Done by Mohammad Binhussein & Mohammad Mini

A 34year-old woman has been having bloody nipple discharge from the right nipple, on and off for several months. There are no palpable masses. What is the diagnosis? Intraductal papllioma

INTRADUCTAL PAPILLOMA It is a benign, solitary polypoid lesion involving epithelium-lined major subareolar ducts. Presents as bloody nipple discharge in premenopausal women.. Major differential diagnosis is between intraductal papilloma and invasive papillary carcinoma Management: Cancer should be ruled out , Ductogram can help Excision of involved duct (microdochectomy) after localization by physical examination

A 43 -year- old women presents with blood tinged discharge from her right nipples. She indicates that this problem has been occurring intermittently over the past several weeks. Her past medical history is significant for hypothyroidism . Her medication consist of OCP and levothyroxine. On examination , she is found to have fibrocystic changes in both breast . there is evidence of thickening in the right retroareolar region . there is no evidence of nipple discharge or adominant mass in the left breast .

A 43 -year- old women presents with blood tinged discharge from her right nipples. She indicates that this problem has been occurring intermittently over the past several weeks. Her past medical history is significant for hypothyroidism . Her medication consist of OCP and levothyroxine. On examination , she is found to have fibrocystic changes in both breast . there is evidence of thickening in the right retroareolar region . there is no evidence of nipple discharge or adominant mass in the left breast .

What should be your next step ? Cytology Mammograghy Us Ductogram Biopsy

History: spontaneous characteristic (bloody, milky , purulent , green to yellow ) uni or bilateral lactation ( duration and time of weaning) pain

Types of Discharge Milky white discharge galactorrhe (bilateral) Pregnancy common after Lactation (as long as two years) Straw-colored, transparent discharge due to a papilloma. The resulting increase in vascular pressure causes a transudate to form in the duct.

Types of Discharge Grossly bloody discharge 1/3 due to an intraductal carcinoma, 1/3 due to bleeding papillomata, and 1/3 from fibrocystic changes with an active intraductal component. Guaiac positive discharge Nipple secretion that is not grossly bloody, but is guaiac positive. causes: intraductal pathologies or plasma cell mastitis with duct ectasia.

Positive guaiac test shown on right Negative on left

Nipple Discharge Causes (in order of frequency) Physiological Duct papilloma Duct ectasia Periductal mastitis Cancer Galactorrhoea

Expressing of discharge

Bilateral multiductal secretion is usually normal and tests negative on the guaiac card (i.e. Not bloody) regardless of color treatment is reassurance and endocrinological follow-up if abnormal However, prolactin and TSH concentration should be measured.

UNILATERAL DISCHARGE -multiductal unilateral discharge is unlikely to represint significant disease and should be investigated similarly to bilateral discharge .    Uniductal discharge is more likely to represent underlying pathology .

Investigation Cytologic examination recommended for guaiac positive or bloody discharge. useful for differentiating between proliferative lesions and inflammatory lesions . Mammography and ultrasound   

Ductography It can often identify intraluminal lesions, Cytology can also be obtained at the time of the ductogram.

    Ductoscopy Ductoscopy is increasingly employed as a minimally invasive method for evaluation and treatment of nipple discharge. (It involves placing a small (outer diameter 0.625 cm) fiberoptic cannula in the offending duct; the procedure can be done in the office or in the operating room. Ductoscopic biopsy is also possible in some cases and obviates the need to excise the surgical duct.)

TREATMENT An isolated papilloma is benign, but diffuse papillomatosis is associated with an increased risk of breast cancer. In both cases, surgery is necessary to treat the nipple discharge and confirm the diagnosis. All guaiac positive and/or bloody nipple discharge without imaging correlate should be resected by a terminal duct excision.

Nipple discharge

KEY POINTS - Nipple discharge is common and usually of benign origin. - Bilateral and multiductal nipple discharge are almost always due to benign processes. - Discharge characteristics associated with a higher risk of underlying malignancy are spontaneous, persistent, unilateral discharge; discharge limited to one duct; presence of a breast mass; and bloody fluid.

- A straw-colored, transparent, sticky discharge is characteristic of an intraductal papilloma. - Cytology should be performed only when nipple discharge is grossly bloody or guaiac positive. Surgical excision is warranted after imaging for grossly bloody or guaiac positive discharge. - Cytology may be useful for differentiating between proliferative lesions and inflammatory lesions in women with guaiac positive discharge. Both processes require excision.

Breast Screening Aim Of Screening: -The early detection of cancer -Any mass < 2 cm is not palpable

Clinical presentation of breast lesion

When should Done ?

When should Done ? No controversy: all women aged 50 and older should have a mammogram (CDC recommendation) , (Grade 1A), every 1-2 year (Grade 2A) Also clinical breast examination (Grade 1B) Women aged 40 to 49 (Grade 2B) In high risk group The decision depends on individual risk .

