3. OBJECTIVES
• Identify & Discuss the Differential Diagnosis of a
Breast Lump
• Present and Interpret a Good History & physical
Examination for a Patient with a Breast Lump.
• Discuss the Possible Causes of Nipple Discharge
According to the Color & Nature of the Discharge.
• Present a sound Approach to Investigate a Patient
with a Breast Lump & Nipple Discharge.
• Present a Possible Approach for Treatment.
11. HISTORY
• Personal Data
• Chief Complaint
• H.C.C : when and how first noticed,
Pain, tenderness, change in size
over time and with menstruation.
12. EVALUATION OF A
BREAST LUMP
Important things to ask about :
• Mastalgia : Cyclic Vs. Non- Cyclic
• Skin Changes : Redness, Warmth,
Tenderness,Dimpling,Peau d’
orange
• Nipple Inversion : Benign Vs.
Malignant
13. EVALUATION OF A
BREAST LUMP
Important Things to Ask About :
• Nipple Discharge
- Clear, Yellow, White, Green
- Blood Stained or Dark
- Purulent Discharge
- Galactorrhoea
• Gynaecomastia ( Males )
14. EVALUATION OF A
BREAST LUMP
• Gynecologic History : parous
state,breast feeding,last period,
drugs (HRT)
• Past Medical History : benign
breast disease, breast cancer,
radiation therapy to breast
• Past Surgical History: breast
biopsy, lumpectomy, mastectomy,
hysterectomy, oophorectomy.
15. EVALUATION OF A
BREAST LUMP
• Family History : Especially in first
degree relatives.
• Constitutional Features :
- Anorexia
- weight loss
- Respiratory Symptoms
- Bone Pain
17. EVALUATION OF A
BREAST LUMP
Characteristics of a Breast mass
• Size
• Position
• Mobility
• Composition ( Fluctuant, Hard,
Rubbery )
• Fixation to underlying tissue or skin
18. Differential Diagnosis of
a Breast Lump
• FIBROCYSTIC DISEASE
• CYSTS
• ADENOMAS
• FIBROADENOMA
• FAT NECROSIS
• PAPILLOMA
• BREAST CANCER
21. DIFFERENTIAL DIAGNOSIS
OF NIPPLE DISCHARGE
• Purulent: superficial or central abscess
• Milky: post-lactation, OCP, prolactinoma
22. INVESTIGATIONS
• Standard Investigations
• Mammography
• U/S
• Biopsy
• Magnetic Resonance Imaging
• Cytology
• Imaging for metastases
23. INVESTIGATIONS
• Standard Investigations
• Mammography
• U/S
• Biopsy
• Magnetic Resonance Imaging
• Cytology
• Imaging for metastases
24. Mammography
Indications
• screening – every 1-2 years for
women ages 50-69.
• metastatic adenocarcinoma of
unknown primary.
• nipple discharge without palpable
mass.
25. Mammography
Mammogram findings indicative of
malignancy
• stellate appearance and spiculated
border - pathognomonic of breast
cancer.
• microcalcifications, ill-defined lesion
border.
• lobulation, architectural distortion
28. Biopsy
• The diagnosis of breast cancer
depends upon examination of tissue
or cells removed by biopsy.
• The safest course is biopsy
examination of all suspicious
masses found on physical
examination and of suspicious
lesions demonstrated by
mammography.
29. Biopsy
• The simplest method is needle
biopsy, either by aspiration of tumor
cells ( fine – needle aspiration
cytology) or by obtaining a small
core of tissue with a hollow needle.
• Open biopsy… ( incisional or
excisional )
30. Magnetic Resonance Imaging
• High Sensitivity for breast cancer
• Can demonstrate the extent of both
invasive & non-invasive disease.
• Determines weather a
mammographic lesion at the site of
previous surgery is due to scar or
recurrence.
• The optimum method for imaging
breast implants and detecting
implant leakage or rupture.
31. cytology
• Cytologic examination of nipple
discharge or cyst fluid may be
helpful on rare occasions.
• As a rule, mammography and breast
biopsy are required when nipple
discharge or cyst fluid is bloody or
cytologically questionable.
32. Imaging for metastases
• Chest x-ray may show pulmonary
metastases.
• CT scanning of liver and brain is of
value only when metastases are
suspected in these areas.
35. FIBROCYSTIC DISEASE
• Benign breast condition consisting
of fibrous and cystic changes in
breast.
• Age : 30-50 years
• Clinical Features
- breast pain
- swelling with focal areas of
nodularity or cysts
- Frequently bilateral
- varies with menstrual cycle
36. FIBROCYSTIC DISEASE
Treatment
• If no dominant mass, observe to
ensure no mass dominates.
• For a dominant mass, FNA
• If > 40 years, mammography every
3 years
• Avoid xanthine-containing products
(coffee, tea, chocolate, cola drinks)
and nicotine.
• For severe symptoms – danozol (2-
3 months), or tamoxifen (4-6 weeks)
37. FIBROADENOMA
• Most common benign breast tumour
in women under age 30.
• No malignant potential
• Clinical features – smooth, rubbery,
discrete, well circumscribed nodule,
non-tender, mobile, hormonally
dependant.
• Management – usually excised to
confirm diagnosis
38. FAT NECROSIS
• Due to trauma (although positive history in only
50%).
• Clinical features – firm, ill-defined mass with skin
or nipple retraction, +/– tenderness.
