Approach to the breast mass - PowerPoint PPT Presentation

Loading...

PPT – Approach to the breast mass PowerPoint presentation | free to download - id: 577ce9-NGQ5Y



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Approach to the breast mass

Description:

Title: PowerPoint Presentation Author: Alex Last modified by: Alex Created Date: 9/16/2007 4:33:48 PM Document presentation format: On-screen Show Company – PowerPoint PPT presentation

Number of Views:259
Avg rating:3.0/5.0
Slides: 135
Provided by: Alex1412
Learn more at: http://msmums.mums.ac.ir
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Approach to the breast mass


1
(No Transcript)
2
(No Transcript)
3
Approach to the breast mass
  • By Dr. Faramarz Shahri
  • Resident of surgery

4
DIAGNOSING BREAST CANCER
  • In 33 of breast cancer cases, the woman
    discovers a lump in her breast.

5
  • Other less frequent presenting signs and symptoms
    of breast cancer include (I) breast enlargement
    or asymmetry (2) nipple changes, retraction, or
    discharge (3) ulceration or erythema of the skin
    of the breast (4) an axillary mass and (5)
    musculoskeletal discomfort.

6
  • up to 50 of women presenting with breast
    complaints have no physical signs of breast
    pathology.
  • Breast pain usually is associated with benign
    disease.

7
  • If a young woman (age 45 years or less) presents
    with a palpable breast mass and equivocal
    mammography finding, ultrasound examination and
    biopsy are used to avoid a delay in diagnosis.

8
Sab History
  • The examiner should determine the patients age
    and obtain a reproductiv history.
  • The age of menarche ,menstrual irregulaities ,and
    the age at menopause should be sougth .

9
Sab
  • Previous surgical procedures should be recorded
    ,including previous breast biopsies and their
    pathologies and wether the ovaries were removed
    if a hysterectomy was performed.

10
Sab
  • Because hysterectomy is a common procedure,
    accurate determination of menopause may be
    difficalt .
  • It is usefull to inquire abaut menopausal
    symptoms in these patients .

11
Sab
  • In younger women, a recent history of pregnancy
    and lactation shoud be recorded .
  • A drug history shoud pay attention to hormone
    replacment therapy or the use of hormones for
    contraception .

12
Sab
  • The family history should be directed to cancer
    of the breast and ovaries (parents, siblings,
    offspring) .
  • In questioning the patient about the specific
    breast problem, it is worthwhile to inquire about
    breast pain, nipple discharge, and new masses in
    the breast.

13
Sab
  • If the mass is present, it helps to know how it
    was found, how long it has been present, what has
    happened scince its discovery, and if it changes
    with the menstrual cycle .

14
Sab
  • If cancer is likely, inquiry about constitutional
    symptoms, bone pain, weight loss, respiratory
    changes, and similar clinical indications of
    metastatic disease may occasionally reveal
    unsuspected distant spread .

15
Examination
16
Inspection
  • The surgeon inspects the woman's breast with her
    arms by her side, with her arms straight up in
    the air, and with her hands on her hips (with and
    without pectoral muscle contraction).

17
  • Symmetry, size, and shape of the breast are
    recorded, as well as any evidence of edema (peau
    d'orange), nipple or skin retraction, and
    erythema.
  • With the arms extended forward and in a sitting
    position, the woman leans forward to accentuate
    any skin retraction.

18
Palpation
  • Examination of the patient in the supine position
    is best performed with a pillow supporting the
    ipsilateral hemithorax.

19
  • The surgeon gently palpates the breast from the
    ipsilateral side, making certain to examine all
    quadrants of the breast from the sternum
    laterally to the latissimus dorsi muscle, and
    from the clavicle inferiorly to the upper rectus
    sheath.

20
  • A systematic search for lymphadenopathy then is
    performed.

21
Sab Breast examination
  • Breast examination shoud be done with respect for
    privacy and patient comfort in a well-lighted
    room , preferably whith an available indirect
    light source.

22
Sab
  • The examination begins with the patient in the
    upright sitting position with careful visual
    inspection for abvious masses, asymetries,and
    skin changes.

23
Sab
  • The nipples are inspected and compared for the
    superficial epidermis in Pagets disease.
  • The use of indirect lighting can unmask subtle
    dimpling of the skin or nipple caused by the
    scirrhous reaction of a carcinoma placing
    Coopers ligament under tention .

24
Sab
  • Simple maneuvers such as gently lifting the
    patients breast may accentuate asymmetries and
    dimplling .

