4. BACKROUND
• INCIDENCE BENIGN
• INCIDENCE MALIGNANT DISEASE
• AFRICAN AMERICAN EXPERIENCE
• OLD SERVICES OFFERED
• A NEW BEGINNING
5.
6. Screening in Breast Cancer-an update
Breast cancer screening in Europe-
current status
Bad press????
Poor technology????
Wrong test???
Overly aggressive
clinicians???
Fault is breast cancer????
8. INTRODUCTION
• INCREASING AWARENESS OF
CANCER
• POSSIBILITY THAT MASTALGIA IS
INDICATIVE OF DISEASE
• PHYSICIANS ARE INADEQUATELY
TRAINED FOR TREATING THIS
CONDITION…..
12. FACT…...
• >90% OF PATIENTS WITH CYCLIC
MASTALGIA AND 64% OF PATIENTS
WITH NONCYCLIC MASTALGIA
OBTAIN RELIEF FROM A
COMBINATION OF
NONPRESCRIPTION AND
PRESCRIPTION DRUGS
15. THOROUGH EXAMINATION
SPECIFICALLY THE BREASTS
FINDINGS
• NORMAL SMALL, MEDIUM OR LARGE
BREASTS
• BREASTS WITH A MASS, NIPPLE
DISCHARGE OR THICKENING
16. ASSESSMENT….
• Normal breast pain
• Extent to which it disrupts the patient’s life
[work, sleep, sex, ….]*
• Provide the patient with a breast pain chart
and a symptom chart
*Check diet and drugs
17. INVESTIGATIONS..
GENERAL
• Blood tests (HIV, Prolactin) and other tests
depending on clinical suspicion
SPECIFICALLY
• Sonar and mammogram depending on the
age of the patient
20. MANAGEMENT OF
MASTALGIA
There is a long list of suggested modalities for
the treatment of an entity that is
ubiquitous; has an unknown aetiology, and
a poorly understood relationship to
fibrocystic disease and cancer.
23. NIPPLE DISCHARGE
• HISTORY & EXAMINATION
one duct, multiple ducts, one breast or both
clear, blood stained, green,yellow black etc
INVESTIGATIONS
• pus swab mc&s
• mammogram, sonar
• ductogram
• bloods: BHCG, prolactin
25. Clinical features of MDAIDS
• Nipple Discharge
• Breast Pain and tenderness
• Nipple Retraction and Subareolar mass
• Subareolar breast abscess and recurrent
abscess
• Periareolar Mammary duct Fistula
26.
27.
28. CONCLUSION
• Antibiotics:
• Surgery for complicated disease
Intractable pain
Recurrent discharge not responding to
antibiotics
Abscess
Fistula
29. MANAGEMENT
• DUCT ECTASIA
• medical antibiotics
• surgery for complications
fistula, abscess, intractable pain and recurrent
discharge non responsive with antibiotics
DUCT PAPILLOMA
surgical excision
Physiological discharge
Medication and Conservative management
30. APPROACH TO A
BREAST MASS
• HISTORY
RELATED TO MASS
position,duration ,noticed when
assoc features
FAMILY HISTORY
any cancer history
breast
other
GYNAE/ENDOCRINE HISTORY
menarche, menopause
children,breastfeeding
OCP, HRT
HISTORY
34. • ALL BREAST MASSES TO GET A
TISSUE DIAGNOSIS
• WHY?
• CANCER IN YOUNG WOMEN
• UNUSUAL DIAGNOSIS
• LYMPHOMA
• TUBERCULOSIS
• HOW?
• FINE NEEDLE ASPIRATE
• CORE/TRUCUT BIOPSY
• SONAR GUIDED FNA OR CORE
• MAMMOGRAM GUIDED
• HOOK WIRE
• LAST RESORT EXCISIONAL DIAGNOSIS
35.
36.
37. 95% of all patients should have
the diagnosis made prior to
surgery
38. From benign to malignant….
• Large variety of benign lesions
• Broad terms used (FCD; BBD) used for
convenience
• Transition theory : benign, hyperplasia,
cellular atypia, carcinoma in situ.
• What is the breast cancer risk and at what
stage should a lesion be considered
malignant ?
39. The Evolution of Breast Cancer
Florid hyperplasia
Lobular carcinoma
in situ
• Normal breast Proliferative Changes Atypical
epithelium (mild to moderate ductal lobular or ductal
or lobular hyperplasia) hyperplasia
DCIS
Nonproliferative changes
(fibroadenoma, duct ectasia, cysts Papillomatosis
fibrosis, apocrine metaplasia, stromal sclerosis) Invasive cancer
40. Lobular Carcinoma In Situ
Epidemiology
• young women (44 - 47yrs)
Pathology
• “Busy Bosom”
• ipsilateral multicentricity / contralateral /
bilateral / ……in almost every case
• homogenous, slow growth, low nuclear
grade
41. Prognosis and Management of
LCIS
• Risk applies equally to both breasts
• Incidence variable [1% per year, lifetime
5% ( 4-13%), 37% of cases]
• Malignancies arising (50-65%) are ductal
• From bilateral mastectomy to ipsilateral
mastectomy and blind contralateral biopsy
to non operative close observation
42. DCIS: More Ominous
Epidemiology
• Females and Males
• Occurs between the age of presentation of
LCIS and Ca
Pathology
• Historically 4 histological types: Papillary
and micropapillary, cribriform and solid.
