Benign and Malignant
Conditions of the Breast
Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg
Orlino Bisquera, MD
2013
Overview of the Breast Health Problem
Benign Conditions of the Breast
Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg
UPM Cente...
Malignant Conditions of the Breast
Orlino Bisquera, MD
2013
Complementary Reading Material
Benign and Malignant Conditions of the
Breast
Module – Self-instructional Program
Reynaldo ...
General Learning Objectives
– To familiarize with the more common benign
lesions of the breast, pathophysiology,
diagnosis...
Specific Learning Objectives
– Enumerate at least 10 more common breast
disorders seen in the Philippines.
– Classify the ...
Specific Learning Objectives
– Categorize the breast disorders by primary
causes
• malignant neoplasms
• benign neoplasms
...
Specific Learning Objectives
– Identify the most probable breast disorder
present in patients presenting with a set of
sym...
Specific Learning Objectives
– Enumerate at least 4 more common
paraclinical diagnostic procedures being done
for patients...
Specific Learning Objectives
– Identify which breast disorders can be
monitored and which should be actively
treated.
Beni...
Specific Learning Objectives
– Given a pretreatment diagnosis of a breast
disorder with the stage of the disorder,
indicat...
Specific Learning Objectives
– Advice patients with nonspecific mastalgia or
mastalgia secondary to hormonal changes.
– Id...
RJOSON’s Session
Are the learning objectives
clear?
enough?
Want to add more?
OVERVIEW OF BREAST HEALTH PROBLEM
BREAST HEALTH PROBLEM
Any condition on the breast
that affects the
biopsychosocial well-being
of an individual
can be cons...
BREAST HEALTH PROBLEM
Three categories:
• breast feeding problem
• breast sexuality problems
• breast disorders
Learning Objectives
– Enumerate at least 10 more common breast
disorders seen in the Philippines.
Benign and Malignant Con...
MORE COMMON BREAST DISORDERS IN
PHILIPPINES
1. Breast cancer
2. Fibroadenoma
3. Macrocyst
4. Galactocoele
5. Mastitis and ...
MORE COMMON BREAST DISORDERS IN
PHILIPPINES
6. Intraductal papilloma
7. Benign cystosarcoma phyllodes or
phyllodes tumor
8...
MOST COMMON BREAST CONDITION (NOT
DISEASE / DISORDER) IN PHILIPPINES
Fibrocystic Breast Condition
Fibrocystic Breast Chang...
Learning Objectives
– Classify the breast disorders into benign and
malignant conditions.
– Categorize the breast disorder...
Classification and Causes – Breast Disorders
CONDITIONS Benign (non-malignant) Malignant
CAUSES
DISORDERS
ANDI* INFECTION ...
Classification and Causes – Breast Disorders
CONDITIONS Benign (non-malignant) Malignant
CAUSES
DISORDERS
ANDI INFECTION B...
Classification and Causes – Breast
Condition / Disorders
CONDITIONS Benign (non-malignant) Malignant
CAUSES
DISORDERS
ANDI...
Learning Objectives
– Identify the most probable breast disorder
present in patients presenting with a set of
symptoms and...
CLINICAL PRESENTATION and DIAGNOSIS OF
BREAST DISORDERS
BREAST DISORDER
MANIFESTATIONS (SYMPTOMS AND SIGNS)
CLINICAL DIAGN...
How to formulate a clinical diagnosis using
processes of pattern recognition and
prevalence
Pattern Recognition - realizat...
Breast
Complete Physical Exam
• Inspection
• Palpation
• Squeezing the nipple for
discharge
• Axillary palpation
Breast
Physical Exam
• Inspection of the breast
– Look for gross abnormality!
Gross Abnormalities of the
Breast
• Unilateral gigantic breast
• Erosions of the nipple
• Skin retraction
• Ulcerations
• ...
Breast
Physical Exam
• Palpation of the breast
–Ask before palpating!
Palpation of the Breast
• Look for pathologic lumps!
–Dominant lumps
• Take note of fibrocystic changes!
–Hormonal changes...
Pathologic Breast Lump
Data needed
• Size (in cm in its greatest diameter)
• Nature (solid or cystic)
• Consistency (hard ...
Breast
Physical Exam
• Gently squeeze the nipple for
any discharge.
• Take note of color of discharge!
Breast
Physical Exam
• Axillary palpation
– Search for palpable lymph
nodes
Algorithm for clinical diagnosis of breast mass
Signs of Inflammation
Positive Negative
Signs of Malignancy
Signs of Benig...
Diagnostic Process
Diagnosis
Look for signs of inflammation
•Pus
•Erythema
•Warmth
•Tenderness
Presence of erythema is eno...
Breast Abscess
Inflammatory
breast cancer
Gram +; Staph aureus
Diagnostic Process
Diagnosis
Look for signs of malignancy
•Hard consistency
•Ill-defined border
•Local invasion
•Fixation
...
