Benign Breast Disease Breast Tenderness (Cyclic Mastalgia)
Breast Tenderness (Non-cyclic Mastalgia)
Classification of Fibrocystic Changes
Breast Tenderness (Cyclic Mastalgia)
The breast tissue cycles hormonally during the menstrual phase, similarly to the uterus. The breasts increase in size and volume by 50% approximately 2 weeks prior to menses. This is often heralded by breast tenderness or mastalgia. The breast usually returns to their premenstrual state approximately one week after menses. This is often called mastitis or fibrocystic disease (actually condition, as 90% of women have fibrocystic changes) but represents a normal condition of the breast. The symptoms can be alleviated many times by reducing caffeine intake (coffee, tea, cola and chocolate), taking vitamin E, or taking Evening Primrose Oil, generally within three to four months.. Ninety percent of the time, breast tenderness is benign or not malignant (cancer). Breast cancer is usually painless.
Breast Tenderness (Non-cyclic Mastalgia)
Generally seen in older women and not related to the menstrual cycles. Non-cyclic mastalgia may be related to a variety of medications (estrogen replacement, lanoxin, pepcid, thiazide diuretics, etc., or arthritic changes of the thoracic spine). Improvement occurs with anti-inflammatories.
These benign tumors usually present as a mass in the breast during adolescence and young adulthood. These masses can enlarge and become tender during menstrual cycle and can become quite large. With increasing age, fibroadenomas may calcify and with this calcification, have a typical mammographic appearance. Rarely are fibroadenomas associated with malignancy.
Appearing during pregnancy or during lactation, they likewise present as a mass (lump) in the breast and are similar to fibroadenomas.
Normally, ten to fifteen ducts open on the surface of the nipple. Seventy percent of women will periodically have nipple discharge. If the discharge is cloudy green, cloudy yellow or milky, from multiple ducts in both breasts, the discharge is usually benign. Galactorrhea (milky discharge) may be associated with hypothyroidism (low levels of thyroid hormone) or pituitary adenomas (benign growths of the pituitary). Determination of TSH (thyroid stimulating hormone) and prolactin levels (blood tests) may indicate these as potential sources of nipple discharge. Many medications can likewise be associated with nipple discharge. Benign multiduct nipple discharge is not an indication for surgical biopsy
Bloody or serous (clear yellow) nipple discharge from a single duct and noted spontaneously, in nightgowns or bras, are concerning for underlying problems and should be evaluated by a physician. Only a third of these discharges are malignant but they represent one of the warning signs for cancer. Galactography or mammary duct excision (surgical procedure to remove the duct) generally reveal an intraductal papilloma, a benign growth of the breast ducts.
This term, is generally used by clinicians to describe the induration (swelling) and tenderness associated with the menstrual cycle. Pathologically, (under the microscope) these changes are characterized by the formation of cysts (fluid filled sacs) of various sizes, stromal fibrosis (scarring of tissue surrounding the functional breast units) and a variety of proliferative lesions (increased layers of cells lining the ducts). These changes are present in 90% of women and can therefore not be classified as a disease but represent the normal changes in the breast with increasing age.
Classification of Fibrocystic Changes
Generally associated with a history of trauma, fat necrosis presents as a firm mass in the breast. Clinically and by mammography it may be indistinguishable from carcinoma of the breast. The diagnosis is usually made by breast biopsy.
Subareolar abscess presents with pain and redness of the nipple areolar complex. The abscess is generally polymicrobial (more than one bacterium) and usually seen in smokers. Treatment of the abscess is by incision and drainage.
Seen within the first weeks after the onset of breast-feeding, the breast usually inflamed (erythematous or red) warm and tender in a wedge shaped distribution. Cracked nipples usually cause this condition. The organism responsible for this infection is usually staph aureus and this condition will respond to antibiotics. If not treated promptly, this condition may lead to breast abscess requiring surgical drainage.
of women will periodically have nipple discharge.
Malignant Breast Disease
Breast cancer is the most common malignancy in women and the second leading cause of cancer death (exceeded by lung cancer in 1985). Breast cancer is three times more common than all gynecologic malignancies put together. The incidence of breast cancer has been increasing steadily from an incidence of 1:20 in 1960 to 1:8 women today.
The American Cancer Society estimates that 182,800 new cases of invasive breast cancer will be diagnosed this year and 40.800 patients will die from the disease. Breast cancer is truly an epidemic among women and we don't know why.