25
Sab
  • Peau dorang when combined with tenderness and
    warmth ,these signs and symptoms are the hallmark
    of Inflammatory carcinoma and may be mistaken for
    acute mastitis.

26
Sab
  • Flattening or actual inversion of the nipple can
    be caused by fibrosis in certain benign
    conditions, especially subareolar duct ectasia.

27
Sab
  • In these cases , the finding is frequently
    bilateral and the history confirms that the
    condition has been present for many years.
  • Unilateral retraction or retraction that develops
    over weeks or months is more suggestive of
    carcinoma.

28
FNA
  • Because needle biopsy of breast masses may
    produce artifacts that make mammography
    assessment more difficult, many radiologists
    prefer to image breast masses before needle
    biopsy.

29
  • However, in practice, the first investigation of
    palpable breast masses is frequently needle
    biopsy, which allows for the early diagnosis of
    cysts.

30
  • If the fluid that is aspirated is not
    bloodstained, then the cyst is aspirated to
    dryness, the needle is removed, and the fluid is
    discarded as cytologic examination of such fluid
    is not cost-effective.

31
  • After aspiration, the breast is carefully
    palpated to exclude a residual mass.
  • If one exists, ultrasound examination is
    performed to exclude a persistent cyst, which is
    reaspirated if present.
  • If the mass is solid, a tissue specimen is
    obtained.

32
  • When cystic fluid is bloodstained, 2 mL of fluid
    are taken for cytology.
  • The mass is then imaged with ultrasound and any
    solid area on the cyst wall is biopsied by needle.

33
  • The presence of blood is usually obvious, but in
    cysts with dark fluid, an occult blood test or
    microscopy examination will eliminate any doubt.

34
  • The two cardinal rules of safe cyst aspiration
    are (I) the mass must disappear completely after
    aspiration, and (2) the fluid must not be
    bloodstained.

35
  • If either of these conditions is not met, then
    ultrasound, needle biopsy, and perhaps excisional
    biopsy are recommended,

36
Sab FNA
  • Cystic fluid is usually turbid dark green or
    amber and can be discarded if the mass totally
    disappears and the fluid is not bloody.

37
Sab
  • By using fine-needle aspiration in the routin
    examination of the breast ,unnecessary open
    biopsy of cystic change is avoided.

38
Sab
  • As a result of adding fine-needele aspiration to
    the routin examination of breast masses , a
    restating of criteria for open biopsy is done
    when

39
Sab
  • 1) needle aspiration prodiuces no cyst fluid and
    a solid mass is diagnosed.
  • 2) the cyst fluid produced is thick and blood
    tinged.
  • 3) fluid is prodiuced but the mass fails to
    resolve completely.

40
Sab
  • Other surgeons have added the frequent
    reappearance of the cyst in the same location and
    the rapid accumulation of fluid after initial
    aspiration (less than 2 weeks).

41
Sab
  • If the mass is solid and the clinical situation
    is consistent with carcinoma, a cytologic
    examination of the aspirated material is
    performed.

42
Sab
  • Most authors do not recommend definitive
    treatment based on a cytologic examination.
  • In addition,the presence of carcinoma cells on
    fine-needle aspiration dose not differentiate
    between in situ and invasive breast cancer.

43
Sab
  • However, a positive result allows for informed
    discussions with the patient, definitive plans
    for treatment, and appropriate consultations or
    second opinions.

44
Imaging Techniques
45
Ductography
  • The primary indication for ductography is nipple
    discharge, particularly when the fluid contains
    blood.

46
  • With the patient in a supine position, 0.1 to 0.2
    mL of dilute contrast media is injected and CC
    and MLO mammography views are obtained without
    compression.

47
  • Intraductal papillomas are seen as small filling
    defects surrounded by contrast media.
  • Cancers may appear as irregular masses or as
    multiple intraluminal filling defects.

48
Mammography
  • Conventional mammography delivers a radiation
    dose of 0.1 centigray (cGy) per study.

49
  • By comparison, a chest x-ray delivers 25 of
    this dose, there is no increased breast cancer
    risk associated with the radiation dose delivered
    with screening mammography.

50
  • With screening mammography, two views of the
    breast are obtained, the craniocaudal (CC) view
    and the mediolateral oblique (MLO) view.

51
  • The MLO view images the greatest volume of breast
    tissue, including the upper outer quadrant and
    the axillary tail of Spence.

52
  • Compared with the MLO view, the CC view provides
    better visualization of the medial aspect of the
    breast and permits greater breast compression.

