Management of patient with breast lump

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Management of patient with breast lump nipple
discharge
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Objectives

• Anatomy of the breast
• Approach to a patient with breast lump
• Common breast problems (benign malignant)
• Approach to a patient with nipple discharge

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Anatomy of the breast
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Anatomy of the breast

• Modified sweat gland Extends from 2nd-6th rib
  from sternal edge-midaxillary line.
• Positioned over the muscles of the chest wall
  (the pectoralis major, serratus anterior,
  external oblique, and rectus abdominus fascia)
• Attached to the chest wall by fibrous strands
  called Coopers ligaments ( suspensory ligament)
  which extend from the deep fascia beneath the
  breast and attach to the dermis of the skin.

Carcinoma invading these ligaments may result in
skin dimpling
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Cont, anatomy of the breast

• The breast is composed of glandular ducts and
  lobules, connective tissue, and fat.
• The nipple and areola are separate structures.
  The unique anatomy explains why 18 of malignant
  cancers are found in the subareolar region
• most breast cancer is thought to originate in the
  terminal ductal lobular unit (TDLU) functional
  secretory unit.
• Half of this glandular tissue is located in the
  upper outer quadrant therefore, nearly one half
  of all breast cancers occur in this area.

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Blood supply

• Arterial supply
• - perforating branches of the internal thoracic
  artery(internal mammary artery)60.
• - the lateral thoracic artery .
• - branches of the axillary artery. ( the
  thoraco-acromial artery long thoracic artery ).
• - intercostal artery perforators .

• Venous drainage
• -internal thoracic vein.
• -lateral thoracic vein.
• -Mainly the axillary vein.
• - intercostals veins .

Most major venous pathways lead to the pulmonary
capillary network (why lung metastases are
common) or the vertebral veins (skeletal
metastases).
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Lymphatic drainage

• Interlobular lymphatic vessels ? sub areolar
  plexus (sappeys plexus)? (75) of the drainage
  to the axillary lymph nodes.
• Medial aspect of the breast ? internal mammery
  lymph nodes or the axillary lymph nodes.

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How to manage a patient with breast lump or
nipple discharge ?
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History

• Personal
• Age
• gender
• Analysis of C/C
• SOCRATES
• 1- Pain
• 2- Lump
• 3- nipple discharge
• 4- abnormal appearance
• Previous Hx of breast problem
• Associated symptoms
• Constitutional symptoms
• Chronic illnesses
• Family Hx

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Cont History

• DDx
• Hx of trauma to the breast
• Any medications
• ask about the risk factors of breast cancer
• - Radiation exposure
• - Menstrual hx
• Early menarche
• Late menopause
• and late pregnancy.
• Lactation
• Metastasis Hx
• - General malaise, weight loss
• - Recent backache, Bone ache
• - Jaundice
• - Mental changes
• - Dyspnoea, pleuritic pain
• - Nodules in the skin

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History

• Local Hx
• -When and how did you first notice the lump?
  changes?
• - Where is the lump located?
• - Does the lump ever disappear? and if, what
  makes the lump to reappear?
• - Have you had any type of injury (trauma) to
  your breast?
• -Have you ever had any other lumps? In the same
  breast or the other ?
• -Do you have other symptoms such as pain, nipple
  discharge (details), skin changes or fever?
• -Are you taking any hormones, medications, or
  supplements? (Endocrine state)
• General Hx
• ask about the risk factors of breast cancer
• -female sex
• -age older than 40 years
• -family history of breast cancer
• -Nulliparity, menarche before age 12 years,
  menopause after age 55 years, and late pregnancy.
• -
• Metastasis Hx
• - Recent backache, Bone ache

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Examination

• Examination (A) Local Ex
• - Position
• - Inspection
• - Palpation (Feel, press, percussion, move, .
  and surrounding tissues)
• - Lump 4S, 2T, edge and composition
• - L.N.
• Axillary and supraclavicular
• (B) General Ex Abdomen, lumbar spine
• Points in Examination Look for
• - Firm mass of variable shape and size
• - Fifty percent of masses found in the upper
  outer quadrant of the breast
• - May have associated pain with palpation, but
  most are painless
• - Nipple discharge or inversion
• - Skin retraction or tethering
• - Axillary lymphadenopathy
• - Inflammatory changes of the skin (e.g. peau
  d'orange)

