Done by Mohammad Binhussein & Mohammad Mini

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. Guaiac Test 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 0.625 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 100.000)

33. Screening Introduction OutCome

34. Number of women needing to be screened to detect one new breast cancer Age Group no. needed • 20 to 24 67,000 • 30 to 34 4,000 • 40 to 44 850 • 50 to 54 375 • 60 to 64 275 • 70 to 74 210 • 80 to 84 210

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

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. 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?