Breast cancer is not exclusively a disease of women. For every 100 women with breast cancer, 1 male will develop the disease. The American Cancer society estimates that 1500 men will develop the disease this year. The evaluation of men with breast masses is similar to that in women, including mammography.
The incidence of breast cancer is very low in the twenties (age) gradually increases and plateaus at the age of forty-five and increases dramatically after fifty. Fifty percent of breast cancer is diagnosed in women over sixty-five indicating the ongoing necessity of yearly screening throughout a woman's life.
Breast cancer is considered a heterogenous disease, meaning that it is a different disease in different women, a different disease in different age groups and has different cell populations within the tumor itself. Generally, breast cancer is a much more aggressive disease in younger women. Autopsy studies show that 2% of the population has undiagnosed breast cancer at the time of death. Older women typically have much less aggressive disease than younger women.
Risk Factors for the Development of Breast Cancer
Early onset of
menses and late menopause: onset of the menstrual cycle prior to the
age of 12 and menopause after 50 causes increased risk of developing breast
Family history of breast cancer: Patients with a positive family history of breast cancer are at increased risk for developing the disease. However, 85% of women with breast cancer have a negative family history!
Family history only includes immediate relatives, mother, sisters and daughters. If a family member was post-menopausal (fifty or older) when she was diagnosed with breast cancer, the lifetime risk is only increased 5%. If the family member was premenopausal, the lifetime risk is 18.6%. If the family member was premenopausal and had bilateral breast cancer, the lifetime risk is 50%.
Women with a significantly positive family history of premenopausal breast cancer should begin screening mammography a decade sooner than their family member was diagnosed. BRCA-1 and BRCA-2 gene testing can identify those patients at increased risk, genetically, for developing not only breast cancer but also a variety of epithelial tumors including ovarian and colon cancer.
At this time genetic testing is investigational. If a woman is determined to have these genetic markers, should we recommend bilateral mastectomy and oophorectomy? Further, if her insurance company knows that she has these genetic markers of increased risk, she may loose her insurance coverage. If a woman decides to proceed with genetic testing, we recommend that this test be paid for by the individual to keep the results confidential.
Late or no pregnancies: Pregnancies prior to the age of twenty-six are somewhat protective. Nuns have a higher incidence of breast cancer.
Moderate alcohol intake: Greater than two alcoholic beverages per day.
Estrogen replacement therapy: Most studies indicate that taking estrogen longer than ten years may lead to a slight increase in risk for developing breast cancer. However, these studies indicate that the positive benefits of taking estrogen as far as reducing the risk for osteoporosis, heart disease and now more recently Alzheimer's and colon cancer, far outweigh the slight increase in risk that may be associated with estrogen replacement therapy.
Caution should be
exercised in those women with a significantly positive family history
of breast cancer or atypical intraductal hyperplasia. Women with breast
cancer are not currently give estrogen replacement. There are no scientific
studies currently justifying this practice. However, until those studies
are available, by convention, women are taken off estrogen.
Female: The mere fact that being female increases the risk of developing breast cancer. However, for every 100 women with breast cancer, 1 male will develop the disease.
Therapeutic irradiation to chest wall i.e., for Hodgkins Disease (cancer of lymph nodes): Patients who have had therapeutic irradiation to the chest are at increased risk for developing breast cancer approximately 10 years later and consideration should be given to earlier screening in this population.
Moderate obesity: The relationship of breast cancer to obesity is more complex but associated with an increased risk.
Breast Cancer Types
Ductal Carcinoma in-situ: Generally divided into comedo (blackhead, the cut surface of the tumor demonstrates extrusion of dead and necrotic tumor cells similar to a blackhead) and non-comedo types. DCIS is early breast cancer confined to the inside of the ductal system. The distinction between comedo and non-comedo types is important as comedocarcinoma in-situ generally behaves more aggressively and may show areas of microinvasion (small areas of invasion through the ductal wall into surrounding tissue).
The surgical management is the same as for other types of breast cancer except axillary node sampling is not done, as only 1% of these lesions will have axillary metastasis. We recommend, however, that irradiation be given if treated with conservative breast surgery to reduce the recurrence rate from 21% without irradiation, to 5%-10% with irradiation. This is a controversial area of the treatment of breast cancer.
