1 Breast Disease Case Discussions Dr Judy Galloway Breast Physician Royal Perth Hospital
2 Relative frequencies of presenting symptoms of breast cancer Lump 76% Pain alone 10% Nipple changes 8% Breast asymmetry or skin dimpling 4% Nipple discharge 2%
3 A woman has a 1 in 8 risk of developing breast cancer in her lifetime Average of diagnosis 60 years Modifiable risk factors include alcohol, post menopausal obesity &?Vitamin D > 50% of breast cancers found by the woman or her doctor
4 CLINICAL FEATURES REQUIRING REFERRAL Distortion/tethering, with or without lump Persisting inflammation, oedema or diffuse induration of the breast compared to the contralateral breast Lump or asymmetrical thickening unexplained by radiology and pathology. Persisting spontaneous nipple discharge, often clear or blood stained Changes to nipple rash, recent inversion
5 TRIPLE ASSESSMENT 1. Clinical History and Examination 2. Breast imaging Mammography/USS/MRI 3. Pathology FNA/Core Biopsy
6 OUTCOMES FROM TRIPLE ASSESSMENT Triple test is negative if ALL components are negative reassure, referral not required Triple test is positive if ANY component is suspicious or malignant referral is essential All 3 components of triple test should correlate
8 Case 1 Mrs C Mrs C is a 32 year old teacher 6 months of intermittent left breast tenderness No family history Previously used OCP for 15 years Only child at 30, breast fed Pre menopausal, no significant PMH
9 On Examination Tender left breast UOQ No palpable masses No chest wall tenderness or costochondral tenderness What next? Differential diagnosis? Investigations?
10 Investigations Ultrasound: fibrocystic change with bilateral scattered sub-centimetre simple cysts slightly more marked in the left breast than the right. No solid lesions Diagnosis? Management?
11 Management: Benign Mastalgia Exclude significant pathology and reassure True breast pain very common (but differentiate from referred chest wall pain ) Hormone aetiology common Cyclical vs. non-cyclical Pain chart may be useful Ultrasound plus Mammography in >35 yo Treatments available Supporting bra Lifestyle modifications (reduce caffeine in diet, stress) Evening primrose oil 1g tds (60% respond)
12 Case 2 Mrs I Mrs I is a 38 year old office worker Tender 2cm mass right breast, grown rapidly FH maternal aunt breast cancer at 55 yr First of 3 children at 23 yr, breast fed OCP previously for 5 years PMH appendicectomy, cholecystectomy Mirena IUD in situ
13 Examination Nil palpable left breast 23mm tender, smooth, well defined mass right UOQ Thoughts? Possible Diagnosis? Investigations?
14 Investigations Mammogram 50 75% parenchymal density 20 mm non calcified mass at site of palpable mass right UOQ plus 10mm non calcified mass left LIQ Ultrasound 18mm simple cyst right UOQ plus a 10mm solid lesion left LIQ Bilateral small scattered simple cysts What next?
15 Further Investigations and Management 1) Right breast: simple cyst. Offer aspiration if symptomatic 2) Left breast: all solid lesions require further assessment FNA or core biopsy? 3) Scattered small cysts require no further assessment.
16 Diagnosis Right breast cyst aspiration to dryness for symptom relief with benign cyst contents Left breast core biopsy confirmed benign fibroadenoma left breast No need to follow up unless new symptoms
17 FIBROADENOMA Arise from hormone-dependant breast lobule Made up of connective tissue (stroma, of low cellularity) and proliferatory epithelium Most common at the time of greatest lobule development, i.e. late teens/early 20 s Natural history most do not change in size, some get smaller or resolve, <5% increase significantly in size May be hormonally active, can change with pregnancy or HRT Consider excision if increasing in size or >3cm
18 PHYLLODES TUMOUR A fibro epithelial tumour composed of an epithelial and a cellular stromal component. (Spectrum of sarcoma) Can be mistaken for a fibroadenoma Benign or malignant Very fast growing, and can increase in size in just a few weeks. Occurrence is most common between the ages of 40 and 50. Require excision to exclude malignancy Malignant but rarely metastasize But local recurrence may be a problem (20%)
19 Case 3 Mrs M Mrs M is 52 year old secretary presented following screening mammogram Mammogram normal (dense breast tissue) Recalled with significant symptom One year left spontaneous single duct clear/serous nipple discharge FH breast cancer paternal aunt 63 yr Twins at 24, bottle fed, OCP for 5 years Post menopausal, HRT for 3 years
20 Examination No palpable masses Single duct serous discharge evident No blood staining visible Thoughts? Investigations? Diagnosis?
