BREAST SURGICAL DISEASES Reynaldo 0. Joson, n.d. + PHYSICAL EXAMINATION OF THE BREAST A physician does a breast examination for two reasons. One is for screening or check-up in’ those with’ no’ breast cdeplaint. The other reason ie for” investigating " ErSSS complaint. i ° ri Examination starts with inspection of the two breaste. A physician Looks for any gross abnormality that may suggest or indicate the presence of a pathology. Examples of” gross abnormalities are the following: 1. Unilateral gigantic breast 2. Erosions of the nipple SI Skin retraction 4. Ulcerations 5. Fungating mass 42 Erythema 72 Discharge on the nipple After inspection comes palpation of the breasts. Before palpation, it is a good practice to” ask” the female, subject 4f she ever palpated a iump in her breasts before: Tf she did, she should be asked to point to the area where she palpated’ the sais lump. On patpating the breasts, the physician should look for lump which’ As considered patholog He shawls try to distinguish a pathologic luap trom a lump that ds part and parcel of Tibrocystic changes. Fibrocystic changes are physiologic and not pathologic. They usually present as mul liple mini-hunps or minute nodulations on the surface of the breasts. Once a pathologic ium Js detected, it should be evaluated as to the following: 1. Size 2) Consistency = whether hard or net hard 5) Content ~ whether cystic or noncystic or solid 41 Tumor border = whether well-defined or 411— defined 4. Presence of tenderness 51 MObsTiEy — whether fixed or mobile 1After palpating the breast proper for any lump, the nipple should then be squrezed gently for any discharges Tt there is discharge, its color and character should be noted down, whether serous, milky, or sanguinous. A complete examination of the breast should include examination of the axiliae, These areas should be palpated for any mass. The mass could be an enlarged lymph nade or a. tuner in’ the aia of Spence (part of the breast). 11. MarmoPATHOLOy There are eleven breast disorders which all physicians should be familiar with.” It da sufficient that they know the ames of diagnostic Iabels and that they know when to suspect ‘thom after physical examination. These eleven breast diserdars are the following: 1. Breast cancer 2. Fibreadensms 3. Macrocyat 4. Galactocoele 4. Intraductal papiltoma 7. Benign cystosarcoma phyllodes @! Tuberculosis of the breast 9. Paget's disease of the breast 10: Hanmomeaa ty. 11. Gynecomastia EREAGT CANCER AND PAGET'S DISEASE OF THE NIPPLE Breast cancer should be suspected in a palpable breast lump of any ize. that in GOLID- and. that’ has’ ILL-DEFINED BORDERS. This is especially so if any of the following is also present + HRD coNsTsTENCY FIXED TO SKIN OR UNDERLYING CHEST WALL SEIN OR NIPPLE ULCERATION FUNGATING Mass ENLARGED LYMPH NODES IN THE IPSILATERAL AXILLAPaget's disease of the nipple is a special, kind of breast cancer. It should be suspected in patients with nipple or Hipple-arsolar erosions. A subarenlar mass mayor may not be prosent. ” Breast cancer usually starts to appear after age 30. Rarely, 2 younger pationt, as young as 2% years old or even younger, my be afflicted with breast cancers FIBROADENOHA Fibreadenoma should be suspected én a palpable breast lump of any size thot in FIRM SOLID, NONTENDER, VERY MOVABLE, and. that has VERY WELL-DEFINED HORDERS. This i especially 50 Af there are no enlarged lymph nodes in the ipsilateral. ayitla and if the patient is 25 years old ar younger. acracysr Hacrocyst should be suspected in a palpable breast tump of any size that is CYSTIC. and that ia Hawn in @ patient With Ho history of RECENT LACTATION: By cystic. as” meant the: Wall of the lump is depressibie as to. suggest = sac containing fluid. ALAC COE. Galactacosle showld be suspected in a palpable breast lump of any size that is CYSTIC ang that {= seen in a patient witha pistory of RECENT LACTATION. MASTITIS AND BREAST ARSCESS Maptitis should be suspected in “any ERYTHEMATOUS, TENDER and WARM breast with no palpable lumps Breast abscess should be suspected in a palpable breast lump of any size that 1e TENDER, WORM, and abwociated with ERYTHEMATOUS overlying skin. Mastitis and breast abscess are usually encountered in lactating, women. They may also be seen in neniactating women at any age.BENION CYSTOSARCHNN PHYLLOES Benign cystosarcoma phyllodes should be suspected ina palpable breast lump that is BIGANTIC, NODULAR, NOP FIXED TO THE UNDERLYING CHEST WALL, and that is NOT aesociated with ENLARGED LYMPH NODES in the IPSILATERAL AXILLA.. The tumor may, be fixed fo the overlying shine TUBERCULOSIS OF THE PREAST Tuberculonie should be suspected in a breast with CHRONIC SINUSES. There may or may not be an underlying lump. INTRADUGTAL, PAPTLLONA Intraductal papilloma should be suspected when there is BLOODY nipple discharge with ND palpable BREAST LUMP. AWMONEGALY Hammonegaly should be suspected of @ GIGANTIC” BREAST with NO underlying Lump. Hannonegaly may be unilateral or Bilateral. ByNECOHASTEA Bynecomastia should be suspected in a male presenting with 9 breast mass of uny size without ipsilateral aviliary ode. TIT, DIAGNOSTIC WORK-UP OF MANNOPATHOLOSY The diagnostic tools that may be utilized in a patient with breast problem consist of the following: 1. Interview 21 