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Importance of Breast Lump: In 33% of breast cancer cases, the woman discovers a lump in her breast Breast cancer

er identified in 11% of patients with lump, and 4% of women with any complaint. Breast cancers that are detected clinically (as compared to mammography) are typically of more advanced stage. Cancer Detection 2nd most common malignancy 2nd leading cause of cancer death 16% of women ages 40-69 sought advice from a physician related to a breast complaint A woman's risk of breast cancer increases with age. The median age at breast cancer diagnosis in women is 61 years 95% of all breast cancer cases being identified in women >40 years old. 2nd most common malignancy 2nd leading cause of cancer death 16% of women ages 40-69 sought advice from a physician related to a breast complaint A woman's risk of breast cancer increases with age. The median age at breast cancer diagnosis in women is 61 years 95% of all breast cancer cases being identified in women >40 years old.

History Length of time present

Presence of pain Change in size or texture Relationship to menstrual cycle Nipple discharge Family history of breast or ovarian cancer and ages Age at first live birth, menarche, menopause

Previous surgical procedures, including previous breast biopsies and their pathologies Any drug history especially hormone replacement therapy or the use of OCP. If cancer is likely, inquiry about o constitutional symptoms, o bone pain, o weight loss, o respiratory changes, for clinical indications of metastatic disease.

Physical examination Inspection Inspect 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). 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.

Examination of the patient in the supine position is best performed with a pillow supporting the ipsilateral hemithorax. A systematic search for lymphadenopathy then is performed.

Patient with large breast mass and retraction at 6 o'clock of left breast, noted on elevating arms

Physical examination alone cannot establish a mass as benign or malignant. However look for: Skin thickening (e.g., peau d'orange) or nipple changes.: Fungating masses Dimpling or retraction of the skin Nipple inversion or excoriation Paget's disease of the breast

PAGETS DISEASE

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

Obvious mass with skin involvement on left breast

Obvious mass with skin involvement on right breast

Symptoms requiring specialist referral


Lumps o All new discrete breast lumps o A new lump in pre-existing nodularity Asymmetrical nodularity persisting after menstruation Breast abscess Persistently refilling or recurrent cysts Axillary lymphadenopathy Breast pain o Pain associated with a lump o Persistent unilateral pain in a postmenopausal woman Nipple discharge o All women aged over 50 years

o Women aged below 50 years with: Bilateral discharge sufficient to stain clothes Blood-stained nipple discharge Persistent discharge from a single duct Family history

Triple assessment Triple assessment comprises of Clinical examination A radiological assessment mammography or ultrasound A pathological assessment cytology or biopsy
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.

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

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 <35 without risk factors, reexamine 3-10 days after onset of menses for resolution.

Ultrasound Patient <35 yrs with breast complaint.


o The false-negative rate for mammography has been reported as high as 52% in patients <35 years old with a palpable malignant breast mass

Determine solid vs. cystic, simple or complex.


Suggested management for patients with "probably benign" masses on breast ultrasound includes: Clinical and ultrasonographic surveillance every 6 months for 2 years, to document stability Core needle biopsy to make a definitive diagnosis while leaving the lesion in situ Surgical removal of the mass, particularly if the lesion is bothersome to the patient.

Cysts

On ultrasound examination cysts have: Smooth walls Sharp anterior and posterior borders Black hypoechoic centres without internal echoes

Ultrasonographic image of a simple cyst

Ultrasonographic image of a complex cyst

Solid lesions
Solid lesions have internal echoes Malignant tumours have:

o Hypoechoic areas interspersed between brighter echoes o Irregular edges o Cast hypoechoic shadows Benign tumours have: o Isoechoic or hypoechoic patterns o Smooth well defined borders o Cast no hypoechoic shadows

Ultrasonographical image of a fibroadenoma

Malignant Solid lesion

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.

Mammography
Abnormalities detected on mammography are classified as: Spiculated masses Stellate lesions Circumscribed masses Microcalcification

Spiculated masses Soft tissue mass with spicules extending into surrounding tissue 95% of spiculated masses are due to invasive cancer Other causes of spiculated masses include: o Ductal carcinoma in-situ (DCIS) o Radial scar / complex sclerosing lesion o Fat necrosis o Fibromatosis o Granular cell myoblastoma

Magnification view demonstrating irregular speculated mass with associated calcifications

Stellate lesions
Localised distortion of the breast parenchyma with no perceptible mass lesion Differential diagnosis of stellate lesions includes: o Radial scar o Invasive cancer o DCIS o Surgical scar

Circumscribed masses
Circumscribed masses should be analysed according to density, outline and size Differential diagnosis of circumscribed masses includes: o Fibroadenoma o Cyst o Mucinous or medullary carcinoma o Lipoma o Abscess

CA

Popcorn calcification (Fibroadenoma)

Microcalcification Microcalcification is due to debris within the duct wall or lumen Sole feature of 33% of screen-detected cancers Malignant microcalcification is usually linear or branching Benign microcalcification is usually rounded and punctate Differential diagnosis of microcalcification includes: o DCIS o Invasive cancer o Papilloma o Fibroadenoma o Fat necrosis

Breast aspiration and biopsy A definitive diagnosis of breast carcinoma requires a breast biopsy. Three main types of biopsies are commonly performed: Fine-needle aspiration (FNA)

Core-needle biopsy Excisional biopsy.

