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
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