Physical examination SI Diagnostic procedures AL Monitoring and constant analysis The initial tools sed in investigating a breast problem consists of the interview and the physical examination. After the. physical examination, a clinical impression or adingnosis should be formulated. Depending on the certainty. of the diagnosis. formulated, a diagnostic procedure may or may be inatituted. Another option ia monitoring and constant analysia (ahat is commonly known as observation) The diagnostic procedures that have been utilized in the work-up af patients with magmopathology consist of the following: J. Needie evaluation 2. Open biopsy 3. Mammography NEEDLE EVALUAT OH Needle evaluation uses a hypodermic needle, usually 6- 19 and 1.8 inch long, attached to a 20-ce plastic. syringe, to evaluate a lump palpated in the breast, There are three parts In a needle evaluation. Une is needling the lump te check ts actual presence snd lo determine ite real consistency, whether gritty, hard, rubbery, soft solid, etc. Second is Sepirating the’ lump to get samples for gross. examination. Third is) preparing a smear out of the samplos aspirated for nicroscopic” evamination. The. third step ts what 48 commonly Rnovn as necdie aspiration biopsy. Needle evaluation can be done right after the physical examination in the clinic officer, The advantages of a needle evaluation are the following 1, Tt can give @ more definite diagnosis than the physical examination, the mammegraphy, and the ta trasount 2. It is a more cost-effective diagnostic procedure than mammography and ultrasound. | Th can give a more definite diagnosis right after or soon after the physical examination (the sovcalled instant diagnosie) « 2 Tt can avoid an operation. 5. Tt can be therapeutic in galactocoeles and aacrocyats:A real-life situation is given below. A Ap-year-old female presented with a hard, hon-tender breast mass with ill-defined borders: Breast concer was suspected. needle evaluation nas done and serous. fluid yas” aspirated and the mass Completely disappeared and did not recur thereafter. The. initial. impression of ireast cancer| was, changed right away to a definitive diagnosis of macrocyst. The wacrocyst, although a cyst, did not feet typtic on palpation. Jt Telt hard because it) was a Kense cyst filled with fluid. If a needie evaluation was not done and an operation ‘open biopsy) was performed, the pationt Sowid pnd up. with an aperation “which would be Considered! unnecessary. The needle evaluation performed. hed” avoided the operation, the scar, the pain, the ‘expanses, and other problems that. “would Gecompany the operstion if it were instituted. If a.mannography were done, it would just show the shadow of the Jump. No definite diagnosis could be Givens “The patient would be spending P 800.00 and be exposed to radiation. Tf on ultrasound were done,it should show a cystic lump. A’needie evaluation would still have te be done. Also, if would take sometine before a definitive Giagnosis and treatment could be gotten. With nesdle evaluation, ihe diagnosis and treatment were completed soon after the physical examination. OPEN BIOPSY Open biopsy can either be section ar excision biopsy. Tk may be done through 3 parattin or a frozen technique. Open biopsy is warranted if a needle biopsy : is inconclusive. If a biopsy in considered for a breast mags, it 4s recommended that a neadle evaluation be tried out Tirst before Considering an open biopsy. The needle evaluation may be sufficient to establish a definitive diagnosis that an open biopsy is not necessary anymore.nother advantage of needie evaluation ever open biopsy, beside avoiding a scar, is in the degree of tumor oF cancer’ seeding, that is, if the lump turns out to. be cancers Needle biopsy definitely is associated with less cancer seeding than open” biopsy. Heedle biopsy 1s & biopsy: procedure of choice LT a patient witha. breast. cancer wants ‘only @ wide excision “anid not total mastectomy. Chances of Jecal Fecurrences with wide excision after an epen biopsy are, expected to be higher than those after needle” biopsy. Hannography is not needed in patients with a palpable breast mass. The only use for mammography is in screening patients with no palpable breast lump and have a, reasonable risk for harboring breast cancer. This rash is oftentimes the history of breast cancer in one breast. The other breast has a high risk ef having cancer. ULTRASAUND ‘The necdie evaluation has maga the use of ultrasound in patients with a breast mass obsolete, The determination of Solid. versus cystic in a breast maze can be done. using. the needle right after the physical examination. 1¥. TREATHENT MACROCYSTS AND GaLAcTOCnELE Neadie aspiration hasTITis Antibiotics pnalgesics BREAST ABSCESS Incision and drainage AntibiotiesTUBERCULOSIS OF BREAST Excision Antimicrobials MAMPONEGALY Reduction mamnoplasty INTRADUGTAL PAPTLLOHE Excision FIBROADENOMA Excision BENIGN CYSTOSARCONA PHYLLODES: Wide excision Gynecomastia Exeiesen BREAST CANCER Resectable and locoregional Wide exeision (breast-c Total mastectony serving surgery) Hodi find radical mastectomy Classified radical mastectomy Consider patop adjuvant therapy chemotherapy Hormonal therapy Radiotherapy Nonresectable and wide spread thena therapy Hormonal therapy Radiotherapy a