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Benign breast disorders
Benign breast disorders
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Breast lump

  1. 1. Approaches of a Patient With a Breast Lump & Nipple Discharge
  2. 2. OBJECTIVES • Identify & Discuss the Differential Diagnosis of a Breast Lump • Present and Interpret a Good History & physical Examination for a Patient with a Breast Lump. • Discuss the Possible Causes of Nipple Discharge According to the Color & Nature of the Discharge. • Present a sound Approach to Investigate a Patient with a Breast Lump & Nipple Discharge. • Present a Possible Approach for Treatment.
  3. 3. ANATOMY
  4. 4. ANATOMY
  5. 5. ANATOMY
  6. 6. ANATOMY
  7. 7. BLOOD SUPPLY
  8. 8. LYMPHATIC DRAINAGE
  9. 9. HISTORY • Personal Data • Chief Complaint • H.C.C : when and how first noticed, Pain, tenderness, change in size over time and with menstruation.
  10. 10. EVALUATION OF A BREAST LUMP Important things to ask about : • Mastalgia : Cyclic Vs. Non- Cyclic • Skin Changes : Redness, Warmth, Tenderness,Dimpling,Peau d’ orange • Nipple Inversion : Benign Vs. Malignant
  11. 11. EVALUATION OF A BREAST LUMP Important Things to Ask About : • Nipple Discharge - Clear, Yellow, White, Green - Blood Stained or Dark - Purulent Discharge - Galactorrhoea • Gynaecomastia ( Males )
  12. 12. EVALUATION OF A BREAST LUMP • Gynecologic History : parous state,breast feeding,last period, drugs (HRT) • Past Medical History : benign breast disease, breast cancer, radiation therapy to breast • Past Surgical History: breast biopsy, lumpectomy, mastectomy, hysterectomy, oophorectomy.
  13. 13. EVALUATION OF A BREAST LUMP • Family History : Especially in first degree relatives. • Constitutional Features : - Anorexia - weight loss - Respiratory Symptoms - Bone Pain
  14. 14. PHYSICAL EXAM – Inspection, Palpation • Skin changes: Edema, Dimpling, Redness, Retraction, Ulceration, Peau d’orande • Nipple: Bloody Discharge, Crusting, Ulceration, Inversion. • Prominent Veins • palpable axillary/supraclavicular lymph nodes • Arm Edema
  15. 15. EVALUATION OF A BREAST LUMP Characteristics of a Breast mass • Size • Position • Mobility • Composition ( Fluctuant, Hard, Rubbery ) • Fixation to underlying tissue or skin
  16. 16. Differential Diagnosis of a Breast Lump • FIBROCYSTIC DISEASE • CYSTS • ADENOMAS • FIBROADENOMA • FAT NECROSIS • PAPILLOMA • BREAST CANCER
  17. 17. DIFFERENTIAL DIAGNOSIS OF NIPPLE DISCHARGE • Bloody: Papilloma, Papillary/Intraductal Carcinoma, Paget’s Disease, Fibrocystic change. • Serous: duct hyperplasia, pregnancy, OCP, menses, cancer. • Green/Brown: mamillary duct ectasia, fibrocystic change.
  18. 18. DIFFERENTIAL DIAGNOSIS OF NIPPLE DISCHARGE • Purulent: superficial or central abscess • Milky: post-lactation, OCP, prolactinoma
  19. 19. INVESTIGATIONS • Standard Investigations • Mammography • U/S • Biopsy • Magnetic Resonance Imaging • Cytology • Imaging for metastases
  20. 20. INVESTIGATIONS • Standard Investigations • Mammography • U/S • Biopsy • Magnetic Resonance Imaging • Cytology • Imaging for metastases
  21. 21. Mammography Indications • screening – every 1-2 years for women ages 50-69. • metastatic adenocarcinoma of unknown primary. • nipple discharge without palpable mass.
  22. 22. Mammography Mammogram findings indicative of malignancy • stellate appearance and spiculated border - pathognomonic of breast cancer. • microcalcifications, ill-defined lesion border. • lobulation, architectural distortion
  23. 23. Mammography NOTE: • normal mammogram does not rule out suspicion of cancer, based on clinical findings.