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DDx

• Swelling of the whole breast
• Bilateral
• - pregnancy, lactation
• - Idiopathic hypertrophy
• - Drug induced (e.g. cimetidine)
• Unilateral
• - Enlargement in the newborn
• - Puberty

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DDx of localized swelling
Painless lump Painful lump
- Cyst - Carcinoma - Fibroadenosis (chronic mastitis) - Fibroadenoma - Fat necrosis - Cyst - Breast abscess - Fibroadenosis Periductal mastitis Carcinoma (rare)
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Investigation
Imaging Studies -Mammography -US -MRI -Other
imaging modalities Diagnostic Procedures
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Mammography
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Mamography

• special type of X-ray imaging used to create
  detailed images of the breast.
• The initial investigation for symptomatic breast
  in women older than 35 years.
• 95 accurate ( 5 - 10 ) false ve.
• 2 views of each breast is taken as standard
  mammography
• - 45 oblique. Mediolateral (MLO)
  
• - Craniocaudal position (CC)
• Additional views are obtained to clarify
  questionable lesion
• -latero-medial (LM)
• -medio-lateral (ML) views
• -exaggerated CC views
• -magnification views
• -spot compression views
• -others
• Unreliable
• because of high dense glandular tissue
• below the age of 35 years.
• Lactating lady .

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Indication of mammogram

• Screening
• -Baseline mammogram for women ages 35-39 years.
• -Mammogram every 1-2 years for women ages
• 40-50 years.
• -every year once they reach 50 years of age .
• diagnostic
• Metastatic adenocarcinoma without known primary.
• Nipple discharge without palpable mass.
• Follow up

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Finding in mammogram
Benign Malignant
Shape Round, uniform density, large, coarse Linear, branching, pleomorphic, casting
Margins Circumscribed mass Smoothly marginated Spiculation
Content Fat-containing lesion Architectural distortion with no history of prior surgery
Calcification (very important read about the difference between benign malignant) Microcalcifications Widely scattered Microcalcifications (lt0.5 mm) Tightly clustered
Long axis Long axis of the lesion is along the normal tissue planes Lesion is taller than it is wide
Homogenicity Homogeneous internal echotexture Heterogenous
Echogenecity Hyperechogenicity Decreased hyperechogenicity, Marked acoustical shadowing
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Ultra-sound
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Ultra-sound

• - The most useful study in younger women lt 35
  years with palpable breast mass.
• - Effective for lesions gt 0.5cm.
• - Easily distinguishes cystic from a solid mass.
• Cystic well defined, round, echo-free lesion
  with posterior enhancement.
• Solid has echo within it posterior
  enhancement.
• the introduction of Doppler enable definition of
  characteristic blood flow patterns. This can aid
  in separating benign and malignant lesions and
  distinguishing lymph node metastases from normal
  or reactive lymph nodes.

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Fibroadenoma Cyst in US

• Fibroadenoma

• Cyst

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MRI
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MRI

• Useful but expensive.
• Usually used in screening of familial cases of
  breast cancer rather than X-ray which could be
  potentially harmful.
• Distinguish scar from recurrence in women who
  have had previous breast conservative therapy for
  cancer (although it is not accurate within 9
  months of radiotherapy because of abnormal
  enhancement).
• The gold standard for imaging the breasts of
  women with implant.

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CT scan

• CT is primarily used to evaluate for extramammary
  involvement of the tumor.