Signs of Malignancy
Carcinoma en cuirasse
Inflammatory carcinoma
Peau d’ orange
Diagnostic Process
Diagnosis
Look for signs of benignity
•Cystic nature of mass
Fibrocystic Changes
Macrocyst
Algorithm for clinical diagnosis of breast
mass
Signs of Inflammation
Positive Negative
Signs of Malignancy
Signs of Benig...
Breast Abscess
Mastitis
TB of the Breast
Galactocoele
Fibrocystic Changes
Macrocyst
Nipple discharge due to nonspecific
cause or fibrocystic changes
Intraductal papilloma
Sanguinous
discharge
No mass
Intraductal Papilloma
Gynecomastia
Gynecomastia
Fibroadenoma
Fibrocystic Changes
Lumpy breast – no dominant mass
Mammomegaly
Reduction Mammoplasty
Fibroadenoma vs Phyllodes
Tumor
Phyllodes Tumor
Nipple retraction
Breast Cancer
Infiltrative Breast Mass
Peau d’orange (orange peel)
Paget’s Disease of the Nipple
Nipple – areolar
erosions
Contact dermatitis, nipple
Benign Conditions of the Breast
Time-out / Recap
For questions and comments,
• pls. text and send to
0918-804-03-04
• or email:
rjoson@maniladoctors.com.p...
Learning Objectives
– Enumerate at least 4 more common
paraclinical diagnostic procedures being done
for patients with pos...
Learning Objectives
– Identify which breast disorders can be
monitored and which should be actively
treated.
Benign and Ma...
CLINICAL PRESENTATION AND RECOGNITION OF
BREAST DISORDERS
• CLINICAL DIAGNOSIS
– Differential diagnoses
• Primary
• Second...
INDICATIONS FOR PARACLINICAL DIAGNOSTIC
PROCEDURE
• DEGREE OF CERTAINTY OF CLINICAL
DIAGNOSIS
• MANAGEMENT PLAN
– Differen...
COMMON PARACLINICAL DIAGNOSTIC
PROCEDURES FOR BREAST DISORDERS
• Monitoring (observation) and constant
analysis
• Biopsy (...
INDICATION FOR MONITORING
If on initial evaluation, based on clinical
findings, chances are,
• breast disorder is of a nat...
Needle Aspiration+/- Biopsy
Galactocoele
Open Biopsy
Mammography
Ultrasound of the Breast
• Solid vs cystic
• Cystic – implication of benignity
• Solid per se – no diagnostic implication
...
Ultrasound of the Breast
Selection of Paraclinical Diagnostic
Procedures – A Process
Options Benefit Risk Cost Availability
1 ++++ ++ +++++ NA
2 ++...
Selection of Paraclinical Diagnostic Procedures
Options Benefit Risk Cost Availability
Needle
evaluation and
biopsy
Open b...
Selection of Paraclinical Diagnostic Procedures
Options Benefit Risk Cost Availability
Needle evaln
& biopsy
Direct exam
a...
Selection of Paraclinical Diagnostic Procedures
Options Benefit Risk Cost Availa
bility
Needle evaln
& biopsy
Direct exam
...
Selection of Paraclinical Diagnostic Procedures
Options Benefit Risk Cost Availa
bility
Needle evaln
& biopsy
Direct exam
...
Selection of Paraclinical Diagnostic Procedures
Options Benefit Risk Cost Availa
bility
Needle evaln
& biopsy
Direct exam
...
Breast Mass
Needle Aspiration+/- Biopsy
Time-out / Recap
For questions and comments,
• pls. text and send to
0918-804-03-04
• or email:
rjoson@maniladoctors.com.p...
Learning Objectives
– Given a pretreatment diagnosis of a breast
disorder with the stage of the disorder,
indicate the usu...
Learning Objectives
– Identify at least two general indications for
referral to a breast specialist.
Benign and Malignant ...
Breast Disorders
Basic Principles of Management
Goal of management:
Resolution of the problem
in such a way that the patie...
PRIMARY GOALS AND MODALITIES OF
TREATMENT OF BREAST DISORDERS
Breast disorders
based on causation
Primary goals in
treatme...
PRIMARY GOALS AND MODALITIES OF
TREATMENT OF BREAST DISORDERS
Breast disorders
based on causation
Primary goals in
treatme...
Treatment of Breast Condition / Disorder
Condition
Disorder
Observe
Monitor
Surgery Drugs
(Chemotx
Hormonal
Antibiotics)
R...
Treatment of Breast Condition / Disorder
Condition
Disorder
Observe
Monitor
Surgery Drugs
(Chemotx
Hormonal
Antibiotics)
R...
Treatment of Breast Condition / Disorder
Condition
Disorder
Observe
Monitor
Surgery Drugs
(Chemotx
Hormonal
Antibiotics)
R...
Learning Objectives
– Advice patients with nonspecific mastalgia or
mastalgia secondary to hormonal changes.
Benign and Ma...
