This document discusses the evaluation and differential diagnosis of breast lumps and nipple discharge. It begins by outlining the objectives, anatomy, history, and physical exam findings relevant to evaluating a patient with a breast lump or nipple discharge. It then reviews the differential diagnosis for breast lumps and types of nipple discharge. Investigations like mammography, ultrasound, and biopsy are discussed. Common benign breast conditions like fibrocystic disease and fibroadenomas are also summarized. The document concludes with an overview of breast cancer including epidemiology, risk factors, pathology, staging, treatment, and prognosis.

2. Approaches of
a Patient With a
Breast Lump &
Nipple
Discharge

3. 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.

4. ANATOMY

5. ANATOMY

6. ANATOMY

7. ANATOMY

8. BLOOD SUPPLY

10. LYMPHATIC DRAINAGE

11. HISTORY
• Personal Data
• Chief Complaint
• H.C.C : when and how first noticed,
Pain, tenderness, change in size
over time and with menstruation.

12. 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

13. 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 )

14. 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.

15. EVALUATION OF A
BREAST LUMP
• Family History : Especially in first
degree relatives.
• Constitutional Features :
- Anorexia
- weight loss
- Respiratory Symptoms
- Bone Pain

16. 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

17. EVALUATION OF A
BREAST LUMP
Characteristics of a Breast mass
• Size
• Position
• Mobility
• Composition ( Fluctuant, Hard,
Rubbery )
• Fixation to underlying tissue or skin

18. Differential Diagnosis of
a Breast Lump
• FIBROCYSTIC DISEASE
• CYSTS
• ADENOMAS
• FIBROADENOMA
• FAT NECROSIS
• PAPILLOMA
• BREAST CANCER

20. 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.

21. DIFFERENTIAL DIAGNOSIS
OF NIPPLE DISCHARGE
• Purulent: superficial or central abscess
• Milky: post-lactation, OCP, prolactinoma

22. INVESTIGATIONS
• Standard Investigations
• Mammography
• U/S
• Biopsy
• Magnetic Resonance Imaging
• Cytology
• Imaging for metastases

23. INVESTIGATIONS
• Standard Investigations
• Mammography
• U/S
• Biopsy
• Magnetic Resonance Imaging
• Cytology
• Imaging for metastases

24. Mammography
Indications
• screening – every 1-2 years for
women ages 50-69.
• metastatic adenocarcinoma of
unknown primary.
• nipple discharge without palpable
mass.

25. Mammography
Mammogram findings indicative of
malignancy
• stellate appearance and spiculated
border - pathognomonic of breast
cancer.
• microcalcifications, ill-defined lesion
border.
• lobulation, architectural distortion

26. Mammography
NOTE:
• normal mammogram does not rule
out suspicion of cancer, based on
clinical findings.

27. Ultrasonography
• Performed primarily to differentiate
cystic from solid lesions.
• Not diagnostic

28. 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.

29. 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 )

30. 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.

31. 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.

32. 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.

33. Benign Breast Lumps
• FIBROCYSTIC DISEASE
• FIBROADENOMA
• FAT NECROSIS
• PAPILLOMA
• FIBROADENOSIS-focal/diffuse
nodularity
• GALACTOCOELE
• ABSCESS
• PERIDUCTAL MASTITIS-secondary to
duct ectasia

35. 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

36. 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)

37. 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

38. 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.

39. PAPILLOMA
• Solitary intraductal benign polyp.
• Most common cause of bloody nipple
discharge.
• Management – excision of involved duct

40. Breast Cancer
• Epidemiology
• Risk factors
• Pathology
• Staging (clinical & pathological)
• Metastasis
• Treatment
• Local/Regional Recurrence
• Prognosis

41. 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

42. 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

43. • 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

44. Sites of Breast Cancer

45. 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.

46. 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.

47. 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

48. Pathology
Invasive
(3)Invasive lobular carcinoma (8-
10%)
•  originates from lobular epithelium
•  more apt to be bilateral, better prognosis
•  does not form microcalcifications


49. 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)

50. 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

51. 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,

52. 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

53. 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

54. 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

55. 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

56. 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

57. • 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

58. 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

59. • 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)

60. 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

61. CHEMOTHERAPY