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Diagnostic procedures
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Fine needle aspiration (FNA)

• Indications Establish cytological diagnosis.
• Advantages
• Minimally invasive office procedure that is well
  tolerated by the patient.
• Often allows for a single trip to operating room.
• Specimen can be processed and interpreted
  rapidly.
• Disadvantages
• 1- False () rate for cancer varies from 0-1
  on an institutional basis.
• 2- Significant false (-) rate ( gt20) for cancer
  because of small sampling size .
• Non palpable mass
• stereotactic , Ultrasonographic or MRI- guided

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Core-needle biopsy (CNB)

• Indications Establish histological diagnosis for
  lt 3 cm mass.
• Advantages
• -Minimally invasive, low-morbidity office
  procedure
• -False () rate for cancer is 0.
• Disadvantages
• -Rare complications of hematoma and pneumothorax.
• -Significant false (-) rate (gt20)for cancer
  because of small sampling size.
• Non palpable mass stereotactic (visualization
  by mammogram , Ultra-sonographic or MRI- guided
  CNB well tolerated False (-) rate for cancer
  is approximately 1.

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Incisional biopsynot used usually

• Indications Establish histological diagnosis for
  a large mass (gt3cm) when FNA and CNB are
  non-diagnostic.
• Advantages
• -Performed under local anaesthesia.
• -False () rate for cancer is 0.
• -False (-) rate for cancer is close to 0.
• Disadvantages
• -Substantially higher cost than FNA or CNB.
• -Open Surgical procedure with associated risks of
  bleeding and wound infection.

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4.Excisional biopsy

• Indications Establish definitive histological
  diagnosis for a small (lt3cm) mass when FNA and
  CNB are non-diagnostic.
• Advantages
• Can be therapeutic as well as diagnostic for
  benign mass and for malignant mass excised with
  negative microscopic margins.
• False () and false (-) rates for cancer are 0.
• Performed under local anaesthesia.
• Disadvantages
• Open Surgical procedure with risks of bleeding
  and wound infection.
• Substantially higher cost than other biopsy
  procedures.

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Wire localization breast biopsyfor non-palbable
mass

• Indications Establish definitive histological
  diagnosis for a non-palpable but visualized
  abnormality.
• Advantages
• -Therapeutic as well as diagnostic for benign
  masses and for malignant masses excised with
  negative margins.
• -False () rate for cancer is 0.
• -False (-) rate is 0 if visualized abnormality is
  completely excised.
• Disadvantages
• Open procedure that requires radiological
  localization before surgical excision.
• Occasional (1) failure to excise abnormality.
  May require relocalization and reoperation.
• Cosmetic deformity may result.

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Ultrasound-Guided Breast Biopsy
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Benign condition of breast swelling
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common causes of a benign breast mass

• Fibrocystic disease the most common breast mass
  in women.
• Fibroadenoma the most common benign tumor.
• Fat necrosis
• Abscess
• Cyst
• Others
• - Intraductal papilloma
• - Ductal/ lobular Hyperplasia
• - Ductectasia
• - Lipoma
• - Granulomatous mastitis

Note 1- in general, Mass cystic or solid,
Tumor solid 2- the difference between
fibrocystic changes and fibroadenoma is that in
fibrocystic changes u cant define a mass while
fibroadenoam is a mass
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Fibrocystic change

• Benign changes
• - Age 30 menopause (and after if HRT used)
• - C./F. Breast pain, swelling, with focal area
  of nodularity, freq. bilateral, mobile and varies
  with menstrual cycle
• - No increase risk of breast cancer but makes
  evaluation of mammographic malignant changes more
  difficult.
• Treatment
• If gt40 y mammography every 3 years
• analgesia, OCP or danazol for sever symptoms.

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Fibroadenoma

• - Most common benign breast tumor in women lt 30y
• - No malignant potential except if sclerosing
  adenosis present.
• - C./F. nodules smooth, rubbery, discrete,
  well-circumscibed, non-tender, mobile, hormone
  dependent .
• - Unlike cysts, needle aspiration yield no fluid
• Investigations
• - Mammogram
• - US
• - FNA to R/O solid lesion
• Rx
• - Generally conservative serial observation
• -Excision if mass rapidly growing, if gt5cm in
  size or if Pt. wants , equivocal result , if the
  pt has no access for follow up, if there is
  family history of cancer.

