Cases in Breast Disease - PowerPoint PPT Presentation

1 / 53
About This Presentation
Title:

Cases in Breast Disease

Description:

Breast cancer identified in 11% of patients with 'lump', and 4% of women with any complaint. ... Breast cancer, especially inflammatory. ... – PowerPoint PPT presentation

Number of Views:447
Avg rating:3.0/5.0
Slides: 54
Provided by: unmc
Category:
Tags: breast | cancer | cases | disease

less

Transcript and Presenter's Notes

Title: Cases in Breast Disease


1
Cases in Breast Disease
  • M3 Student Lecture
  • Jennifer Griffin, MD
  • Department of Obstetrics and Gynecology

2
Breast Anatomy
  • Glands (Lobules)
  • Milk Ducts
  • Connective Tissue
  • Fat
  • With age, glands involute and are replaced by
    fat.
  • Pathology can occur in any of the above
    structures.

3
Reasons to Examine the Breasts
  • Routine screening
  • Annually, women 18 years
  • Patient complaints
  • Breast Pain (Mastalgia)
  • Nipple Discharge
  • Breast Mass

4
Reasons to Examine the Breasts
  • Cancer Detection
  • 2nd most common malignancy
  • 2nd leading cause of cancer death
  • US 1 in 8 lifetime risk (12.5)

5
Reasons to Examine the Breasts
  • 16 of women ages 40-69 sought advice from a
    physician related to a breast complaint
  • 23 visits per 1000 woman years

6
Reasons to Examine the Breasts
  • Breast cancer identified in 11 of patients with
    lump, and 4 of women with any complaint.
  • Failure to diagnose breast cancer is the 1
    malpractice claim in the U.S.

7
How to Examine the Breasts
  • Ideally, after menses in premenopausal female.
  • Visualize breasts for skin changes, symmetry.
  • Palpate chest wall, breasts, and axillae.
  • Assess for nipple discharge.
  • Lying and sitting positions.

8
Case 1
  • 25 year old female, G0
  • c/o bilateral breast pain, especially during week
    prior to her menses.
  • Feels that breast swell before menses.
  • Exam doughy, irregular texture, no discrete
    masses, no nipple discharge or adenopathy
  • Diagnosis??

9
Mastalgia
  • 45 of women reported breast pain, 21 severe.
  • 2/3 cyclical.
  • 1/3 non-cyclical.

10
Mastalgia
  • Cyclic
  • Hormonal changes
  • Fibrocystic changes

11
Mastalgia
  • Non-cyclic
  • Mastitis
  • Large pendulous breasts
  • Breast cancer, especially inflammatory.
  • Patients presenting with breast cancer had
    mastalgia as only complaint in 8 / 15 of cases.
  • Caffeine, tobacco?
  • HRT
  • Ductal ectasia
  • Chest wall pain

12
Evaluation of Mastalgia
  • Physical exam.
  • No imaging needed if discharge.
  • If 35 without masses or discharge, screening
    mammography.
  • If mass or discharge present, evaluate as
    appropriate.

13
Case 1
  • 25 year old female, G0
  • c/o bilateral breast pain, especially during week
    prior to her menses.
  • Feels that breast swell before menses.
  • Exam doughy, irregular texture, no discrete
    masses, no nipple discharge or adenopathy
  • Diagnosis??

14
Fibrocystic Changes
  • Most common breast condition.
  • Occurs in up to 60 of women.
  • Usually during reproductive years.
  • Fibrocystic disease????

15
Fibrocystic Changes
  • Stages
  • Stromal proliferation or hyperplasia
  • Adenosis (increased glands)
  • Cyst formation

16
Fibrocystic Changes
  • Management
  • Breast support.
  • Dietary reduce caffeine, salt?
  • Intermittent diuretics.
  • Evaluate medsOCPs, HRT.
  • Mastectomy in extreme cases.
  • Ultrasound discrete masses.
  • Aspiration of cysts.
  • Biopsy may be necessary.

17
Case 2
  • 32 y/o female, G2P2.
  • Presents for annual exam 2 days prior to her
    menses.
  • Exam noted to have a 1.5 cm palpable, mobile
    mass in UOQ right breast.
  • No nipple discharge, skin changes, adenopathy.
    No tenderness.
  • What should you do??