Nonspecific Mastalgia (Nonspecific Breast Pain)
Operational definition
Pain in/on the breast in which the cause cannot be ...
Nonspecific Mastalgia (Nonspecific Breast Pain)
Operational definition
If a definite cause is identified, then the
diagnos...
Nonspecific Mastalgia (Nonspecific Breast Pain)
Recommendation on PARACLINICAL PROCEDURES
No technical paraclinical diagno...
Nonspecific Mastalgia (Nonspecific Breast Pain)
Recommendation on TREATMENT
•Give advice – as clear AND convincing as poss...
Nonspecific Mastalgia (Nonspecific Breast Pain)
Recommendation on TREATMENT
•Give advice – as clear AND convincing as poss...
NONSPECIFIC
MASTALGIA
(Nonspecific
Breast Pain)
Sample of Advice
and Informed
Consent
FIBROCYSTIC
BREAST
CHANGES
Sample of
Advice and
Informed
Consent
Learning Objectives
– Identify at least two general indications for
referral to a breast specialist.
• NOT certain of diag...
Time-out / Recap
For questions and comments,
• pls. text and send to
0918-804-03-04
• or email:
rjoson@maniladoctors.com.p...
Overview of the Breast Health Problem
Benign Conditions of the Breast
Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg
UPM Cente...
CLINICAL BREAST EXAM
• Examination done by a physician on a patient
consulting with a breast complaint or for a
breast che...
Breast Self-
Examination
A Primer
Reynaldo O. Joson, MD
Breast Self-Examination
The best and most practical and the
most economical way of detecting
breast cancer rests in a heal...
Breast Self-Examination
Examine your own breast regularly
at least once a month to become
familiar with usual appearance a...
Breast Self-Examination
Familiarity makes it easier to notice
any change.
Early discovery of a change from
what is “normal...
Breast Self-Examination
Time to do BSE:
- while taking a bath
- anytime at your convenience
Breast Self-Examination
Time to do BSE:
For menstruating women -
one week after menstrual
period
breasts least likely to b...
Breast Self-Examination
Time to do BSE:
For postmenopausal women -
1st day of the month
or
last day of the month
How to Do
Breast Self-Examination
How to do BSE
INSPECTION
How to do BSE
INSPECTION
Look for anything unusual!
If present, consult breast specialist ASAP! Don’t delay!
How to do BSE
INSPECTION
Look for anything unusual!
Visibly
unequal
breasts
If present, consult breast specialist ASAP! Do...
How to do BSE
INSPECTION
Look for anything unusual!
Markedly
unequal
breasts
If present, consult breast specialist ASAP! D...
How to do BSE
INSPECTION
Look for anything unusual!
Change in
contour
If present, consult breast specialist ASAP! Don’t de...
How to do BSE
INSPECTION
Look for anything unusual!
Visible
lumps
If present, consult breast specialist ASAP! Don’t delay ...
How to do BSE
INSPECTION
Look for anything unusual!
Nipple
erosions
If present, consult breast specialist ASAP! Don’t dela...
How to do BSE
INSPECTION
Look for anything unusual!
Nipple
retraction
If present, consult breast specialist ASAP! Don’t de...
How to do BSE
INSPECTION
Look for anything unusual!
Nipple
discharge
If present, consult breast specialist ASAP! Don’t del...
How to do BSE
INSPECTION
Look for anything unusual!
If present, consult breast specialist ASAP! Don’t delay!
How to do BSE
PALPATION
How to do BSE
PALPATION
Palpate for lump or thickening!
How to do BSE
PALPATION
Palpate as illustrated by pressing and rotating fingers
against breast and chest wall to look for ...
How to do BSE
PALPATION
Explore breast
FIRMLY, CAREFULLY, & THOROUGHLY!
Make sure to cover the entire 2 breasts!
How to do BSE
PALPATION
Up to armpit!
Breast Mass
Different Sizes on
Detection
The Smaller The Better
Breast Mass
Different Sizes on
Detection
The Smaller The Better
Don’t wait for lumps to grow to
these sizes!
TOO LATE! HOPELESS!
How to do BSE
PALPATION
Palpate for lump or thickening!
If you palpate something unusual, consult breast specialist
ASAP! ...
How to do BSE
PALPATION
Gently squeeze nipple!
How to do BSE
Nipple
discharge
If present, consult breast specialist ASAP! Don’t delay!
PALPATION
Gently squeeze nipple!
Breast Self-Examination
If you find
something unusual or abnormal,
consult a breast specialist
ASAP!
Don’t delay consult!
...
Breast Self-Examination
Most breast lumps are NOT serious.
But all should come to a breast
specialist’s attention for expe...
Breast Self-Examination
Only a breast specialist can make
sure of the diagnosis.
So, see a breast specialist right away
an...
Breast Self-Examination
If it is cancer,
chances you have discovered it early!
With early treatment,
you can save your lif...
Breast Self-Examination
A breast check
so simple
yet so important
that requires practically
NO time!