53
  • In addition to the MLO and CC views, a diagnostic
    examination may use views that better define the
    nature of any abnormalities, such as the
    90-degree lateral and spot compression views.

54
  • The compression device minimizes motion artifact,
    improves definition, separates overlying tissues,
    and decreases the radiation dose needed to
    penetrate the breast.

55
  • Mammography also is used to guide interventional
    procedures, including needle localization and
    needle biopsy

56
  • Specific mammography features that suggest a
    diagnosis of a breast cancer include a solid mass
    with or without stellate features, asymmetric
    thickening of breast tissues, and clustered
    microcalcifications.

57
  • The presence of fine, stippled calcium in and
    around a suspicious lesion is suggestive of
    breast cancer and occurs in as many as 50 of
    nonpalpable cancers.

58
  • These microcalcifications are an especially
    important sign of cancer in younger women, in
    whom it may be the only mammography abnormality.

59
  • That normal-risk women age 20 years or older
    should have a breast exam at least every 3 years.
  • At age 40 years, breast exams should be performed
    yearly along with a yearly mammogram.

60
  • Xeromammography techniques are identical to those
    of mammography with the exception that the image
    is recorded on a xerography plate, which provides
    a positive rather than a negative image

61
  • Details of the entire breast and the soft tissues
    of the chest wall may be recorded with one
    exposure.

62
Sab Breast imaging
  • Breast radiographic imaging is used to detect
    small ,nonpalpable breast abnormalities ,to
    evaluate clinical findings, and to guide
    diagnostic procedures.

63
Sab
  • Mamography is the most sensitive and specific
    imaging test currently available,though 10 to
    15 of clinically evident breast cancers have no
    mammographic correlate.

64
Sab
  • Digital mammography is a tecnology that acquires
    digital image and stores them electronically .
  • This allows users to manipulate images of the
    breast to enhance certain strictures or densities
    while reducing the background of others.

65
Sab
  • Film screen and digital mammography are
    equivalent in their ability to detect breast
    cancers.

66
Sab Screening mammography
  • It is performed in efforts to detect breast
    cancer that is not clinically evident
  • It identifies women whose mammograms contain an
    abnormality and separates these women from those
    whose mammograms are clearly normal .

67
Sab
  • At present , screening mammography schoud be
    offered annually to women age 50and older , and
    at least biennialy in women age 40 to 49 with the
    screening interval made on an individual basis
    and considering the risk factors for breast
    cancer .

68
Sab
  • Younger women with a significant family history ,
    histologic risk factor , or a history of prior
    breast cancer shoud be offerrd annual screening .

69
Sab Diagnostic mammography
  • It is performed when there is a abnormality on
    clinical exmination or screening mammography .

70
Sab
  • It includes magnification and compression imaging
    in the MLO and CC views obtained with screening
    mammography , and is frequently supplemented by
    ultrasound .

71
Sab
  • The mammographic features of malignancy can be
    broadly divided into density abnormalities
    (masses , architectural distortion, and
    assymetries ) and microcalcifications .

72
Sab
  • Each mammogram is also assessed for the presence
    of abnormalities in the axillary nodes and for
    the presence of skin or nipple changes , such as
    thickening or retraction.

73
Ultrasonography
  • Second only to mammography in frequency of use
    for breast imaging ultrasonography is an
    important method of resolving equivocal
    mammography findings, defining cystic masses, and
    demonstrating the echogenic qualities of specific
    solid abnormalities.

74
  • On ultrasound examination, breast cysts are well
    circumscribed, with smooth margins and an
    echo-free cent.
  • Benign breast masses usually show smooth
    contours, round or oval shapes, weak internal
    echoes, and well-defined anterior and posterior
    margins.

75
  • Breast cancer characteristically has irregular
    walls, but may have smooth margins with acoustic
    enhancement.

76
  • It is highly reproducible and has a high patient
    acceptance rate, but does not reliably detect
    lesions that are 1cm or less in diameter.

77
MRI
  • In the process of evaluating MRI as a means of
    characterizing mammography abnormalities,
    additional breast lesions have been detected.

78
  • However, in the circumstance of both a negative
    mammogram and a negative physical examination,
    the probability of a breast cancer being
    diagnosed by MRI is extremely low.

79
  • There is current interest in using MRI to screen
    the breasts of high-risk women and of women with
    a newly diagnosed breast cancer

80
Sab CT.Scan
  • CT appears to be the best way to image internal
    mammary nodes and to evaluate the chest and
    axilla after mastectomy.

