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Breast - Benign and Malignant Conditions - Overview of Breast Health Problem - Benign Conditions of the Breast - ROJoson's Lecture to UP College of Medicine Level 4 Students - 13sept 16
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Benign and Malignant Conditions of the Breast
Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg
Orlino Bisquera, MD
2013
Overview of the Breast Health ProblemBenign Conditions of the Breast
Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg
UPM Centennial Professorial Chair (2008)
2013
Malignant Conditions of the Breast
Orlino Bisquera, MD
2013
Complementary Reading Material
Benign and Malignant Conditions of the Breast
Module – Self-instructional Program
Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg
General Learning Objectives
– To familiarize with the more common benign lesions of the breast, pathophysiology, diagnosis and corresponding treatment.
– To familiarize with the different malignancies arising the breast, its diagnosis, and management.
Benign and Malignant Conditions of the Breast
Specific Learning Objectives
– Enumerate at least 10 more common breast disorders seen in the Philippines.
– Classify the breast disorders into benign and malignant conditions.
Benign and Malignant Conditions of the Breast
Specific Learning Objectives
– Categorize the breast disorders by primary causes • malignant neoplasms • benign neoplasms• aberration of normal development and involution or
ANDI • infection
Benign and Malignant Conditions of the Breast
Specific Learning Objectives
– Identify the most probable breast disorder present in patients presenting with a set of symptoms and signs referable to the breast.
Benign and Malignant Conditions of the Breast
Specific Learning Objectives
– Enumerate at least 4 more common paraclinical diagnostic procedures being done for patients with possible breast disorders.
– Identify the usual indications for the different diagnostic procedures commonly used in patients for possible breast disorders.
Benign and Malignant Conditions of the Breast
Specific Learning Objectives– Identify which breast disorders can be
monitored and which should be actively treated.
Benign and Malignant Conditions of the Breast
Specific Learning Objectives– Given a pretreatment diagnosis of a breast
disorder with the stage of the disorder,
indicate the usual goal of treatment and its corresponding recommended primary treatment.
Benign and Malignant Conditions of the Breast
Specific Learning Objectives
– Advice patients with nonspecific mastalgia or mastalgia secondary to hormonal changes.
– Identify at least two general indications for referral to a breast specialist.
Benign and Malignant Conditions of the Breast
RJOSON’s Session
Are the learning objectives
clear?enough?
Want to add more?
OVERVIEW OF BREAST HEALTH PROBLEM
BREAST HEALTH PROBLEM
Any condition on the breast
that affects the
biopsychosocial well-being
of an individual
can be considered as a
“breast health problem”
BREAST HEALTH PROBLEM
Three categories:
• breast feeding problem
• breast sexuality problems
• breast disorders
Learning Objectives
– Enumerate at least 10 more common breast disorders seen in the Philippines.
Benign and Malignant Conditions of the Breast
MORE COMMON BREAST DISORDERS IN PHILIPPINES
1. Breast cancer
2. Fibroadenoma
3. Macrocyst
4. Galactocoele
5. Mastitis and breast abscess
MORE COMMON BREAST DISORDERS IN PHILIPPINES
6. Intraductal papilloma
7. Benign cystosarcoma phyllodes or phyllodes tumor
8. Tuberculosis of the breast
9. Paget’s disease of the nipple (a type of breast cancer)
10. Mammomegaly (virginal hypertrophy in females; gynecomastia in males)
MOST COMMON BREAST CONDITION (NOT DISEASE / DISORDER) IN PHILIPPINES
Fibrocystic Breast ConditionFibrocystic Breast ChangesFibrocystic Changes
Lumpiness of the breast with / without pain
Hormonal changes
Normal
Learning Objectives
– Classify the breast disorders into benign and malignant conditions.
– Categorize the breast disorders by primary causes • malignant neoplasms • benign neoplasms• aberration of normal development and involution or
ANDI • infection
Benign and Malignant Conditions of the Breast
Classification and Causes – Breast Disorders
CONDITIONS Benign (non-malignant) Malignant
CAUSES
DISORDERS
ANDI* INFECTION BENIGN NEOPLASM
MALIGNANT NEOPLASM
Breast Cancer
Fibroadenoma
Macrocyst
Galactocoele
Mastitis and breast abscess
*ANDI – Aberration of normal development and involution
Classification and Causes – Breast Disorders
CONDITIONS Benign (non-malignant) Malignant
CAUSES
DISORDERS
ANDI INFECTION BENIGN NEOPLASM
MALIGNANT NEOPLASM
Intraductal papilloma
Phyllodes tumor
Tuberculosis of the breast
Paget’s disease of the nipple
Mammomegaly
*ANDI – Aberration of normal development and involution
Classification and Causes – Breast Condition / Disorders
CONDITIONS Benign (non-malignant) Malignant
CAUSES
DISORDERS
ANDI INFECTION BENIGN NEOPLASM
MALIGNANT NEOPLASM
Fibrocystic Breast Condition
Fibroadenoma
Macrocyst
Galactocoele
Mammomegaly
*ANDI – Aberration of normal development and involution
Learning Objectives
– Identify the most probable breast disorder present in patients presenting with a set of symptoms and signs referable to the breast.