Breast Self-Examination
A breast check
so simple
costs nothing
yet so important
and life-saving!
Time-out / Recap
For questions and comments,
• pls. text and send to
0918-804-03-04
• or email:
rjoson@maniladoctors.com.p...
Overview of the Breast Health Problem
Benign Conditions of the Breast
Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg
UPM Cente...
Overview of Breast Health Problems with Focus on Benign Breast Conditions
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Breast - Benign and Malignant Conditions - Overview of Breast Health Problem - Benign Conditions of the Breast - ROJoson's Lecture to UP College of Medicine Level 4 Students - 13sept 16

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Overview of Breast Health Problems with Focus on Benign Breast Conditions

  1. 1. Benign and Malignant Conditions of the Breast Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg Orlino Bisquera, MD 2013
  2. 2. Overview of the Breast Health Problem Benign Conditions of the Breast Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg UPM Centennial Professorial Chair (2008) 2013
  3. 3. Malignant Conditions of the Breast Orlino Bisquera, MD 2013
  4. 4. Complementary Reading Material Benign and Malignant Conditions of the Breast Module – Self-instructional Program Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg
  5. 5. General Learning Objectives – To familiarize with the more common benign lesions of the breast, pathophysiology, diagnosis and corresponding treatment. – To familiarize with the different malignancies arising the breast, its diagnosis, and management. Benign and Malignant Conditions of the Breast
  6. 6. Specific Learning Objectives – Enumerate at least 10 more common breast disorders seen in the Philippines. – Classify the breast disorders into benign and malignant conditions. Benign and Malignant Conditions of the Breast
  7. 7. Specific Learning Objectives – Categorize the breast disorders by primary causes • malignant neoplasms • benign neoplasms • aberration of normal development and involution or ANDI • infection Benign and Malignant Conditions of the Breast
  8. 8. Specific Learning Objectives – Identify the most probable breast disorder present in patients presenting with a set of symptoms and signs referable to the breast. Benign and Malignant Conditions of the Breast
  9. 9. Specific Learning Objectives – Enumerate at least 4 more common paraclinical diagnostic procedures being done for patients with possible breast disorders. – Identify the usual indications for the different diagnostic procedures commonly used in patients for possible breast disorders. Benign and Malignant Conditions of the Breast
  10. 10. Specific Learning Objectives – Identify which breast disorders can be monitored and which should be actively treated. Benign and Malignant Conditions of the Breast
  11. 11. Specific Learning Objectives – Given a pretreatment diagnosis of a breast disorder with the stage of the disorder, indicate the usual goal of treatment and its corresponding recommended primary treatment. Benign and Malignant Conditions of the Breast
  12. 12. Specific Learning Objectives – Advice patients with nonspecific mastalgia or mastalgia secondary to hormonal changes. – Identify at least two general indications for referral to a breast specialist. Benign and Malignant Conditions of the Breast
  13. 13. RJOSON’s Session Are the learning objectives clear? enough? Want to add more?
  14. 14. OVERVIEW OF BREAST HEALTH PROBLEM
  15. 15. BREAST HEALTH PROBLEM Any condition on the breast that affects the biopsychosocial well-being of an individual can be considered as a “breast health problem”
  16. 16. BREAST HEALTH PROBLEM Three categories: • breast feeding problem • breast sexuality problems • breast disorders
  17. 17. Learning Objectives – Enumerate at least 10 more common breast disorders seen in the Philippines. Benign and Malignant Conditions of the Breast
  18. 18. MORE COMMON BREAST DISORDERS IN PHILIPPINES 1. Breast cancer 2. Fibroadenoma 3. Macrocyst 4. Galactocoele 5. Mastitis and breast abscess
  19. 19. MORE COMMON BREAST DISORDERS IN PHILIPPINES 6. Intraductal papilloma 7. Benign cystosarcoma phyllodes or phyllodes tumor 8. Tuberculosis of the breast 9. Paget’s disease of the nipple (a type of breast cancer) 10. Mammomegaly (virginal hypertrophy in females; gynecomastia in males)
