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Common Breast Disease. Dr. Chan Wing Cheong Surgeon-in-charge Breast Surgery, NTEC. Symptoms & P ossible D iagnosis. Infections : Lactational & Non-lactational. Common Presenting Symptoms. Over 80 % Lump
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Common Breast Disease Dr. Chan Wing Cheong Surgeon-in-charge Breast Surgery, NTEC
Symptoms & Possible Diagnosis Infections : Lactational & Non-lactational
Common Presenting Symptoms Over 80 % • Lump • Painful lump or lumpiness • Pain Under 20 % • Nipple discharge • Nipple change • Miscellaneous
Lymphatic Drainage • Axillary nodes level 1,2,3 • most of the breast drain into axilla. • pectoral nodes / breast and anterior chest wall • sub scapular nodes / posterior chest wall and arm • lateral nodes/ arm • central (medial and apical) nodes/ drains all of the above three groups of nodes • Infraclavicular • Supra-clavicular nodes • Internal mammary nodes • Abdominal nodes
Normal Breast Development and Physiology • At puberty the breast develops under the influence of the hypothalamus, anterior pituitary, and ovaries and also requires insulin and thyroid hormone • During each menstrual cycle 3 to 4 days before menses, increasing levels of estrogen and progesterone cause cell proliferation and water retention. After menstruation cellular proliferation regresses and water is lost. • During pregnancy cellular proliferation occurs under the influence of estrogen and progesterone, plus placental lactogen, prolactin and chorionic gonadotropin. At delivery, there is a loss of estrogen and progesterone, and milk production occurs under the influence of prolactin. • At menopause involution of the breast occurs because of the progressive loss of glandular tissue.
ANDI classification ( Hughes et al, 1992 ) Normal Aberration ?? Disease Reproductive phases cysts, duct ectasia, mild epithelial hyperplasia cyclical mastalgia & nodularity fibroadenoma, juvenile hypertrophy Periductal mastitis Epithelial hyperplasia with atypia Giant fibroadenoma (> 5cms) Multiple fibroadenomata (> 5 per breast) Involution Cyclical & secretory Development Spectrum of breast changes
Aetiopathogenesis – Some Theories • Endocrine factors 1. Disturbances in the Hypothalamo Pituitary Gonadal steroid axis 2. Altered Prolactin profile – qualitative /quantitative change Non endocrine factors • Methyl xanthines, Stress Genetic predisposition to catecholamine supersensitivity Intra cellular C - AMP mediated events cellular proliferation 2. Diet rich in saturated fat Altered plasma essential fatty acid profile receptor supersensitivity to normal levels of Oestrogen & Progesterone 3. Iodine deficiency Receptor supersensitivity to normal levels of Oestrogen & Progesterone
Triple Assessment for Breast Problem • Clinical • Symptoms & signs • Assessment of risk factors • Imaging • Ultrasonography / Mammography • Other imaging tests • Pathological • Fine needle aspiration cytology • Core biopsy
Risk Estimation for Breast Cancer • RELATIVE RISK <2 Early menarche < 12 years Late menopause > 55 years Nulliparity Proliferative benign disease Obesity Alcohol use Hormone replacement therapy • RELATIVE RISK 2–4 Age 35 first birth First-degree relative with breast cancer Radiation exposure Prior breast cancer • RELATIVE RISK >4 Gene mutation Lobular carcinoma in situ Atypical hyperplasia
Left Mammography
Galactography / Ductogram Intraduct papilloma
Case 1 • F/22 • Right breast swelling for 1 month • No other symptoms • What are the questions you want to ask?
Case 1 • USG breast: • Compatible with a 1.5 cm fibroadenoma • What would you offer her? • What is the natural history of fibroadenoma?
Fibroadenoma Natural history Majority remain small & static 50% involute spontaneously No future risk of malignancy Types Solitary Few (< 5 / breast ) Multiple (> 5 / breast ) Giant (> 4 / 5 cm) & Juvenile
Management Algorithm for Fibroadenoma Chances of malignancy masquerading as Fibroadenoma Age 20 – 25 yrs 1: 3000 possibility Age 25 – 30 yrs 1: 300 possibility
Case 2 • Same lady as case 1 • No surgery after discussion • However • Come back 7 months later • Size of lesion increases up to 5 cm • What investigation do you want to do?
Case 2 • USG • Compatible with a giant fibroadenoma or phylloides tumour • Do you want to do FNA? • What would you offer?
Case 2 • Wide local resection performed • Pathology: • Phylloides tumour of undetermined malignant potential, margins appear to be clear • How do you advice this patient?
Phyllodes Tumours • Comprise less than 1% of all breast neoplasms • May occur at any age but usually in 5th decade of life • No clinical or histological features to predict recurrence • 16-30% may be malignant • Common sites of metastasis : lungs, skeleton, heart and liver
Treatment of Phyllodes Tumours • 1. Primary treatment • Local excision with • a rim of normal tissue • 2. Recurrence • Re excision or • Mastectomy with or without reconstruction • Response to chemotherapy and radiotherapy for recurrences and metastases poor
Case 3 • F/52 • Recently noticed a left breast lump • No pain • No other breast symptoms • Just menopause • What other questions regarding her problem that you will ask ?
Risk Estimation for Breast Cancer • RELATIVE RISK <2 Early menarche < 12 years Late menopause > 55 years Nulliparity Proliferative benign disease Obesity Alcohol use Hormone replacement therapy • RELATIVE RISK 2–4 Age 35 first birth First-degree relative with breast cancer Radiation exposure Prior breast cancer • RELATIVE RISK >4 Gene mutation Lobular carcinoma in situ Atypical hyperplasia
Case 3 • P/E: • 2.5 cm mass over upper outer aspect of left breast • Quite mobile • No palpable axillary LN
Left Case 3
Case 3 • MMG / USG breast • 2.5 cm mass • No axillary nodes • Core needle biopsy • Invasive carcinoma • What would you offer?
Options • Modified radical mastectomy • MRM + reconstruction • Autologus tissue flap • Prosthesis • Wide local excision + axillary dissection + post-op RT
Any adjuvant therapy? • Chemotherapy • ? Indications • Radiotherapy • ? Indications • Hormonal therapy • ? Indications
Case 4 • F/55 • Good past health • Routine physical check-up • Screening mammogram • Left breast microcalcification
Options • Stereostatic core biopsy • Mammotome • Contra-indicated in suspicious lesion ( BIRAD ) • For small & likely benign microcalcification • Hook-wire guided excision biopsy • For suspicious lesion • Aims to achieve a clear margin
If core biopsy confirms DCIS, what’s next? • If solitary, < 3cm, not high grade • Wide local excision + RT • Otherwise, • Total mastectomy +/- reconstruction • Axillary node dissection not required • Hormonal therapy if ER / PR positive
Case 5 • F/ 43 • Recent onset of left breast mastalgia • Clinically palpable thickening of breast tissue over L3H • MMG not revealing • Needle biopsy: insufficient material • Thus open excision biopsy
Case 5 • Histopathology: • Lobular carcinoma in situ • No invasive component • All margins appear to be clear of tumour cells What would you suggest to the patient?
Lobular Carcinoma in situ • Lobular carcinoma in situ (LCIS) is not a cancer, but its presence means that there is a small increase in the risk of developing breast cancer later in life. • Management • Surveillance with Breast Examination / MMG • Chemoprevention • Prophylactic Subcutaneous Mastectomy +/- reconstruction
Case 6 • F/ 36 • Mother of 2 children • Brownish stain on the inside of undergarment • No pain • No nipple change