Benign and Malignant Conditions of the Breast
CLINICAL PRESENTATION and DIAGNOSIS OF BREAST DISORDERS
BREAST DISORDER
MANIFESTATIONS (SYMPTOMS AND SIGNS)
CLINICAL DIAGNOSIS
Processes
Pattern RecognitionPrevalence
How to formulate a clinical diagnosis using processes of pattern recognition and
prevalence
Pattern Recognition - realization that patient’s presentation (signs and symptoms) conforms to a previously learned picture or pattern of disease.
Prevalence - choice of diagnosis is based on frequency of occurrence of disease in a certain locality, certain age and sex group, and in affected organ and system.
Breast Complete Physical Exam
• Inspection
• Palpation
• Squeezing the nipple for discharge
• Axillary palpation
BreastPhysical Exam
• Inspection of the breast
– Look for gross abnormality!
Gross Abnormalities of the Breast
• Unilateral gigantic breast
• Erosions of the nipple
• Skin retraction
• Ulcerations
• Fungating mass
• Erythema
• Nipple discharge
BreastPhysical Exam
• Palpation of the breast
–Ask before palpating!
Palpation of the Breast
• Look for pathologic lumps!– Dominant lumps
• Take note of fibrocystic changes!– Hormonal changes
– Lumpy breast substance
Pathologic Breast Lump
Data needed• Size (in cm in its greatest diameter)• Nature (solid or cystic)• Consistency (hard or not hard – firm/ soft)• Tumor border (well-defined or ill-defined)• Tenderness (presence or absence)• Mobility (movable or fixed – overlying /
underlying tissue)
BreastPhysical Exam
• Gently squeeze the nipple for any discharge.
• Take note of color of discharge!
BreastPhysical Exam
• Axillary palpation– Search for palpable lymph
nodes
Algorithm for clinical diagnosis of breast mass
Signs of Inflammation
Positive Negative
Signs of Malignancy
Signs of Benignity
Positive Negative
Diagnostic Process
Diagnosis
Look for signs of inflammation
•Pus•Erythema•Warmth•Tenderness
Presence of erythema is enough basis to suspect inflammation!
Take note though of “Inflammatory breast cancer”!
Breast Abscess
Inflammatory breast cancer
Gram +; Staph aureus
Diagnostic Process
Diagnosis
Look for signs of malignancy•Hard consistency•Ill-defined border•Local invasion•Fixation•Regional spread•Distant spread
Presence of ONE sign of malignancy is enough basis to suspect malignancy!
Signs of Malignancy
Carcinoma en cuirasse
Inflammatory carcinoma
Peau d’ orange
Diagnostic Process
Diagnosis
Look for signs of benignity
•Cystic nature of mass
Fibrocystic ChangesMacrocyst
Algorithm for clinical diagnosis of breast mass
Signs of Inflammation
Positive Negative
Signs of Malignancy
Signs of Benignity
Positive Negative
Breast Abscess
Mastitis
TB of the Breast
Galactocoele
Fibrocystic ChangesMacrocyst
Nipple discharge due to nonspecific cause or fibrocystic changes
Intraductal papilloma
Sanguinous discharge
No mass
Intraductal Papilloma
Gynecomastia
Gynecomastia
Fibroadenoma
Fibrocystic Changes
Lumpy breast – no dominant mass
Mammomegaly
Reduction Mammoplasty
Fibroadenoma vs Phyllodes Tumor
Phyllodes Tumor
Nipple retraction
Breast Cancer
Infiltrative Breast Mass
Peau d’orange (orange peel)
Paget’s Disease of the Nipple
Nipple – areolar erosions
Contact dermatitis, nipple
Benign Conditions of the Breast
Time-out / Recap
For questions and comments,
• pls. text and send to
0918-804-03-04
• or email:
[email protected]@yahoo.com
Learning Objectives
– Enumerate at least 4 more common paraclinical diagnostic procedures being done for patients with possible breast disorders.