  20. 20. MOST COMMON BREAST CONDITION (NOT DISEASE / DISORDER) IN PHILIPPINES Fibrocystic Breast Condition Fibrocystic Breast Changes Fibrocystic Changes Lumpiness of the breast with / without pain Hormonal changes Normal
  21. 21. Learning Objectives – Classify the breast disorders into benign and malignant conditions. – Categorize the breast disorders by primary causes • malignant neoplasms • benign neoplasms • aberration of normal development and involution or ANDI • infection Benign and Malignant Conditions of the Breast
  22. 22. Classification and Causes – Breast Disorders CONDITIONS Benign (non-malignant) Malignant CAUSES DISORDERS ANDI* INFECTION BENIGN NEOPLASM MALIGNANT NEOPLASM Breast Cancer √ Fibroadenoma √ √ Macrocyst √ Galactocoele √ Mastitis and breast abscess √ *ANDI – Aberration of normal development and involution
  23. 23. Classification and Causes – Breast Disorders CONDITIONS Benign (non-malignant) Malignant CAUSES DISORDERS ANDI INFECTION BENIGN NEOPLASM MALIGNANT NEOPLASM Intraductal papilloma √ Phyllodes tumor √ Tuberculosis of the breast √ Paget’s disease of the nipple √ Mammomegaly √ *ANDI – Aberration of normal development and involution
  24. 24. Classification and Causes – Breast Condition / Disorders CONDITIONS Benign (non-malignant) Malignant CAUSES DISORDERS ANDI INFECTION BENIGN NEOPLASM MALIGNANT NEOPLASM Fibrocystic Breast Condition √ Fibroadenoma √ √ Macrocyst √ Galactocoele √ Mammomegaly √ *ANDI – Aberration of normal development and involution
  25. 25. Learning Objectives – Identify the most probable breast disorder present in patients presenting with a set of symptoms and signs referable to the breast. Benign and Malignant Conditions of the Breast
  26. 26. CLINICAL PRESENTATION and DIAGNOSIS OF BREAST DISORDERS BREAST DISORDER MANIFESTATIONS (SYMPTOMS AND SIGNS) CLINICAL DIAGNOSIS Processes Pattern Recognition Prevalence
  27. 27. How to formulate a clinical diagnosis using processes of pattern recognition and prevalence Pattern Recognition - realization that patient’s presentation (signs and symptoms) conforms to a previously learned picture or pattern of disease. Prevalence - choice of diagnosis is based on frequency of occurrence of disease in a certain locality, certain age and sex group, and in affected organ and system.
  28. 28. Breast Complete Physical Exam • Inspection • Palpation • Squeezing the nipple for discharge • Axillary palpation
  29. 29. Breast Physical Exam • Inspection of the breast – Look for gross abnormality!
  30. 30. Gross Abnormalities of the Breast • Unilateral gigantic breast • Erosions of the nipple • Skin retraction • Ulcerations • Fungating mass • Erythema • Nipple discharge
  31. 31. Breast Physical Exam • Palpation of the breast –Ask before palpating!
  32. 32. Palpation of the Breast • Look for pathologic lumps! –Dominant lumps • Take note of fibrocystic changes! –Hormonal changes –Lumpy breast substance
  33. 33. Pathologic Breast Lump Data needed • Size (in cm in its greatest diameter) • Nature (solid or cystic) • Consistency (hard or not hard – firm/ soft) • Tumor border (well-defined or ill-defined) • Tenderness (presence or absence) • Mobility (movable or fixed – overlying / underlying tissue)
  34. 34. Breast Physical Exam • Gently squeeze the nipple for any discharge. • Take note of color of discharge!
  35. 35. Breast Physical Exam • Axillary palpation – Search for palpable lymph nodes
  36. 36. Algorithm for clinical diagnosis of breast mass Signs of Inflammation Positive Negative Signs of Malignancy Signs of Benignity Positive Negative
  37. 37. Diagnostic Process Diagnosis Look for signs of inflammation •Pus •Erythema •Warmth •Tenderness Presence of erythema is enough basis to suspect inflammation! Take note though of “Inflammatory breast cancer”!
  38. 38. Breast Abscess Inflammatory breast cancer Gram +; Staph aureus
  39. 39. Diagnostic Process Diagnosis Look for signs of malignancy •Hard consistency •Ill-defined border •Local invasion •Fixation •Regional spread •Distant spread Presence of ONE sign of malignancy is enough basis to suspect malignancy!
