Download Approach to Breast Disease

Approach to Breast Disease
DR C A BENN
INTRODUCTION
• Ultimate goal as doctors
• Surgical evolution versus “revolution”
BACKROUND
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INCIDENCE BENIGN
INCIDENCE MALIGNANT DISEASE
AFRICAN AMERICAN EXPERIENCE
OLD SERVICES OFFERED
• A NEW BEGINNING
Screening in Breast Cancer-an update
Breast cancer screening in Europecurrent status
Bad press????
Poor technology????
Wrong test???
Overly aggressive
clinicians???
Fault is breast cancer????
How patients present……..
• Mass
• Pain
• Discharge
• Basic management
INTRODUCTION
• INCREASING AWARENESS OF
CANCER
• POSSIBILITY THAT MASTALGIA IS
INDICATIVE OF DISEASE
• PHYSICIANS ARE INADEQUATELY
TRAINED FOR TREATING THIS
CONDITION…..
• HELP !
ACADEMICS
• CYCLIC MASTALGIA
(67%)
• NONCYCLIC MASTALGIA
(26%)
• CHEST WALL PAIN
(7%)
FACT…...
• >90% OF PATIENTS WITH CYCLIC
MASTALGIA AND 64% OF PATIENTS
WITH NONCYCLIC MASTALGIA
OBTAIN RELIEF FROM A
COMBINATION OF
NONPRESCRIPTION AND
PRESCRIPTION DRUGS
HISTORY
• IS THIS BREAST
PAIN ?
EXCLUDE..
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Cardiac
Respiratory
Gastrointestinal
Dermatological
Musculoskeletal
Endocrine
Gynaecological
Haematological
Habits
THOROUGH EXAMINATION
SPECIFICALLY THE BREASTS
FINDINGS
• NORMAL SMALL, MEDIUM OR LARGE
BREASTS
• BREASTS WITH A MASS, NIPPLE
DISCHARGE OR THICKENING
ASSESSMENT….
• Normal breast pain
• Extent to which it disrupts the patient’s life
[work, sleep, sex, ….]*
• Provide the patient with a breast pain chart
and a symptom chart
*Check diet and drugs
INVESTIGATIONS..
GENERAL
• Blood tests (HIV, Prolactin) and other tests
depending on clinical suspicion
SPECIFICALLY
• Sonar and mammogram depending on the
age of the patient
• FIBROCYSTIC
CHANGE IS NOT
DISEASE
• ANDI
CLASSIFICATION
THEORIES OF CAUSATION
MANAGEMENT OF
MASTALGIA
There is a long list of suggested modalities for
the treatment of an entity that is
ubiquitous; has an unknown aetiology, and
a poorly understood relationship to
fibrocystic disease and cancer.
MASTALGIA MANAGEMENT
SUMMARY
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THOROUGH HISTORY
PHYSICAL EXAMINATION
MAMMOGRAPHY AND /OR SONAR
ABNORMALITIES…….BIOPSY
CLASSIFY
REASSURANCE
MASTALGIA MANAGEMENT
SUMMARY
• ABSTENTION FROM CERTAIN
MEDICATIONS AND FOOD
• EVENING PRIMROSE OIL
• DRUGS
NIPPLE DISCHARGE
• HISTORY & EXAMINATION
one duct, multiple ducts, one breast or both
clear, blood stained, green,yellow black etc
INVESTIGATIONS
• pus swab mc&s
• mammogram, sonar
• ductogram
• bloods: BHCG, prolactin
Nipple Discharge
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Introduction
Clinical features
Investigations
Treatment Plan
General Comments
Clinical features of MDAIDS
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Nipple Discharge
Breast Pain and tenderness
Nipple Retraction and Subareolar mass
Subareolar breast abscess and recurrent
abscess
• Periareolar Mammary duct Fistula
CONCLUSION
• Antibiotics:
• Surgery for complicated disease
Intractable pain
Recurrent discharge not responding to
antibiotics
Abscess
Fistula
MANAGEMENT
• DUCT ECTASIA
• medical antibiotics
• surgery for complications
fistula, abscess, intractable pain and recurrent
discharge non responsive with antibiotics
DUCT PAPILLOMA
surgical excision
Physiological discharge
Medication and Conservative management
APPROACH TO A
BREAST MASS
• HISTORY
HISTORY
RELATED TO MASS
position,duration ,noticed when
assoc features
FAMILY HISTORY
any cancer history
breast
other
GYNAE/ENDOCRINE HISTORY
menarche, menopause
children,breastfeeding
OCP, HRT
APPROACH TO BREAST
MASS
EXAMINATION
EXAMINATION
GENERAL
pale, jaundiced
wasted
VITALS
BREAST EXAM
inspection
palpatioin
both breasts
THE BODY
head & neck
thorax
abdomen
BREAST
MASSES
REQUIRE A
TISSUE
DIAGNOSIS
REGARDLESS
OF THE AGE
OF THE
PATIENT
• ALL BREAST MASSES TO GET A
TISSUE DIAGNOSIS
• WHY?
