Breast

Question 1

Gynecomastia

Answer 1

Enlarged breast in males >2cm

Physiologic:
1. Neonate: Effect of maternal oestrogen on neonatal breasts
2. Adolescence: U/l
3. Senescence: B/l- 50-70 years- low testosterone levels

Klinefelter’s XXY- gynecomastia- predisposes to breast CA

Grades of gynecomastia
1- Mild enlargement without skin redundancy
2a- moderate enlargement without skin redudndancy
2b- moderate enlargement with skin redundancy
3- marked enlargement with skin redundancy and ptosis

Etiology:

1. Oestrogen excess states:
   Testicular/ non testicular tumors

Liver disorders- Alc/ non alc
Endocrine disorders- Hyper/ hypo thyr
Nutritional alterations- Prot , fat deprivation

2. Androgen deficient states
   Senescence
   Primary testicular failure- Klinefelter’s XXY- hypergonadotrophic hypogonadism, azoospermia
   Secondary testicular failure- Trauma, orchitis, irradiation, cryptorchidism
3. Drugs
4. Idiopathic

Subcutaneous mastectomy, local excision

Question 2

Benign breast disorders

Answer 2

Aberrations of Normal Development and Involution (ANDI) classification:

Early reproductive ages (15-25 yrs)- Fibroadenoma (lobular development), nipple inversion

Late reproductive ages (25-40 yrs)- Fibrocystadenosis (cyclical mastalgia), epithelial hyperplasia of pregnancy

Involution (35-55 yrs)- Cysts, duct ectasia, nipple retraction

Question 3

Fibroadenoma

Answer 3

Small
Large
Giant

Question 4

Carcinoma in situ

Answer 4

LCIS- Marker of increased risk of invasive breast CA- TDLU- Large cells with normal N:C ratio,

DCIS- Anatomic precursor for invasive ductal CA.
Cribriform growth pattern
Solid growth pattern
Comedo growth pattern with calcification in areas of necrosis

Question 5

Invasive Breast CA

Answer 5

1. Paget’s disease of the nipple- A/w DCIS/ any invasive CA. Chronic, eczematous eruption of the nipple with ulcerations and discharge. Palpable seldom present. Large, pale vacuolated cells- similar to DCIS.
2. Invasive ductal CA
3. Invasive lobular CA
4. Medullary CA
5. Mucinous CA
6. Papillary CA
7. Tubular CA

Question 6

Breast Imaging

Answer 6

Mammography:
Craniocaudal view- Visualises medial aspect of the breast better. With 90 degree lateral view- Triangulated the lesion.
Mediolateral oblique view- Visualises more of the breast tissue- upper outer quadrant

Spot compression view- Reduces motion artifacts, lesser radiation dose reqd.

> 20yrs- once in 3 yrs- Breast/E
40yrs- yearly breast/E and mammography

USG

Ductography: For nipple discharge especially bloody. Duct cannulated- patient put in supine position- contrast injected- Mammography done without compression.

MRI

Question 7

BIRADS

Question 8

TNM Staging

AJCC 7th ed

Answer 8

T0- No e/o tumour
Tis- DCIS/ LCIS/ Paget’s disease of nipple not a/w invasive CA/ CIS.
T1 <2cm
T2 2-5cm
T3 >5cm
T4a- Involvement of chest wall- not pectoralis major/ skin
T4b- Skin involvement- Ulcerations/ satellite nodules/ Peau d orange
T4c- 4a+4b
T4d- Inflammatory CA

N0- No LN metastases
N1
N2a
N2b
N3a
N3b
N3c

pN

Mo
cM0(i+) <0.2mm
M1 >02mm

Question 9

Stage 0 - In situ breast CA

Answer 9

LCIS- b/l MRM

DCIS-