81
Sab MRI
  • MRI is the imaging method of choice to evaluate
    implant rupture.

82
  • It may be used in efforts to identify the primary
    site of cancer in the breast of a woman who
    presents with malignant axillary adenopathy in
    the context of an un revealing breast physical
    examination and mammogram(accult breast cancre ).

83
Sab
  • Particularly for an invasive lobular breast
    cancer diagnosed by core needle biopsy , where
    physician examination and mammography may
    underestimate the extent of disease , MRI may
    facilitate the decision as to whether the patient
    is an appropriate candidate for breast
    conservation .

84
Sab
  • Its efficacy as a screening tool remain unproven
    , though studies in population at increesed risk
    for breast cancer appear promising .
  • MRI sensitivity for invasive cancer approches
    100, but is only 60 at best for DCIS .

85
Sab
  • Specificity remain low , with significant overlap
    in the appearance of benign and malignant lesions
    .

86
Breast Biopsy
87
Nonpalpable Lesions
  • Image-guided breast biopsies are frequently
    required to diagnose nonpalpable lesions.
  • Ultrasound localization techniques are employed
    when a mass is present, while stereotactic
    techniques are used when no mass is present
    (microca1cifications only).

88
  • The combination of diagnostic mammography,
    ultrasound or stereotactic
  • localization, and fine-needle aspiration (FNA)
    biopsy is almost 100 accurate in the diagnosis
    of breast cancer.

89
  • However, while FNA biopsy permits cytologic
    evaluation, core-needle or open biopsy also
    permits the analysis of breast tissue
    architecture and allows the pathologist to
    determine whether invasive cancer is present.

90
  • Core-needle biopsy is accepted as an alternative
    to open biopsy for nonpalpable breast lesions.

91
  • The advantages of core-needle biopsy include a
    low complication rate, avoidance of scarring, and
    a lower cost.

92
Sab Non palpable mammographic abnormalities
  • Mammographic abnormalities that cannot be
    detected by physical examination are classified
    in three broad categoty (1) lesions consisting
    of microcalcification only , (2)density lesions
    (masses ,architectural distortion , and
    asymmetries),and (3)those with both
    calcifications and density abnormalities .

93
Sab
  • The incidence of malignancy after biopsy depends
    on the characteristics of the radiographic
    finding .

94
Sab
  • Lesion with microcalcification with an assosiated
    mass and linear branching calcifications carry
    the highest probability of being malignant .

95
Sab
  • However , even well-defined , smooth densities
    can be malignant .
  • Not every abnormalities should undergo biopsy ,
    and recommendation should be made by surgeons in
    consultation with an experienced radiologist .

96
Sab
  • For some patients not undergoing biopsy , a
    mammogram repeated in a shorter interval
    (6months) may be recommended to establish
    stability of the abnormality .

97
Sab
  • The two methods available to evaluate a
    nonpalpable mammographic abnormality include wire
    localization with surgical excisional biopsy and
    image-guided stereotactic or ultrasound-guided
    large-core needle biopsy .

98
Sab Large core needle biopsy(LCNB)
  • Since the early 1990s,LCNB increasingly is the
    diagnostic method of choice to histologically
    evaluate nonpalpable mammographic abnormalities .
  • In experienced centers , it is considered the
    standard of care .

99
Sab
  • LCNB can be performed using either mammographic
    (stereotactic) or ultrasound guidance .
  • Mammographic calcifications are typically sampled
    using stereotactic capabilities .

100
Sab
  • In the experienced centers , 65of women who
    undergo the procedure are found to have a benign
    diagnosis and can resume annual mammographic
    screening .

101
Sab
  • 25 of patients are found to have a malignancy.
  • The diagnosis of malignancy by core biopsy
    affords the apportunity to proceed with one
    definitive surgery , with efforts toward breast
    preservation when appropriate and chosen by the
    patient.

102
Sab
  • The remaining 10 of patients are found to have
    inconclusive histology , including (1)atypical
    cells on pathology (atypical ductal hyperplesia
    ),(2)biopsy result that are discordant from the
    mammography findings ,(3) increased cellularity
    within a fibroadenoma,or(4)inadiquate sampling of
    the site.

103
Sab
  • In these cases where the core obtained does not
    contain cancer , and the histology does not
    entierly explain the mammographic finding,
    surgical biopsy is recommended.

104
Sab
  • The false-negative rate of stereotactic biopsy
    shoud be extremely low if these guidelines are
    followed.