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CANCER IN YOUNG WOMEN
UNUSUAL DIAGNOSIS
LYMPHOMA
TUBERCULOSIS
• HOW?
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FINE NEEDLE ASPIRATE
CORE/TRUCUT BIOPSY
SONAR GUIDED FNA OR CORE
MAMMOGRAM GUIDED
HOOK WIRE
LAST RESORT EXCISIONAL DIAGNOSIS
95% of all patients should have
the diagnosis made prior to
surgery
From benign to malignant….
• Large variety of benign lesions
• Broad terms used (FCD; BBD) used for
convenience
• Transition theory : benign, hyperplasia,
cellular atypia, carcinoma in situ.
• What is the breast cancer risk and at what
stage should a lesion be considered
malignant ?
The Evolution of Breast Cancer
Florid hyperplasia
Lobular carcinoma
in situ
• Normal breast
epithelium
Proliferative Changes
(mild to moderate ductal
or lobular hyperplasia)
Atypical
lobular or ductal
hyperplasia
DCIS
Nonproliferative changes
(fibroadenoma, duct ectasia, cysts
Papillomatosis
fibrosis, apocrine metaplasia, stromal sclerosis)
Invasive cancer
Lobular Carcinoma In Situ
Epidemiology
• young women (44 - 47yrs)
Pathology
• “Busy Bosom”
• ipsilateral multicentricity / contralateral /
bilateral / ……in almost every case
• homogenous, slow growth, low nuclear
grade
Prognosis and Management of
LCIS
• Risk applies equally to both breasts
• Incidence variable [1% per year, lifetime
5% ( 4-13%), 37% of cases]
• Malignancies arising (50-65%) are ductal
• From bilateral mastectomy to ipsilateral
mastectomy and blind contralateral biopsy
to non operative close observation
DCIS: More Ominous
Epidemiology
• Females and Males
• Occurs between the age of presentation of
LCIS and Ca
Pathology
• Historically 4 histological types: Papillary
and micropapillary, cribriform and solid.
• Comedo versus Non Comedo
Applying a relative risk reduction
to treatment decisions
• Individual treatment algorythm
Family history of Breast /other cancer
Age at diagnosis
Tumour necrosis and Nuclear Grade
Resection margins
STAGING
• TNM CLASSIFICATION
• MANCHESTER
• A BIOLOGICAL CLASSIFICATION
Breast Cancer management
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Multimodal Approach
Surgical
Radiation therapy
Chemotherapy
Surgery
1. Breast conservation or mastectomy with
immediate/delayed reconstruction
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Size of the breast
Size of the tumour
Patients wishes
1. Axilla
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Clearance (> 7 lymph nodes)
Sentinel node biopsy if trained
Radiation Therapy
Breast
• All breast conserving surgery
• Mastectomy with margins <1cm
• Locally advanced breast cancer
Axilla
• 4 or more nodes positive
Chemotherapy
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Tumours >1,5cm
All lymph node positive tumours
All receptor negative tumours
Tumours with poor prognostic indicators
her2neu, lymph vascular invasion
Breast conserving procedures are being
employed with increasing frequency...
• How strong is the justification for the
changes that have occurred?
• Why have they come about?
• Has science played a role?
• Is this few tampering with tradition?
• Is this consumer pressure?
