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ASSESSMENT OF BREAST SYMPTOMS/LUMPS Professor P Grantley Gill Specialists Without Borders Seminar in Surgery Rwanda, September 2010
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SIGNS AND SYMPTOMS AT PRESENTATION Palpable mass Thickening, Pain Mass or pain in the axilla Nipple discharge Oedema or erythema of the skin www.specialistswithoutborders.org
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CAUSES OF BREAST LUMPS – Fibroadenoma – Cyst – Fibrocystic change – Cancer – Duct ectasia – Fat necrosis – Haematoma www.specialistswithoutborders.org
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BREAST CANCER RISK FACTORS – Age – History of breast cancer – Family history of breast cancer, especially in first degree relatives – Specific genetic mutations e.g. BRCA-1, BRCA-2 – Benign breast “cancer” atypical hyperplasia – Early menarche, late menopause – Late first pregnancy/no pregnancy – Exogenous oestrogens – Radiation – Diet, alcohol www.specialistswithoutborders.org
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EXAMINATION OF BREAST – Inspection – Palpation – Lymph node basins (axilla, neck) – Contralateral breast www.specialistswithoutborders.org
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INSPECTION www.specialistswithoutborders.org
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NIPPLE RETRACTION www.specialistswithoutborders.org
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SKIN DIMPLING www.specialistswithoutborders.org
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PAGET’S DISEASE www.specialistswithoutborders.org
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PAGET’S DISEASE www.specialistswithoutborders.org
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TRIPLE ASSESSMENT OF A BREAST LUMP – Clinical – Imaging Mammography Ultrasound – Pathology Fine needle aspiration cytology (FNAC) Core biopsy www.specialistswithoutborders.org
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PALPABLE LYMPH NODES www.specialistswithoutborders.org
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MAMMOGRAPHIC STAGING – Masses – Asymmetry Architectural distortion – Calcification – Skin changes www.specialistswithoutborders.org
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NORMAL FATTY REPLACEMENT
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www.specialistswithoutborders.org NORMAL INVOLUTION
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DENSE BREASTS www.specialistswithoutborders.org
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DENSE BREASTS – RETROAREOLAR TISSUE LEFT www.specialistswithoutborders.org
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DENSE BREASTS +++ ALL OF LIFE www.specialistswithoutborders.org
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ULTRASOUND A: Fibroadenoma B: Carcinoma www.specialistswithoutborders.org
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FINE NEEDLE ASPIRATION CYTOLOGY (FNAC) www.specialistswithoutborders.org
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FNAC INTERPRETATION AND ACTION www.specialistswithoutborders.org INTERPRETATONACTION Unsatisfactory for diagnosisRepeat or core Cellular, benignAccept if consistent with imaging; repeat or core if not Cellular, some atypiaCore biopsy Open biopsy SuspiciousCore biopsy Open biopsy MalignantTreatment
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TRIPLE ASSESSMENT OUTCOME www.specialistswithoutborders.org ASSESSMENTCONCORDANTDISCORDANT Clinical Accept results benign or malignant Core biopsy Open biopsy Imaging Cytology
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CONCLUSION – Confirm malignancy in ≥90% by triple assessment – Open biopsy if not possible www.specialistswithoutborders.org
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