Screening Introduction OutCome Incidence for women > 50 yrs (rate per 100.000)

Screening Introduction OutCome

Number of women needing to be screened to detect one new breast cancer Age Group no. needed 20 to 24 67,000 30 to 34 4,000 40 to 44 850 50 to 54 375 60 to 64 275 70 to 74 210 80 to 84 210

Radiological Sign irregular border , 90% of such lesion is invasive carcinoma

Well Circumscribed Mass D.D ( Fibroadenoma Fibrocystic Changes )

Multiple Clusters Of Small , Irregular Calcifications In A Segmental Distribution The suspicious Calcification Should Be Biopsied 20% to 30% is DCIS

Reading the Mammogram Where is the suspecious lesion???

Medically proven malignancy.

A benign microcacification

Reading the Mammogram Best if read by radiologist specializing in mammography. Using Category of American College Of Radiology.

Category of American College Of Radiology BioRads Assessment Category 0 Needs Additional Imaging Evaluation Category 1 Negative (5/10,000 risk of breast cancer) Category 2 Benign Finding (5/10,000 risk of breast cancer) Category 3 Probably Benign Finding: Short Interval Follow up Suggested (generally 6 months) Category 4 Suspicious Abnormality-Biopsy Should be considered (risk cancer 25-50%) Category 5 Highly suggestive of malignancy- Appropriate Action should be taken (obvious cancer: 75-100%risk)

Limitation of Mammogram Mammogram is best method of detecting breast cancer at an early stage, but is it perfect ?? There is No perfect test , screening mammogram lead to over-diagnosis and subsequent problem of false positive

CASE PRESENTATION A 59-year-old Woman Comes into your office for health maintenance examination. Her PMH is remarkable for mild hypertension controlled on thiazide. Her PSH is unremarkable. On exam. her vitals within normal range thyroid is norm. to palpation. The breasts are nontender and without masses. Pelvic exam. Is unremarkable.

CASE PRESENTATION A 59-year-old Woman Comes into your office for health maintenance examination. Her PMH is remarkable for mild hypertension controlled on thiazide. Her PSH is unremarkable. On exam. her vitals within normal range thyroid is norm. to palpation. The breasts are nontender and without masses. Pelvic exam. Is unremarkable.

Mammography revealed a small cluster of calcifications around a small mass.

What Is Your Next Step? U.S guided FNAC vs. U.S guided core biopsy , Unfortunately the lesion not seen by ultra sound Then what is your next step?

needle-localization excisional biopsy Stereotactic Biopsy or needle-localization excisional biopsy Depends on the site of the lesion and/or patient preference

Case Discussion What are stereotactic core biopsy and needle localization core biopsy?

Stereotactic core biopsy: biopsies are taken as directed with computer-assisted techniques. (For non palpable mass) and has 2% to 4% “miss rates”

Case Discussion If FNA cytology detecting benign cells, so either continue routine screening, (or close follow-up in non-certain cytological analysis) .

Case Discussion If FNA cytology detecting malignant cells, so Needle localization core-biopsy should be obtained as many as 50% of such a case will reveal a (DCIS). ACS surgery principle and practice 2006 (Nowadays they use iodine-125 seed localizing biopsy in some center to avoid needle placement) a called emerging technique

The tissue biopsy come back and diagnosed as Case Discussion The tissue biopsy come back and diagnosed as DCIS.

Case Discussion What is the management ? 1- wide excision →→ assess the margins once negative →→ +/- irradiate breast and follow up. 2 – If margins are positive, patient worried of recurrence and/or lesion > 5 cm →→ simple mastectomy +/- reconstruction

Lobular Carcinoma in Situ LCIS Rare , occurs in young women Always almost incidental finding in biopsy for other reason. found bilaterally in 25% of cases Marker of increased risk for invasive carcinoma Treatment either close follow up or prophylactic simple mastectomy.

Miscellaneous

Studies evaluating Breast Self Examination No difference in breast cancer mortality No difference in stage of cancer at diagnosis More provider visits: 8% vs. 4% More benign biopsies Chinese 266,000 women age 39-72 in monthly BSE with extensive training, 2 reinforcement sessions, multiple reminders: Planned for 10 year F/U – powered to find 30% difference in mortality. At 10 years, no difference in mortality (135 vs. 131) Russia: 122,000 women aged 40-64 with similar BSE teaching. No difference in mortality at 9 years. Neither has reached maturity but a large benefit would be unlikely and the continuation of both studies is threatened from a political perspective. Chinese and Russian study: no benefit Non-randomized trial of BSE in UK Nested case control in a Canadian screening study NO REDUCTION IN MORTALITY

Nipple Laceration Keep clean and dry. Stop breastfeeding that side and allow to heal Antibiotics usually not necessary

Supernumerary Breasts Relatively common Found along “milk line” Most identified during pregnancy/lactation Most common in axilla Not dangerous

Supernumerary Nipples More common than supernumerary breasts Found along milk line May darken during pregnancy Not dangerous

Mondor’s disease thrombophlebitis of lateral thoracic vein.

Male breast Carcinoma Risk factor are: 1- gynecomastia 2- BRCA 2