to hormonal treatment and is a positive prognostic indicator

Treatment

• Modalities (palliative vs. curative)

– Surgery

• Local treatment

– Radiation

• Local treatment

– Chemotherapy and hormonal therapy

• Systemic treatment

Surgery

– Breast conservation therapy

• Stage I, stage II, and sometime stage III carcinomas

• Lumpectomy, axillary lymphadenectomy, and postoperative radiation therapy

• Contraindications: tumors > 5 cm , gross multifocal disease, and diffuse malignant microcalcifications

• Local recurrence more than mastectomy so follow up important

– Modified radical mastectomy (most common mastectomy procedure for invasive breast cancer)

• Entire breast and axillary contents are removed

• Pectoralis muscles remains

– Halsted radical mastectomy • Removes breast, axillary contents, and pectoralis major muscle

• Cosmetically deforming

• Only indicated when pectoralis muscle involved

– Simple mastectomy • All breast tissue is removed, axillary contents not removed

• Treatment for non-invasive breast cancer

Radiation

• Utilized for primary and metastatic disease

• Useful in breast conservation therapy to

reduce rate of recurrence.

– Radiate entire breast

Chemotherapy and Hormonal

Therapy • Chemotherapy

– Eradicates risk of occult distant disease in stage I and stage II patients.

– All patients with axillary node involvement are candidates along with patients with negative axillary node involvement who are high risk by other prognostic indicators.

– Example treatment is 6 months of cyclophosphamide, methotrexate or adriamycin, and flourouracil along with paclitaxel.

• Improvement in disease free interval and overall survival

• Hormonal therapy – Tamoxifen

• Generally taken for five years in patientss with estrogen receptor positive tumors.

– As effective as chemotherapy in post-menopausal patients with estrogen receptor positive tumors

Classification

Lesions with Increased Risk of Ca Ductal hyperplasia

Sclerosing adenosis

Complex fibroadenomas

Atypical hyperplasia

Radial scars

Micheal S sabel .Overview of benign breast disease. Uptodate 2008, November 14

Classification

Lesions with no Increased risk of Ca Fibrocystic disease

Duct ectasia

Solitary papillomas

Simple fibroadenomas

Mastitis or breast abscess

Galactocele

Fat necrosis

Lipoma

Alternative medicine • There are also several alternative medicines that can help to reduce or

eliminate breast cancer.

• Vitamin A, Betacarotine, Vitamin C, and Vitamin E all increase the effect of

chemotherapy.

• CO-Q10 reduces the toxicity of chemotherapy

• Vitamin D, and Cholecalciferol helps inhibits growth in cancer cells

• Melitonin (which is a natural chemical produced in our brain) blocks the

estrogen receptors to the cancer

Alternative medicine • Also Astragalus acts as an anti-viral and enhances the natural killer cells

• Cur cumin turmeric (is an anti tumor) increases you leukocyte production

• And Caud’ Arco is a mild herb that acts as an anti tumor

Therapeutic massage, acupuncture, and stress relieving techniques are also

used.

Treat the whole person not just the illness

Bone marrow transplant • Getting a bone marrow transplant is one of the newest options for cancer.

• It is used when you receive high doses of radiation and chemotherapy. Because chemotherapy kills all the cells both good, and bad it replaces what was destroyed by the treatments.

• Bone marrow is donated from another person and then frozen and placed in the cancer patients body by injection.

• A word of caution though this is still in the preliminary stages of trials & testing for breast cancer.

Nutrition

• Perhaps one of the best ways to help prevent cancer is an easy one but often overlooked.

• Diets high in meat, fast foods, refined carbohydrates, simple sugars, low in fruit and veggies are at high risk of developing cancer.

• Diets need to be well balanced in that you need to eat your 5 servings of fruits and veggies a day. Don’t forget the whole grain foods as well.

• Picture from usda.gov

Nutrition • Alcohol is associated with increasing the chances of many types of cancer, including

breast cancer.

• “An average alcohol intake of three drinks per day is associated with doubling the risk

of breast cancer” • (chapter 16 core concepts in health, Insel)

• One should also avoid smoking because it increases the risk also.

• Fiber is also an interregnal part of our daily diets. Many foods that contain fiber also

contain many other vitamins that are considered “potential cancer fighting agents”.

• Fruits and veggies also contain anti carcinogens, carotenoids, antioxidants, and free

radicals that help protect our DNA.

Exercise • Another aspect is to maintain a healthy body weight.

• That means to get off the couch an do something, walk the dog, ride a bike

or just exercise in you own home.

• If you stay away from fatty foods, (i.e.; fast foods) and eat a well balanced

diet. Then you will greatly reduce your chances of getting cancer.

• Don’t forget to take care of your self!!