  40. 40. Signs of Malignancy Carcinoma en cuirasse Inflammatory carcinoma Peau d’ orange
  41. 41. Diagnostic Process Diagnosis Look for signs of benignity •Cystic nature of mass
  42. 42. Fibrocystic Changes Macrocyst
  43. 43. Algorithm for clinical diagnosis of breast mass Signs of Inflammation Positive Negative Signs of Malignancy Signs of Benignity Positive Negative
  44. 44. Breast Abscess
  45. 45. Mastitis
  46. 46. TB of the Breast
  47. 47. Galactocoele
  48. 48. Fibrocystic Changes Macrocyst
  49. 49. Nipple discharge due to nonspecific cause or fibrocystic changes
  50. 50. Intraductal papilloma Sanguinous discharge No mass
  51. 51. Intraductal Papilloma
  52. 52. Gynecomastia
  53. 53. Gynecomastia
  54. 54. Fibroadenoma
  55. 55. Fibrocystic Changes Lumpy breast – no dominant mass
  56. 56. Mammomegaly
  57. 57. Reduction Mammoplasty
  58. 58. Fibroadenoma vs Phyllodes Tumor
  59. 59. Phyllodes Tumor
  60. 60. Nipple retraction
  61. 61. Breast Cancer
  62. 62. Infiltrative Breast Mass
  63. 63. Peau d’orange (orange peel)
  64. 64. Paget’s Disease of the Nipple Nipple – areolar erosions
  65. 65. Contact dermatitis, nipple
  66. 66. Benign Conditions of the Breast
  67. 67. Time-out / Recap For questions and comments, • pls. text and send to 0918-804-03-04 • or email: rjoson@maniladoctors.com.ph rjoson2001@yahoo.com
  68. 68. Learning Objectives – Enumerate at least 4 more common paraclinical diagnostic procedures being done for patients with possible breast disorders. – Identify the usual indications for the different diagnostic procedures commonly used in patients for possible breast disorders. Benign and Malignant Conditions of the Breast
  69. 69. Learning Objectives – Identify which breast disorders can be monitored and which should be actively treated. Benign and Malignant Conditions of the Breast
  70. 70. CLINICAL PRESENTATION AND RECOGNITION OF BREAST DISORDERS • CLINICAL DIAGNOSIS – Differential diagnoses • Primary • Secondary • PARACLINICAL DIAGNOSTIC PROCEDURES (ANCILLARY DIAGNOSTIC PROCEDURES)
  71. 71. INDICATIONS FOR PARACLINICAL DIAGNOSTIC PROCEDURE • DEGREE OF CERTAINTY OF CLINICAL DIAGNOSIS • MANAGEMENT PLAN – Differences in mgt of primary and secondary diagnoses – Will the diagnostic procedure affect significantly your management?
  72. 72. COMMON PARACLINICAL DIAGNOSTIC PROCEDURES FOR BREAST DISORDERS • Monitoring (observation) and constant analysis • Biopsy (needle evaluation or open biopsy) • Mammography • Ultrasound
  73. 73. INDICATION FOR MONITORING If on initial evaluation, based on clinical findings, chances are, • breast disorder is of a nature that it is NOT malignant and • treatment is usually by monitoring and observation where no active treatment is needed Example: Fibrocystic changes
  74. 74. Needle Aspiration+/- Biopsy
  75. 75. Galactocoele
  76. 76. Open Biopsy
  77. 77. Mammography
  78. 78. Ultrasound of the Breast • Solid vs cystic • Cystic – implication of benignity • Solid per se – no diagnostic implication – may be benign or malignant • Complex mass – combination of cystic and solid component
  79. 79. Ultrasound of the Breast
  80. 80. Selection of Paraclinical Diagnostic Procedures – A Process Options Benefit Risk Cost Availability 1 ++++ ++ +++++ NA 2 ++ + ++ RA 3 +++ ++ +++ RA
  81. 81. Selection of Paraclinical Diagnostic Procedures Options Benefit Risk Cost Availability Needle evaluation and biopsy Open biopsy Mammography Ultrasound
  82. 82. Selection of Paraclinical Diagnostic Procedures Options Benefit Risk Cost Availability Needle evaln & biopsy Direct exam and sampling Yield > 90% Open biopsy Direct exam and sampling Yield > 98% Mammo Indirect exam – imaging Malignant calcifications Ultrasound Indirect exam – imaging cystic vs solid
  83. 83. Selection of Paraclinical Diagnostic Procedures Options Benefit Risk Cost Availa bility Needle evaln & biopsy Direct exam and sampling Yield > 90% Pain Hematoma No scar Open biopsy Direct exam and sampling Yield > 98% Pain / Hematoma Scar Anesthesia – side effect Mammo Indirect exam – imaging Malignant calcifications Pain on compression Radiation Ultrasound Indirect exam – imaging cystic vs solid Painless
  84. 84. Selection of Paraclinical Diagnostic Procedures Options Benefit Risk Cost Availa bility Needle evaln & biopsy Direct exam and sampling Yield > 90% Pain Hematoma No scar P2T Open biopsy Direct exam and sampling Yield > 98% Pain / Hematoma Scar Anesthesia – side effect P8T Mammo Indirect exam – imaging Malignant calcifications Pain on compression Radiation P2T Ultrasound Indirect exam – imaging cystic vs solid Painless P1T
  85. 85. Selection of Paraclinical Diagnostic Procedures Options Benefit Risk Cost Availa bility Needle evaln & biopsy Direct exam and sampling Yield > 90% Pain Hematoma No scar P2T RA Open biopsy Direct exam and sampling Yield > 98% Pain / Hematoma Scar Anesthesia – side effect P8T RA Mammo Indirect exam – imaging Malignant calcifications Pain on compression Radiation P2T RA NRA Ultrasound Indirect exam – imaging cystic vs solid Painless P1T RA
  86. 86. Breast Mass
  87. 87. Needle Aspiration+/- Biopsy
  88. 88. Time-out / Recap For questions and comments, • pls. text and send to 0918-804-03-04 • or email: rjoson@maniladoctors.com.ph rjoson2001@yahoo.com
  89. 89. Learning Objectives – Given a pretreatment diagnosis of a breast disorder with the stage of the disorder, indicate the usual goal of treatment and its corresponding recommended primary treatment. – Advice patients with nonspecific mastalgia or mastalgia secondary to hormonal changes. Benign and Malignant Conditions of the Breast
  90. 90. Learning Objectives – Identify at least two general indications for referral to a breast specialist. Benign and Malignant Conditions of the Breast
  91. 91. Breast Disorders Basic Principles of Management Goal of management: Resolution of the problem in such a way that the patient does NOT end up - dead, - with disability, - with complication, and in such a manner that the patient is satisfied and does NOT file a medicolegal suit.
