Approach and management of a case of breast lump and nipple discharge - PowerPoint Presentation

1. Approach and management of a case of breast lump and nipple dischargeDr.talal saadPrince sattam universityCollege of medicine

2. 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.

3. Triple assessmentIn any patient who presents with a breast lump or other symptoms suspicious of carcinoma, the diagnosis should be made by a combination of clinical assessment, radiological imaging and a tissue sample taken for either cytological or histological analysis .

4. Breast lumpHISTORYDuration of massChanges in size over time .associated with pain or nipple discharge. ----Nipple inversion or eversion.Change relative to menstrual cycle . Pain or swelling Redness, fever, lymph node enlargmentmedications Current medications History of hormone therapy.Associated symptoms : weight loss , loss of appetite, bone pain ,jaundice, change in bowel habits ,change of level of coinscness,respiratory symptoms

5. Medical and surgical history:Personal history of breast cancer Previous breast masses and biopsiesRecent breast trauma or surgeryRecent radiation therapy or chemotherapyOther exposure to radiation.Age at first childbearing. Age at menarche. Age at menopause. Current lactation status. History of breastfeeding. Number of children Family history History of breast disease Relationship to patient. Relative’s age at onset and any other type of cancer

6. PHYSICAL EXAMINATIONA complete clinical breast examination (CBE) includes an assessment of both breasts and the chest, axillae, and regional lymphatic's. In premenopausal women, the CBE is best done the week following menses, when breast tissue is least engorged. With the patient in an upright position, the physician visually inspects the breasts, noting asymmetry, nipple discharge, obvious masses, and skin changes, such as dimpling, inflammation, rashes, and unilateral nipple retraction or inversion..

7. With the patient supine and one arm raised, the physician thoroughly palpates breast tissue on the raised-arm side in the superficial, intermediate, and deep tissue planes (i.e., the “triple touch” technique); axilla; supraclavicular area; neck; and chest wall, assessing the size, texture, and location of any masses . The physician should note the size of the masses to document changes over time. Next, the physician should inspect the areola-nipple complex for any discharge

8. Benign masses generally cause no skin change and are smooth, soft to firm, and mobile, with well-defined margins. Diffuse, symmetric thickening, which is common in the upper outer quadrants, may indicate fibro-cystic changes. Malignant masses generally are hard, immobile, and fixed to surrounding skin and soft tissue, with poorly defined or irregular margins. However, mobile or nonfixed masses can be cancerous. Infections such as mastitis and cellulitis tend to be erythematous, tender, and warm to the touch; they may be more circumscribed if an abscess has formed. Similar symptoms may occur in patients with inflammatory breast cancer. Therefore, caution should be used in assessing patients with suspected breast infections.

9. Imaging MammographyAll women 40 years or older with a breast mass-mammography . Multi-focal or multi-centric disease should be noted.Beneficial in finding occult malignancies.

10. UltrasoundUltrasound is particularly useful in young women with dense breasts in whom mammograms are difficult to interpret, and in distinguishing cysts from solid lesions It can also be used to localise impalpable breast lumps.Magnetic resonance imagingMagnetic resonance imaging (MRI) is of increasing interest to breast surgeons in a number of settings: it can be useful to distinguish scar from recurrence in women who have had previous breast conservation therapy for cancer it is the gold standard for imaging the breasts of women with implants.

11. Fine-needle aspiration cytology(FNAC) 22- to 26-gauge needle into the breast mass and extracting cells • Cells can be placed on a slide or made into a cell block • Advantages – fast and easy to perform and it can be done in the OPD – distinguish benign from malignant lesions – for evaluating axillary lymph nodes • Disadvantages – does not show histological architecture – Cannot differentiate ductal carcinoma in situ from invasive malignancy

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13. Core needle biopsy • Using an 8- to 14-gauge needle Provides a larger tissue sample than FNAC. Fast and easy to perform, and allows histological diagnosis Performed by palpation, under stereotactic control, or by ultrasound guidance . Method of choice for histological diagnosis .

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15. Excisional biopsy Removing the entire breast mass-accurate histological diagnosis Invasive technique Benign asymptomatic mass, may be unnecessary Malignant mass, it may not obviate the need for a second procedure to treat

16. Differential Diagnosis of a Breast Lump FIBROCYSTIC DISEASEFIBROADENOMA FAT NECROSIS intraductal PAPILLOMAPhyllodes tumourBREAST CANCER

17. FIBROCYSTIC DISEASECysts are a common cause of breast masses in premenopausal women more than40 yrs of age CLINICAL FEATURES: Often fluctuate with menstrual cycle . usually well demarcated from the surrounding breast tissue. Characteristically firm and mobile . Cysts that have filled rapidly may be tenderUltrasonography.Aspiration: can be both diagnostic and therapeutic.

18. INDICATIONS OF SURGICAL BIOPSYIf the aspirated fluid is bloody. If the palpable abnormality does not resolve completely after the aspiration. recurrence of the cyst after multiple aspirations in a short period of time.

19. FAT NECROSISTraumatic fat necrosis may be acute or chronic, and usually occurs in stout, middle-aged women. Following a blow, or even indirect violence(e.g. contraction of the pectoralis major), a lump, often painless, appears. This may mimic a carcinoma, even displaying skin tethering and nipple retraction, and biopsy is required for diagnosis.