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Phylloid tumor (cystosarcoma)

• Rare type of fibroadenoma.
• typically large, fast growing masses that form
  from the periductal stromal cells of the breast.
• most common between the ages of 40 and 50, prior
  to the menopause.
• Although it is mostly benign , It can recur after
  excision .
• The malignant form (10) can metastasize
• hematogenously most commonly to the lungs .
• The common treatment for phyllodes is wide local
  excision.

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Fat necrosis

• - Result of trauma (may be minor, ve trauma Hx
  in only 50)
• - Firm, ill-defined mass with skin or nipple
  retraction /- tenderness
• Regress spontaneously, but complete excisional
  biopsy to rule out carcinoma .
• It resembles cancer clinically radiologically.
  The only way to differentiate is by biopsy.

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Abscess

• - Unilateral localized pain and erythema.
• - R/O inflammatory carcinoma, as indicated
• - Staphylococcus aureus are the most common
  organisms .

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Cyst

• C\F Fluid-filled sacs that often feel like soft
  grapes. Can sometimes be tender, especially just
  before the menstrual period.
• Cysts may be drained in the clinic.
• Rx
• If the fluid removed is clear or greenish,
• and the lump disappears completely after it is
  drained, no further treatment is needed.
• -If the fluid is bloody, it is sent to the lab to
  look for cancer cells. If the lump doesn't
  disappear, or recurs, it is usually removed
  surgically.

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Galactocele

• is a cystic tumor containing milk or a milky
  substance that is usually located in the mammary
  glands.
• Galactoceles are benign and are not a cause for
  concern.
• It is caused by a protein plug that blocks off
  the outlet. Once lactation has ended the cyst
  will resolve on its own without intervention.
• A galactocele does not cause infection as the
  milk within is sterile and has no outlet for
  which to become contaminated.
• Attempts to drain the cyst are unsuccessful
  because the protein plug remains intact and milk
  production continues.

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Granulomatous mastitis

• Characteristic for granulomatous mastitis are
  multinucleated giant cells and epithelioid
  histiocytes around lobules. Often minor ductal
  and periductal inflammation is present. The
  lesion is in some cases very difficult to
  distinguish from breast cancer.
• most often completely aseptic but infectious
  causes must be considered as well.
• C\Fdistinct firm mass mostly in the subareolar
  region.
• PREDISPOSING FACTORS
• -2 years and up to 6 years after pregnancy, usual
  age range is 17 to 42 years.
• -Use of hormonal contraceptives, prolactin
  raising medications and hyperprolactinemia .

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Breast Cancer
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Epidemiology

• The 2nd leading cause of cancer mortality in
  women (1st?)
• - Lifetime risk 11-13

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Risk factors of breast cancer

• - 99 female
• - 80 gt40 y.o.
• - Prior Hx of BC, prior breast biopsy.
• 1st degree relative with BC( incr. risk if
  premenopausal )
• risk in (HYPERESTROGENEMIA STATE)
• - early menarche lt12y
• - late menopausegt55y
• - 1st pregnancy gt30y,
• - nulliparity
• - OCP
• - HRT for 5y
• - ?risk with lactation, early menopause, early
  childbirth
• - Radiation exposure
• - Hx of specific benign breast disease ( Atypical
  hyperplsia 4x )

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• Types and presentation

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1- Non- invasive

• a) Ductal carcinoma in situ (DCIS)
• - Completely contained within breast ducts
• - 80 non-palpable, detected by screening
  mammogram
• b) Lobular carcinoma in situ (LCIS)
• -Completely contained within breast lobule
• -No palpable mass, no mammographic findings,
  usually incidental finding on breast biopsy.

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2- invasive

• Infiltrating ductal carcinoma (most common 80)
• hard ,scirrhousthe most common type
  ,infiltrating tentacles
• Papillary ,medullary ,mucinouse ,tubular cancers
• Generally better prognosis.
• Invasive lobular carcinoma (8-15)
• -20 bilatral
• -Dose not form microcalcification , harder to
  detect mammographically .
• Pagets disease (1-3)
• Ductal carcinoma that invades nipple with
  scaling ,eczematous lesion .