Infiltrating Ductal: The most common type of breast cancer representing 78% of all malignancies. These lesions can be stellate (star like in appearance on mammography) in appearance or well circumscribed (rounded). The stellate lesions generally have a poorer prognosis.
Medullary Carcinoma: Comprise 15% of breast cancers. These lesions are generally well circumscribed and may be difficult to distinguish from fibroadenoma by mammography or sonography. Medullary carcinoma is estrogen and progesterone receptor (prognostic indicator) negative 90% of the time. Medullary carcinoma usually has a better prognosis than ordinary breast cancer.
Infiltrating Lobular: Representing 15% of breast cancer these lesions generally present in the upper outer quadrant of the breast as a subtle thickening and are difficult to diagnose by mammography. Infiltrating lobular can be bilateral (involve both breasts). Microscopically, these tumors exhibit a linear array of cells (Indian filing) and grow around the ducts and lobules (targeting).
Tubular Carcinoma: Orderly or well differentiated carcinoma of the breast. These lesions make up about 2% of breast cancer. They have a favorable prognosis with nearly a 95% 10-year survival.
Mucinous Carcinoma: Represents 1%-2% of carcinoma of the breast and has a favorable prognosis. These lesions are usually well circumscribed (rounded).
Inflammatory Carcinoma: A particularly aggressive type of breast cancer the presentation is usually noted in changes in the skin of the breast including redness (erythema), thickening of the skin and prominence of the hair follicles resembling an orange peel (peau d' orange). The diagnosis is made by a skin biopsy, which reveals tumor in the lymphatic and vascular channels 50% of the time.
Tumor size: As the size of the tumor increases the risk of axillary and systemic metastasis increases.
the appearance of the tumor cells under the microscope and graded
from 1) well differentiated, 2) Moderately differentiated and 3) poorly
differentiated. The survival diminishes with increasing histologic grade.
Axillary Nodes: The most important prognostic indicator. Patients with negative axillary nodes (microscopically) have improved disease free and long-term survival.
DNA Flow Cytometry: Test that determines the genetic material within the cell. Tumors with a normal amount of DNA (diploid) have a better disease free and long-term survival than those with an abnormal amount of DNA (aneuploid). This study also determines the percentage of cells in active division. Tumors with active cellular division of < 10% have a better prognosis.
Her-2/neu: Protein product secreted by the tumor indicating a decreased disease free and long term survival.
Breast Cancer Staging
Stages of Breast Cancer
Five Year Survival Rate by Stage
Mammography should continue yearly after 40 throughout a woman's
Treatment Options for Breast Cancer
Historical Aspects of Surgical Management
Historical Aspects of Surgical Management
We have known about breast cancer for thousands of years. The Smith Papyrus talks about breast cancer in 3000 BC. It was treated with a variety of topical agents or poultices and understandably, these women did not survive. There were early attempts to treat breast cancer surgically in the early 1100's.
Anesthesia was not developed until 1846 and antibiotics not until 1927. The breast was rapidly amputated with women awake. If the surgical procedure was not fatal, about 20% of these women died from infection. In 1893, William Halstead, M.D. (the father of American Surgery) developed an operation called the radical mastectomy. This operation removed the breast, chest wall muscles and the lymph nodes from under the arm. It was a very cosmetically deforming operation and women had a great deal of disability involving their extremity but there were long-term survivors from breast cancer. Women typically presented with large tumors or extensive disease (mammography was not utilized until the 1970's). This was the standard operation for the treatment of breast cancer through the late 1960's.
In the 1970's we began treating women with modified radical mastectomies. This operation removed the breast, preserving the chest wall muscles and sampling the axillary nodes. These women survived just as long as those women who had radical mastectomies did. Modified radical mastectomy then became the standard operation for the treatment of breast cancer and remains an option today.
Italian investigators began doing early conservative breast surgery (lumpectomy and irradiation) in the early 1970's. The criteria that they used to select women for conservative breast surgery were the mass had to be less than 2 cm. in size and the lymph nodes were not enlarged on a clinical examination.
A quarter of the breast was removed, the lymph nodes sampled and the breast irradiated. These women survived just as long as those that had modified radical or radical mastectomy. In the United States, the criteria that are used to select patients for conservative breast surgery are that the mass is less than 4 cm. in size, the lymph nodes can be clinically enlarged on a breast examination. These women are surviving just as long as those that had a modified radical or a radical mastectomy. The whole breast must be treated in some fashion, either removing it or irradiating the breast as breast cancer can be multifocal (involve multiple areas of the breast 23%-55% of the time).
