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

1. Benign and Malignant
Conditions of the Breast
Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg
Orlino Bisquera, MD
2013

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. Malignant Conditions of the Breast
Orlino Bisquera, MD
2013

4. Complementary Reading Material
Benign and Malignant Conditions of the
Breast
Module – Self-instructional Program
Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg

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. 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. 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. 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. 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. Specific Learning Objectives
– Identify which breast disorders can be
monitored and which should be actively
treated.
Benign and Malignant Conditions of the Breast

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. 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. RJOSON’s Session
Are the learning objectives
clear?
enough?
Want to add more?

14. OVERVIEW OF BREAST HEALTH PROBLEM

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. BREAST HEALTH PROBLEM
Three categories:
• breast feeding problem
• breast sexuality problems
• breast disorders

17. Learning Objectives
– Enumerate at least 10 more common breast
disorders seen in the Philippines.
Benign and Malignant Conditions of the Breast

18. MORE COMMON BREAST DISORDERS IN
PHILIPPINES
1. Breast cancer
2. Fibroadenoma
3. Macrocyst
4. Galactocoele
5. Mastitis and breast abscess

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. 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. 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. 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. 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. 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. 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. CLINICAL PRESENTATION and DIAGNOSIS OF
BREAST DISORDERS
BREAST DISORDER
MANIFESTATIONS (SYMPTOMS AND SIGNS)
CLINICAL DIAGNOSIS
Processes
Pattern Recognition
Prevalence

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. Breast
Complete Physical Exam
• Inspection
• Palpation
• Squeezing the nipple for
discharge
• Axillary palpation

29. Breast
Physical Exam
• Inspection of the breast
– Look for gross abnormality!

30. Gross Abnormalities of the
Breast
• Unilateral gigantic breast
• Erosions of the nipple
• Skin retraction
• Ulcerations
• Fungating mass
• Erythema
• Nipple discharge

31. Breast
Physical Exam
• Palpation of the breast
–Ask before palpating!

32. Palpation of the Breast
• Look for pathologic lumps!
–Dominant lumps
• Take note of fibrocystic changes!
–Hormonal changes
–Lumpy breast substance

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. Breast
Physical Exam
• Gently squeeze the nipple for
any discharge.
• Take note of color of discharge!

35. Breast
Physical Exam
• Axillary palpation
– Search for palpable lymph
nodes

36. Algorithm for clinical diagnosis of breast mass
Signs of Inflammation
Positive Negative
Signs of Malignancy
Signs of Benignity
Positive Negative

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. Breast Abscess
Inflammatory
breast cancer
Gram +; Staph aureus

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. Signs of Malignancy
Carcinoma en cuirasse
Inflammatory carcinoma
Peau d’ orange

41. Diagnostic Process
Diagnosis
Look for signs of benignity
•Cystic nature of mass

42. Fibrocystic Changes
Macrocyst

43. Algorithm for clinical diagnosis of breast
mass
Signs of Inflammation
Positive Negative
Signs of Malignancy
Signs of Benignity
Positive Negative

44. Breast Abscess

45. Mastitis

46. TB of the Breast

47. Galactocoele

48. Fibrocystic Changes
Macrocyst

49. Nipple discharge due to nonspecific
cause or fibrocystic changes

50. Intraductal papilloma
Sanguinous
discharge
No mass

51. Intraductal Papilloma

52. Gynecomastia

53. Gynecomastia

54. Fibroadenoma

55. Fibrocystic Changes
Lumpy breast – no dominant mass

56. Mammomegaly

57. Reduction Mammoplasty

58. Fibroadenoma vs Phyllodes
Tumor

59. Phyllodes Tumor

60. Nipple retraction

61. Breast Cancer

62. Infiltrative Breast Mass

63. Peau d’orange (orange peel)

64. Paget’s Disease of the Nipple
Nipple – areolar
erosions

65. Contact dermatitis, nipple

66. Benign Conditions of the Breast

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. 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. Learning Objectives
– Identify which breast disorders can be
monitored and which should be actively
treated.
Benign and Malignant Conditions of the Breast

70. CLINICAL PRESENTATION AND RECOGNITION OF
BREAST DISORDERS
• CLINICAL DIAGNOSIS
– Differential diagnoses
• Primary
• Secondary
• PARACLINICAL DIAGNOSTIC PROCEDURES
(ANCILLARY DIAGNOSTIC PROCEDURES)

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. COMMON PARACLINICAL DIAGNOSTIC
PROCEDURES FOR BREAST DISORDERS
• Monitoring (observation) and constant
analysis
• Biopsy (needle evaluation or open biopsy)
• Mammography
• Ultrasound

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. Needle Aspiration+/- Biopsy