  24. 24. Ultrasonography • Performed primarily to differentiate cystic from solid lesions. • Not diagnostic
  25. 25. Biopsy • The diagnosis of breast cancer depends upon examination of tissue or cells removed by biopsy. • The safest course is biopsy examination of all suspicious masses found on physical examination and of suspicious lesions demonstrated by mammography.
  26. 26. Biopsy • The simplest method is needle biopsy, either by aspiration of tumor cells ( fine – needle aspiration cytology) or by obtaining a small core of tissue with a hollow needle. • Open biopsy… ( incisional or excisional )
  27. 27. Magnetic Resonance Imaging • High Sensitivity for breast cancer • Can demonstrate the extent of both invasive & non-invasive disease. • Determines weather a mammographic lesion at the site of previous surgery is due to scar or recurrence. • The optimum method for imaging breast implants and detecting implant leakage or rupture.
  28. 28. cytology • Cytologic examination of nipple discharge or cyst fluid may be helpful on rare occasions. • As a rule, mammography and breast biopsy are required when nipple discharge or cyst fluid is bloody or cytologically questionable.
  29. 29. Imaging for metastases • Chest x-ray may show pulmonary metastases. • CT scanning of liver and brain is of value only when metastases are suspected in these areas.
  30. 30. Benign Breast Lumps • FIBROCYSTIC DISEASE • FIBROADENOMA • FAT NECROSIS • PAPILLOMA • FIBROADENOSIS-focal/diffuse nodularity • GALACTOCOELE • ABSCESS • PERIDUCTAL MASTITIS-secondary to duct ectasia
  31. 31. FIBROCYSTIC DISEASE • Benign breast condition consisting of fibrous and cystic changes in breast. • Age : 30-50 years • Clinical Features - breast pain - swelling with focal areas of nodularity or cysts - Frequently bilateral - varies with menstrual cycle
  32. 32. FIBROCYSTIC DISEASE Treatment • If no dominant mass, observe to ensure no mass dominates. • For a dominant mass, FNA • If > 40 years, mammography every 3 years • Avoid xanthine-containing products (coffee, tea, chocolate, cola drinks) and nicotine. • For severe symptoms – danozol (2- 3 months), or tamoxifen (4-6 weeks)
  33. 33. FIBROADENOMA • Most common benign breast tumour in women under age 30. • No malignant potential • Clinical features – smooth, rubbery, discrete, well circumscribed nodule, non-tender, mobile, hormonally dependant. • Management – usually excised to confirm diagnosis
  34. 34. FAT NECROSIS • Due to trauma (although positive history in only 50%). • Clinical features – firm, ill-defined mass with skin or nipple retraction, +/– tenderness. • Management – will regress spontaneously but complete excisional biopsy is the safest approach to rule out carcinoma.
  35. 35. PAPILLOMA • Solitary intraductal benign polyp. • Most common cause of bloody nipple discharge. • Management – excision of involved duct
  36. 36. Breast Cancer • Epidemiology • Risk factors • Pathology • Staging (clinical & pathological) • Metastasis • Treatment • Local/Regional Recurrence • Prognosis
  37. 37. EPIDEMIOLOGY • Most common cancer in women. • Second leading cause of cancer mortality in women. • Most common cause of death in 5th decade. • Lifetime risk of 1/9
  38. 38. RISK FACTORS • age - 80% > 40y.o • sex - 99% female • 1st degree relative with breast cancer - Risk increases if relative was premenopausal. • Geographic - highest national mortality in England and Wales, lowest in Japan. • Nulliparity • late age at first pregnancy>30y.o
  39. 39. • Early menarche < 12; late menopause > 55 • obesity • excessive alcohol intake, high fat diet • certain forms of fibrocystic change • prior history of breast ca • history of low-dose irradiation • prior breast biopsy regardless of pathology • OCP/estrogen replacement may increase risk
  40. 40. Sites of Breast Cancer
  41. 41. Pathology Non-invasive (DCIS and LCIS)  (1)Ductal carcinoma in situ (DCIS) •  proliferation of malignant epithelial cells completely contained within breast ducts • risk of development of infiltrating ductal carcinoma in same breast is 25-30% • considered a pre-malignant lesion.
