EVALUATION OF BREAST EVALUATION OF BREAST PROBLEM & BENIGN PROBLEM & BENIGN BREAST DISEASESBREAST DISEASES

January 24, 2008January 24, 2008

III-C4III-C4

◙ ◙ Nayal ◙ Nematian ◙ Nery ◙ Ng, C ◙ Ng, Nayal ◙ Nematian ◙ Nery ◙ Ng, C ◙ Ng, V ◙V ◙

3 females with age 3 females with age 23, 35 and 55 years 23, 35 and 55 years respectively went to respectively went to see you for consult. see you for consult. All have breast mass All have breast mass in one of their in one of their breast.breast.

What important general data What important general data from the patients do you from the patients do you think are important to be think are important to be able to guide you in your able to guide you in your diagnosis? Explain.diagnosis? Explain.

Breast lump Breast lump characteristicscharacteristics – Changes in size over Changes in size over

timetime– Change relative to Change relative to

menstrual cyclemenstrual cycle– Duration of massDuration of mass– Pain or swellingPain or swelling– Redness, fever, or Redness, fever, or

dischargedischarge

Diet and Diet and medications medications

– Current medicationsCurrent medications– History of hormone History of hormone

therapytherapy

HistoryHistory Family historyFamily history

– History of breast History of breast diseasedisease

– Relationship to Relationship to patientpatient

– Relative's age Relative's age at onsetat onset

Medical and Medical and surgical historysurgical history – Personal history Personal history

of breast cancerof breast cancer– Previous breast Previous breast

masses and masses and biopsiesbiopsies

– Recent breast Recent breast trauma or trauma or surgerysurgery

– Recent radiation Recent radiation therapy or therapy or chemotherapychemotherapy

HistoryHistory Personal Personal

characteristicscharacteristics – Age at first childbearingAge at first childbearing– Age at menarcheAge at menarche– Age at menopauseAge at menopause– Current ageCurrent age– Current lactation statusCurrent lactation status– History of breastfeedingHistory of breastfeeding– Number of childrenNumber of children

Social historySocial history– Radiation and Radiation and

chemical chemical exposureexposure

– SmokingSmoking

In the Physical examination, In the Physical examination, differentiate a benign from a differentiate a benign from a malignant lesionmalignant lesion

Malignant MassMalignant Mass– HardHard– ImmobileImmobile– Fixed to the Fixed to the

surrounding skin/ surrounding skin/ soft tissuessoft tissues

– Poorly defined, Poorly defined, irregular marginsirregular margins

Benign MassBenign Mass– Cause no skin Cause no skin

changechange– Smooth Smooth – Soft to firmSoft to firm– Mobile Mobile – Well defined Well defined

marginsmargins

How will you approach How will you approach the 35 year old, with a 2 x the 35 year old, with a 2 x 2 x 2cm, firm, mobile, 2 x 2cm, firm, mobile, well circumscribed non well circumscribed non tender mass on the right tender mass on the right breast?breast?

A mammogram was taken as seen in A mammogram was taken as seen in the picture:the picture:

BENIGN CYSTBENIGN CYST

Benign cyst: ImagingBenign cyst: Imaging MammographyMammography

– To screen the normal surrounding To screen the normal surrounding breast tissue and the opposite breast tissue and the opposite breast for non-palpable cancersbreast for non-palpable cancers

UltrasoundUltrasound– to differentiate solid from cystic to differentiate solid from cystic

massesmasses– to provide guidance for to provide guidance for

interventional breast procedures interventional breast procedures such as cyst aspiration or core such as cyst aspiration or core biopsybiopsy

– useful when a palpable mass is useful when a palpable mass is partially or poorly seen on a partially or poorly seen on a mammogram, especially in young mammogram, especially in young womenwomen

Radiologic difference Radiologic difference between a benign and between a benign and malignant massmalignant mass

BENIGNBENIGN– Smooth contourSmooth contour– Well-Well-

circumscribedcircumscribed– Encapsulated Encapsulated – With “halo sign”With “halo sign”– Will not change Will not change

much in shape or much in shape or sizesize

MALIGNANTMALIGNANT– Grow Grow

significantlysignificantly– Stellate or star-Stellate or star-

bust shaped that bust shaped that extends in all extends in all directionsdirections

– CalcificationsCalcifications

Difference in Difference in ultrasound findingsultrasound findings

BENIGNBENIGN intense uniform intense uniform

hyperechogenicithyperechogenicityy

ellipsoid or wider-ellipsoid or wider-than-tall (parallel) than-tall (parallel) orientation along orientation along with a thin, with a thin, echogenic echogenic capsule capsule

2 or 3 gentle 2 or 3 gentle lobulations and a lobulations and a thin, echogenic thin, echogenic capsulecapsule

MALIGNANTMALIGNANT Irregular/spiculated Irregular/spiculated

borders (“Silhouette borders (“Silhouette sign”)sign”)

taller-than-wide taller-than-wide orientationorientation

angular marginsangular margins marked marked

hypoechogenicityhypoechogenicity posterior acoustic posterior acoustic

shadowingshadowing punctate punctate

calcificationscalcifications duct extensionduct extension branch patternbranch pattern microlobulation.microlobulation.