Clinical trials testing the
Alternative Hypothesis
• NSABP B-04 trial (Aug 1971) to evaluate
different regimens of surgical a
management for primary breast cancer
• NSABP B-06 trial (1976)
Conclusion
• Local excision with radiation produces
equivalent results, in terms of survival,
when compared to mastectomy (proven by
7 randomised trials)
• lumpectomy with level 1 & 2 axillary LN
dissection + DXT= total mastectomy +
axillary LN dissection : If tomour is < 4cm
and margins are clear
Breast conservation Pressure
• Use of pre-operative treatment for
downstaging large breast cancers
• Chemotherapy is the standard
• Tamoxifen for elderly (chemo unfit)
• Pre-operative radiotherapy
Each case as an individual
• Tumour size
• Grade
• Other markers
NOT THE CENTIMETRES OR MILLIMETRES BUT
THE AGE OF THE PATIENT!!!!!!
Key Questions
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When should we operate?
What operations should we be doing ?
Should we operate at all?
What are the complications of surgery?
Axillary surgery?
Is there a uniform treatment plan?
IS SURGERY NECESSARY ?
• Non-surgical tumour ablation?
• Complete response to chemotherapy and
omission of surgery
• Does complete clinical response correlate to
complete pathological response?
• Accurate assessment of tumour response
Breast Reconstruction
Post-mastectomy
• Mastectomy remains the most common treatment
for stage 1 & 2 breast cancer
• Potential for avoiding radiotherapy if do breast
recon.
• Patients with in situ tumours (DCIS) are
significantly more likely to undergo recon.
• Histological grade was not a significant predictor
of use of recon.
• Patients’ age most important factor
Post-mastectomy recon. …….
• Post-mastectomy recon. does not interfere
with ability to detect local recurrence
• Does not delay the administration of
chemotherapy
• Various options with improved aesthetic
outcome
• ? Lack of patient desire or failure of
surgeon to offer recon.
• Expanding indications for RT
• Problems with RT on timing and choice of
reconstructive techniques
BREAST RECONSTRUCTION
• Initial or delayed
• Implant
creation of a pocket beneath pec major and
insertion of a tissue expander followed by a
sialastic implant.
• Autologous tissue
use of either a rectus abdominis musculocutaneous
flap or a latissimus dorsi flap
Altering breast cancer
management
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Young patients
Use of radiation therapy
Use of Chemotherapy
Most important is surgical management
Planning
Procedure
Margins
Conservative treatment of the
axilla
• Detection (75% -95%)
• False negative rate (0-20%)
• Uncertain: injection site;micromets; FN
rate; clinical practice vs random trials
• Surgical experience and pathological study
of the node
Questions
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Variable training
NB trials: ACOSOG; NSABP;ALMANAC;EORTC
There are side effects of procedure
Non axillary nodes (25%): int mammary, sub supra clav
Clinical relevance: sole positive SN
“Epidemiology” vs “Scare
Mongering”
• Oral contraception and
HRT
• Mammographic
screening
Hormones and Breast Cancer
• Tamoxifen survival
advantage for ER +ve,
node - or + tumours
• SERM’S and target
site specificity
• Treatment new
SERM’S
BREAST CANCER
PREVENTION
• SURVEILLANCE
• SURGERY
Options are both skin sparing and total
(simple) mastectomy
• CHEMOPREVENTION
• Who is at high risk?
How do we determine people at
risk?
• Slight risk 1,5-2 times
• Moderate risk 4-5 times
• High risk 9-11times
• Gail model risk factors (family history, age,
personal history [age at first birth, age of
menarche, previous breast biopsies])
The Future Pap smear
• High risk women
..diagnosis?
• FNA / NAC
• Is it possible to
determine ADH by
cytology
Applying a relative risk reduction
to treatment decisions
Individual treatment algorithm
• Family history of Breast /other cancer
• Age at diagnosis
• Tumour necrosis and Nuclear Grade
• Resection margins
SURGICAL OPTIONS
• Subcutaneous mastectomy
breast tissue is removed preserving the
nipple areolar complex (no)
• Total (simple) mastectomy
• Skin sparing mastectomy
TOTAL MASTECTOMY
• Higher level of risk reduction but still does
not remove all the breast tissue
• Immediate reconstruction ………problems
relating to implants ( 17,3% at 1 yr; 30,4%
at 5 yr)
• Contralateral mastectomy after unilateral
breast cancer diagnosis
Where to from here…?