  42. 42. Pathology Non invasive (2)Lobular carcinoma in situ (LCIS) •  proliferation of malignant epithelial cells completely contained within breast lobule •  no palpable mass, no mammographic findings, usually found on biopsy for another abnormality.
  43. 43. Pathology Invasive (1)Ductal carcinoma (most common - 80%) •  originates from ductal epithelium and infiltrates supporting stroma   (2)Paget’s disease (1-3%) •  ductal carcinoma that invades nipple with scaling, eczematoid lesion
  44. 44. Pathology Invasive (3)Invasive lobular carcinoma (8- 10%) •  originates from lobular epithelium •  more apt to be bilateral, better prognosis •  does not form microcalcifications 
  45. 45. Pathology Invasive (4)Inflammatory carcinoma (1-4%) •  ductal carcinoma that involves dermal lymphatics •  most aggressive form of breast cancer •  presents with erythema, skin edema, warm swollen tender breast, +/– lump •  peau d’orange indicates advanced disease (IIIb-IV)
  46. 46. staging Clinical: • assess tumor size, nodal involvement, and metastasis • tumor size by palpation, mammogram • nodal involvement by palpation • metastasis by physical exam, CXR, LFTs, bone scan
  47. 47. staging Pathological • Histology • axillary dissection should be performed for accurate staging and to reduce risk of axillary recurrence • estrogen/progesterone receptor testing presence or absence of estrogen and progesterone receptors,
  48. 48. Staging of Breast Cancer (American Joint Committee) Stage Tumor Regional Metastasis Nodes O In situ no no 1 <2 cm no no 2 <2 cm or Movable no 2-5 cm or ipsilateral >5 cm 3 Any size fixed no 4 any any distant
  49. 49. Treatment • Primary Treatment of Breast Cancer • total mastectomy – removes breast tissue, nipple-areolar complex and skin • modified radical mastectomy (MRM) – removes breast tissue, pectorali fascia, nipple-areolar complex, skin and axillary lymph nodes
  50. 50. Treatment stage 0 DCIS – total ipsilateral mastectomy vs. wide local excision (WLE) plus radiation therapy (XRT), • axillary node dissection is not required for DCIS LCIS – close observation vs. bilateral total mastectomy, axillary node dissection is not required Paget’s disease – total mastectomy vs. MRM
  51. 51. Treatment stages I,II surgery for cure MRM vs. WLE with axillary node dissection plus XRT adjuvant chemotherapy in node- positive patients and high risk node- negative patient
  52. 52. Treatment Stages III,IV operate for local control includes surgery, radiation and systemic therapy individualized, but mastectomy is most common procedure • even with aggressive therapy most patients die as a result of distant metastasis Indication of chemotherapy tumors > 5 cm inflammatory carcinomas chest wall or skin extention
  53. 53. • Adjuvant Therapy – Combination Chemotherapy • indications – node-positive patients, high risk node-negative patients, and palliation for metastatic disease, • ER negative patients • CMF (cyclophosphamide, methotrexate, 5- flurouracil) x 6 months
  54. 54. Adjuvant Therapy - Hormonal • indications – ER positive, pre- or post-menopausal, node-positive or high risk node-negative patients. • • adjuvant or palliative therapy • Tamoxifen (anti-estrogen) – is agent of choice, continue for 5 years • alternatives to tamoxifen
  55. 55. • Adjuvant Therapy - Radiation • with breast-conserving surgery • those with high-risk of local recurrence • adjuvant radiation to breast decreases local recurrence, increases disease free survival • (no change in overall survival)
  56. 56. Post-Surgical Management 1.follow-up of post-mastectomy patient history and physical every 4-6 months yearly mammogram of remaining breast 2.follow-up of segmental mastectomy patient history and physical every 4-6 months mammograms every 6 months x 2 years, then yearly thereafter 3.when clinically indicated chest x-ray bone scan LFTs CT of abdomen CT of brain
  57. 57. CHEMOTHERAPY

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