  92. 92. PRIMARY GOALS AND MODALITIES OF TREATMENT OF BREAST DISORDERS Breast disorders based on causation Primary goals in treatment Primary modalities of treatment Aberrations of normal development and involution To allay anxiety and fear that the breast condition is cancer ANDI is NOT cancer ANDI does NOT lead to cancer! Advice and tempered assurance Monitoring and observation Analgesics, if needed Aspiration for cysts Excision for solid mass as a last resort Infections To resolve the infection Antibiotics Drainage / debridement
  93. 93. PRIMARY GOALS AND MODALITIES OF TREATMENT OF BREAST DISORDERS Breast disorders based on causation Primary goals in treatment Primary modalities of treatment Benign neoplasms To resolve the mass Excision Monitoring and observation for small fibroadenomas Malignant neoplasms To control the cancer Surgery, radiotherapy, chemotherapy, hormonal therapy, singly or in combination
  94. 94. Treatment of Breast Condition / Disorder Condition Disorder Observe Monitor Surgery Drugs (Chemotx Hormonal Antibiotics) Radiotx Breast cancer & Paget’s disease √ (subtotal / total / modified radical mastectomy) √ √ Fibrocystic Changes √ Macrocyst √ √ (aspiration) Galactocoele √ √ (aspiration) Fibroadenoma √ √ (excision)
  95. 95. Treatment of Breast Condition / Disorder Condition Disorder Observe Monitor Surgery Drugs (Chemotx Hormonal Antibiotics) Radiotx Mastitis and breast abscess √ (aspiration / incision - drainage) √ TB of the breast √ (aspiration / incision - drainage) √
  96. 96. Treatment of Breast Condition / Disorder Condition Disorder Observe Monitor Surgery Drugs (Chemotx Hormonal Antibiotics) Radiotx Intraductal papilloma √ (excision) Phyllodes tumor √ (wide excision) Mammomegaly √ √ (reduction mammoplasty)
  97. 97. Learning Objectives – Advice patients with nonspecific mastalgia or mastalgia secondary to hormonal changes. Benign and Malignant Conditions of the Breast
  98. 98. Nonspecific Mastalgia (Nonspecific Breast Pain) Operational definition Pain in/on the breast in which the cause cannot be exactly established and chances are it is NOT due to a pathologic condition / disorder (there is no pattern indicative of a definite breast disorder.) Usually, hormone-induced, cyclical or noncyclical
  99. 99. Nonspecific Mastalgia (Nonspecific Breast Pain) Operational definition If a definite cause is identified, then the diagnostic label should be mastalgia secondary to …….example, trauma, mastitis, etc.)
  100. 100. Nonspecific Mastalgia (Nonspecific Breast Pain) Recommendation on PARACLINICAL PROCEDURES No technical paraclinical diagnostic procedures needed Just monitoring / check-up (breast self-examination and clinical breast examination) at planned intervals (1 mo , then 3 mos – 6 mos – 9 mos – 12 mos)
  101. 101. Nonspecific Mastalgia (Nonspecific Breast Pain) Recommendation on TREATMENT •Give advice – as clear AND convincing as possible to allay fear of cancer and to develop trust and confidence •Secure informed consent on your recommendations •Give stand-by prescription of a safe and affordable analgesics, such as paracetamol, if needed (in case of intolerable pain at home) •No need for antibiotics (a common practice)
  102. 102. Nonspecific Mastalgia (Nonspecific Breast Pain) Recommendation on TREATMENT •Give advice – as clear AND convincing as possible to allay fear of cancer and to develop trust and confidence Clinical diagnosis of a NONSPECIFIC MASTALGIA (not due to cancer) with quantification of degree / percentage of certainty – may be as high as 98% No need for technical paraclinical diagnostic procedures Importance / necessity of monitoring and check-up
  103. 103. NONSPECIFIC MASTALGIA (Nonspecific Breast Pain) Sample of Advice and Informed Consent
  104. 104. FIBROCYSTIC BREAST CHANGES Sample of Advice and Informed Consent
  105. 105. Learning Objectives – Identify at least two general indications for referral to a breast specialist. • NOT certain of diagnosis • Certain that a breast specialist is in the best position to manage the patient • Probable breast cancer diagnosis • Patient needs treatment more than a prescription of analgesics and antibiotics Benign and Malignant Conditions of the Breast
  106. 106. Time-out / Recap For questions and comments, • pls. text and send to 0918-804-03-04 • or email: rjoson@maniladoctors.com.ph rjoson2001@yahoo.com
  107. 107. Overview of the Breast Health Problem Benign Conditions of the Breast Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg UPM Centennial Professorial Chair (2008) 2013
  108. 108. CLINICAL BREAST EXAM • Examination done by a physician on a patient consulting with a breast complaint or for a breast check vs • Breast self-examination – Examination by a person on her/his own breasts – The “person” includes physicians who may be a patient now or in the future
  109. 109. Breast Self- Examination A Primer Reynaldo O. Joson, MD
  110. 110. Breast Self-Examination The best and most practical and the most economical way of detecting breast cancer rests in a health habit called Breast Self-Examination (BSE).