– Identify the usual indications for the different diagnostic procedures commonly used in patients for possible breast disorders.
Benign and Malignant Conditions of the Breast
Learning Objectives– Identify which breast disorders can be
monitored and which should be actively treated.
Benign and Malignant Conditions of the Breast
CLINICAL PRESENTATION AND RECOGNITION OF BREAST DISORDERS
• CLINICAL DIAGNOSIS– Differential diagnoses
• Primary • Secondary
• PARACLINICAL DIAGNOSTIC PROCEDURES
(ANCILLARY DIAGNOSTIC PROCEDURES)
INDICATIONS FOR PARACLINICAL DIAGNOSTIC PROCEDURE
• DEGREE OF CERTAINTY OF CLINICAL DIAGNOSIS
• MANAGEMENT PLAN – Differences in mgt of primary and secondary
diagnoses– Will the diagnostic procedure affect
significantly your management?
COMMON PARACLINICAL DIAGNOSTIC PROCEDURES FOR BREAST DISORDERS
• Monitoring (observation) and constant analysis
• Biopsy (needle evaluation or open biopsy)
• Mammography
• Ultrasound
INDICATION FOR MONITORING
If on initial evaluation, based on clinical findings, chances are,
• breast disorder is of a nature that it is NOT malignant and
• treatment is usually by monitoring and observation where no active treatment is needed
Example: Fibrocystic changes
Needle Aspiration+/- Biopsy
Galactocoele
Open Biopsy
Mammography
Ultrasound of the Breast
• Solid vs cystic
• Cystic – implication of benignity
• Solid per se – no diagnostic implication – may be benign or malignant
• Complex mass – combination of cystic and solid component
Ultrasound of the Breast
Selection of Paraclinical Diagnostic Procedures – A Process
Options Benefit Risk Cost Availability
1 ++++ ++ +++++ NA
2 ++ + ++ RA
3 +++ ++ +++ RA
Selection of Paraclinical Diagnostic Procedures
Options Benefit Risk Cost Availability
Needle evaluation and biopsy
Open biopsy
Mammography
Ultrasound
Selection of Paraclinical Diagnostic Procedures
Options Benefit Risk Cost Availability
Needle evaln & biopsy
Direct exam and sampling
Yield > 90%
Open biopsy Direct exam and sampling
Yield > 98%
Mammo Indirect exam – imaging
Malignant calcifications
Ultrasound Indirect exam – imaging
cystic vs solid
Selection of Paraclinical Diagnostic Procedures
Options Benefit Risk Cost Availability
Needle evaln & biopsy
Direct exam and sampling
Yield > 90%
Pain
Hematoma
No scar
Open biopsy Direct exam and sampling
Yield > 98%
Pain / Hematoma
Scar
Anesthesia – side effect
Mammo Indirect exam – imaging
Malignant calcifications
Pain on compression
Radiation
Ultrasound Indirect exam – imaging
cystic vs solid
Painless
Selection of Paraclinical Diagnostic Procedures
Options Benefit Risk Cost Availability
Needle evaln & biopsy
Direct exam and sampling
Yield > 90%
Pain
Hematoma
No scar
P2T
Open biopsy Direct exam and sampling
Yield > 98%
Pain / Hematoma
Scar
Anesthesia – side effect
P8T
Mammo Indirect exam – imaging
Malignant calcifications
Pain on compression
Radiation
P2T
Ultrasound Indirect exam – imaging
cystic vs solid
Painless P1T
Selection of Paraclinical Diagnostic Procedures
Options Benefit Risk Cost Availability
Needle evaln & biopsy
Direct exam and sampling
Yield > 90%
Pain
Hematoma
No scar
P2T
RA
Open biopsy Direct exam and sampling
Yield > 98%
Pain / Hematoma
Scar
Anesthesia – side effect
P8T RA
Mammo Indirect exam – imaging
Malignant calcifications
Pain on compression
Radiation
P2T
RA
NRA
Ultrasound Indirect exam – imaging
cystic vs solid
Painless P1T RA
Breast Mass
Needle Aspiration+/- Biopsy
Time-out / Recap
For questions and comments,
• pls. text and send to
0918-804-03-04
• or email:
[email protected]@yahoo.com
Learning Objectives– Given a pretreatment diagnosis of a breast
disorder with the stage of the disorder,
indicate the usual goal of treatment and its corresponding recommended primary treatment.
– Advice patients with nonspecific mastalgia or mastalgia secondary to hormonal changes.
Benign and Malignant Conditions of the Breast
Learning Objectives– Identify at least two general indications for
referral to a breast specialist.
