Download BREAST BENIGN

EVALUATION OF BREAST
PROBLEM & BENIGN BREAST
DISEASES
January 24, 2008
III-C4
◙ Nayal ◙ Nematian ◙ Nery ◙ Ng, C ◙ Ng, V ◙
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.
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
History

Family history
– History of breast
disease
– Relationship to
patient
– Relative's age at
onset

Medical and
surgical history
– Personal history of
breast cancer
– Previous breast
masses and
biopsies
– Recent breast
trauma or surgery
– Recent radiation
therapy or
chemotherapy
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
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
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?
BENIGN CYST
Benign cyst: Imaging

Mammography
– 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
Radiologic difference
between a benign and
malignant mass

BENIGN
– 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
Difference in ultrasound
findings

BENIGN
intense uniform
hyperechogenicity
 ellipsoid or widerthan-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.
The patient has a mother
who is a breast cancer
survivor. How would you
handle such patient?
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
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
Breast Cancer Screening
Tests

Breast MRI
– Fore extremely dense breast tissue that
make mammograms difficult to interpret
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?
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
Differential Diagnosis





Cyst
Fibroadenoma
Phyllodes tumor
Lipoma
Fat necrosis
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.
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).
A 43 year old female
consulted because of a
rapidly growing left
breast. Axilla is negative
for clinically palpable
nodes.
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


Final diagnosis
Behavior of the above?
Treatment?
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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)
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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
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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
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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?
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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
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Nipple discharges that are usually benign
Suspicious nipple discharges
http://www.breastdiagnostic.com/anatomy.html
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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
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Diagnosis: Intraductal Papilloma
-
-
benign wart-like growth in a major
lactiferous duct of the breast
usually affects women aged 35-55 years
usually located close to the nipple
signs & symptoms
-
nipple discharge: clear, sticky or bloody
breast pain
breast lump
breast enlargement
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Treatment: Intraductal Papilloma

Excision of involved duct
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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
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.
How will you manage the 20 year
old?


Conservative management – followup every 6 months (until complete
regression)
Pain or tenderness or unusually large
tumors - excision
The 48 year old had surgery showing
the gross finding, What is your
treatment?
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 (400-800 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.
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
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
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
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)
THANK YOU!
NAYAL-NEMATIAN-NERY-NG,C-NG,V
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