105
Sab Atypia on core needle biopsy
  • For patient with atypia on core needle biopsy ,a
    wire localization and excisional biopsy are
    performed to clarify the histology.

106
Sab DCIS on core needle biopsy
  • For patients with a core needle biopsy diagnosis
    of DCIS , 7 have had the lesion fully excised
    with the core needle .

107
Sab
  • At the time of surgical excision ,an upgrade of
    the DCIS is seen in 12 of patient who had
    undergone core needle biopsy using an
    11-gauge,vacum-assisted needle device .

108
Palpable Lesions
  • FNA biopsy of a palpable breast mass is performed
    in an outpatient setting.
  • The cellular material is then expressed onto
    microscope slides.

109
  • Both air-dried and 95 ethanol-fixed microscopy
    sections are prepared for analysis.

110
  • When a breast mass is clinically and
    mammographically suspicious, the sensitivity and
    the specificity of FNA biopsy approaches 100.

111
  • Core-needle biopsy of palpable breast masses is
    performed using a 14-gauge needle, such as the
    Tru Cut needle.
  • Automated devices also are available.

112
  • While the false-negative rate for core-needle
    biopsy is very low, a tissue specimen that does
    not show breast cancer cannot conclusively rule
    out that diagnosis because a sampling error may
    have occurred.

113
(No Transcript)
114
  • ???? ?? ???? ???? ??? ???? ?? ?????
  • ??????
    ???? ?????? ??

  • ????
    ?????

115
(No Transcript)
116
(No Transcript)
117
Fibroadenomas
  • Removal of all fibroadenomas has been advocated
    irrespective of patient age or other
    considerations, and solitary fibroadenomas in
    young women are frequently removed to alleviate
    patient concern.

118
  • Yet most fibroadenomas are self-limiting and many
    go undiagnosed, so a more conservative approach
    is reasonable.

119
  • Careful ultrasound examination with core-needle
    biopsy will provide for an accurate diagnosis,
    Subsequently, the patient is counseled concerning
    the biopsy results, and excision of the
    fibroadenoma may be avoided.

120
Sclerosing Disorders
  • The clinical significance of sclerosing adenosis
    lies in its mimicry of cancer,
  • It may be confused with cancer on physical
    examination, by mammography, and at gross
    pathologic examination,

121
  • Excisional biopsy and histologic examination are
    frequently necessary to exclude the diagnosis of
    cancer
  • The diagnostic workup for radial scars and
    complex sclerosing lesions frequently involves
    stereoscopic biopsy,

122
  • It is usually not possible to differentiate these
    lesions with certainty from cancer by mammography
    features, so biopsy is recommended.

123
Periductal Mastitis
  • Painful and tender masses behind the
    nipple-areola complex are aspirated with a
    12-gauge needle attached to a 10-mL syringe.

124
  • Any fluid obtained is submitted for cytology and
    for culture using a transport medium appropriate
    for the detection of anaerobic organisms.

125
  • In the absence of pus, women are started on a
    combination of metronidazole and dicloxacillin
    while awaiting the results of culture.

126
  • when there is considerable pus present, surgical
    treatment is recommended.
  • Unlike puerperal abscesses, a subareolar abscess
    is usually unilocular and often is associated
    with a single duct system.

127
  • Preoperative ultrasound will accurately delineate
    its extent.
  • In a woman of childbearing age,
  • simple drainage is preferred, but if there is
    an anaerobic infection, recurrent infection
    frequently develops.

128
  • Recurrent abscess with fistula is a difficult
    problem and may be treated by fistulectomy or by
    major duct excision, depending on the
    circumstances.

129
(No Transcript)
130
  • When a localized periareolar abscess recurs at
    the previous site and a fistula is present, the
    preferred operation is fistulectomy, which has
    minimal complications and a high degree of
    success.

131
  • when subareolar sepsis is diffuse rather than
    localized to one segment or when more than one
    fistula is present, total duct excision is the
    preferred procedure,

132
  • fistula excision is the preferred initial
    procedure for localized sepsis irrespective of
    age.
  • Antibiotic therapy is useful for recurrent
    infection after fistula excision, and a 2- to
    4-week course is recommended prior to total duct
    excision

133
Nipple Inversion
  • Congenital nipple inversion.
  • Secondary to duct ectasia.
  • Surgical complications altered nipple
    sensation, nipple necrosis, and postoperative
    fibrosis with nipple retraction.

134
  • Because nipple inversion is a result of
    shortening of the subareolar ducts, a complete
    division of these ducts is necessary for
    permanent correction of the disorder.
About PowerShow.com