Benign and Malignant Conditions of the Breast
Breast DisordersBasic Principles of Management
Goal of management:
Resolution of the problem in such a way that the patient does NOT end up
- dead,- with disability, - with complication, and
in such a manner that the patientis satisfied and does NOT file a medicolegal suit.
PRIMARY GOALS AND MODALITIES OF TREATMENT OF BREAST DISORDERS
Breast disorders based on causation
Primary goals in treatment
Primary modalities of treatment
Aberrations of normal development and involution
To allay anxiety and fear that the breast condition is cancer
ANDI is NOT cancer
ANDI does NOT lead to cancer!
Advice and tempered assurance
Monitoring and observation
Analgesics, if needed
Aspiration for cysts
Excision for solid mass as a last resort
Infections To resolve the infection
Antibiotics
Drainage / debridement
PRIMARY GOALS AND MODALITIES OF TREATMENT OF BREAST DISORDERS
Breast disorders based on causation
Primary goals in treatment
Primary modalities of treatment
Benign neoplasms To resolve the mass Excision
Monitoring and observation for small fibroadenomas
Malignant neoplasms
To control the cancer Surgery, radiotherapy, chemotherapy, hormonal therapy, singly or in combination
Treatment of Breast Condition / Disorder
Condition
Disorder
Observe
Monitor
Surgery Drugs (Chemotx
Hormonal
Antibiotics)
Radiotx
Breast cancer & Paget’s disease
(subtotal / total / modified radical
mastectomy)
Fibrocystic Changes
Macrocyst (aspiration)
Galactocoele (aspiration)
Fibroadenoma (excision)
Treatment of Breast Condition / Disorder
Condition
Disorder
Observe
Monitor
Surgery Drugs (Chemotx
Hormonal
Antibiotics)
Radiotx
Mastitis and breast abscess
(aspiration /
incision - drainage)
TB of the breast
(aspiration /
incision - drainage)
Treatment of Breast Condition / Disorder
Condition
Disorder
Observe
Monitor
Surgery Drugs (Chemotx
Hormonal
Antibiotics)
Radiotx
Intraductal papilloma
(excision)
Phyllodes tumor
(wide excision)
Mammomegaly
(reduction mammoplasty)
Learning Objectives– Advice patients with nonspecific mastalgia or
mastalgia secondary to hormonal changes.
Benign and Malignant Conditions of the Breast
Nonspecific Mastalgia (Nonspecific Breast Pain)Operational definition
Pain in/on the breast in which the cause cannot be exactly established and
chances are it is NOT due to a pathologic condition / disorder (there is no pattern indicative of a definite breast disorder.)
Usually, hormone-induced, cyclical or noncyclical
Nonspecific Mastalgia (Nonspecific Breast Pain)Operational definition
If a definite cause is identified, then the diagnostic label should be mastalgia secondary to …….example, trauma, mastitis, etc.)
Nonspecific Mastalgia (Nonspecific Breast Pain)Recommendation on PARACLINICAL PROCEDURES
No technical paraclinical diagnostic procedures needed
Just monitoring / check-up (breast self-examination and clinical breast examination) at planned intervals (1 mo , then 3 mos – 6 mos – 9 mos – 12 mos)
Nonspecific Mastalgia (Nonspecific Breast Pain)Recommendation on TREATMENT
•Give advice – as clear AND convincing as possible to allay fear of cancer and to develop trust and confidence
•Secure informed consent on your recommendations
•Give stand-by prescription of a safe and affordable analgesics, such as paracetamol, if needed (in case of intolerable pain at home)
•No need for antibiotics (a common practice)
Nonspecific Mastalgia (Nonspecific Breast Pain)Recommendation on TREATMENT
•Give advice – as clear AND convincing as possible to allay fear of cancer and to develop trust and confidence
Clinical diagnosis of a NONSPECIFIC MASTALGIA (not due to cancer) with quantification of degree / percentage of certainty – may be as high as 98%
No need for technical paraclinical diagnostic procedures
Importance / necessity of monitoring and check-up
NONSPECIFIC MASTALGIA (Nonspecific Breast Pain)
Sample of Advice and Informed
Consent
FIBROCYSTIC BREAST
CHANGES
Sample of Advice and Informed Consent
Learning Objectives– Identify at least two general indications for
referral to a breast specialist.
