Survey
* Your assessment is very important for improving the work of artificial intelligence, which forms the content of this project
Download BREAST LUMPS
Document related concepts
no text concepts found
Transcript
BREAST LUMPS DR AMBREEN MUNIR FRCS, BAPRAS Fellowship Breast, PG-D Bioethics Associate Professor Surgery INTRODUCTION Of all breast disorders, palpable breast lump is 2nd most common presentation, pain being the first Generally a breast lump in adolescents and young female is nearly always regarded as benign at first instance and patient may falsely be reassured with the result she refrain from further consultation INTRODUCTION On the other hand, all lumps are not cancers; however the possibility of cancer must always be considered, as approximately 10% of all breast lumps are finally diagnosed as cancer. Case scenario A 25 year old School teacher came to you and she is worried about a lump she just found in her right breast. Additional History History of trauma Is lump painful? Nipple Discharge Any other lump? Axilla Otherwise she is healthy Her weight is stable She is married She takes OCP Her menstrual cycle is regular No family history of cancer Triple Assessment Examination Imaging Cytology/ Biopsy Breast Examination Inspection- sitting position symmetry, level of both breasts, Contour, skin changes Ask her to lift arms, put arms against waist Palpate the axilla in sitting position Palpate supraclavicular lymph nodes Palpation of breast- supine position with hands above head Examine both breasts Normal first Examine with the flat of the hand to avoid pinching up tissue Four quadrants in clockwise direction Nipples & areola If you have difficulty finding a discrete lump, ask the patient to demonstrate it for you About Lump Site - describe the location of the lump as a position on a clockface i.e. 'A firm mass is felt at 2 o'clock'. Size Shape Surface/ Overlying skin Tenderness Consistency Mobility and attachment If you are unable to move the skin over the lump it implies fixation or tethering If patient mentioned nipple discharge ask her to squeeze nipple for a sample of the discharge Examination Findings Solitary 1.5 cm mass of right breast, upper outer quadrant at 10 oclock Mass is non-tender Lesion is freely movable No obvious skin changes over the lesion No nipple discharge No axillary masses Possibilities Fibroadenoma Fibrocystic disease Simple cyst Fat necrosis Cancer Benign Breast diseases ANDI Infections Trauma Fibroadenoma • Benign overgrowth of one lobule of the breast, usually isolated, may be multiple or giant • Composed of both stromal and epithelial elements in the breast • Well-defined, mobile, painless, discrete • Common in younger women, and is most common tumor in women younger than age 30 years Fibrocystic disease Combination of localized fibrosis, inflammation, cyst formation and hormone driven breast pain Occurs almost exclusively between menarche and menopause Causing cyclical pain and swelling, lumpy breasts, multiple breast cysts Cysts • Fluid-filled, epithelium-lined cavities often associated with FBD • Common after age 35, and rare before 25 • Round symmetrical lumps, may be discrete or multiple, occasionally painful • Three types Simple cyst, clear or green fluid and is benign. Milk-filled cyst, called galactocele and is benign. Bloody cyst is a cause of concern for malignancy. Infections & Inflammations Lactational Mastitis Due to acute staphylococcal infection of mammary ducts Breast Abscess When infection progress Infections & Inflammations Mammary duct ectasia Due to dilated, scarred, chronically inflammed subareolar mammary ducts Recurrent yellow green nipple discharge or recurrent breast abscess Mondor’s disease Phlebitis of the thoracoepigastric vein Palpable, visible, tender cord along lower quadrants Fat Necrosis • Associated with trauma or radiation therapy to breast • There is organization of acute traumatic injury by fibrosis, organized haematoma & occasionally calcification • Can simulate cancer with mass or skin retraction Next step in assessment Imaging- choice of imaging modality depends on specific characteristics of the patient e.g. age, and findings on clinical examination Ultrasound scan or Mammography MRI of breast Indications of U/S To evaluate the breast in patients who are under the age of 35 years To differentiate solid and cystic lesions Women who are pregnant and cannot have mammography To complement mammography To guide fine needle aspiration and core biopsies Next step in this case Solid lesions- have internal echoes Benign tumours have isoechoic or hypoechoic patterns, smooth well defined borders Malignant tumours have hypoechoic areas,interspersed between brighter echoes, irregular edges Cysts- Smooth walls, sharp anterior and posterior borders, black hypoechoic centres without internal echoes U/S report in this case is benign solid lesion U2 To complete the triple assessment, this lesion needs to be biopsied There are a number of different types of biopsy( cytological or histopathological) Fine needle aspiration (FNA) Core biopsy • FNA-Sensitivity is 80-98%, specificity 100% False negatives are 2-10% • Core Biopsy-More tissue, however still possibility of false negative and could represent sampling error • Incisional biopsy- For large (>4 cm) lesions for whom pre-op chemotherapy or radiation will be desirable • Excisional biopsy-Removal of entire lesion and a margin of normal breast parenchyma Triple Assessment gives confident diagnosis in 95% of cases On other hand, Triple assessment is not always needed to investigate breast lumps, as it would be viable to diagnose a breast cyst purely on ultrasound A solid lump will require a core biopsy to confirm its benign or malignant state Treatment Most benign breast lumps will not require treatment. This is especially true of small fibroadenomas,If they are increasing in size they may be removed FNA is used for simple and recurrent cysts. In this case FNA would be used as a treatment rather than a diagnostic tool. Complete resolution, follow