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Breast Infections: Principles, Pathology and Management
Breast Infections: Principles, Pathology and Management
• For a subareolar abscess, removal of the sinus tract as well as the segmental
duct should be considered.
1. Malignancy
2. idiopathic granulomatous mastitis
3. Wegener’s granuloma
4. Sarcoidosis
5. Tuberculosis
6. histoplasmosis.
• Arise from the terminal duct lobular unit when fluid accumulates because of
distension and obstruction of the efferent ductile occur mainly during lobular
development, menstrual cyclic changes, and lobular involution in
premenopausal and postmenopausal women
• Aspiration if symptomatic.
• If the aspirated fluid is:
1. Non bloody
2. The palpable mass completely resolves
• No further diagnostic evaluation is required.
• Management:
– biopsy through FNA, core biopsy, or excisional biopsy. Or
– ultrasound and mammography with CBE every 6 months for 2 years to document
stability.
• If any change occurred (solid component, increasing in size, etc) biopsy should be
performed
Management:
• Biopsy (of the solid part) with metallic clipmarking the biopsy site
• then follow-up with CBE and ultrasound imaging every 6 to 12 months for 1 to 2 years to
document stability.
• For any concerning changes in the appearance of the lesion or increase in size, excisional
biopsy should be performed.
Dr. Mahmoud W. Qandeel
Fibroadenoma
• The most common breast lump in young females
• Are benign solid tumors made of glandular as well as fibrous tissue
• Abundant stroma with normal cellular element
• Peak 15-35 years
• Present as well-circumscribed mobile masses not fixed to the surrounding breast tissue
(mouse of the breast) Usually 1-2 cm
• Hormonal dependence
• Cancer risk is 0.2 %
• Giant form more than 4 cm
• More than 5 in one side is a disease
- These calcifications are calcified cellular debris or secretions within the intraductal lumen.
- The uneven calcification of the cellular debris explains the fragmentation and irregular
contours of the calcifications.
- These calcifications are extremely variable in size, density and form (i.e. pleomorphic)
- Sometimes they form a complete cast of the ductal lumen.
- This explains why they often have a fine linear or branching form and distribution.
- Intraductal calcifications are suspicious of malignancy.
Lobular calcifications Intraductal calcifications
Benign Calcifications
Coarse heterogeneous
• Fibroadenoma
• Fibrosis
• Post-traumic representing evolving dystrophic
calcifications (fat necrosis)
• DCIS Fine Pleomorphic (DCIS)
2. PROLIFERATIVE BREAST LESIONS WITHOUT ATYPIA
• Intraductal papillomas
• Ductal hyperplasia
• Radial scars
• Consist of a monotonous array of papillary cells that grow from the wall of a duct or
cyst into its lumen.
• Management:
– Surgical excision
– If no atypia or DCIS is found at the time of excision, no further treatment is
necessary.
Dr. Mahmoud W. Qandeel
Ductal hyperplasia
• Characterized by an increased number of benign looking cells within the ductal space
• Management:
– Surgical excision
– If the surgical excisional biopsy confirms a radial scar, no additional treatment is
needed.
Dr. Mahmoud W. Qandeel
Sclerosing adenosis
• May be found in patients with fibrocystic changes and refers to an
increased number of small terminal ductules associated with stromal
tissue proliferation.
• Management:
• Surgical excision, as an upgrade to DCIS or invasive breast cancer can occur in 10% to
20% of cases.
Management:
• If adequate sample, no role for excision.
• Breast Self-Examination
• BSE has not been shown to have an impact on the rates of breast cancer diagnosis,
stage at diagnosis, or breast cancer mortality.
• In addition, BSE may result in higher rates of breast biopsy for benign disease.
• Most guidelines suggest routine screening mammography at the age of 40 years then
annually.