• Management – will regress spontaneously but
complete excisional biopsy is the safest approach
to rule out carcinoma.
39. PAPILLOMA
• Solitary intraductal benign polyp.
• Most common cause of bloody nipple
discharge.
• Management – excision of involved duct
41. EPIDEMIOLOGY
• Most common cancer in women.
• Second leading cause of cancer
mortality in women.
• Most common cause of death in 5th
decade.
• Lifetime risk of 1/9
42. RISK FACTORS
• age - 80% > 40y.o
• sex - 99% female
• 1st degree relative with breast cancer
- Risk increases if relative was premenopausal.
• Geographic - highest national mortality in England
and Wales, lowest in Japan.
• Nulliparity
• late age at first pregnancy>30y.o
43. • Early menarche < 12; late
menopause > 55
• obesity
• excessive alcohol intake, high fat
diet
• certain forms of fibrocystic change
• prior history of breast ca
• history of low-dose irradiation
• prior breast biopsy regardless of
pathology
• OCP/estrogen replacement may
increase risk
45. Pathology
Non-invasive (DCIS and LCIS)
(1)Ductal carcinoma in situ (DCIS)
• proliferation of malignant epithelial cells
completely contained within breast ducts
• risk of development of infiltrating ductal
carcinoma in same breast is 25-30%
• considered a pre-malignant lesion.
46. Pathology
Non invasive
(2)Lobular carcinoma in situ (LCIS)
• proliferation of malignant epithelial cells
completely contained within breast lobule
• no palpable mass, no mammographic
findings, usually found on biopsy for
another abnormality.
47. Pathology
Invasive
(1)Ductal carcinoma (most common -
80%)
• originates from ductal epithelium and
infiltrates supporting stroma
(2)Paget’s disease (1-3%)
• ductal carcinoma that invades nipple
with scaling, eczematoid lesion
48. Pathology
Invasive
(3)Invasive lobular carcinoma (8-
10%)
• originates from lobular epithelium
• more apt to be bilateral, better prognosis
• does not form microcalcifications
49. Pathology
Invasive
(4)Inflammatory carcinoma (1-4%)
• ductal carcinoma that involves dermal
lymphatics
• most aggressive form of breast cancer
• presents with erythema, skin edema,
warm swollen tender breast, +/– lump
• peau d’orange indicates advanced
disease (IIIb-IV)
50. staging
Clinical:
• assess tumor size, nodal involvement,
and metastasis
• tumor size by palpation, mammogram
• nodal involvement by palpation
• metastasis by physical exam, CXR, LFTs,
bone scan
51. staging
Pathological
• Histology
• axillary dissection should be performed for accurate
staging and to reduce risk of axillary recurrence
• estrogen/progesterone receptor testing
presence or absence of estrogen and progesterone
receptors,
52. Staging of Breast Cancer (American
Joint Committee)
Stage Tumor Regional Metastasis
Nodes
O In situ no no
1 <2 cm no no
2 <2 cm or Movable no
2-5 cm or ipsilateral
>5 cm
3 Any size fixed no
4 any any distant
53. Treatment
• Primary Treatment of Breast Cancer
• total mastectomy – removes breast tissue,
nipple-areolar complex and skin
• modified radical mastectomy (MRM) –
removes breast tissue, pectorali fascia,
nipple-areolar complex, skin and axillary
lymph nodes
54. Treatment stage 0
DCIS – total ipsilateral mastectomy vs. wide local
excision (WLE) plus radiation therapy (XRT),
• axillary node dissection is not required for DCIS
LCIS – close observation vs. bilateral total
mastectomy, axillary node dissection is not
required
Paget’s disease – total mastectomy vs. MRM
55. Treatment stages I,II
surgery for cure
MRM vs. WLE with axillary node
dissection plus XRT
adjuvant chemotherapy in node-
positive patients and high risk node-
negative patient
56. Treatment Stages III,IV
operate for local control
includes surgery, radiation and systemic therapy
individualized, but mastectomy is most common
procedure
• even with aggressive therapy most patients die as a result of
distant metastasis
Indication of chemotherapy
tumors > 5 cm
inflammatory carcinomas
chest wall or skin extention
57. • Adjuvant Therapy –
Combination Chemotherapy
• indications – node-positive patients, high
risk node-negative patients, and palliation
for metastatic disease,
• ER negative patients
• CMF (cyclophosphamide, methotrexate, 5-
flurouracil) x 6 months
58. Adjuvant Therapy -
Hormonal
• indications – ER positive, pre- or
post-menopausal, node-positive or
high risk node-negative patients.
• • adjuvant or palliative therapy
• Tamoxifen (anti-estrogen) – is agent
of choice, continue for 5 years
• alternatives to tamoxifen
59. • Adjuvant Therapy -
Radiation
• with breast-conserving surgery
• those with high-risk of local
recurrence
• adjuvant radiation to breast
decreases local recurrence,
increases disease free survival
• (no change in overall survival)
60. Post-Surgical Management
1.follow-up of post-mastectomy patient
history and physical every 4-6 months
yearly mammogram of remaining breast
2.follow-up of segmental mastectomy patient
history and physical every 4-6 months
mammograms every 6 months x 2 years, then
yearly thereafter
3.when clinically indicated
chest x-ray
bone scan
LFTs
CT of abdomen
CT of brain
