Breast

Breast short note by S.Wichien (SNG KKU) Embryology 5th,6th wk -2 ventral bands of ectoderm (mammary ridge/milk line) (axilla to inguinal area) Polymastia -accessory breast Polythelia -accessory nipple -small canular -0.1-0.2 ml contrast is injected -filling defect-->intraductal papilloma MRI -hi-sen, low spec than MRM 1.ALN+ve, unknown 1° 2.promblematic MMG 3.rupture silicone Nonpalpable lesion Bx -u/s localization--have mass -stereotactic technic --no mass Palpable lesion Bx -FNA Bx -CNBx CNBx need further excision 1.ADH, ALH 2.radial scar 3.papilloma lesion 4.vascular proliferation 5.phylloides tumor Indice of Poliferation Apoptosis Angiogenesis GF Steroid H.R

PCNA Bcl2 protein Bax : Bcl2 ratio (low=poor prog) VGEF EGF, HER2/neu EP, PR

Breast short note by S.Wichien (SNG KKU) Gynecomastia -Male breast enlarge,elongate,inc epi -often unilateral -12-15 yr -at least 2 cm in diameter -usually not predispose ca Physiologic 1.neonate 2.adolescent 3.senescence--dec T,relative inc E Klinefelter synd (XXY) -hypoandrogenic state -inc risk of ca breast Classification gr1-mild enlarge,wo skin redundancy gr2a-mod enlarge,wo skin redundancy gr2b-mod enlarge,w skin redundancy gr3-mark enlarge,as female breast Cause Estrogen excess 1.testicular tumor -germ cell tumor--seminoma -gonodal tumor--leydig,sertoli cell 2.non testicular tumor -adrenal cortical tumor -lung ca -hepatoma 3.non alc/alc cirrhosis Androgen deficiency 1.senescene 2.hypogonadism 1°testicular failure--klinefelter synd 2°testicular failure :trauma,orchitis,cryptorchidism,XRT Tx -add testosterone Drugs reserpine,theophylline verapamil TCA,furosemide Tx -stop drugs Idiopathic -tamoxifen 40 mg/d 1-4 m

ANDI Abberrant of Normal Development and Involution Early reproductive yr (15-25yr) Normal 1.lobular development 2.stromal development 3.nipple eversion Disorder 1.fibroadenoma (3cm) 2.gigantomastia 3.subareolar absecss Mammary duct fistula Later reproductive yr (25-40yr) Normal 1.cyclic change of menstruation 2.epi hyperplasia of preg Disorder 1.cyclic mastalgia and nodularity 2.bloody nipple discharge Disease 1.incapacitating mastalgia 2.Involution Normal 1.lobular involution 2.duct involution--dilatation/sclerosis 3.epi turnover Disorder 1.macrocyst/sclerosing lesion 2.duct ectasia/nipple retraction 3.epi hyperplasia Disease 1.2.periductal mastitis 3.epi hyperplasia w atypia

Breast short note by S.Wichien (SNG KKU) Benign breast disease 1.Non-proiferative disorder ¤no inc risk ca -fibrocystic disease (cyst & apocrine metaplasia) -duct ectasia -mild ductal epi hyperplasia -calcification -fibroadenoma and related lesion 2.proliferative disorder wo atypia ¤no inc risk ca -sclerosing adenosis -radial & complex sclerosing lesion -ductal epi hyperplasia -intraductal papilloma 3.atypical proliferative lesion ¤inc risk ca 4x -atypical lobular hyperplasia -atypical ductal hyperplasia

Benign breast Tx Cyst -cyst aspiration Fibrocystic dz -reassure/symp Tx -danazol,nsaid,tamoxifen,bromocrip Fibroadenoma giant fibroadenoma >5cm -should r/o phyllodes tumor Sx I/C ->40yr -rapid growth>20% ->5cm Sclerosing disorder -excision bx are needed to r/o ca -stereotactic guide bx Periductal mastitis -ATB--metro+cloxa -abscess--drainage Recurrent abscess w fistula Fistulectomy Total d excision -small abscess large>50%areolar -same lesion different lesion -no N.inversion mark N.inversion -young pt old pt -no d/c pus d/c -no fistulec recur after fistulec Nipple inversion -shortening subareolar duct -sx correction--cosmetic reason -c/p--nipple sensation/necrosis, fibrosis-->nipple retraction Intraductal papilloma -microdochectomy Cyclic mastalgia 1st=Pimrose oil (Gamma Linoleic Acid) 2nd=Danazol 3rd=Bromocriptine 4th=Tamoxifen

Breast short note by S.Wichien (SNG KKU) Infection 1.bact infection -Staph--localized,deep abscess Strep--diffuse superficial involve -breast feeding -subareolar,periduct,retromam space Tx -local w care--warm comp -iv ATB -I&D--should Bx abscess cavity Zuska disease (recurrent periductal mastitis) -recurrent retroarolar infect/abscess Tx -ATB+I&D 2.mycotic infection -blastomycosis or sporotrichosis -intra oral fungi--sucking infant -abscess close to NAC Tx -antifungal agent -+/-drainage 3.hiradenitis supparativa -axilla--sebaceous gl NAC--Montgoney gl -mimic chronic inflam,paget,ca 4.mondor s dz -variant of thrombophlebritis -superficial v of ant chest wall -lateral thoracic v,thoracoepigastric v superficial epigastric v -tender,cord like structure -benign, self limited dz--4-6 wk Tx -anti-inflam -warm compression -restrict of motion of ipsilat ext -braissiere support -not improve-->excision

