Approach to a Patient with

BREAST LUMPPresented by:

Dr. Sara Khalid Memon,House Officer, SU 3

Lets Revise the BASICS … !!

How to APPROACH??

By History By Examination By Investigation

What to ask in HISTORY ? Biodata Presenting complain with its duration All questions of breast lump (when and

how first noticed, Pain, tenderness, change in size over time and with menstruation.)

Associated symptoms (discharge, any other swelling, skin changes, body aches, etc)

Other Important Headings like 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. Family History : Especially in first degree relatives. Constitutional Features : - Anorexia - weight loss -

Respiratory Symptoms - Bone Pain

Examination INSPECTIONSite SizeShapeExtentSkin changes (Redness, dimpling, edema, ulceration,

Peaud orange)DischargeNipple (everted or inverted, crusted, ulcerated)Prominent VeinsAny other lump in vicinity

PALPATION

SizePositionExtentMobilityComposition ( Fluctuant, Hard, Rubbery )Fixation to underlying tissue or skin

What could be the cause of this LUMP??

DIFFERENTIAL DIAGNOSIS OF BERAST LUMP FIBROCYSTIC DISEASE CYSTS FIBROADENOMA FAT NECROSIS PAPILLOMA BREAST CANCER

INVESIGATIONSoBaseline Investigations (CBC, RBS, Xray Chest, Ultrasound Abdomen, HbsAg and Anti HCV, Serum urea creatinine and electrolytes)

Specific InvestigationsoMammography oU/S BreastoBiopsy of the LumpoMagnetic Resonance Imaging oCytologyoImaging for metastases

Mammographyo Indications • screening – every 1-2 years for women ages 50-69. • metastatic adenocarcinoma of unknown primary. • nipple discharge without palpable mass.o Mammogram findings indicative of malignancy• stellate appearance and spiculated border - pathognomonic of breast cancer.• microcalcifications, ill-defined lesion border.• lobulation, architectural distortionNOTE:• normal mammogram does not rule out suspicion of cancer, based on clinical findings.

UltrasonographyoBest initial test in women less than

35 years of age with breast Lumpo  Performed primarily to differentiate

cystic from solid lesions.oNot diagnostic

Biopsy of the Lesion

o The diagnosis of breast cancer depends upon examination of tissue or cells removed by biopsy.

o The safest course is biopsy examination of all suspicious masses found on physical examination and of suspicious lesions demonstrated by mammography.

o 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.

o And by Open biopsy… ( incisional or excisional )

o 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.o Cytology • Cytological 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.o 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.

LETS TREAT IT NOW !!

Benign Breast Lumps !o FIBROCYSTIC DISEASE o FIBROADENOMA o FAT NECROSIS o PAPILLOMA o FIBROADENOSIS-focal/diffuse nodularityo GALACTOCOELE o ABSCESS o PERIDUCTAL MASTITIS-secondary to duct

ectasia

Fibrocystic diseaseo 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 cycleo 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)

Fibro adenoma 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 dependent. • Management – usually excised to confirm diagnosis

Fat NecrosisDue 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.

Papilloma

 Solitary intraductal benign polyp.

• Most common cause of bloody nipple discharge.

• Management – excision of involved duct

Breast Cancero Epidemiology o Risk factors o Pathology o Staging (clinical & pathological)o Metastasiso Treatment o Local/Regional Recurrence o Prognosis

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

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• 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

TREATMENTPrimary Treatment of Breast Cancer is..

• total mastectomy – removes breast tissue, nipple-areolar complex and skin • modified radical mastectomy (MRM) – removes breast tissue, pectoralis fascia, nipple-areolar complex, skin and axillary lymph nodes

Post Surgical Managemento Follow-up of post-mastectomy patient

history and physical every 4-6 months yearly mammogram of remaining breast

o Follow-up of segmental mastectomy patient history and physical every 4-6 months mammograms every 6 months x 2 years, then yearly thereafter

o When clinically indicated chest x-ray bone scan LFTs CT of abdomen CT of brain

JAZAKALLAHU KHAIR