Strange phenomenon of mirror image in invasive lobular carcinoma... The cancer tends to occur at exactly the same quadrant as the contralateral breast, sometimes prophylactic quadrantectomy on the other appearantly healthy side may be done
#Breast
#Breast
Bloody nipple discharge
◼️The primary goal is to exclude breast carcinoma (the dark shadow of carcinoma seems to follow every single breast disease).
◼️Bloody discharge may occur from a single duct or from multiple duct.
◼️Single duct bloody discharge may occur from intraductal papilloma, carcinoma or from duct ectasia.
◼️Bloody discharge from multiple ducts can also signify carcinoma, duct ectasia or even fibrocystic disease (which is not really a disease, its called now with the updated name abberration of normal development and involution for short ANDI).
◼️CAREFUL palpation of the breast and axillary lymph nodes is essential to detect underlying mass.
◼️Mammography may be done to detect subclinical mass.
◼️The discharge may be sent for cytology, but if negative, this do not exclude carcinoma.
#Breast
◼️The primary goal is to exclude breast carcinoma (the dark shadow of carcinoma seems to follow every single breast disease).
◼️Bloody discharge may occur from a single duct or from multiple duct.
◼️Single duct bloody discharge may occur from intraductal papilloma, carcinoma or from duct ectasia.
◼️Bloody discharge from multiple ducts can also signify carcinoma, duct ectasia or even fibrocystic disease (which is not really a disease, its called now with the updated name abberration of normal development and involution for short ANDI).
◼️CAREFUL palpation of the breast and axillary lymph nodes is essential to detect underlying mass.
◼️Mammography may be done to detect subclinical mass.
◼️The discharge may be sent for cytology, but if negative, this do not exclude carcinoma.
#Breast
Nomenclature
◼️Halsted mastectomy = involve removal of breast, pectoralis major and minor, with axillary nodes fascia and fat. No longer done.
◼️Modified 'patey' mastectomy = en bloc removal of breast, skin (centre of which overlies the tumor but always includes the nipple), axillary dissection.
◼️Wide local excision = removal of the tumor with a rim of healthy tissue of atleast 1 cm.
◼️Quadrantectomy = removal of the segment containing the tumor.
◼️QUART = combination of quadrantectomy, axillary dissection and radiotherapy.
#Breast
◼️Halsted mastectomy = involve removal of breast, pectoralis major and minor, with axillary nodes fascia and fat. No longer done.
◼️Modified 'patey' mastectomy = en bloc removal of breast, skin (centre of which overlies the tumor but always includes the nipple), axillary dissection.
◼️Wide local excision = removal of the tumor with a rim of healthy tissue of atleast 1 cm.
◼️Quadrantectomy = removal of the segment containing the tumor.
◼️QUART = combination of quadrantectomy, axillary dissection and radiotherapy.
#Breast
Note
Radical Halsted mastectomy which involved removal of the breast, pectoralis major and minor muscles, and axillary lymph nodes is no longer indicated because it causes significant morbidity with no survival benefit.
#Breast
Radical Halsted mastectomy which involved removal of the breast, pectoralis major and minor muscles, and axillary lymph nodes is no longer indicated because it causes significant morbidity with no survival benefit.
#Breast
Indications for mastectomy
Recently there has been a gradual shift towards more conservative techniques, clinical trials has shown that mastectomy has equal efficacy to local excision and radiotherapy, therefore nowadays mastectomy is strictly indicated only in the following conditions:
◼️Large tumor in relation to the size of the breast (small breast).
◼️Central tumor beneath or involving the nipple.
◼️Multifocal especially seen in lobular carcinoma.
◼️Local recurrence.
◼️Patient preference.
#Breast
Recently there has been a gradual shift towards more conservative techniques, clinical trials has shown that mastectomy has equal efficacy to local excision and radiotherapy, therefore nowadays mastectomy is strictly indicated only in the following conditions:
◼️Large tumor in relation to the size of the breast (small breast).
◼️Central tumor beneath or involving the nipple.
◼️Multifocal especially seen in lobular carcinoma.
◼️Local recurrence.
◼️Patient preference.
#Breast
Lymphangiosarcoma (stewart treves syndrome) following longstanding lymphedema is a rare complication that occur years after the original treatment, it presents with multiple subcutaneous nodules in the upper arm (see image above), it has poor prognosis although some patients responds to cytotoxic drugs and radiotherapy, some patients may need interscapulothoracic amputation.