up to ensure it does not recur,Incomplete resolution treat as breast mass and excise Treatment • Mondor’s disease Treatment self-limited, can use NSAIDs if necessary • Antibiotics can be used to treat infections of the breast and abscesses are treated by incision & drainage Treatment • Mondor’s disease Treatment self-limited, can use NSAIDs if necessary • Antibiotics can be used to treat infections of the breast and abscesses are treated by incision & drainage BREAST CANCER DR AMBREEN MUNIR FRCS, BAPRAS Fellowship Breast, PG Diploma Bioethics Associate Professor Surgery Overview The most common form of cancer among women The second most common cause of cancer related mortality One out of nine Pakistani women is likely to suffer from Breast Cancer at some point of life Overview Highest incidence of Breast cancer in the Asia At Least 90,000 Women Suffer From Breast Cancer In Pakistan Every Year 40,000 Deaths Per Year, Which Is Alarming Risk factors Female Aging First degree Relative Menstrual history ◦ early onset ◦ late menopause Child birth ◦ After the age of 30 Risk Factors Hormonal replacement therapy(HRT) 30% increased risk with long term use • Oral Contraceptives(OC) risk slight risk returns to normal once the use of OC’s has been discontinued Radiation exposure Risk Factors Breast disease ◦ Atpyical Hyperplasia ◦ Intraductal carcinoma in situ ◦ Intralobular carcinoma in situ Obesity Diet ◦ Fat ◦ Alcohol Genetic Risk Factors BRCA-1 BRCA-2 P53 Her-2/neu Because of enhanced Public awareness, number of patients reporting with complaints of breast diseases has increased in recent years Breast diseases are common in females because of more complex structure of female breast, greater volume and influence of various hormones Subjected to constant physiological changes throughout reproductive life and beyond. These changes lead to a number of conditions Mostly these conditions are benign e.g. bilateral nodularity, tender lumpy breasts Our aim should be to exclude cancer That aim is achieved through proper assessment Triple Assessment Clinical History Examination Imaging Ultrasound Mammography Histopathology FNAC Trucut Biopsy History Age Family history of breast and other cancers with emphasis on gynaecological cancers History Reproductive history age at menarche age at first delivery number of pregnancies, children and miscarriages age at onset of menopause history of hormonal use including: contraceptive pills (type and duration) hormonal replacement therapy (type and duration) Signs/Symptoms Any new discrete breast lump Any new lump in a pre-existing nodularity Recurrent breast cysts Unilateral axillary lump Unusual increase in the size of one breast Signs/Symptoms Persistent or unilateral breast pain Pain associated with a lump Signs/Symptoms Nipple discharge other than breast milk Blood stained Single duct Bilateral troublesome discharge in more than 50 years New nipple retraction Nipple eczema if not elsewhere or unresponsive to steroids Signs/Symptoms A puckering of skin of breast Skin irritation or dimpling Redness, scaling or thickening of skin of breast Swelling of arm Clinical Examination Annually for women over 40 At least every 3 years for women between 20 and 40 More frequent examination for high risk patients Clinical examination Breast Sitting Supine Both Axillae & Supraclavicular fossae Local examination of possible metastatic sites Mammography Not recommended under the age of 35 unless there is a strong clinical suspicion of cancer Mammography allows for efficient diagnosis of breast cancers at an earlier stage Normal mammogram does not rule out possibility of cancer completely Mammogram Two of the most important mammographic indicators of breast cancers Masses Microcalcifications: Tiny flecks of calcium – like grains of salt – in the soft tissue of the breast that can sometimes indicate an early cancer. Malignant masses have a more spiculated appearance Calcifications show up as white spots on a mammogram Round well-defined, larger calcifications are more likely benign Tight cluster of tiny, irregularly shaped calcifications may indicate cancer Breast Ultrasound To see whether the lump is solid or cystic Margins, complexity For aspiration or biopsy Histopathology Fine needle aspiration cytology performed with 5 cc disposable needle as outpatient procedure Trucut biopsy performed with core cut needle under local anaesthesia Treatment Based on many factors Varies from reassurance to radical Surgery TNM Staging TX: primary tumor cannot be assessed T0: no evidence of tumor Tis: carcinoma in situ T1: tumor <2 cm T2: tumor 2-5 cm T3: tumor >5 cm T4: direct extension to chest wall or skin TNM staging NX:regional nodes cannot be assessed N0: negative lymph nodes N1: metastases to moveable ipsilateral axillary lymph nodes N2: metastases to fixed ipsilateral axillary lymph nodes N3:metastases to ipsilateral internal mammary nodes TNM staging MX: distant sites cannot be assessed M0: no distant metastases M1: distant metastases Breast cancer treatment Breast Conserving surgery Mastectomy Axillary sampling( Sentinel node biopsy) Axillary clearance Chemotherapy Radiotherapy Hormone Therapy Oncoplastic Surgery The combination of reconstructive surgery in cancer surgery. Immediate breast reconstruction following partial or total Mastectomy Oncoplastic Tumours smaller than 3 cm Nodal status-N0, N1 Peripheral tumors Large breasts Conclusion The diagnosis of breast cancer is devastating for most women and is compounded by mental anguish associated with the anticipated changes in their appearance Conclusion As clinical breast examination (CBE) may play a positive role in detecting cancer earlier, especially in reducing tumour size from 5 cm to 2 cm at presentation in developing countries without a mammography screening programme, the practice of CBE by doctors and trained nurses should be encouraged. Conclusion If breast cancer patients are offered breast oncoplasty procedures, more women are likely to come forward for treatment at an early stage.