• Comedo versus Non Comedo
43. Applying a relative risk reduction
to treatment decisions
• Individual treatment algorythm
Family history of Breast /other cancer
Age at diagnosis
Tumour necrosis and Nuclear Grade
Resection margins
47. Surgery
1. Breast conservation or mastectomy with
immediate/delayed reconstruction
• Size of the breast
• Size of the tumour
• Patients wishes
1. Axilla
• Clearance (> 7 lymph nodes)
• Sentinel node biopsy if trained
48. Radiation Therapy
Breast
• All breast conserving surgery
• Mastectomy with margins <1cm
• Locally advanced breast cancer
Axilla
• 4 or more nodes positive
49. Chemotherapy
• Tumours >1,5cm
• All lymph node positive tumours
• All receptor negative tumours
• Tumours with poor prognostic indicators
her2neu, lymph vascular invasion
50. Breast conserving procedures are being
employed with increasing frequency...
• How strong is the justification for the
changes that have occurred?
• Why have they come about?
• Has science played a role?
• Is this few tampering with tradition?
• Is this consumer pressure?
51. Clinical trials testing the
Alternative Hypothesis
• NSABP B-04 trial (Aug 1971) to evaluate
different regimens of surgical a
management for primary breast cancer
• NSABP B-06 trial (1976)
52. Conclusion
• Local excision with radiation produces
equivalent results, in terms of survival,
when compared to mastectomy (proven by
7 randomised trials)
• lumpectomy with level 1 & 2 axillary LN
dissection + DXT= total mastectomy +
axillary LN dissection : If tomour is < 4cm
and margins are clear
53. Breast conservation Pressure
• Use of pre-operative treatment for
downstaging large breast cancers
• Chemotherapy is the standard
• Tamoxifen for elderly (chemo unfit)
• Pre-operative radiotherapy
54. Each case as an individual
• Tumour size
• Grade
• Other markers
NOT THE CENTIMETRES OR MILLIMETRES BUT THE AGE OF
THE PATIENT!!!!!!
55. Key Questions
• When should we operate?
• What operations should we be doing ?
• Should we operate at all?
• What are the complications of surgery?
• Axillary surgery?
• Is there a uniform treatment plan?
56. IS SURGERY NECESSARY ?
• Non-surgical tumour ablation?
• Complete response to chemotherapy and
omission of surgery
• Does complete clinical response correlate to
complete pathological response?
• Accurate assessment of tumour response
57. Breast Reconstruction
Post-mastectomy
• Mastectomy remains the most common treatment
for stage 1 & 2 breast cancer
• Potential for avoiding radiotherapy if do breast
recon.
• Patients with in situ tumours (DCIS) are
significantly more likely to undergo recon.
• Histological grade was not a significant predictor
of use of recon.
• Patients’ age most important factor
58. Post-mastectomy recon. …….
• Post-mastectomy recon. does not interfere
with ability to detect local recurrence
• Does not delay the administration of
chemotherapy
• Various options with improved aesthetic
outcome
• ? Lack of patient desire or failure of
surgeon to offer recon.
59. • Expanding indications for RT
• Problems with RT on timing and choice of
reconstructive techniques
60. BREAST RECONSTRUCTION
• Initial or delayed
• Implant
creation of a pocket beneath pec major and
insertion of a tissue expander followed by a
sialastic implant.
• Autologous tissue
use of either a rectus abdominis musculocutaneous
flap or a latissimus dorsi flap
61. Altering breast cancer
management
• Young patients
• Use of radiation therapy
• Use of Chemotherapy
• Most important is surgical management
1. Planning
2. Procedure
3. Margins
62.
63. Conservative treatment of the
axilla
• Detection (75% -95%)
• False negative rate (0-20%)
• Uncertain: injection site;micromets; FN
rate; clinical practice vs random trials
• Surgical experience and pathological study
of the node
64.
65. Questions
• Variable training
• NB trials: ACOSOG; NSABP;ALMANAC;EORTC
• There are side effects of procedure
• Non axillary nodes (25%): int mammary, sub supra clav
• Clinical relevance: sole positive SN
68. Hormones and Breast Cancer
• Tamoxifen survival
advantage for ER +ve,
node - or + tumours
• SERM’S and target
site specificity
• Treatment new
SERM’S
70. How do we determine people at
risk?