#Breast
#Breast
Carcinoma en cuirasse
◼️It is an infileration of the chest skin by cancer that became likened to a coat.
◼️It is a rare form of cutaneous involvement by breast cancer, it is usually a form of local recurrence following mastectomy, and usually seen following the distribution of chest wall irradiation.
◼️Prognosis is poor
#Breast
◼️It is an infileration of the chest skin by cancer that became likened to a coat.
◼️It is a rare form of cutaneous involvement by breast cancer, it is usually a form of local recurrence following mastectomy, and usually seen following the distribution of chest wall irradiation.
◼️Prognosis is poor
#Breast
Peau d' orange
◼️It is a clinical manifestation of advanced breast cancer.
◼️Peau d orange is a french term, which means skin of the orange (resembling peel of orange fruit).
◼️It is a lymphatic cutaneous edema due to lymphatic vessel permeation and obstruction by malignant cells.
◼️The above image shows typical peau d orange, with circumferenial nipple retraction, the pits in the skin are due to tethered sweat gland ducts which cannot swell.
◼️This condition may also occur in chronic breast abscess (always remember that the closest mimicer of a breast cancer is a chronic breast abscess which too can cause nipple retraction)
#Breast
◼️It is a clinical manifestation of advanced breast cancer.
◼️Peau d orange is a french term, which means skin of the orange (resembling peel of orange fruit).
◼️It is a lymphatic cutaneous edema due to lymphatic vessel permeation and obstruction by malignant cells.
◼️The above image shows typical peau d orange, with circumferenial nipple retraction, the pits in the skin are due to tethered sweat gland ducts which cannot swell.
◼️This condition may also occur in chronic breast abscess (always remember that the closest mimicer of a breast cancer is a chronic breast abscess which too can cause nipple retraction)
#Breast
Causes of nipple retraction
◼️ Carcinoma (must exclude first).
◼️ Duct ectasia (slit like retraction).
◼️ Chronic abscess
◼️Idiopathic simple nipple inversion of puberty.
◼️ Advanced ANDI.
#Breast
◼️ Carcinoma (must exclude first).
◼️ Duct ectasia (slit like retraction).
◼️ Chronic abscess
◼️Idiopathic simple nipple inversion of puberty.
◼️ Advanced ANDI.
#Breast
How does eczema differ from paget disease clinically?
◼️Paget disease is associated with nipple destruction, whereas the nipple is intact in eczema.
◼️Paget disease do not respond to treatment whereas eczema does.
◼️Paget disease is usually unilateral whereas eczema is usually bilateral.
◼️Eczema is itchy whereas paget disease usually is not
#Breast
◼️Paget disease is associated with nipple destruction, whereas the nipple is intact in eczema.
◼️Paget disease do not respond to treatment whereas eczema does.
◼️Paget disease is usually unilateral whereas eczema is usually bilateral.
◼️Eczema is itchy whereas paget disease usually is not
#Breast
Operative note
When performing a circumareolar incision, do not cut beyond half of the circumference of the areola, in hopes that the attached part will provide enough blood supply to the remainder,, if extensive incision is done, necrosis of the areolar tissue follows.
#Breast
When performing a circumareolar incision, do not cut beyond half of the circumference of the areola, in hopes that the attached part will provide enough blood supply to the remainder,, if extensive incision is done, necrosis of the areolar tissue follows.
#Breast
Note
Athelia means abscent nipple (usually with amazia = abscent breast)
Polythelia = multiple nipples (supernumerary nipple)
#Breast
Athelia means abscent nipple (usually with amazia = abscent breast)
Polythelia = multiple nipples (supernumerary nipple)
#Breast
Examples of tumors presenting with signs and symptoms of acute inflammation
◼️Inflammatory breast carcinoma.
◼️Testicular neoplasm.
◼️Hepatocellular carcinoma.
◼️Ewing sarcoma.
#Surgery
◼️Inflammatory breast carcinoma.
◼️Testicular neoplasm.
◼️Hepatocellular carcinoma.
◼️Ewing sarcoma.
#Surgery
Interesting rare case of a male inflammatory breast carcinoma, these are highly malignant tumors with undifferentiated histology, they appear as redness, warmth, and cutaneous edema of the breast, BECAREFUL, it mimics breast abscess,, histology is required for diagnosis.