LCIS & DCIS 1.age 2.incidence 3.clinical 4.MMG 5.premeno 6.synchro 7.multicentric 8.bilat 9.axilla metas 10.male 11.subsequent interval to dx histo incidence laterality

LCIS DCIS 44-47 54-58 yr 2-5 5-10% no mass,pain,dc no microcalci 2/3 1/3 5 2-46% 60-90 40-80% 50-70 10-20% 1 1-2% 5% ca 15-20 5-10 yr ductal ductal 25-35% 25-70% bilat ipsilat

LCIS -only in female breast -Terminal Duct Lobular Unit--TDLU -distort/distend TDLU -maintain normal N:C ratio -calcify in adjacent tissue -incidental finding DCIS -can seen in male breast ca -proliferation of epi in duct -papillary growth -intraductal ca 1.cribiform pattern 2.solid growth pattern 3.comedo growth pattern Classification of DCIS Histo nu.gr necrosis DCIS grade comedo hi extensive high IM IM focal/no IM noncomedo low absent low ¤IM--intermediate

Breast short note by S.Wichien (SNG KKU) Ca breast 1.sporadic 65-75% 2.familial 20-30% 3.hereditary 5-10% BRCA1 45% BRCA2 35% p53(Li fraumeni) 1% STK11/LKB1(Peutz Jegh) =10 or IMLN/SCLN/IFLN M M0-no M1-distant metas

Sentinel LN bx -T1,2,3 , No C/I -palpable lymphadenopathy -prior sx,CMT,XRT -multifocal breast ca Agent 1.radioactive colloid -intraop gamma probe -radioactivity count 2.isosulfan blue dyle (Lymphazurin) -intraop visualization *combine 1+2=more accurate Procedure -4ml of isosulfan blue dye is inject -1ml inject between ca site and skin -nonpalpate--u/s guide,wire localize -3-4 cm incision curved transverse -lower axilla just below hairline -identify lateral of pectoralis m -divided clavipectoral fascia -exposed axilla content Tx -false+ve--3% (3% skip to level 3) Macrometas(pN1) ->2mm Tx--must ALND Micrometas(pN1mic) -0.2-2mm Tx--should ALND

Early breast ca—stage1, 2a Locally advance—stage2b,3a,3b,3c (T3/N2)

Isolated tumor cell or tumor cruster (pN0) -myocutaneous flap Immediate after sx -after mastectomy for early inva ca Delayed 6mo after complete adju Tx -for advanced breast ca -ensure locoregional control of ds Myocutaneous flap 1.latissimus dorsi flap -skin paddle--latissimus dorsi m. -thoracodorsal a.--from post ICS a 2.rectus abdominis flap -Transverse Rectus Abdominis Myocutaneous flap (TRAM) -skin paddle--rectus abdominis m. -inf epigastric a -free TRAM--microvascu.anastomosis Chest wall defect -ca involved chest wall -1,2 rib -- ok ->2 rib--Marlex mesh -then cove by flap Breast RT I/C -BCT--aftet sx 2-3 wk, not>6 wk -T3,4 -inflam breast -skin,fascia,pectoralis involve -lymphovascular invasion -close margin,free margin 4node :>2cm :matted node>3 nodes :gross extracapsular invasion -palliative tx for stage 4/recurrent

Endocrine Tx -all in HR+ve -premense--tamoxifen > AI :20mg/d *5yr :stop if AUB,thromboembolic -postmense--AI > Tamoxifen :upfront--tamoxifen 5yr :switching--tamoxifen 2yr--AI 3yr :extended AI--tamoxifen 5yr--AI 3yr Determining menopause -prior bilat oophorectomy ->=60yr, =12mo Drugs 1.antiestrogen -tamoxifen,toremifene,fulvestrant Tamoxifen s/e -DVT,pulmo.emboli -endometrial ca -hot flush--most common -thrombocytopenia,leukopenia 2.AI -anastrozol--arimidex -letrozole--femara AI s/e -osteoporosis 3.LHRH -goserelin,leuprolide,buserelin Chemotherapy I/C -T>1cm -all in node +ve -ER,PR -ve -lymphovascular invasion -hi nuclear grade -HER2/neu overexpression 3 groups 1.non-anthracyclin based regimen--CMF -low risk of recurrent 2.anthracycline based regimen -FAC*6, CAF*6 -ET CT or (antra) (antra/tax) CT-->ET (CMF/antra) CT-->ET CT-->ET CT (antra) (antra) (tax)

E.responsive--ER/PR+ve E.uncertain--ER/PR+ve but 98% :microcalcify--f/u 6 mo :mass--f/u 4 mo 4=suspicious abnormality--5-95%--bx 4a=low probability 4b=intermediate probability 4c=intermediate but not typical 5=highly suspicious-->=95%--bx/sx 6=known bx proven malignancy