• NOT certain of diagnosis• Certain that a breast specialist is in the best
position to manage the patient• Probable breast cancer diagnosis• Patient needs treatment more than a prescription of
analgesics and antibiotics
Benign and Malignant Conditions of the Breast
Time-out / Recap
For questions and comments,
• pls. text and send to
0918-804-03-04
• or email:
[email protected]@yahoo.com
Overview of the Breast Health ProblemBenign Conditions of the Breast
Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg
UPM Centennial Professorial Chair (2008)
2013
CLINICAL BREAST EXAM
• Examination done by a physician on a patient consulting with a breast complaint or for a breast check
vs• Breast self-examination
– Examination by a person on her/his own breasts– The “person” includes physicians who may be a
patient now or in the future
Breast Self-Examination
A Primer
Reynaldo O. Joson, MD
Breast Self-Examination
The best and most practical and the most economical way of detecting
breast cancer rests in a health habit called Breast Self-Examination
(BSE).
Breast Self-Examination
Examine your own breast regularly at least once a month to become
familiar with usual appearance and usual feel of breast.
Breast Self-Examination
Familiarity makes it easier to notice any change.
Early discovery of a change from what is “normal”
main idea behind
BSE
Breast Self-Examination
Time to do BSE:
- while taking a bath
- anytime at your convenience
Breast Self-Examination
Time to do BSE:
For menstruating women -
one week after menstrual period
breasts least likely to be tender and swollen
Breast Self-Examination
Time to do BSE:
For postmenopausal women -
1st day of the month
or
last day of the month
How to Do Breast Self-Examination
How to do BSE
INSPECTION
How to do BSEINSPECTION
Look for anything unusual!
If present, consult breast specialist ASAP! Don’t delay!
How to do BSEINSPECTION
Look for anything unusual!
Visibly unequal breasts
If present, consult breast specialist ASAP! Don’t delay!
How to do BSEINSPECTION
Look for anything unusual!
Markedly unequal breasts
If present, consult breast specialist ASAP! Don’t delay further!
How to do BSEINSPECTION
Look for anything unusual!
Change in contour
If present, consult breast specialist ASAP! Don’t delay further!
How to do BSEINSPECTION
Look for anything unusual!
Visible lumps
If present, consult breast specialist ASAP! Don’t delay further!
How to do BSEINSPECTION
Look for anything unusual!
Nipple erosions
If present, consult breast specialist ASAP! Don’t delay further!
How to do BSEINSPECTION
Look for anything unusual!
Nipple retraction
If present, consult breast specialist ASAP! Don’t delay further!
How to do BSEINSPECTION
Look for anything unusual!
Nipple discharge
If present, consult breast specialist ASAP! Don’t delay!
How to do BSEINSPECTION
Look for anything unusual!
If present, consult breast specialist ASAP! Don’t delay!
How to do BSEPALPATION
How to do BSEPALPATION
Palpate for lump or thickening!
How to do BSEPALPATION
Palpate as illustrated by pressing and rotating fingers against breast and chest wall to look for lumps!
Do NOT grab breast with fingers!
How to do BSEPALPATION
Explore breast
FIRMLY, CAREFULLY, & THOROUGHLY!
Make sure to cover the entire 2 breasts!
How to do BSEPALPATION
Up to armpit!
Breast MassDifferent Sizes on
DetectionThe Smaller The Better
Breast MassDifferent Sizes on
DetectionThe Smaller The Better
Don’t wait for lumps to grow to these sizes!
TOO LATE! HOPELESS!
How to do BSEPALPATION
Palpate for lump or thickening!
If you palpate something unusual, consult breast specialist ASAP! Don’t delay!
How to do BSEPALPATION
Gently squeeze nipple!
How to do BSE
Nipple discharge
If present, consult breast specialist ASAP! Don’t delay!
PALPATION
Gently squeeze nipple!
Breast Self-Examination
If you find
something unusual or abnormal,
consult a breast specialist ASAP!
Don’t delay consult!
PALPATIONINSPECTION
Breast Self-Examination
Most breast lumps are NOT serious.
But all should come to a breast specialist’s attention for expert opinion.
Breast Self-Examination
Only a breast specialist can make sure of the diagnosis.
So, see a breast specialist right away and give yourself a peace of mind!
Breast Self-Examination
If it is cancer,
chances you have discovered it early!
With early treatment,
you can save your life!
Breast Self-Examination
A breast check
so simple
yet so important
that requires practically NO time!
Breast Self-Examination
A breast check
so simple
costs nothingyet so important
and life-saving!
Time-out / Recap
For questions and comments,
• pls. text and send to
0918-804-03-04
• or email:
[email protected]@yahoo.com
Overview of the Breast Health ProblemBenign Conditions of the Breast
Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg
UPM Centennial Professorial Chair (2008)
2013