EVALUATION OF BREAST PROBLEM & BENIGN BREAST DISEASES January 24, 2008 III-C4 ◙ Nayal ◙ Nematian ◙ Nery ◙ Ng, C ◙ Ng, V ◙

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

What important general data from the patients do you think are important to be able to guide you in your diagnosis? Explain. Breast lump characteristics Changes in size over time Change relative to menstrual cycle Duration of mass Pain or swelling Redness, fever, or discharge Diet and medications Current medications History of hormone therapy

History Medical and surgical history Family history Personal history of breast cancer Previous breast masses and biopsies Recent breast trauma or surgery Recent radiation therapy or chemotherapy Family history History of breast disease Relationship to patient Relative's age at onset

History Social history Personal characteristics Age at first childbearing Age at menarche Age at menopause Current age Current lactation status History of breastfeeding Number of children Social history Radiation and chemical exposure Smoking

In the Physical examination, differentiate a benign from a malignant lesion Benign Mass Cause no skin change Smooth Soft to firm Mobile Well defined margins Malignant Mass Hard Immobile Fixed to the surrounding skin/ soft tissues Poorly defined, irregular margins

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

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

Benign cyst: Imaging Mammography Ultrasound To screen the normal surrounding breast tissue and the opposite breast for non-palpable cancers Ultrasound to differentiate solid from cystic masses to provide guidance for interventional breast procedures such as cyst aspiration or core biopsy useful when a palpable mass is partially or poorly seen on a mammogram, especially in young women

Radiologic difference between a benign and malignant mass Smooth contour Well-circumscribed Encapsulated With “halo sign” Will not change much in shape or size MALIGNANT Grow significantly Stellate or star-bust shaped that extends in all directions Calcifications

Difference in ultrasound findings BENIGN intense uniform hyperechogenicity ellipsoid or wider-than-tall (parallel) orientation along with a thin, echogenic capsule 2 or 3 gentle lobulations and a thin, echogenic capsule MALIGNANT Irregular/spiculated borders (“Silhouette sign”) taller-than-wide orientation angular margins marked hypoechogenicity posterior acoustic shadowing punctate calcifications duct extension branch pattern microlobulation.

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

Breast Cancer Screening Tests Mammogram is the best tool available for early breast cancer detection can often identify cancer before symptoms appear and can reveal calcium deposits in the breast, which may be an early sign of cancer ****HIGH RISK: annual mammogram beginning at an age that is 5 to 10 years younger than the youngest member of the family with breast cancer

Breast Cancer Screening Tests Clinical breast exam thorough physical examination of the breasts done by a physician or nurse practitioner HIGH RISK: recommended every 6 to 12 months Self breast exam identify breast abnormalities and should be performed monthly, about one week after the end of your period

Breast Cancer Screening Tests Breast MRI Fore extremely dense breast tissue that make mammograms difficult to interpret

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

Imaging of choice ULTRASOUND For patients younger than 30 years The patient is spared radiation exposure to differentiate solid from cystic masses to provide guidance for interventional breast procedures such as cyst aspiration or core biopsy

Differential Diagnosis Cyst Fibroadenoma Phyllodes tumor Lipoma Fat necrosis

Management Cyst Ultrasound or cyst aspiration useful to differentiate between solid and cystic mass. With aspiration, if mass does not disappear completely or if fluid is bloody, send for cytology and refer to surgeon. Re-examine breast in six weeks for recurrence.

Management Fibroadenoma The lump may be left in place or removed, depending on the patient and the lump. If left in place, it may be watched over time with physical examinations, mammograms, and ultrasounds. The lump may be surgically removed at the time of an open biopsy. (excisional biopsy) Alternative treatments include removing the lump with a needle, and destroying the lump without removing it (such as freezing, called cryoablation). Women in their teens or early 20s may not need a biopsy if the lump appears to be a typical fibroadenoma and does not change.

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

Final diagnosis Behavior of the above? Treatment?

Final diagnosis: Phyllodes tumor most commonly occurring nonepithelial neoplasm of the breast represents only about 1% of tumors in the breast rare, predominantly benign tumor sharply demarcated smooth texture typically freely movable relatively large tumor (average size:5 cm) Cystosarcoma phyllodes (CSP) is a rare, predominantly benign tumor that occurs almost exclusively in the female breast. Its name is derived from the Greek words sarcoma, meaning fleshy tumor, and phyllo, meaning leaf. Grossly, the tumor displays characteristics of a large malignant sarcoma, takes on a leaflike appearance when sectioned, and displays epithelial cystlike spaces when viewed histologically (hence the name). Because most tumors are benign, the name may be misleading. Thus, the favored terminology is now phyllodes tumor. Phyllodes tumor is the most commonly occurring nonepithelial neoplasm of the breast but represents only about 1% of tumors in the breast. It has a sharply demarcated smooth texture and is typically freely movable. It is a relatively large tumor, and the average size is 5 cm. However, lesions more than 30 cm in size have been reported. Prognosis: Although CSP is considered a clinically benign tumor, the possibility for local recurrence following excision always exists, particularly with lesions that display malignant histology. Tumors initially treated by wide local excision that recur locally should ideally be treated by total mastectomy. Metastatic disease is typically observed in the lung, mediastinum, and skeleton. The clinical course is variable. If the tumor is benign, the long-term prognosis is excellent following adequate local excision. If the tumor recurs locally after excision, further local excision or total mastectomy is typically curative.

