1. Done by
Mohammad Binhussein
&
Mohammad Mini

2. 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

3. 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

4. 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 .

5. 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 .

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

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

10. 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.

11. 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.

12. Positive guaiac test shown on right
Negative on left

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

15. Expressing of discharge

16. 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.

17. 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 .

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

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

20.     Ductoscopy
Ductoscopy is increasingly employed as a minimally invasive method for evaluation and treatment of nipple discharge.
(It involves placing a small (outer diameter 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.)

22. 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.

23. Nipple discharge

24. 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.

25. - 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.

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

28. Clinical presentation of breast lesion

29. When should Done ?

30. 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 .

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

33. Screening Introduction OutCome

34. Number of women needing to be screened to detect one new breast cancer
Age Group no. needed
20 to ,000
30 to ,000
40 to
50 to
60 to
70 to
80 to

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

36. Well Circumscribed Mass D.D
( Fibroadenoma Fibrocystic Changes )

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

38. Reading the Mammogram
Where is the
suspecious lesion???

39. Medically proven malignancy.

40. A benign microcacification

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

42. 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: %risk)

43. 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

45. 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.

46. 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.

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

48. 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?

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

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

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

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

53. 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

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

56. 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

57. 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.

59. Miscellaneous

60. 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 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 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

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

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

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

64. Mondor’s disease
thrombophlebitis of lateral thoracic vein.

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