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• Inflammatory carcinoma (1-4)
• Ductal carcinoma that invades dermal lymphatics
• Most aggressive form of breast cancer
• Erythema , skin edema ,warm, swollon ,tender -
  lump
• Male breast cancer (lt1)
• Most commonly infiltrating ductal carcinoma
• Often diagnosed at later stages
• Sarcoma
• Rare ,most commonly cystosarcoma phyllodes , a
  variant of fibroadenoma
• Lymphoma rare

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Staging

• 1-TNM Classification
• 2-Clinical staging

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Primary tumor (T)

• TIS carcinoma in situ
• T0- no primary tumour located
• T1- tumour less than 2 cm
• T2- tumour 2-5 cm
• T3- tumour greater than 5cm
• T4 extension to chest wall

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Regional lymph nodes (N)

• N0-no nodal involvement
• N1-mobile ipsilateral axillary nodes
• N2-fixed ipsilateral axillary nodes
• N3 - ipsilateral supraclavicular nodes

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Metastasis (M)

• M0 No distant spread.
• M1 Spread to distant organs is present.
• (The most common sites are bone, lung, brain,
  and liver.)

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Clinical staging
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AJCC stage groupings
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Stage T N M Survival (5 year)
O In situ None None 99
I Less 2cm None None 94
II A Less 2cm Mobile ipsilatral None 85
IIB 2-5 cm or more 5 cm None or mobile ipsilatral None None None 70
IIIA Any size Fixed ipsilatral or internal mammary None 52
IIIB Skin /chest wall invasion Any None 48
IIIC Any size Ipsilatral infraclavicular /internal mammary plus axillary node ipsilatral supraclavicular nodes axillary nodes None 33
IV Any Any Distant 18
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Treatment
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• Primary Surgical
• 1- Breast conserving surgery (BCS)- lumpectomy
  with wide local excision
• -for stage I and II
• -Combined with radiation
• -axillary lymph node dissection (ALND)
• For staging of nodes and reduced recurrance in
  axilla
• Complication of ALND
• Arm lymphedema (10-15),decreased arm sensation
  ,shoulder pain .

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• BCS not appropriate if
• Factors present that increase risk of local
  recurrance extensive malignant type
  calcification on mammogram , multifocal primary
  tumuor .
• Contraindication to radiation therapy( pregnancy,
  cardiac or skin disease, pnumonitis)
• Large tumor size (stage ????3
• Patient prefers mastectomy .
• Bad cosmetic result.
• (In all the previous we do mastectomy)

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• 2- Mastectomy
• - Modified radical mastectomy (MRM)-removes all
  breast tissue ,nipple areolar complex ,skin ,
  axillary nodes .
• Simple (total) mastectomy
• similar to MRM but axillary nodes not removed .
• - Offer breast reconstruction

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• Adjuvant
• Radiation
• Decrease risk of local recurrence and almost
  always used before BCS, sometimes after
  mastectomy .
• Axillary nodal radiation may added if nodal
  involvement .
• For high risk of local recurrence , inoperable
  locally advanced cancer (no clear margins after
  excision) ,metastases.
• In Stage I/II .

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• Chemotherapy
• Classically CMF ( cyclophosphamide, methotrexate,
  5-fluorouracil)
• Almost all pt. with stage III disease
• In stage I at high risk
• ER (Estrogen receptor ) ve plus node ve /high
  risk node ve .
• ER ve and young age .
• Palliation for metastatic disease.
• ( premenopausal pt with ve or ve nodes need
  chemo, post-menopausal with ve node need chemo)

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• Hormonal
• Indication
• ER ve (pre-/post-menopausal )plus node ve or
  high risk node ve .
• Palliation for metastases .
• Tamoxifen or aromatase inhibitor (eg.
  anastrozole) , ovarian ablation
  (GnRH agonist ,oophorectomy ),
  Progestins (e.g. megestrol acetate ), androgens
  (fluoxymesterone ).