However, not all women are candidates for breast conservation. The following may exclude from consideration some women from breast conservation.
Options Currently Recommended for the
Stage I and stage II lesions are treated in the above fashion. Stage III lesions are generally treated with chemotherapy first, then surgery and possibly irradiation. Tumors with greater than 4 positive lymph nodes, will generally receive adjuvant irradiation in addition to surgery and chemotherapy.
Sentinel Node Biopsy
Sentinel node biopsy is an experimental technique that utilizes a radioactive tracer or blue dye injected into the tumor. The contrast material is absorbed by the lymphatic system. The contrast material then travels to the first lymph node draining the tumor called the sentinel node. If the sentinel node is negative, a woman may not need a more extensive axillary dissection (sampling of the axillary nodes) and avoid the potential complications of axillary dissection (lymphedema: swelling of the arm secondary to lymphatic obstruction).
Prior to 1988, if a woman had pathologically negative axillary nodes (no tumor in the lymph nodes under the microscope) chemotherapy was not recommended. In 1988, the NIH (National Institute of Health) recommended that all women receive chemotherapy. Seventy percent of women achieve long-term disease free survival with surgery alone. Based on this recommendation, 100% of women would receive chemotherapy when only 30% would benefit. This recommendation was based on the observation that some women with stage I disease would recur 15-20 years later with a focus of breast cancer elsewhere (metastatic disease). As a result, our thinking about breast cancer has changed. Breast cancer may well be a systemic disease (microscopic disease elsewhere) at the time of diagnosis.
Nationally, this recommendation has been modified. Recommendations for chemotherapy are made for node negative women based on prognostic indicators. If the tumor is greater than 1 cm in size and the prognostic indicators suggest an increased recurrence rate, chemotherapy is recommended. Essentially all patients with positive axillary nodes receive chemotherapy.
A variety of chemotherapy agents are utilized in the treatment of breast cancer including cytoxan, methotrexate and 5-fluoruracil (CMF), adriamyacin and cytoxan (AC), Taxol or Taxotere and Tamoxifen. The medical oncologist selects these various agents based on the prognostic indicators, the age of the patient and underlying medical condition. Chemotherapy generally begins within 2 weeks of surgery and continues for several months. Chemotherapy can reduce the risk of recurrence by 30%-40% and reduce the risk of developing breast cancer on the other side by the same percentage. The side effects of chemotherapy vary depending upon the agents utilized and the individual.
A wavelength of light used to treat the breast in conservative breast surgery, for consolidation of extensive local disease (large tumors or more than 4 positive axillary nodes) or local recurrence of breast cancer. Irradiation destroys the microscopic residual disease that remains after surgery or not apparent clinically. Like surgery, it is a local treatment, in contrast to chemotherapy, which is a systemic treatment. The side effects of irradiation include erythema of the skin (sunburn), turning into a brawny induration (thickening and increased pigmentation of the skin) and some shrinkage of the breast tissue with conservative breast surgery. Some women note fatigue after treatment. Irradiation generally occurs after chemotherapy, if chemotherapy is given. Irradiation can also be utilized for palliation (relief of symptoms, i.e. bone pain) with recurrent disease.
Local Recurrence and Systemic or Metastatic Disease
At the time of diagnosis, breast cancer may be a systemic disease in other words there may be microscopic or macroscopic (larger lesions, clinically detectable through imaging) disease elsewhere. This is the reason for the current recommendations for chemotherapy. How do we know that you do not have disease elsewhere? Prior to surgery, a chest x-ray and blood tests looking at liver function studies and serum calcium will be obtained. If the results of these studies are negative, less than 4% of women will have disease that can be demonstrated elsewhere. This does not mean that microscopic disease is not present just that it cannot be demonstrated with additional imaging modalities. However, a CT scan of the chest and upper abdomen as well as a bone scan will generally be obtained during the course of your treatment to serve as base line studies to compare future studies. Routine annual imaging, other than mammography, is not accomplished, as there is no survival advantage in detecting an asymptomatic recurrence. Systemic recurrence is treated with chemotherapy.
Local recurrence after conservative breast surgery is treated with salvage mastectomy. Local recurrence with mastectomy is treated with wide surgical excision if possible and irradiation. Both are usually given additional chemotherapy.
10% of breast cancer may present as an axillary node alone.