• Slight risk 1,5-2 times
• Moderate risk 4-5 times
• High risk 9-11times
• Gail model risk factors (family history, age,
personal history [age at first birth, age of
menarche, previous breast biopsies])
71. The Future Pap smear
• High risk women
..diagnosis?
• FNA / NAC
• Is it possible to
determine ADH by
cytology
72. Applying a relative risk reduction
to treatment decisions
Individual treatment algorithm
• Family history of Breast /other cancer
• Age at diagnosis
• Tumour necrosis and Nuclear Grade
• Resection margins
73.
74. SURGICAL OPTIONS
• Subcutaneous mastectomy
breast tissue is removed preserving the
nipple areolar complex (no)
• Total (simple) mastectomy
• Skin sparing mastectomy
75. TOTAL MASTECTOMY
• Higher level of risk reduction but still does
not remove all the breast tissue
• Immediate reconstruction………problems
relating to implants ( 17,3% at 1 yr; 30,4%
at 5 yr)
• Contralateral mastectomy after unilateral
breast cancer diagnosis
76. Where to from here…?
• Chemoprevention BCPT (NSABP (P1))
STAR trials
• Most meticulous prophylactic mastectomy
does not afford 100% protection
• Prevention more aggressive than treatment
• Does chemoprevention offer protection for
BRCA1 & 2 and receptor negative tumours
77. Chemoprevention
BCPT P-1
• Used Gail model risk factors
• Randomized to Tamoxifen 20mg or placebo
• Tamoxifen reduced the risk of invasive
breast cancer mainly ER +ve by 49%
• Tamoxifen reduced the risk of non invasive
breast cancer by 50%
• STAR trial
78.
79. INTRODUCTION
• ¼ of women diagnosed with breast cancer
are premenopausal
• Average age of diagnosis of pregnant
patients with breast ca is 28-32
• Accepted definition of this condition is
Pregnancy associated breast cancer
80. ISSUES
• Diagnosis and staging of the cancer
• Consideration of termination of the
pregnancy
• Risks of surgery and anaesthesia during
pregnancy
• Risks and timing of local and systemic
adjuvant therapy
• Question of future pregnancies
81. POPULAR MISCONCEPTIONS
• Pregnancy confers a worse prognosis
• Increased incidence of inflammatory ca
• Hormonal milieu accelerates tumour growth
• Vascular and lymphatic engorgement
promoted tumour dissemination
• Diagnostic surgical procedures lead to a
milk fistula
82. • SIGNIFICANT DELAY IN
DIAGNOSTICS AND
TREATMENT RESULT IN
A POORER PROGNOSIS
83. DIAGNOSIS OF PABC
• Physician tendency to observe
• Good history ……..milk rejection sign
• Physical examination
• What investigations?
• Needle biopsy when in doubt
• Surgical biopsy is a last resort
84. LONG TERM AND FUTURE
PREGNANCIES
• Relative risk of dying
• 2 year waiting period
• Chance of conceiving
85. SUMMARY
• Avoid delay in diagnosis
• Correct investigations
• Team approach to management
• Close follow-up
86. GYNAECOMASTIA
DR C A BENN ,FCS SA
CHRIS HANI BARA, JHB GEN BREAST CLINICS
NETCARE BREAST CARE CENTRE OF EXCELLENCE
87. INTRODUCTION
• Definition: female type mammary gland in
the male
• Common and most examples not a disease
• Categorized as physiological or endogenous
(mostly idiopathic)
• Clinical, anatomical and biochemical
advances have clarified the etiology and
natural history
88. INCIDENCE
• Occurs in 60-70% of pubertal boys
• 40% of men over 60
• Understand terms :pubertal gynaecomastia
and prepubertal gynaecomastia and
senescent gynaecomastia
• Why is this an increasing problem and how
can we manage it?
91. History and Examination
• Besides usual ask : gym and squash, raves,
dagga, stress
• Examination: epitrochlear nodes, discrete
breast masses, asymmetry, tenderness
• Investigations: breast sonar, mammogram,
needle biopsy, blood tests
92.
93. management
• Medical: tamoxifen citrate, danazol and
testolactone
• Radiotherapy: small dose
• Surgery: various techniques, combined with
liposuction
95. The bir t h of Venus…
A National Breast Care Centre
• Why?
• Who?
• How?
• What?
96. • All people should be entitled to a
standard of excellence with
regard to medical care
97. What is excellence in breast care?
• Screening mammography
• Specialised radiological centres
• Early diagnosis of cancer
• Diagnosis should be made prior to definitive
surgical procedure
• Patient informed about management options
• mammography
• Specialised radiological centres
• Early diagnosis of cancer
• Diagnosis should be made prior to definitive
surgical procedure
• Patient informed about management options
98. Br ea st Ca r e
Excel l ence
• Awareness of surgical treatment options
• Value of multimodal treatment
• Knowledge of which patients should
receive chemotherapy
• Team approach
radiologist, pathologist, surgeon, plastic
surgeon, oncologist and radiation
oncologist