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Stage 0

• Ductal Carcinoma In Situ (DCIS)
• Ipsilateral total mastectomy.
• WLE and radiation therapy.
• No need for axillary node dissection.
• Overall 5-year survival rate is 95-100.
• Lobular Carcinoma In Situ (LCIS)
• Bilateral total mastectomy.
• Tamoxifen 20mg daily for 5 years with close
  observation.
• No need for axillary node dissection.
• Invasive carcinoma (invasive on biopsy but no
  mass, no nodes)
• Modified radical mastectomy.
• WLE with axillary node dissection and radiation
  therapy.
• Pagets disease
• Total mastectomy.
• Modified radical mastectomy.

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Stage I and II

• Modified radical mastectomy.
• WLE with axillary node dissection and radiation
  therapy.
• Adjuvant chemotherapy for node-positive or high
  risk node-negative patients.
• Overall 5-year survival rate is 80 for stage I
  and 60 for stage II.

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Stage III and IV

• Multimodality therapy.
• Mastectomy remains the mainstay of surgical
  treatment.
• Overall 5-year survival rate is 20 for stage III
  and 0 for stage IV.

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• Post-Treatment follow up
• - Regular visits (3-6 m x 2y)
• - Annual mammography
• - Psychosocial support and counseling
• - Signs of recurrence (CXR, CT abdomen, liver
  enzymes, bone sacan, CT brain, MRI spine.)
• Metastasis
• - Bone gt lungs gt pleura gt liver gt brain
• - Rx is palliative hormonal therapy,
  chemotherapy, radiation.

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Key points

• The most common breast lumps occurring lt 35 yrs
  are fibroadenomas fibrocystic disease.
• The most common breast lumps occurring gt 50 yrs
  are Carcinomas Cysts.
• Pain is more characteristic of infection /
  inflammation than tumors.
• Skin tethering is more characteristic of tumors
  than benign disease
• Multiple lesions are usually benign (cystic or
  fibrocystic) disease.

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• Nipple Discharge

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Definition

• Abnormal nipple discharge is abnormal fluid
  leakage from one or both nipples of the breast.
• The likelihood of nipple discharge increase with
  age and number of pregnancies.

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Causes

• common cause
• 1. Duct ectasia (periductal mastitis).
• 2. Intraduct papilloma (small noncancerous growth
  in the breast).
• Other causes
• a) Prolactinoma ( tumor in the brain).
• b) Breast abscess (most commonly seen in women
  during breastfeeding).
• c) Breast cancer.
• d) Fibrocystic change in the breast.

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DDx of nipple discharge
Serous Early pregnancy fibroadenosis
Milky Late pregnancy Lactation Puberty prolactinoma
Yellow, brown, green fibroadenosis
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Thick and creamy Duct ectasia
Purulent Retroareolar abscess Breast abscess TB
Bloody Intraduct. ca Intraduct. papilloma Pagets disease
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Duct ectasia (periductal mastitis)

• Etiology unknown.
• Pathological feature
• Dilated duct ? engorged with breast secretion ?
  infection ? retroareolar abscess ? fibrosis ?
  nipple retraction.
• Clinical features
• - Pain usually cyclical.
• - Periareolar erythema.
• - Nipple discharge thick creamy or greenish
  brown.
• - Periareolar tender mass.
• - Nipple retraction (when healing occurs by
  fibrosis).

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• Investigations
• - Mammogram opaque mass of dilated ducts skin
  indentation.
• - Cytology for discharge.
• Managements
• - Infection aspiration antibiotic.
• - Abscess drainage.
• - Severe discharge or recurrent sepsis
  mammadochectomy (nipple ducts excised through a
  circumareolar incision preserving the nipple).

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Intraduct papilloma

• Benign.
• Occurring in middle-aged women.
• Clinical features
• - Bloodstained discharge.
• - Bleeding from a single duct orifice
• - (pressure over a certain spot or the palpable
  mass).
• - Small mass NOT usually.
• Investigation
• - Mammogram (exclude carcinoma).
• - Cytology assessment.
• Managements
• - Duct orifice (bleeding) is identified
  microdochectomy.
• - If not excision of the major nipple ducts.

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• Thank you