18
Evaluation of a Palpable Mass
  • Serial examination
  • If physical exam does not confirm presence of a
    dominant mass, then repeat exam should be done in
    2-3 months.
  • If patient 3-10 days after onset of menses for resolution.

19
Evaluation of a Palpable Mass
  • Ultrasound
  • Patient
  • Determine solid vs. cystic, simple or complex.
  • Mammogram
  • Indicated for screening starting at age 40.
  • Diagnostic mammogram if U/S suggests complex or
    solid lesion, or if exam suspicious for cancer
    and patient 35 yrs.

20
Evaluation of a Palpable Mass
  • Fine needle aspiration
  • Performed with a 22-24 gauge needle.
  • If fluid clear and cyst resolves, patient can be
    reassured and reevaluated in 4-6 weeks for
    recurrance.
  • If fluid bloody, send for cytology and consider
    further workup.
  • If no fluid, further work-up necessary.

21
Evaluation of a Palpable Mass
  • Core needle biopsy
  • Performed with a 14-18 gauge needle, generally
    using U/S or stereotactic mammography.
  • Histologic specimen obtained.
  • Correlates with open biopsy 94 of the time, with
    less cost.

22
Evaluation of a Palpable Mass
  • Triple diagnosis
  • Using exam, imaging, and FNA
  • 0.7 with cancer if all three suggest benign
    disease
  • 99.4 with cancer if all three suggest
    malignancy.
  • If there is discordance between the three steps,
    open biopsy or core needle biopsy should be done.

23
Case 2
  • 32 y/o female, G2P2.
  • Presents for annual exam 2 days prior to her
    menses.
  • Exam noted to have a 1.5 cm palpable, mobile
    mass in UOQ right breast.
  • No nipple discharge, skin changes, adenopathy.
    No tenderness.
  • What should you do??

24
Fibroadenomas
  • Occur in 10-20 of women.
  • Often young women.
  • May be multiple. (15-20 of pts.)
  • Slow growing, do not change with menses.
  • May be followed conservatively. (only with
    appropriate pt selection)

25
Case 3
  • 43 y/o female presents with c/o unilateral bloody
    nipple discharge.
  • Exam No palpable mass, light serosanguinous
    discharge from right nipple, no adenopathy.
  • Differential??

26
Causes of Nipple Discharge
  • Blood
  • malignancy vs papilloma
  • Purulent
  • infection, usually related to lactation
  • Milky
  • after childbearing up to one year
  • hypothyroidism, prolactinomas
  • medications OCPs, tricyclic antidepressants,
    dopamine agonists
  • Grey, brown, green, sticky
  • Duct ectasia. Common 5th decade, with nipple
    tenderness and pain.

27
Causes of Nipple Discharge
  • Spontaneous, bloody, unilateral, from one duct
    more likely cancer
  • Non-spontaneous, non-bloody, bilateral less
    likely cancer

28
Case 3
  • 43 y/o female presents with c/o unilateral bloody
    nipple discharge.
  • Exam No palpable mass, light serosanguinous
    discharge from right nipple, no adenopathy.
  • Differential??

29
Case 3
  • Classic finding of intraductal papilloma.
  • Malignancy must be excluded.
  • Usually 2-5 mm, non-palpable.
  • May perform cytology on discharge.
  • Ductography may diagnose.
  • Biopsy may be necessary.
  • May increase risk of breast cancer, even if
    singular without hyperplasia

30
Case 4
  • 27 y/o G1P1, POD3 following c-section, complains
    of tender mass in her armpit.
  • Exam soft, tender 4 cm mass in axillae on left,
    patient is afebrile.
  • Diagnosis??

31
Galactocele
  • Lactating patients may develop soft, cystic
    masses from dilated ducts or glands that are not
    draining.
  • Treatment Decompressionvia breastfeeding or
    pumping, may require needle aspiration to prevent
    infection

32
Mastitis
  • Occurs in 1-3 of breastfeeding mothers.
  • Fevers, tender area of breast, myalgias.
  • Exam erythematous wedge- shaped tender area of
    breast.
  • Treatment??