• If the patient has positive family history, mammography should start 10 years earlier
than the age her relative was diagnosed at
• Right, Clustered
microcalcifications. Fine,
pleomorphic, and linear
calcifications that cluster
together suggest the diagnosis of
ductal carcinoma in situ
• Radial scar
• Fat necrosis
• Milk of calcium
1. BRCA mutations
2. First degree relatives of known BRCA mutation carriers
3. Those with a lifetime risk of breast cancer that is estimated to be ≥20%
based on risk prediction models
4. Patients who received radiation treatment to the chest between ages 10
and 30 and
5. TP53 (Li–Fraumeni syndrome) mutations
6. PTEN genetic (Cowden syndrome) mutations.
Gender
• 100 times more frequently in women than in men.
• In the US, annually
– 200,000 in women
– 2000 in men
Increasing Age
85 % of breast cancers occur after 50 years of age.
Dr. Mahmoud W. Qandeel
Estrogen Exposure
A- Radiation exposure
• Ionizing radiation of the chest, such as for treatment of Hodgkin lymphoma,
especially in prepuberty stage (age 10 to 14 years)has the most effect
• The age at diagnosis of the first-degree relative is also important, risk is 3 fold
higher when the diagnosis occurs before age 30 , 1.5-fold higher if the diagnosis
is after age 60
Premenopausal
• women with BMI ≥31 were 46% less likely to develop breast cancer than
those with a BMI <21
• Tamoxifen and raloxifene are both approved by the FDA for the
prevention of breast cancer
• Recent studies showed similar results with aromatase inhibitors
Obvious lump or
thickening in breast
infiltration
Ulceration
Dimpling seen by
muscle
contraction
A- Sporadic
• The majority of breast cancers are caused by sporadic mutations (mutations
that occur in somatic cells that cannot be inherited).
• For women who have first- or second-degree relatives with breast cancer
but do not meet the hereditary breast cancer definition noted above.
• It is likely that both genetic and environmental factors play a role in their
susceptibility.
• Most patients with hereditary breast cancer have mutations in the BRCA1
(chromosome 17)or BRCA2 genes (chromosome 13)
• The lifetime risk of breast cancer in BRCA1 and BRCA2 mutation carriers is
85%, (compared to 12% in the general population)
Dr. Mahmoud W. Qandeel
Ovarian cancer risk
• BRCA1 :40% to 60%
• BRCA2 : 15%.
• In males with breast cancer who have a BRCA mutation, One third of mutations
involve BRCA1 and two-thirds involve BRCA2.
• In addition, prostate and pancreatic cancer is more common in patients with BRCA2
mutations
Dr. Mahmoud W. Qandeel
Other hereditary associated breast cancer
• ATM mutations:
– childhood neurologic disorder referred to as ataxia—telangiectasia, with growth
retardation
– 5 times higher risk for developing breast cancers
Dr. Mahmoud W. Qandeel
• CDH1 or E-cadherin mutations:
– 70% lifetime risk for diffuse gastric cancer
– 40% risk for lobular breast cancer
1. Grade 1 (well differentiated): Cells that infiltrate the stroma as solid nests of glands and
where the nuclei are relatively uniform with little or no evidence of mitotic activity.
2. Grade 2 (moderately differentiated): the tumor cells infiltrate as solid nests with some
glandular differentiation and nuclear pleomorphism is present, the mitotic activity is
moderate.
3. Grade 3 (Poorly differentiated): solid nests of neoplastic cells without evidence of gland
formation are present with marked nuclear atypia and high mitotic activity
• Luminal B HER2+ and HER2 subtypes benefit from targeted therapies against
HER2.
• Basal like or Triple negative breast cancer has the worst prognosis
Dr. Mahmoud W. Qandeel
Diagnostic Breast MRI
• No data from prospective randomized trials demonstrating improved outcomes with the addition
of MRI to the diagnostic evaluation of newly diagnosed breast cancers,
• However NCCN guidelines suggest that diagnostic MRI should be considered in patients with
newly diagnosed breast cancer :
1. When the clinical extent of disease appears larger than what is observed on mammography
2. When there is concern about pectoralis muscle involvement
3. When there is no evidence of a breast primary in the presence of axillary lymph node
metastases
4. When there is no disease identified on physical examination or mammography in the
presence of Paget’s disease of the breast
5. In women at very high risk for contralateral breast cancers such as those with BRCA1/2
mutations
Dr. Mahmoud W. Qandeel
Ductal Carcinoma In Situ (DCIS)
• Defined as the proliferation of malignant epithelial cells within the mammary ductal
system with no evidence of invasion into the surrounding stroma on routine light
microscopic examination
• Histologic subtypes:
1. Comedo (Worst prognosis)
2. Non-comedo:
1. Micropapillary
2. Papillary
3. Cribriform
4. Solid
• DCIS is designated as Tis (DCIS) by the TNM staging system and considered a stage 0
breast cancer
Dr. Mahmoud W. Qandeel
• More than 90% of all cases of DCIS are detected incidentally on imaging
studies – commonly as microcalcifications on mammography (most are
asymptomatic).