The patient has a The patient has a mother who is a breast mother who is a breast cancer survivor. How cancer survivor. How would you handle such would you handle such patient?patient?

Breast Cancer Breast Cancer Screening TestsScreening Tests

MammogramMammogram – is the best tool available for early breast is the best tool available for early breast

cancer detection cancer detection – can often identify cancer before symptoms can often identify cancer before symptoms

appear and can reveal calcium deposits in the appear and can reveal calcium deposits in the breast, which may be an early sign of cancer breast, which may be an early sign of cancer

****HIGH RISK: ****HIGH RISK: annual mammogram annual mammogram beginning at an age that is 5 to 10 years beginning at an age that is 5 to 10 years younger than the youngest member of the younger than the youngest member of the family with breast cancer family with breast cancer

Breast Cancer Breast Cancer Screening TestsScreening Tests Clinical breast examClinical breast exam

– thorough physical examination of the thorough physical examination of the breasts done by a physician or nurse breasts done by a physician or nurse practitioner practitioner

– HIGH RISK: recommended every 6 to 12 HIGH RISK: recommended every 6 to 12 monthsmonths

Self breast examSelf breast exam – identify breast abnormalities and should be identify breast abnormalities and should be

performed monthly, about one week after performed monthly, about one week after the end of your period the end of your period

Breast Cancer Breast Cancer Screening TestsScreening Tests Breast MRIBreast MRI

– Fore extremely dense breast tissue Fore extremely dense breast tissue that make mammograms difficult to that make mammograms difficult to interpretinterpret

How will you approach How will you approach the 23 year old, with a the 23 year old, with a 2 X 2 X 2cm, firm, 2 X 2 X 2cm, firm, mobile, well mobile, well circumscribed non-circumscribed non-tender mass in the left tender mass in the left breast?breast?

Imaging of choiceImaging of choice

ULTRASOUNDULTRASOUND– For patients younger than 30 yearsFor patients younger than 30 years– The patient is spared radiation The patient is spared radiation

exposureexposure– to differentiate solid from cystic to differentiate solid from cystic

massesmasses– to provide guidance for interventional to provide guidance for interventional

breast procedures such as cyst breast procedures such as cyst aspiration or core biopsyaspiration or core biopsy

Differential DiagnosisDifferential Diagnosis

CystCyst FibroadenomaFibroadenoma Phyllodes tumorPhyllodes tumor LipomaLipoma Fat necrosisFat necrosis

ManagementManagement

CystCyst– Ultrasound or cyst aspiration useful to Ultrasound or cyst aspiration useful to

differentiate between solid and cystic differentiate between solid and cystic mass.mass.

– With aspiration, if mass does not With aspiration, if mass does not disappear completely or if fluid is bloody, disappear completely or if fluid is bloody, send for cytology and refer to surgeon. send for cytology and refer to surgeon.

– Re-examine breast in six weeks for Re-examine breast in six weeks for recurrence. recurrence.

ManagementManagement

FibroadenomaFibroadenoma– The lump may be left in place or removed, The lump may be left in place or removed,

depending on the patient and the lump. depending on the patient and the lump. – If left in place, it may be watched over time with If left in place, it may be watched over time with

physical examinations, mammograms, and physical examinations, mammograms, and ultrasounds. ultrasounds.

– The lump may be surgically removed at the time The lump may be surgically removed at the time of an open biopsy. (excisional biopsy) of an open biopsy. (excisional biopsy)

– Alternative treatments include removing the lump Alternative treatments include removing the lump with a needle, and destroying the lump without with a needle, and destroying the lump without removing it (such as freezing, called removing it (such as freezing, called cryoablation). cryoablation).

A 43 year old female A 43 year old female consulted because of consulted because of a rapidly growing left a rapidly growing left breast. Axilla is breast. Axilla is negative for clinically negative for clinically palpable nodes.palpable nodes.