20. FibroadenomaThese usually arise in the fully developed breast during the 15—25-year period, although occasionally they occur in much older women. They arise from hyperplasia of a single lobule, and usually grow up to 2—3 cm in size. They are surrounded by a well-marked capsule and can thusbe enucleated through a cosmetically appropriate incision. However, in a patient under 30 years these do not require excision unless

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22. associated with suspicious cytology, or if they become very large, or if the patient expressly desires the lump to be removed. Giant fibroadenomas occur occasionally during puberty. They are over 5cm in diameter and are often rapidly growing, but in other respects are similar .to smaller fibroadenomas and can be enucleated through a submammary incision

23. Phyllodes tumorThese benign tumors, previously sometimes known as serocystic disease of Brodie or cystsarcoma phyllodes, usually occur in women over the age of 40 but can appear in younger women .They present as a large, sometimes massive tumour.Occasionally ulceration of overlying skin occurs owing to pressure necrosis. In spite of their size they remain mobile on the wall. Histologically there is a resemblance to a fibroadenoma, but despite the name of cystosarcoma phyllodes they are rarely cystic and only very rarely develop features of a sarcomatous tumor. These may metastasis via the bloodstream.

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25. TreatmentTreatment for the benign type is enucleation in very young women or wide local excision. Massive tumors, recurrent tumors and those of the malignant type will require mastectomy

26. The first noticeable symptom of breast cancer is typically a lump that feels different from the rest of the breast tissue. More than 80% of breast cancer cases are discovered when the woman feels a lump. The earliest breast cancers are detected by a mammogram. Lumps found in lymph nodes located in the armpits can also indicate breast cancer

27. The most common place for breast cancer to metastasize is into the lymph nodes under the arm .BrainBones Liver

28. diagnosis

29. U/sBiopsytake a very small piece of tissue from the body for examination and testing. examined by a pathologist

30. stagingThe stages 0-IVStage 0 is noninvasive breast cancer, that is, carcinoma in situ with no affected lymph nodes or metastasis. This is the most favorable stage to find breast cancer. Stage I is breast cancer that is less than three quarters of an inch in diameter and has not spread from the breast.Stage II is breast cancer that is fairly small in size but has spread to lymph nodes in the armpit OR cancer that is somewhat larger but has not spread to the lymph nodes

31. Stage III is breast cancer of a larger size (greater than 2 inches in diameter), with greater lymph node involvement, or of the inflammatory type. Spreading to other areas around the breast.Stage IV is metastatic breast cancer: a tumor of any size or type that has metastasized to another part of the body (ex. bones, lungs, liver, brain). This is the least favorable stage to find breast cancer

32. TreatmentRadiation ChemotherapySurgery Hormonal therapy :Tamoxifen is the most commonly prescribed hormone treatment

33. Nipple dischargeAbnormal discharges from the nippleDischarge can occur from one or more lactiferous ducts. Management depends on the presence of a lump (which should always be givenpriority in diagnosis and treatment) and of the presence of blood in the discharge or discharge from a single duct. Mammography is rarely useful except to exclude an underlying impalpable mass. Cytology may reveal malignant cells but a negative result does not exclude a carcinoma.

34. A clear, serous discharge may be ‘physiological’ in a parous woman or may be associated with a duct papilloma or mammary dysplasia.A blood-stained discharge may be caused by duct ectasia or less commonly a duct papilloma or carcinoma. A duct papilloma is usually single and situated in one of the larger lactiferous ducts and is sometimes associated with a cystic swelling beneath the areola.A black or green discharge is usually due to duct ectasia and its complications

35. Treatment must firstly be to exclude a carcinoma by occult blood test and cytology. Simple reassurance may then be sufficient, but if the discharge is proving intolerable an opera-tion to remove the affected duct or ducts can be performed.

36. PATHOLOGICAL NIPPLE DISCHARGE : -SPONTANEOUS . -BLOODY. -ASSOCIATED WITH MASS. -UNILATERAL. -CONFINED TO ONE DUCT.PHYSIOLOLGICAL NIPPLE DISCHARGE : -OBTAINED ONLY WITH COMPRESSION. -BY MULTIPLE DUCT INVOLVEMENT. -FREQUENTLY BILATERAL.

37. Work upLOCALIZATIOIN OF THE AFFECTED DUCT .EXAMINATION OF THE DISCHARGE FOR OCCULT BLOOD.MAMMOGRAM SHOULD BE OBTAINED TO LOOK FOR NONPALPABLE MASSES OR CALCIFICATIONS.

38. THE INDICATIOINS FOR SURGERYPALPABLE MASS .MAMMOGRAPHICALY DETECTED MASS.BREAST MICROCALCIFICATIONS.UNILATERAL DISCHARGE.SPONTANEOUS DISCHARGE.BLOODY DISCHARGE.SEROUS DISCHARGE

39. intraductal papillomas of the breast are benign lesions with an incidence of approximately 2-3% in humans.Two types of intraductal papillomas are generally distinguished. The central type develops near the nipple. They are usually solitary and often arise in the period nearing menopause. On the other hand, the peripheral type are often multiple papillomas arising at the peripheral breasts, and are usually found in younger women.

40. They are the most common cause of bloody nipple discharge in women age 20-40 and generally do not show up on mammography due to their small size. They may be detectable on ultrasound. A galactogram is the most definitive test but is somewhat invasive.The masses are often too small to be palpated or felt. A galactogram is therefore necessary to rule out the lesion.Excision is sometimes performed microdochectomy (removal of a breast duct) is the treatment of choice.

41. duct ectasiathe duct widening is commonly believed to be a result of secretory stasis, including stagnant colostrum, which also causes periductal inflammation and fibrosis. However, because nonspecific duct widening is common it might be also coincidental finding in many processes.

42. duct ectasiaA dirty white, greenish or black nipple discharge from one or both nipplesTenderness in the nipple or surrounding breast tissueRedness of the nipple and sometimes the surrounding areaA breast lump or thickening near the clogged duct.Diagnosis: Diagnostic ultrasound of the nipple and areola.MammographyTTT:Antibiotics, Pain medication, Surgery