75. Galactocoele

76. Open Biopsy

77. Mammography

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. Ultrasound of the Breast

80. Selection of Paraclinical Diagnostic
Procedures – A Process
Options Benefit Risk Cost Availability
1 ++++ ++ +++++ NA
2 ++ + ++ RA
3 +++ ++ +++ RA

81. Selection of Paraclinical Diagnostic Procedures
Options Benefit Risk Cost Availability
Needle
evaluation and
biopsy
Open biopsy
Mammography
Ultrasound

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. 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. 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. 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. Breast Mass

87. Needle Aspiration+/- Biopsy

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. 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. Learning Objectives
– Identify at least two general indications for
referral to a breast specialist.
Benign and Malignant Conditions of the Breast

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. 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. 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. 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. 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. 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. Learning Objectives
– Advice patients with nonspecific mastalgia or
mastalgia secondary to hormonal changes.
Benign and Malignant Conditions of the Breast

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. 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. 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. 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. 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. NONSPECIFIC
MASTALGIA
(Nonspecific
Breast Pain)
Sample of Advice
and Informed
Consent

104. FIBROCYSTIC
BREAST
CHANGES
Sample of
Advice and
Informed
Consent

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. 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. 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

109. 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

110. Breast Self-
Examination
A Primer
Reynaldo O. Joson, MD

111. 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).

112. Breast Self-Examination
Examine your own breast regularly
at least once a month to become
familiar with usual appearance and
usual feel of breast.

113. Breast Self-Examination
Familiarity makes it easier to notice
any change.
Early discovery of a change from
what is “normal”
main idea behind
BSE

114. Breast Self-Examination
Time to do BSE:
- while taking a bath
- anytime at your convenience

115. Breast Self-Examination
Time to do BSE:
For menstruating women -
one week after menstrual
period
breasts least likely to be
tender and swollen

116. Breast Self-Examination
Time to do BSE:
For postmenopausal women -
1st day of the month
or
last day of the month

117. How to Do
Breast Self-Examination

118. How to do BSE
INSPECTION

119. How to do BSE
INSPECTION
Look for anything unusual!
If present, consult breast specialist ASAP! Don’t delay!

120. How to do BSE
INSPECTION
Look for anything unusual!
Visibly
unequal
breasts
If present, consult breast specialist ASAP! Don’t delay!

121. How to do BSE
INSPECTION
Look for anything unusual!
Markedly
unequal
breasts
If present, consult breast specialist ASAP! Don’t delay further!

122. How to do BSE
INSPECTION
Look for anything unusual!
Change in
contour
If present, consult breast specialist ASAP! Don’t delay further!

123. How to do BSE
INSPECTION
Look for anything unusual!
Visible
lumps
If present, consult breast specialist ASAP! Don’t delay further!

124. How to do BSE
INSPECTION
Look for anything unusual!
Nipple
erosions
If present, consult breast specialist ASAP! Don’t delay further!

125. How to do BSE
INSPECTION
Look for anything unusual!
Nipple
retraction
If present, consult breast specialist ASAP! Don’t delay further!

126. How to do BSE
INSPECTION
Look for anything unusual!
Nipple
discharge
If present, consult breast specialist ASAP! Don’t delay!

127. How to do BSE
INSPECTION
Look for anything unusual!
If present, consult breast specialist ASAP! Don’t delay!

128. How to do BSE
PALPATION

129. How to do BSE
PALPATION
Palpate for lump or thickening!

130. 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!

131. How to do BSE
PALPATION
Explore breast
FIRMLY, CAREFULLY, & THOROUGHLY!
Make sure to cover the entire 2 breasts!

132. How to do BSE
PALPATION
Up to armpit!

133. Breast Mass
Different Sizes on
Detection
The Smaller The Better

134. Breast Mass
Different Sizes on
Detection
The Smaller The Better

135. Don’t wait for lumps to grow to
these sizes!
TOO LATE! HOPELESS!

136. How to do BSE
PALPATION
Palpate for lump or thickening!
If you palpate something unusual, consult breast specialist
ASAP! Don’t delay!

137. How to do BSE
PALPATION
Gently squeeze nipple!

138. How to do BSE
Nipple
discharge
If present, consult breast specialist ASAP! Don’t delay!
PALPATION
Gently squeeze nipple!

139. Breast Self-Examination
If you find
something unusual or abnormal,
consult a breast specialist
ASAP!
Don’t delay consult!
PALPATIONINSPECTION

140. Breast Self-Examination
Most breast lumps are NOT serious.
But all should come to a breast
specialist’s attention for expert
opinion.

141. 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!

142. Breast Self-Examination
If it is cancer,
chances you have discovered it early!
With early treatment,
you can save your life!

143. Breast Self-Examination
A breast check
so simple
yet so important
that requires practically
NO time!

144. Breast Self-Examination
A breast check
so simple
costs nothing
yet so important
and life-saving!

145. 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

146. 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