33
Mastitis
  • Dicloxicillin 500 mg qid x 10 days.
  • Alternatives
  • Cephalexin (Keflex)
  • Augmentin
  • Perform culture and sensitivity if persistent
    24-48 hrs or recurrent.
  • Anti-inflammatories.
  • Continue nursing!

34
Breast Abcess
  • Mastitis fluctuant mass.
  • Complication of 5-10 of mastitis.
  • Requires incision and drainage.
  • Continue to nurse and pump.

35
Case 5
  • 58 y/o female presents with complaint of breast
    mass she felt on self-exam.
  • Exam Rubbery, 3 cm, non-discrete lesion. Some
    dimpling of skin over area. No nipple discharge.

36
Breast Cancer
  • Classic exam characteristics
  • Single lesion
  • Hard
  • Immovable
  • Irregular border
  • Skin dimpling
  • Size 2 cm
  • 90 are found by the patient!!

37
Demographics
  • 1 in 8 lifetime risk.
  • 1 in 2000 for woman in her 20s.
  • 1 in 25 for woman in her 70s.

38
Demographics
  • BRCA mutations
  • Less than 1 of women are carriers.
  • Account for 3-10 of breast CA.
  • BRCA carrier 85-90 lifetime risk.

39
Relative Risk
  • Lower Risk (RR
  • Menarche 17 years.
  • Menopause
  • Oophorectomy
  • Term pregnancy
  • Table 32.2 text

40
Relative Risk
  • RR 1.1-2.0
  • Menarche
  • Menopause 55 years.
  • First term pregnancy 35 years.
  • No term pregnancies.
  • Personal hx of endometrial, ovary, or colon CA.
  • Never breast fed.
  • Recent OCPs/ HRT.

41
Relative Risk
  • RR 2.1-4.0
  • One first degree relative with breast cancer.
  • Atypical hyperplasia on biopsy.
  • Personal hx of salivary gland CA.

42
Relative Risk
  • RR 4.0
  • Personal hx of breast cancer.
  • 2 1st degree relatives with breast CA.
  • Age 65.
  • Inherited genetic mutations.
  • RR 8.0
  • Premenopausal 1st degree relative with bilateral
    breast cancer.

43
Modifiable Risk Factors
  • Obesity.
  • Sedentary lifestyle.
  • Excessive alcohol use.

44
Histologic Risk Factors
Relative Risk of Breast Cancer with Different
Breast Lesions
Breast cancer will often occur many years later
and in a different location than the original
lesion.
45
Oncogenic Biomarkers
  • Her-2/neu
  • Cyclooxygenase 2 (COX 2)

46
Gail Model
47
Evaluation
  • U/S for patients with dense breasts
  • Mammography
  • Digital vs. Conventional
  • MRI, PET scan???
  • Referral for biopsy for palpable mass.

48
Mammography
  • Able to detect lesions down to 1mm, 2 years
    prior to palpated mass.
  • Diagnostic for palpable masses.
  • Screening age 40 q 1-2 years, age 50 every
    year.

49
Mammography
  • Features suggestive of cancer
  • Increased density.
  • Irregular border.
  • Spiculation.
  • Clustered irregular microcalcifications.

50
Mammography
  • BI-RADS Classification
  • 0 Needs more imaging
  • 1 Negative
  • 2 Benign findings
  • 3 Probable benign, repeat imaging
  • 4 Suspicious abnormality
  • 5 Highly suspicious

51
Biopsy Techniques
  • Cyst aspiration (cytology FN 20)
  • Fine needle aspiration (FN 20)
  • Stereotactic core biopsy
  • Open biopsy

52
Breast Cancer
  • Types
  • Ductal, Lobular, Nipple
  • Pagets Disease
  • 70-80-- invasive ductal carcinoma

53
Breast Cancer
  • Breast Conserving Therapy
  • Contraindications
  • Persistently positive margins
  • Multicentric disease
  • Prior radiation
  • Pregnancy
Write a Comment
User Comments (0)
About PowerShow.com