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.

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.

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. 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. 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.

CRITERIA OR OPEN BIOPSY AFTER FNAC:


Needle aspiration produces no cyst fluid and a solid mass is diagnosed. The cyst fluid produced is thick and blood tinged. Fluid is produced but the mass fails to resolve completely.

The frequent reappearance of the cyst in the same location and the rapid accumulation of fluid after initial aspiration (< 2 weeks). 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.

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.

Causes of Nipple Discharge


Blood o malignancy vs papilloma Purulent o infection, usually related to lactation Milky o after childbearing up to one year o hypothyroidism, prolactinomas o medications: OCPs, tricyclic antidepressants, dopamine agonists Grey, brown, green, sticky o Duct ectasia. Common 5th decade, with nipple tenderness and pain. Spontaneous, bloody, unilateral, from one duct = more likely cancer Non-spontaneous, non-bloody, bilateral = less likely cancer

Ductogram demonstrating multiple intraductal papillomas

APPROACH:

SUMMARY:
Differential diagnosis Fibroadenoma Macrocysts Galactoceles Lipoma Abscess Rare causes- sclerosing adenosis, cystosarcoma phyllodes Malignancy

Work up

Exam Imagingo Diagnostic mammogram- less sensitive in younger women due to breast density o Ultrasound- can distinguish cystic lesions from solid masses (require further evaluation) o Consider referral to breast surgeon Biopsyo FNAC, Core needle biopsy, Open biopsy 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.

Ph-Ex

If Discharg Ducto

If Nonpalp mass Mammo MRI Solid or comb

If Palp mass Sono

CT Scan

cyst

Mamo

FNAB

FNAB

Asp

LCNB

Re Asp

Ex Biop

Just to Summarize

Evaluation U/S for patients with dense breasts Mammography Digital vs. Conventional MRI, PET scan??? Referral for biopsy for palpable mass. 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. Features suggestive of cancer: Increased density. Irregular border. Spiculation. Clustered irregular microcalcifications BI-RADS Classification: 0: Needs more imaging 1: Negative 2: Benign findings 3: Probable benign, repeat imaging

4: Suspicious abnormality 5: Highly suspicious

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

A mass History Breast examination Breast examination shoud be done with respect for privacy and patient comfort in a welllighted room , preferably whith an available indirect light source.

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

If either of these conditions is not met, then ultrasound, needle biopsy, and perhaps excisional biopsy are recommended, By using fine-needle aspiration in the routin examination of the breast ,unnecessary open biopsy of cystic change is avoided. 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 : 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. the frequent reappearance of the cyst in the same location and the rapid accumulation of fluid after initial aspiration (less than 2 weeks). 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.

Imaging Techniques

Ductography The primary indication for ductography is nipple discharge, particularly when the fluid contains blood. Intraductal papillomas are seen as small filling defects surrounded by contrast media. Cancers may appear as irregular masses or as multiple intraluminal filling defects.

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

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 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. 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. Breast cancer characteristically has irregular walls, but may have smooth margins with acoustic enhancement. It is highly reproducible and has a high patient acceptance rate, but does not reliably detect lesions that are 1cm or less in diameter.

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

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

Specificity remain low , with significant overlap in the appearance of benign and malignant lesions

Breast Biopsy When a breast mass is clinically and mammographically suspicious, the sensitivity and the specificity of FNA biopsy approaches 100%. Core-needle biopsy of palpable breast masses is performed using a 14-gauge needle, such as the Tru Cut needle. 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.

Ph-Ex If Discharg Ducto If Nonpalp mass Mammo MRI Solid or comb Mamo If Palp mass Sono cyst

CT Scan

FNAB

Differential diagnosis Fibroadenoma Macrocysts Galactoceles Lipoma Abscess Rare causes- sclerosing adenosis, cystosarcoma phyllodes Malignancy

Work up Exam Imaging Diagnostic mammogram- less sensitive in younger women due to breast density Ultrasound- can distinguish cystic lesions from solid masses (require further evaluation) Consider referral to breast surgeon

Biopsy Fine needle aspiration, Core needle biopsy, Open biopsy

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.

Fibroadenoma Second most common benign breast disease, most common benign solid tumor Firm, painless, mobile breast mass, 2-3 cm, commonly in upper outer quadrants Usually women aged 20-40 Multiple in 15-20% of patients Slow growing, do not regress spontaneously Can be stimulated by exogenous estrogen, progesterone, lactation, pregnancy Management- biopsy or excision

Macrocysts Most often women age 35-50 Fluid-filled sac Often solitary but can be multiple Can have associated nipple discharge Aspiration for diagnosis and therapy

Galactocele Milk-filled cyst Usually follows lactation Firm, tender mass Usually in upper quadrants Diagnostic aspiration often curative

Breast cancer 211,000 new cases per year (estimated from 2005)

40,000 deaths per year (estimated from 2005) Second leading cause of cancer-related death in women Lifetime risk of breast cancer 12% One in eight women will develop breast cancer 80% in women >50 yrs old, 20% in women <50 yrs old Early- mammo abnormality, painless, mobile tumor 80% present with mass Pain is not usually early symptom, more likely benign Later- borders less distinct, fixed to supporting ligaments or underlying fascia, nipple discharge, skin changes (peau dorange), retraction of nipple

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