1 / 83

Common Breast Disease

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

naida
Télécharger la présentation

Common Breast Disease

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Common Breast Disease Dr. Chan Wing Cheong Surgeon-in-charge Breast Surgery, NTEC

  2. Symptoms & Possible Diagnosis Infections : Lactational & Non-lactational

  3. Common Presenting Symptoms Over 80 % • Lump • Painful lump or lumpiness • Pain Under 20 % • Nipple discharge • Nipple change • Miscellaneous

  4. Benign vs. Malignant

  5. Over 90% are benign conditions

  6. Breast Anatomy and Location of Disease Processes

  7. Normal Breast Histology

  8. 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

  9. 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.

  10. 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

  11. 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

  12. Assessment : Breast Problem

  13. 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

  14. 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

  15. Breast Examination

  16. Left Mammography

  17. Breast Ultrasonography

  18. Galactography / Ductogram Intraduct papilloma

  19. Fine Needle Aspiration Cytology

  20. Core Biopsy

  21. Mammotome Biopsy

  22. Hook-wire Guided Excision

  23. Case Scenario

  24. Case 1 • F/22 • Right breast swelling for 1 month • No other symptoms • What are the questions you want to ask?

  25. Case 1 • USG breast: • Compatible with a 1.5 cm fibroadenoma • What would you offer her? • What is the natural history of fibroadenoma?

  26. 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

  27. Management Algorithm for Fibroadenoma Chances of malignancy masquerading as Fibroadenoma Age 20 – 25 yrs 1: 3000 possibility Age 25 – 30 yrs 1: 300 possibility

  28. 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?

  29. Case 2 • USG • Compatible with a giant fibroadenoma or phylloides tumour • Do you want to do FNA? • What would you offer?

  30. Case 2 • Wide local resection performed • Pathology: • Phylloides tumour of undetermined malignant potential, margins appear to be clear • How do you advice this patient?

  31. 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

  32. 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

  33. 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 ?

  34. 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

  35. Case 3 • P/E: • 2.5 cm mass over upper outer aspect of left breast • Quite mobile • No palpable axillary LN

  36. What would you do next ?

  37. Left Case 3

  38. Case 3 • MMG / USG breast • 2.5 cm mass • No axillary nodes • Core needle biopsy • Invasive carcinoma • What would you offer?

  39. Options • Modified radical mastectomy • MRM + reconstruction • Autologus tissue flap • Prosthesis • Wide local excision + axillary dissection + post-op RT

  40. Any adjuvant therapy? • Chemotherapy • ? Indications • Radiotherapy • ? Indications • Hormonal therapy • ? Indications

  41. Case 4 • F/55 • Good past health • Routine physical check-up • Screening mammogram • Left breast microcalcification

  42. What is your plan?

  43. 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

  44. Mammotome Biopsy

  45. Hook-wire Guided Excision

  46. 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

  47. 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

  48. 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?

  49. 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

  50. Case 6 • F/ 36 • Mother of 2 children • Brownish stain on the inside of undergarment • No pain • No nipple change

More Related