• Chemoprevention BCPT (NSABP (P1))
STAR trials
• Most meticulous prophylactic mastectomy
does not afford 100% protection
• Prevention more aggressive than treatment
• Does chemoprevention offer protection for
BRCA1 & 2 and receptor negative tumours
Chemoprevention
BCPT P-1
• Used Gail model risk factors
• Randomized to Tamoxifen 20mg or placebo
• Tamoxifen reduced the risk of invasive
breast cancer mainly ER +ve by 49%
• Tamoxifen reduced the risk of non invasive
breast cancer by 50%
• STAR trial
INTRODUCTION
• ¼ of women diagnosed with breast cancer
are premenopausal
• Average age of diagnosis of pregnant
patients with breast ca is 28-32
• Accepted definition of this condition is
Pregnancy associated breast cancer
ISSUES
• Diagnosis and staging of the cancer
• Consideration of termination of the
pregnancy
• Risks of surgery and anaesthesia during
pregnancy
• Risks and timing of local and systemic
adjuvant therapy
• Question of future pregnancies
POPULAR MISCONCEPTIONS
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Pregnancy confers a worse prognosis
Increased incidence of inflammatory ca
Hormonal milieu accelerates tumour growth
Vascular and lymphatic engorgement
promoted tumour dissemination
• Diagnostic surgical procedures lead to a
milk fistula
• SIGNIFICANT DELAY IN
DIAGNOSTICS AND
TREATMENT RESULT IN
A POORER PROGNOSIS
DIAGNOSIS OF PABC
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Physician tendency to observe
Good history ……..milk rejection sign
Physical examination
What investigations?
Needle biopsy when in doubt
Surgical biopsy is a last resort
LONG TERM AND FUTURE
PREGNANCIES
• Relative risk of dying
• 2 year waiting period
• Chance of conceiving
SUMMARY
• Avoid delay in diagnosis
• Correct investigations
• Team approach to management
• Close follow-up
GYNAECOMASTIA
DR C A BENN ,FCS SA
CHRIS HANI BARA, JHB GEN BREAST CLINICS
NETCARE BREAST CARE CENTRE OF EXCELLENCE
INTRODUCTION
• Definition: female type mammary gland in
the male
• Common and most examples not a disease
• Categorized as physiological or endogenous
(mostly idiopathic)
• Clinical, anatomical and biochemical
advances have clarified the etiology and
natural history
INCIDENCE
• Occurs in 60-70% of pubertal boys
• 40% of men over 60
• Understand terms :pubertal gynaecomastia
and prepubertal gynaecomastia and
senescent gynaecomastia
• Why is this an increasing problem and how
can we manage it?
Physiological gynaecomastia
• Neonatal gynaecomastia
• Pubertal gynaecomastia
• Senescence
History and Examination
• Besides usual ask : gym and squash, raves,
dagga, stress
• Examination: epitrochlear nodes, discrete
breast masses, asymmetry, tenderness
• Investigations: breast sonar, mammogram,
needle biopsy, blood tests
management
• Medical: tamoxifen citrate, danazol and
testolactone
• Radiotherapy: small dose
• Surgery: various techniques, combined with
liposuction
Summary
• Good patient
evaluation
• Age specific treatment
• Documented followup
• A few tricks
The birTh of Venus…
A National Breast Care Centre
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Why?
Who?
How?
What?
• All people should be entitled to a
standard of excellence with
regard to medical care
What is excellence in
breast
care?
• Screening mammography
• Specialised radiological centres
• Early diagnosis of cancer
• Diagnosis should be made prior to definitive
surgical procedure
• Patient informed about management options
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mammography
Specialised radiological centres
Early diagnosis of cancer
Diagnosis should be made prior to definitive
surgical procedure
• Patient informed about management options
Breast Care
Excellence
• Awareness of surgical treatment options
• Value of multimodal treatment
• Knowledge of which patients should
receive chemotherapy
• Team approach
radiologist, pathologist, surgeon, plastic
surgeon, oncologist and radiation
oncologist