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

2. 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.

3. 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

4. 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

5. 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

6. 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

7. 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?

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

9. 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

10. 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

11. 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.

12. 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?

13. 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

14. 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

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

16. 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?

17. 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

18. Differential Diagnosis
Cyst
Fibroadenoma
Phyllodes tumor
Lipoma
Fat necrosis

19. 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.

20. 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.

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

22. Final diagnosis
Behavior of the above?
Treatment?

23. 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.

24. 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.

25. 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.

26. 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?

27. 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.

28. Nipple discharges that are usually benign
Suspicious nipple discharges

30. 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.  
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.

31. Diagnosis: Intraductal Papilloma
benign wart-like growth in a major lactiferous duct of the breast
usually affects women aged 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)

33. 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.

34. 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

35. 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

36. 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.

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

38. 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 ( 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.

39. 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

40. 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

41. 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

42. 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)

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