#Breast
#Breast
Paget disease of the nipple
◼️This is an eczema like condition of the nipple and areola.
◼️It is indicative of an underlying breast carcinoma.
◼️The nipple becomes slowly eroded until its completely obsecured (see image above black arrow) , if left, the underlying carcinoma will sooner or later become clinically evident.
◼️The pathophysiology is uncertain, according to the migratory theory, malignant cells travel along the duct system and eventually reach the nipple and areola, the motility of these cells being induced by motility factors acting through HER2/NEU receptors.
◼️Microscopic picture include presence of large ovoid malignant cells with abundant pale cytoplasm in the malpighian layer of epidermis.
◼️It should be suspected strongly when a presumed eczema of the nipple fails to respond to local treatment, whenever in doubt, biopsy of the nipple should be obtained to confirm the diagnosis.
#Breast
◼️This is an eczema like condition of the nipple and areola.
◼️It is indicative of an underlying breast carcinoma.
◼️The nipple becomes slowly eroded until its completely obsecured (see image above black arrow) , if left, the underlying carcinoma will sooner or later become clinically evident.
◼️The pathophysiology is uncertain, according to the migratory theory, malignant cells travel along the duct system and eventually reach the nipple and areola, the motility of these cells being induced by motility factors acting through HER2/NEU receptors.
◼️Microscopic picture include presence of large ovoid malignant cells with abundant pale cytoplasm in the malpighian layer of epidermis.
◼️It should be suspected strongly when a presumed eczema of the nipple fails to respond to local treatment, whenever in doubt, biopsy of the nipple should be obtained to confirm the diagnosis.
#Breast
Ductal carcinoma
◼️This is the commonest histologic variant of breast cancer.
◼️The malignant cells arise from the epithelial lining of the duct system, which can occur anywhere in these ducts.
◼️Ductal carcinoma in situ (malignant cells did not invade the basement membrane), previously was a rare finding, but now with the advent of screening programs, it became increasingly recognized (above is a histologic section showing ductal carcinoma in situ DCIS).
#Breast
◼️This is the commonest histologic variant of breast cancer.
◼️The malignant cells arise from the epithelial lining of the duct system, which can occur anywhere in these ducts.
◼️Ductal carcinoma in situ (malignant cells did not invade the basement membrane), previously was a rare finding, but now with the advent of screening programs, it became increasingly recognized (above is a histologic section showing ductal carcinoma in situ DCIS).
#Breast
Note
Obestiy = more adipose tissue = more conversion of steroids to estradiol = more risk of breast cancer.
#Breast
Obestiy = more adipose tissue = more conversion of steroids to estradiol = more risk of breast cancer.
#Breast
Aetiologic factors in breast cancer
◼️Geographic
Breast cancer is more common in developed western counteries, it account for 3-5% of all deaths, whereas in developing counteries the incidence is lower and account for 1-3% of all deaths. It was found to be rare in japan.
◼️Age
Breast cancer is extremely rare below the age of 20 years, but thereafter, the risk steadily increasea until it becomes 20% at 90 years.
◼️Gender
Males represent less than 0.5% of all cases of breast cancer.
◼️Genetic
Breast cancer is more common in women with a family history of breast cancer,, breast cancers that are due to a specific mutation represent about 5% of all cases, and they will be discussed later in details.
◼️Diet
It was found that there is a link to diets with low phytoestrogens, also high alcohol consumption increase the risk.
◼️Endocrine
Estrogenic drive seems to increase the risk of breast cancer, it was found that nulliparous women are more likely to have breast cancer, also having the first child at an early age is protective, breastfeeding in protective, also late menarche and early menopause seem to be protective.
The role of oral contraceptive pills and hormonal replacement therapy is controversial, it seems that the benefits from these treatments outweight the small putative risk.
#Breast
◼️Geographic
Breast cancer is more common in developed western counteries, it account for 3-5% of all deaths, whereas in developing counteries the incidence is lower and account for 1-3% of all deaths. It was found to be rare in japan.
◼️Age
Breast cancer is extremely rare below the age of 20 years, but thereafter, the risk steadily increasea until it becomes 20% at 90 years.
◼️Gender
Males represent less than 0.5% of all cases of breast cancer.
◼️Genetic
Breast cancer is more common in women with a family history of breast cancer,, breast cancers that are due to a specific mutation represent about 5% of all cases, and they will be discussed later in details.
