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Breast lump

Breast lump






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    Breast lump Breast lump Presentation Transcript

    • Approaches ofa Patient With aBreast Lump &NippleDischarge
    • 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.
    • HISTORY• Personal Data• Chief Complaint• H.C.C : when and how first noticed, Pain, tenderness, change in size over time and with menstruation.
    • EVALUATION OF ABREAST 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
    • EVALUATION OF ABREAST LUMP Important Things to Ask About : • Nipple Discharge - Clear, Yellow, White, Green - Blood Stained or Dark - Purulent Discharge - Galactorrhoea • Gynaecomastia ( Males )
    • EVALUATION OF ABREAST 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.
    • EVALUATION OF ABREAST LUMP• Family History : Especially in first degree relatives.• Constitutional Features : - Anorexia - weight loss - Respiratory Symptoms - Bone Pain
    • 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
    • EVALUATION OF ABREAST LUMPCharacteristics of a Breast mass• Size• Position• Mobility• Composition ( Fluctuant, Hard, Rubbery )• Fixation to underlying tissue or skin
    • 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.
    • DIFFERENTIAL DIAGNOSISOF NIPPLE DISCHARGE• Purulent: superficial or central abscess• Milky: post-lactation, OCP, prolactinoma
    • INVESTIGATIONS• Standard Investigations• Mammography• U/S• Biopsy• Magnetic Resonance Imaging• Cytology• Imaging for metastases
    • INVESTIGATIONS• Standard Investigations• Mammography• U/S• Biopsy• Magnetic Resonance Imaging• Cytology• Imaging for metastases
    • Mammography Indications • screening – every 1-2 years for women ages 50-69. • metastatic adenocarcinoma of unknown primary. • nipple discharge without palpable mass.
    • MammographyMammogram findings indicative of malignancy• stellate appearance and spiculated border - pathognomonic of breast cancer.• microcalcifications, ill-defined lesion border.• lobulation, architectural distortion
    • MammographyNOTE:• normal mammogram does not rule out suspicion of cancer, based on clinical findings.
    • Ultrasonography• Performed primarily to differentiate cystic from solid lesions.• Not diagnostic
    • 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.
    • 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 )
    • 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.
    • 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.
    • 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.
    • 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
    • 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)
    • 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
    • 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.
    • PAPILLOMA • Solitary intraductal benign polyp. • Most common cause of bloody nipple discharge. • Management – excision of involved duct
    • Breast Cancer • Epidemiology • Risk factors • Pathology • Staging (clinical & pathological) • Metastasis • Treatment • Local/Regional Recurrence • Prognosis
    • 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
    • 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
    • • 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
    • Sites of Breast Cancer
    • 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.
    • 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.
    • 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
    • Pathology Invasive (3)Invasive lobular carcinoma (8- 10%) •  originates from lobular epithelium •  more apt to be bilateral, better prognosis •  does not form microcalcifications 
    • 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)
    • 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
    • stagingPathological• 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,
    • Staging of Breast Cancer (AmericanJoint 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
    • 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
    • Treatment stage 0DCIS – total ipsilateral mastectomy vs. wide local excision (WLE) plus radiation therapy (XRT),• axillary node dissection is not required for DCISLCIS – close observation vs. bilateral total mastectomy, axillary node dissection is not requiredPaget’s disease – total mastectomy vs. MRM
    • 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
    • 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 metastasisIndication of chemotherapy tumors > 5 cm inflammatory carcinomas chest wall or skin extention
    • • 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
    • 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
    • • 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)
    • Post-Surgical Management 1.follow-up of post-mastectomy patienthistory 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