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Final diagnosisFinal diagnosis Behavior of the above?Behavior of the above? Treatment?Treatment?

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Final diagnosis: Final diagnosis: Phyllodes tumorPhyllodes tumor

most commonly occurring nonepithelial most commonly occurring nonepithelial neoplasm of the breastneoplasm of the breast

represents only about 1% of tumors in represents only about 1% of tumors in the breastthe breast

rare, predominantly benign tumor rare, predominantly benign tumor sharply demarcated smooth texturesharply demarcated smooth texture typically freely movabletypically freely movable relatively large tumor (average size:5 relatively large tumor (average size:5

cm)cm)23

Final diagnosis: Final diagnosis: Phyllodes tumorPhyllodes tumor

firm, mobile, well-circumscribed, nontender firm, mobile, well-circumscribed, nontender breast mass breast mass

tends to involve the left breast more tends to involve the left breast more commonly than the right breast commonly than the right breast

overlying skin may display a shiny overlying skin may display a shiny appearance and be translucent enough that appearance and be translucent enough that underlying breast veins are visibleunderlying breast veins are visible

physical findings are similar to fibroadenoma physical findings are similar to fibroadenoma (mobile masses with distinct borders)(mobile masses with distinct borders)

manifest as larger masses and with rapid manifest as larger masses and with rapid growth growth

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Treatment: Phyllodes Treatment: Phyllodes tumortumor SurgerySurgery

– wide local excision with a rim of wide local excision with a rim of normal tissue normal tissue

– if high tumor:breast ratio: total if high tumor:breast ratio: total mastectomy w/ or w/o mastectomy w/ or w/o reconstructionreconstruction

– if (+) clinically suspicious nodes: if (+) clinically suspicious nodes: axillary lymph node dissectionaxillary lymph node dissection

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A 55 year old female A 55 year old female consulted because of consulted because of bloody nipple bloody nipple dischargedischarge

1. Differentiate a 1. Differentiate a physiologic from physiologic from pathologic nipple pathologic nipple dischargedischarge

2. Describe the maneuver 2. Describe the maneuver how to localize the how to localize the involved duct.involved duct.

3. Diagnosis? Treatment? 3. Diagnosis? Treatment?

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Physiologic vs. Pathologic Physiologic vs. Pathologic nipple dischargenipple discharge

Discharge only Discharge only with compressionwith compression

Usually bilateral, Usually bilateral, Involvement of Involvement of multiple ductsmultiple ducts

More viscousMore viscous milky to yellow, milky to yellow,

gray, brown, or gray, brown, or dark greendark green

SpontaneousSpontaneous Associated with a Associated with a

massmass Usually unilateral, Usually unilateral,

confined to one confined to one ductduct

usually serous, usually serous, bloody or clear, and bloody or clear, and has a watery has a watery consistencyconsistency

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http://www.breastdiagnostic.com/anatomy.html

Nipple discharges that are usually benign

Suspicious nipple discharges

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Contrast ductogram Contrast ductogram mammographymammography retrograde injection of contrast retrograde injection of contrast

medium into a discharging duct, medium into a discharging duct, with subsequent mammographic with subsequent mammographic imaging of the breast in at least 2 imaging of the breast in at least 2 planesplanes

allows for visualization and allows for visualization and localization of involved duct and localization of involved duct and lesionlesion

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Diagnosis: Intraductal Diagnosis: Intraductal PapillomaPapilloma

- benign wart-like growth in a major benign wart-like growth in a major lactiferous duct of the breastlactiferous duct of the breast

- usually affects women aged 35-55 usually affects women aged 35-55 yearsyears

- usually located close to the nipple usually located close to the nipple - signs & symptomssigns & symptoms

- nipple discharge: clear, sticky or bloodynipple discharge: clear, sticky or bloody- breast painbreast pain- breast lumpbreast lump- breast enlargementbreast enlargement

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Treatment: Intraductal Treatment: Intraductal PapillomaPapilloma

Excision of involved ductExcision of involved duct

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2 ladies age 20 and 48 years 2 ladies age 20 and 48 years respectively consulted because respectively consulted because of bilateral breast tenderness.of bilateral breast tenderness.

In the 20 year old, what is your In the 20 year old, what is your foremost consideration? foremost consideration? FibroadenomaFibroadenoma

In the 48 year old, what is your In the 48 year old, what is your foremost consideration?foremost consideration? Fibrocystic Fibrocystic breast changebreast change

How do you differentiate How do you differentiate the diagnosis in 1 from that the diagnosis in 1 from that of 2?of 2?