◼️Diet
It was found that there is a link to diets with low phytoestrogens, also high alcohol consumption increase the risk.
◼️Endocrine
Estrogenic drive seems to increase the risk of breast cancer, it was found that nulliparous women are more likely to have breast cancer, also having the first child at an early age is protective, breastfeeding in protective, also late menarche and early menopause seem to be protective.
The role of oral contraceptive pills and hormonal replacement therapy is controversial, it seems that the benefits from these treatments outweight the small putative risk.
#Breast
Phyllodes tumor
◼️Previously known as serocystic disease of Brodie, but also known as cystosarcoma phyllodes.
◼️They may reach massive size (see picture above), and may cause pressure necrosis and ulceration of the overlying skin (note the ulcerations in the picture above), despite all this they remain mobile on the chest wall, and you can insert a probe between the tumor and the skin (usually not fixed).
◼️Phyllodes tumors are usually of the benign type,, only very rarely they are malignant.
◼️Histology is variable, some tumors show low malignant potential, resembling a fibroadenoma, some show high mitotic index which is worrying.
◼️The name cystosarcoma phyllodes, is really out of character, because these tumors are rarely cystic, and very rarely act like a malignant sarcoma.
◼️Treatment can be done by enucleation or wide local excision, but if the tumor is massive, recurrent or of the malignant type, mastectomy is indicated.
#Breast
◼️Previously known as serocystic disease of Brodie, but also known as cystosarcoma phyllodes.
◼️They may reach massive size (see picture above), and may cause pressure necrosis and ulceration of the overlying skin (note the ulcerations in the picture above), despite all this they remain mobile on the chest wall, and you can insert a probe between the tumor and the skin (usually not fixed).
◼️Phyllodes tumors are usually of the benign type,, only very rarely they are malignant.
◼️Histology is variable, some tumors show low malignant potential, resembling a fibroadenoma, some show high mitotic index which is worrying.
◼️The name cystosarcoma phyllodes, is really out of character, because these tumors are rarely cystic, and very rarely act like a malignant sarcoma.
◼️Treatment can be done by enucleation or wide local excision, but if the tumor is massive, recurrent or of the malignant type, mastectomy is indicated.
#Breast
Note
Another theory to suggest the pathogenesis of duct ectasia, is that periductal mastitis is the initial event, supported by the presence of anaerobic bacteria in some patients.
#Breast
Another theory to suggest the pathogenesis of duct ectasia, is that periductal mastitis is the initial event, supported by the presence of anaerobic bacteria in some patients.
#Breast
Duct ectasia/Periductal mastitis
◼️The pathology, is a dilated duct with surrounding periductal inflammation.
◼️The pathogenesis is unclear, the classic event is that dilatation of a large lactiferous duct takes place, then a green or brown secretion fills up the dilated duct, and becomes stagnant, it may discharge from the nipple.
◼️This stagnation initiate irritation of surrounding tissues, and lead to periductal mastitis, abscess formation (see figure yellow arrow), this abscess may open into the skin leading to a fistula (black arrow).
◼️Sometimes these inflammatory changes causes an indurated subareolar mass, which mimics carcinoma.
◼️Eventually, fibrosis takes place and causes a slit like nipple retraction (white arrow).
◼️Smoking clearly increases the risk, some say because it causes an arteriopathy which is an aetiologic factor, others say that it increase virulence of commencal bacteria, either ways, cessation of smoking clearly increase chance of long term cure.
#Breast
◼️The pathology, is a dilated duct with surrounding periductal inflammation.
◼️The pathogenesis is unclear, the classic event is that dilatation of a large lactiferous duct takes place, then a green or brown secretion fills up the dilated duct, and becomes stagnant, it may discharge from the nipple.
◼️This stagnation initiate irritation of surrounding tissues, and lead to periductal mastitis, abscess formation (see figure yellow arrow), this abscess may open into the skin leading to a fistula (black arrow).
◼️Sometimes these inflammatory changes causes an indurated subareolar mass, which mimics carcinoma.
◼️Eventually, fibrosis takes place and causes a slit like nipple retraction (white arrow).
◼️Smoking clearly increases the risk, some say because it causes an arteriopathy which is an aetiologic factor, others say that it increase virulence of commencal bacteria, either ways, cessation of smoking clearly increase chance of long term cure.
#Breast