Final diagnosis: Phyllodes tumor firm, mobile, well-circumscribed, nontender breast mass tends to involve the left breast more commonly than the right breast overlying skin may display a shiny appearance and be translucent enough that underlying breast veins are visible physical findings are similar to fibroadenoma (mobile masses with distinct borders) manifest as larger masses and with rapid growth Prognosis: Although CSP is considered a clinically benign tumor, the possibility for local recurrence following excision always exists, particularly with lesions that display malignant histology. Tumors initially treated by wide local excision that recur locally should ideally be treated by total mastectomy. Metastatic disease is typically observed in the lung, mediastinum, and skeleton. The clinical course is variable. If the tumor is benign, the long-term prognosis is excellent following adequate local excision. If the tumor recurs locally after excision, further local excision or total mastectomy is typically curative.

Treatment: Phyllodes tumor Surgery wide local excision with a rim of normal tissue if high tumor:breast ratio: total mastectomy w/ or w/o reconstruction if (+) clinically suspicious nodes: axillary lymph node dissection If the tumor-to-breast ratio is sufficiently high to preclude a satisfactory cosmetic result by segmental excision, total mastectomy, with or without reconstruction, is an alternative. More radical procedures are not generally warranted. Perform axillary lymph node dissection only for clinically suspicious nodes. However, virtually all of these nodes are reactive and do not contain malignant cells. The treatment of these tumors is surgical. As they have a significant rate of local recurrence, surgical local control is essential. For small benign cystosarcoma phyllodes, a wide local excision can be performed with meticulous, life long, post-operative monitoring. For large tumors or malignant / borderline tumors, a total mastectomy is the procedure of choice. No axillary lymphadenectomy is performed as the rate of axillary metastasis is less than 0.9%. Some authors have proposed a simultaneous sentinel lymphadenectomy; although this approach is reasonable, no guidelines have been set.

A 55 year old female consulted because of bloody nipple discharge 1. Differentiate a physiologic from pathologic nipple discharge 2. Describe the maneuver how to localize the involved duct. 3. Diagnosis? Treatment?

Physiologic vs. Pathologic nipple discharge Discharge only with compression Usually bilateral, Involvement of multiple ducts More viscous milky to yellow, gray, brown, or dark green Spontaneous Associated with a mass Usually unilateral, confined to one duct usually serous, bloody or clear, and has a watery consistency Nipple discharges are classified as pathologic if they are spontaneous, bloody or associated with a mass. Pathologic discharges are usually unilateral and confined to one duct. Physiologic discharges are characterized by discharge only with compression and by multiple duct involvement. These discharges are frequently bilateral. With either type, the discharge fluid may be clear, yellow, white or dark green. PHYSIOLOGIC Exogenous or endogenous hormones, medications, stress, direct stimulation, or endocrine abnormalities can cause physiologic nipple discharge. In cases where a hormonal influence is pathologic, as is the case with prolactinoma, the ductal system itself has no abnormality so the resultant discharge is classified as physiologic Causes of Physiologic discharge Hormonal variation Pregnancy/Post lactational Mechanical stimulation Galactorrhea Duct ectasia /periductal mastitis Infection Fibrocystic change Medications Medications causing nipple discharge Oestrogens/Progestrogen Long term opiates Antidepressants Antipyschotics Metachlopramide Cimetidine PATHOLOGIC abnormality of the duct epithelium The fluid produced by the lesion collects in the dilated duct and is subsequently released when the plug is removed or the duct is compressed.

Nipple discharges that are usually benign Suspicious nipple discharges http://www.breastdiagnostic.com/anatomy.html

Contrast ductogram mammography retrograde injection of contrast medium into a discharging duct, with subsequent mammographic imaging of the breast in at least 2 planes allows for visualization and localization of involved duct and lesion A contrast ductogram mammography will help image and localize the area from which the discharge originates. This can only be done when there is an active discharge and is done only when the discharge occurs from a single duct. The most common causes of occult blood in nipple discharge are, in order of frequency, intraductal papilloma, duct ectasia, "fibrocystic change," and carcinoma. Glyptography (also called ductogram) -- contrast mammogram's obtained by injecting a radio-opaque dye into the discharging duct -- is the diagnostic procedure of choice in patients with a suspicious nipple discharge. This technique allows the clinician to visualize and localize the involved duct and lesion.   http://www.breastdiagnostic.com/anatomy.html Galactography involves the retrograde injection of water-soluble radiopaque contrast material into a discharging duct, with subsequent mammographic imaging.  not indicated unless the nipple discharge is spontaneous, unilateral, and expressed from a single pore. If discharge cannot be expressed at the time of galactography, the affected duct cannot be identified or cannulated.