FibroadenomaFibroadenoma

women less than 30 years women less than 30 years of ageof age

firm, rubbery, freely mobile firm, rubbery, freely mobile with well-defined borderswith well-defined borders

tender in the days before a tender in the days before a period or grow bigger period or grow bigger during pregnancy during pregnancy

approximately 10 percent approximately 10 percent of fully recede each yearof fully recede each year

fibroadenoma growths are fibroadenoma growths are usually painless, but size usually painless, but size and location of the growth and location of the growth can cause breast can cause breast tenderness or pain.tenderness or pain.

Fibrocystic changeFibrocystic change

35-50 (premenopausal)35-50 (premenopausal) dense, irregular and bumpy dense, irregular and bumpy

"cobblestone" consistency "cobblestone" consistency in the breast tissue in the breast tissue

premenstrual tenderness premenstrual tenderness and swellingand swelling

result of prolonged cyclic result of prolonged cyclic stimulation of repeated stimulation of repeated menstrual cycle menstrual cycle

breasts feel full breasts feel full fibrous growth between the fibrous growth between the

breast glands or cyst breast glands or cyst formation within the formation within the glands, this condition is glands, this condition is called atypical hyperplasia.called atypical hyperplasia.

How will you manage the 20 How will you manage the 20 year old?year old?

Conservative management – Conservative management – follow-up every 6 months (until follow-up every 6 months (until complete regression)complete regression)

Pain or tenderness or unusually Pain or tenderness or unusually large tumors - excision large tumors - excision

The 48 year old had surgery The 48 year old had surgery showing the gross finding, What is showing the gross finding, What is your treatment?your treatment?

Treatment of Fibrocystic Treatment of Fibrocystic changechange

Pain managementPain management Aspiration of cystic lesionsAspiration of cystic lesions Supportive bra in the week before their mensesSupportive bra in the week before their menses Eliminating caffeine, alcohol and reducing salt Eliminating caffeine, alcohol and reducing salt

intakeintake Taking vitamin E (400-800 IU daily) and A Taking vitamin E (400-800 IU daily) and A

(150,000 IU daily) may help some women(150,000 IU daily) may help some women Using diuretics during the week before the Using diuretics during the week before the

menstrual period can help ease uncomfortable, menstrual period can help ease uncomfortable, swollen breasts. swollen breasts.

Treatment of Fibrocystic Treatment of Fibrocystic changechange

Birth control pills – regulate estrogen and Birth control pills – regulate estrogen and progesterone levelsprogesterone levels

Bromocriptine - reduces prolactin release and Bromocriptine - reduces prolactin release and suppresses breast milk production after suppresses breast milk production after pregnancypregnancy

Danazol -severe cases, inhibits the Danazol -severe cases, inhibits the production of hormones called production of hormones called gonadotrophins by the pituitary gland gonadotrophins by the pituitary gland

How will you approach the 55 year How will you approach the 55 year old menopausic, with 2 cm old menopausic, with 2 cm diameter, mobile, firm non tender diameter, mobile, firm non tender mass on the right breast.mass on the right breast.

Postmenopausal Postmenopausal

Bilateral mammographyBilateral mammography

BiopsyBiopsy

Role of imaging modality in Role of imaging modality in this case?this case?

mammography more helpful in older women mammography more helpful in older women because breast tissue undergoes fatty because breast tissue undergoes fatty replacement with age and masses are more easily replacement with age and masses are more easily visible; young women have more fibrous tissue visible; young women have more fibrous tissue making mammogram harder to interpretmaking mammogram harder to interpret

the primary purpose of the mammogram is to the primary purpose of the mammogram is to screen the normal surrounding breast and the screen the normal surrounding breast and the opposite breast for nonpalpable cancersopposite breast for nonpalpable cancers

Diagnosis - CystDiagnosis - Cyst

FNAc revealed NEGATIVE FOR FNAc revealed NEGATIVE FOR MALIGNANT CELLS. How willMALIGNANT CELLS. How willYou manage the patient.You manage the patient.

Annual mammographyAnnual mammography clinically suspicious mass – excisional clinically suspicious mass – excisional

biopsybiopsy( distinct mass - should be removed and sent for ( distinct mass - should be removed and sent for

examination for malignancy because examination for malignancy because mammograms and cytologic needle biopsies can mammograms and cytologic needle biopsies can have falsely negative results and can miss have falsely negative results and can miss cancer)cancer)

THANK YOU!THANK YOU!

NAYAL-NEMATIAN-NERY-NG,C-NG,VNAYAL-NEMATIAN-NERY-NG,C-NG,V

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