Age as a Risk Factor

RISK

By age 30 1 out of 2,000

By age 40 1 out of 233

By age 50 1 out of 53

By age 60 1 out of 22

By age 70 1 out of 13

By age 80 1 out of 9

Lifetime risk 1 out of 8

NCI SEER Program, 1995-1997

Risk Factors

Controllable

• Alcohol drinking

• Being overweight

• Never having

children

• 1st child >30yrs of

age

• Hormone

Replacement

• Birth control pills

(very slight)

Uncontrollable

• Getting older

• First degree

relative with breast

cancer

• A previous breast

biopsy showing

atypical changes

Risk Factors

• Controllable

• Being exposed to

large amounts of

radiation

• Uncontrollable

• Being young (<12) at the

time of menses

• Starting menopause after

age 55

• Having an inherited

mutation in the breast

cancer genes (BRCA 1 or

2)

ACS Breast Cancer Facts 2001-02

Breast Cancer Screening Methods For Healthy Women

1. Breast Self Exam — Status

– Guiding principal “Know your breasts —

they are not land mines”

2. Clinical Breast Exam

– Age 20-39: every 3 years

– Age after 40: every year

3. Mammography

– Age after 40: every year

Balloon and lumpectomy

A dose of 34 Gy was delivered at a depth of 1 cm over the

course of 5 days. CT scans were used to assess the

conformance of the resection cavity tissue to the

MammoSite® RTS balloon.

Balloon on CT

Coping with your Diagnosis

• Express your emotions

• Develop a fighting spirit

• Build a strong support group

• Trust your health care team

Revised Differential Diagnosis

1 Fibroadenoma

2 Cyst

3 Fibrocytic Mass

4 Breast Cancer

Components of Appropriate

Screening Program

• Professional Physical Examination

• Breast Self Examination (BSE)

• Mammography

Screening Recommendations

Professional Breast Exam

Age Physical Exam

20 – 40 yrs Every 3 years

> 40 yrs Annually

Carcinoma

Tabar L, Dean P.

Teaching atlas of

mammography. 2nd ed.

New York, New York:

Thieme Inc; 1985:91.

Comedo Carcinoma

Dean P. Teaching

atlas of

mammography. New

York, New York:

Thieme Inc; 1985:168

Ductal Carcinoma

Tabar L, Dean P. Teaching atlas of mammography. 2nd ed. New York, New

York: Thieme Inc. 1985:169

Sclerosing Duct Hyperplasia

Tabar L, Dean P.

Teaching atlas of

mammography. 2nd ed.

New York, New York:

Thieme Inc. 1985:106

Fibro-adeno-lipoma

Tabar L, Dean P.

Teaching atlas of

mammography. 2nd ed.

New York, New York:

Thieme Inc. 1985:25

Lipoma

Tabar L, Dean P.

Teaching atlas of

mammography. 2nd ed.

New York, New York:

Thieme Inc. 1985:21

Fibroadenoma

Tabar L, Dean P.

Teaching atlas of

mammography. 2nd ed.

New York, New York:

Thieme Inc. 1985:200

Cystosarcoma Phylloides

Tabar L, Dean P. Teaching atlas of mammography. 2nd ed. New York, New York:

Thieme Inc. 1985:63

Intraductal Papilomatosis

Tabar L, Dean P. Teaching atlas of mammography. 2nd ed. New York, New

York: Thieme Inc. 1985:192

Intraductal Papillomatosis

Tabar L, Dean P. Teaching atlas of mammography. 2nd ed. New York, New

York: Thieme Inc. 1985:48

Carcinoma

Tabar L, Dean P.

Teaching atlas

of

mammography.

2nd ed. New

York, New York:

Thieme Inc.

1985:95

Paget Disease , Mammary

Paget’s Disease

• Uncommon

• Usually involves the nipple

• Histologically, vacuolated cells are seen in the epidermis of the nipple and result in an eczematous dermatitis of the nipple.

• It is generally associated with an underlying intraductal or invasive carcinoma. – Mammography should be performed

• About 30% of patients have axillary node metastasis at diagnosis.

• Mastectomy is the standard of treatment – 80% have a 10 year survival rate if there is no mass present and

no axillary nodes are involved.

The Male Breast

• Gynecomastia – Prepubertal gynecomastia

• Rare, adrenal carcinoma and testicular tumor can cause this.

– Pubertal gynecomastia • Occurs in 60-70% of pubertal boys.

– Senescent gynecomastia • 40% of aging men have this to some degree.

• Drugs, such as steroids, digitalis, hormones, spironolactone, and antidepressants can cause this.

• Male breast carcinoma – 0.7% of all breast cancers

– <1% of male cancers

– Average age of diagnosis is 63.6 years old

– Painless unilateral mass that is usually subareolar with skin fixation, chest wall fixation,, and ulceration.

– Mostly ductal carcinoma

– Males generally present at later stage than woman • Overall survival worse in men, however when compared stage for stage the survival

rates are similar.

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