Mr Mike PuttickGeneral Surgeon

Auckland City Hospital

Breast Associates

17:10 - 17:30 Managing Common Breast Disease in Primary Care

Managing Common Breast Diseases in Primary Care

Michael PuttickConsultant Oncoplastic Breast Surgeon

Auckland City Hospital & Breast Associates

Managing Common Breast Diseases in Primary Care

Michael PuttickConsultant Oncoplastic Breast Surgeon

Auckland City Hospital & Breast Associates

Disorders

Nomenclature- is unhelpful

Clinical Entity Exclusion of Cancer

Much of breast “disease” is normality

Who should you refer….....….and who can you manage?

•Lumps

•Pain

•Family History

When is a lump not a lump?

When is a lump not a lump?

Discrete Persistent

Fixed Growing

Suspicious

When is nodularity a lump?

When Dominant or Persistent1. Examine both breasts2. Confirm or refute with US3. Biopsy if necessary4. Review 6-8 weeks

Could be● Prominent fat lobules● Prominent rib● Intramammary node● Accessory breast tissue● Edge of a biopsy site

MoH High Suspicion Criteria

• Discrete, hard breast lump with fixation (with or without skin tethering)

• Discrete breast lump that presents in women with one or more of the following: • age 40 years or older, and persists after her next period or presents after

menopause

• aged younger than 40 years and the lump is increasing in size or where there are other risk factors, such as strong family history

• with previous breast cancer or ovarian cancer

MoH High Suspicion Criteria

• Discrete, hard breast lump with fixation (with or without skin tethering)

• Discrete breast lump that presents in women with one or more of the following: • age 40 years or older, and persists after her next period or presents after

menopause

• aged younger than 40 years and the lump is increasing in size or where there are other risk factors, such as strong family history

• with previous breast cancer or ovarian cancer

Lumps need Triple Assessment• Clinical Assessment

• History• Examination

• Radiology• USS• Mammograms• (MRI)

• Biopsy• FNA• Core Biopsy

KEY = Concordance

1. Normal / non-diagnostic

2. Benign

3. Probably benign

4. Probably malignant

5. Malignant

What Imaging?

• Mammogram > 35yrs

• Tomosynthesis of dense tissue

• USS <35yrs

• Characterize lumps

• Targeted

• MRI• Should be in a breast clinic

Which Biopsy?

• Core Biopsy

• FNA for benign lumps

• Cysts

44 year old

Sudden onset lump UOQ L breastApprox 3cmTenderPersisted after her period

What is it?

Breast Cysts• Commonest discrete benign breast mass

• 7-10% of ♀• Simple cysts can be aspirated• Recurrent cysts can be aspirated• Standard breast screening is appropriate follow-up in most cases

“.....if US not available, the first investigation of an easily palpable lump in the breast should be the insertion of a needle….”

Typical Breast Cyst Fluid

Mastalgia

Mastalgia

Breast pain is an uncommon symptom in breast cancer, but it does not exclude the diagnosis

Cyclical changes of menstruation

Cyclical mastalgiaIncapacitating

mastalgia

33 year old

Painful breasts 3 monthsL>RSome cyclical variationNeeding occasional paracetamolCousin had breast cancer aged 47

What would you do?

Mastalgia Management

1. Exclude Cancer

2. Reassurance

3. Define Pattern1. Cyclical; start with EPO2. True Non-cyclical; EPO

4. Define musculo-skeletal pain

Mastalgia – who needs imaging?

• Risk factors for breast cancer

• History/exam ≠ classical cyclical painE.g. sudden onset focal pain, nipple discharge

• Focal pain without a mass

• Breast lump (discrete or general lumpiness)

• Patient/doctor needs reassurance

Family History of Breast Cancer….

….what should I do?

Family History of Breast Cancer….

….what should I do?

Stratify Risk• High

• Medium

• Low

Family History of Breast Cancer….

….what should I do?

Stratify Risk• High

• Medium

• Low

1. Screening

2. Risk reducing strategies

3. Genetic Testing

BIA-ALCL

• Breast Implant Associated Anaplastic Large Cell Lymphoma

• Rare• 1 in 60,000

• Associated with certain textured implants

• Curable

• Do NOT need surveillance

• Changes should be investigated

Summary

• Spectrum of Normal

• Triple Assessment for lumps

• Aspirate cysts

• Mastalgia: reassurance +/- imaging

• Family History

• BIA-ALCL

Thank you