Diagnosis: Intraductal Papilloma benign wart-like growth in a major lactiferous duct of the breast usually affects women aged 35-55 years usually located close to the nipple signs & symptoms nipple discharge: clear, sticky or bloody breast pain breast lump breast enlargement Having an intraductal papilloma does not increase the risk of developing breast cancer. A mammogram often does not show papillomas. Ultrasound may be helpful. An x-ray with contrast injected into the affected duct (ductogram) may be performed. Cellular (cytologic) examination of discharge may be performed to identify potentially malignant (cancerous) cells. A breast biopsy is necessary to make a definitive diagnosis and rule out cancer . Other tests include: A breast biopsy to rule out cancer An examination of the discharge to see if the cells are cancerous (malignant) An x-ray with contrast dye injected into the affected duct (ductogram)

Treatment: Intraductal Papilloma Excision of involved duct Expectations (prognosis): The outcome is expected to be excellent for patients with solitary tumors. Patients with multiple papillomas or who develop them at an early age may have an increased risk of developing cancer, particularly if they have a family history of cancer or there are abnormal cells in the biopsy. Complications: The possible complications of surgery include bleeding, infection, and the risk of the anaesthesia used. If the biopsy shows cancer, further surgery may be needed.

2 ladies age 20 and 48 years respectively consulted because of bilateral breast tenderness. In the 20 year old, what is your foremost consideration? Fibroadenoma In the 48 year old, what is your foremost consideration? Fibrocystic breast change

How do you differentiate the diagnosis in 1 from that of 2? Fibroadenoma women less than 30 years of age firm, rubbery, freely mobile with well-defined borders tender in the days before a period or grow bigger during pregnancy approximately 10 percent of fully recede each year fibroadenoma growths are usually painless, but size and location of the growth can cause breast tenderness or pain. Fibrocystic change 35-50 (premenopausal) dense, irregular and bumpy "cobblestone" consistency in the breast tissue premenstrual tenderness and swelling result of prolonged cyclic stimulation of repeated menstrual cycle breasts feel full fibrous growth between the breast glands or cyst formation within the glands, this condition is called atypical hyperplasia. During the menstrual cycle, the breasts swell as the milk glands and ducts enlarge and the breasts retain water. After menstruation the breast swelling goes down and the breasts return to normal. Pathologically, (under the microscope) these changes are characterized by the formation of cysts (fluid filled sacs) of various sizes, stromal fibrosis (scarring of tissue surrounding the functional breast units) and a variety of proliferative lesions (increased layers of cells lining the ducts

How will you manage the 20 year old? Conservative management – follow-up every 6 months (until complete regression) Pain or tenderness or unusually large tumors - excision For women in which a fibroadenoma is diagnosed before the age of 35, we recommend conservative management with a protocol of follow-up every 6 months in order to detect any changes of the lesion (Fig. 4). In cases of regression, the follow-up should continue until complete regression. Fibroadenomas that either do not completely regress, or remain unchanged by the age of 35, should be excised surgically. Fibroadenomas that become larger should be excised without delay. In patients with a family history of breast cancer, or known changes of complex fibroadenoma, we recommend excisional biopsy shortly after diagnosis has been established.

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

Treatment of Fibrocystic change Pain management Aspiration of cystic lesions Supportive bra in the week before their menses Eliminating caffeine, alcohol and reducing salt intake Taking vitamin E (400-800 IU daily) and A (150,000 IU daily) may help some women Using diuretics during the week before the menstrual period can help ease uncomfortable, swollen breasts.

Treatment of Fibrocystic change Birth control pills – regulate estrogen and progesterone levels Bromocriptine - reduces prolactin release and suppresses breast milk production after pregnancy Danazol -severe cases, inhibits the production of hormones called gonadotrophins by the pituitary gland

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

Role of imaging modality in this case? mammography more helpful in older women because breast tissue undergoes fatty replacement with age and masses are more easily visible; young women have more fibrous tissue making mammogram harder to interpret the primary purpose of the mammogram is to screen the normal surrounding breast and the opposite breast for nonpalpable cancers Diagnosis - Cyst

FNAc revealed NEGATIVE FOR MALIGNANT CELLS FNAc revealed NEGATIVE FOR MALIGNANT CELLS. How will You manage the patient. Annual mammography clinically suspicious mass – excisional biopsy ( distinct mass - should be removed and sent for examination for malignancy because mammograms and cytologic needle biopsies can have falsely negative results and can miss cancer)

NAYAL-NEMATIAN-NERY-NG,C-NG,V THANK YOU! NAYAL-NEMATIAN-NERY-NG,C-NG,V