• Management options
A. Breast-conserving surgery as a component of breast conservation therapy (BCT) (partial
mastectomy and post op radiation therapy) OR
B. Simple mastectomy with breast reconstruction
• Contraindications of BCT:
1. Multicentric disease
2. Extensive disease where resection would result in poor cosmesis
3. Patients who cannot receive radiation therapy.
• Noninvasive lesion that arises from the lobules and terminal ducts of the
breast.
• Options:
a) Careful lifetime surveillance protocol
b) Chemoprevention with a SERM and/or AI
c) Prophylactic bilateral mastectomy
• More than 95% of patients with Paget disease have an underlying breast
carcinoma
• The median age at diagnosis is 68 years, 5 years older than that in women.
• The majority of men with breast cancer have a breast mass, and when
matched for age and stage, survival is similar to that in women.
• Simple mastectomy removes all breast tissue, the nipple–areola complex, and
necessary skin
• NSM (nipple sparing mastectomy) removes only breast tissue and preserves
the whole skin and the nipple-areola complex.
• MRM (Modified Radical Mastectomy) removes all breast tissue, the nipple–
areola complex, necessary skin, and the level I and II axillary lymph nodes.
• ALND in breast cancer involves removal of the level 1 and 2 lymph nodes
• Level 3 nodes are palpated and only in the presence of gross disease is
dissection performed.
• Postmastectomy radiation therapy is often recommended for women at high risk for
locoregional recurrence, including women with:
1. ≥ 4 positive lymph nodes (stage III)
2. Tumor size > 5 cm (stage III)
3. Positive surgical margins
4. Skin or chest wall involvement
5. Inflammatory CA
• In these instances, postmastectomy radiation can reduce the rate of chest wall
recurrence by 65% to 75%.
Dr. Mahmoud W. Qandeel
Chemotherapy
• Mostly given as adjuvant therapy and often initiated 4 to 6 weeks after surgery
• For patients at high risk for recurrence, a regimen based on the combination of an
anthracycline and taxane has been proven to be the most effective.
• The goal of neoadjuvant therapy is to shrink the primary breast cancer prior to surgery,
facilitating BCT.
OncotypeDX:
21-gene signature RT-PCR assay to calculate RS—predicts 10-y distant
recurrence rate;
– Low (RS <18) 6.8%;
– Intermediate (RS 18–30) 14.3%;
– High (RS ≥31) 30.5%.
– if high clinical risk including 1–3 LN, but good prognosis genetic risk,
may be able to avoid chemo (MINDACT, Lancet 2005, updated NEJM
2016)
• Consider Bisphosphonates
• Adjuvant denosumab 60 mg twice per year reduces the risk of clinical fractures
(50%) in postmenopausal women with breast cancer receiving aromatase
inhibitors, and can be administered without added toxicity.
• Nearly all women have lymph node involvement at the time of presentation and
approximately a third of patients will have distant metastases
• The prognosis for patients with IBC remains poor with 5-year disease-free
survival rates of 20% to 45% and an overall survival of 30% to 70%.
Management:
• Is present in its pure form, the distant metastatic potential is very low.
• The diagnosis is made when characteristic angulated tubules, composed of cells
with low-grade nuclei, constitute at least 90% of the carcinoma.
• For selected cases of pure tubular carcinoma removed with an adequate negative
margin, mastectomy, radiation therapy, or even axillary lymph node staging may be
unnecessary.