  111. 111. Breast Self-Examination Examine your own breast regularly at least once a month to become familiar with usual appearance and usual feel of breast.
  112. 112. Breast Self-Examination Familiarity makes it easier to notice any change. Early discovery of a change from what is “normal” main idea behind BSE
  113. 113. Breast Self-Examination Time to do BSE: - while taking a bath - anytime at your convenience
  114. 114. Breast Self-Examination Time to do BSE: For menstruating women - one week after menstrual period breasts least likely to be tender and swollen
  115. 115. Breast Self-Examination Time to do BSE: For postmenopausal women - 1st day of the month or last day of the month
  116. 116. How to Do Breast Self-Examination
  117. 117. How to do BSE INSPECTION
  118. 118. How to do BSE INSPECTION Look for anything unusual! If present, consult breast specialist ASAP! Don’t delay!
  119. 119. How to do BSE INSPECTION Look for anything unusual! Visibly unequal breasts If present, consult breast specialist ASAP! Don’t delay!
  120. 120. How to do BSE INSPECTION Look for anything unusual! Markedly unequal breasts If present, consult breast specialist ASAP! Don’t delay further!
  121. 121. How to do BSE INSPECTION Look for anything unusual! Change in contour If present, consult breast specialist ASAP! Don’t delay further!
  122. 122. How to do BSE INSPECTION Look for anything unusual! Visible lumps If present, consult breast specialist ASAP! Don’t delay further!
  123. 123. How to do BSE INSPECTION Look for anything unusual! Nipple erosions If present, consult breast specialist ASAP! Don’t delay further!
  124. 124. How to do BSE INSPECTION Look for anything unusual! Nipple retraction If present, consult breast specialist ASAP! Don’t delay further!
  125. 125. How to do BSE INSPECTION Look for anything unusual! Nipple discharge If present, consult breast specialist ASAP! Don’t delay!
  126. 126. How to do BSE INSPECTION Look for anything unusual! If present, consult breast specialist ASAP! Don’t delay!
  127. 127. How to do BSE PALPATION
  128. 128. How to do BSE PALPATION Palpate for lump or thickening!
  129. 129. How to do BSE PALPATION Palpate as illustrated by pressing and rotating fingers against breast and chest wall to look for lumps! Do NOT grab breast with fingers!
  130. 130. How to do BSE PALPATION Explore breast FIRMLY, CAREFULLY, & THOROUGHLY! Make sure to cover the entire 2 breasts!
  131. 131. How to do BSE PALPATION Up to armpit!
  132. 132. Breast Mass Different Sizes on Detection The Smaller The Better
  133. 133. Breast Mass Different Sizes on Detection The Smaller The Better
  134. 134. Don’t wait for lumps to grow to these sizes! TOO LATE! HOPELESS!
  135. 135. How to do BSE PALPATION Palpate for lump or thickening! If you palpate something unusual, consult breast specialist ASAP! Don’t delay!
  136. 136. How to do BSE PALPATION Gently squeeze nipple!
  137. 137. How to do BSE Nipple discharge If present, consult breast specialist ASAP! Don’t delay! PALPATION Gently squeeze nipple!
  138. 138. Breast Self-Examination If you find something unusual or abnormal, consult a breast specialist ASAP! Don’t delay consult! PALPATIONINSPECTION
  139. 139. Breast Self-Examination Most breast lumps are NOT serious. But all should come to a breast specialist’s attention for expert opinion.
  140. 140. Breast Self-Examination Only a breast specialist can make sure of the diagnosis. So, see a breast specialist right away and give yourself a peace of mind!
  141. 141. Breast Self-Examination If it is cancer, chances you have discovered it early! With early treatment, you can save your life!
  142. 142. Breast Self-Examination A breast check so simple yet so important that requires practically NO time!
  143. 143. Breast Self-Examination A breast check so simple costs nothing yet so important and life-saving!
  144. 144. Time-out / Recap For questions and comments, • pls. text and send to 0918-804-03-04 • or email: rjoson@maniladoctors.com.ph rjoson2001@yahoo.com
  145. 145. Overview of the Breast Health Problem Benign Conditions of the Breast Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg UPM Centennial Professorial Chair (2008) 2013

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