21 CAUSES OF NIPPLE DISCHARGE Physiological Galactorrhoea, exclude pituitary tumourprolactinoma (v rare)?drug related Duct ectasia-yellow/green Intraduct papilloma-single duct, bloody or serous Breast carcinoma (<5% of all nipple discharge)
22 Investigations Nipple discharge analysis (urine dipstick for blood) : negative Nipple discharge cytology (air dried slide): negative, acellular Mammogram (if over 35) already done, normal Ultrasound: dilated retro-areolar ducts but no solid lesion seen
23 DISCHARGE CYTOLOGY If acellular (eg proteinaceous debris), & no other clinical or radiological features of concern, discharge is probably physiological If duct epithelial cells present this is suggestive of intraductal proliferative lesion and may be benign or malignant. Surgical referral is recommended.
24 Nipple Discharge Probability (%) of cancer by age and nature of discharge Age <60 Age >60 Serous <1% 3% Bloody 3% 9% Discharge cytology has a low sensitivity (45%) but is highly specific for cancer Spontaneous, unilateral, bloody or serous discharge from a single duct raises the possibility of cancer, especially in an older woman
25 Multi-duct coloured discharged is common and it may be physiological or due to duct ectasia Single-duct bloody discharge is more likely to be associated with papilloma, epithelial hyperplasia or carcinoma
26 Management Refer persistent spontaneous single duct nipple discharge for surgical assessment Microdochectomy to exclude intraductal lesion and to resolve the troublesome discharge Note: excisional biopsy recommended for all papillomas to exclude malignancy
27 Case 4 Mrs F Mrs F, 46 year old housewife with lumpy breasts requesting an MRI due to anxiety regarding breast cancer and difficulty examining her breasts Well lady, nulliparous, premenopausal, previously used OCP 10 years No significant PMH and no medications Last screening mammogram 12 months ago
28 Family history Mother breast cancer at 47 Maternal 1 st cousin breast cancer at 52 Paternal grandmother at 63 No FH ovarian cancer Thoughts? Imaging? MRI?
29 DISPELLING SOME MYTHS The great majority of women with a family history of breast cancer do not fall into a high-risk group and do not develop breast cancer In most populations, specific cancer susceptibility genes appear directly responsible for 5% or less of all breast cancers
30 Assessing Risk & Useful Links Careful family history Multiple close relatives especially young age (early 30s) of close family relative or of ovarian cancer (especially under 50) raise suspicion of genetic aetiology Familial Risk Assessment Breast and Ovarian Cancer (FRABOC) Risk management guidelines
31 Familial Risk Assessment Breast and Ovarian Cancer (FRABOC)
33 NBOCC family history breast cancer guidelines
34 POTENTIALLY HIGH RISK Lifetime risk between 25 and 50% Less than 1% female population Two or more 1 st or 2nd degree relatives on same side of family diagnosed with breast or ovarian cancer plus one of: Additional relative with breast or ovarian cancer Breast cancer diagnosed before 40 years old Bilateral breast cancer Breast and ovarian cancer in same woman Ashkenazi Jewish ancestry Breast cancer in male relative One 1 st or 2 nd degree relative with breast cancer at 45 years or younger plus further relative with sarcoma at 45 years or younger Member of family with high risk gene mutation
35 Back to Case 4 Mrs F, 46 year old housewife with lumpy breasts requesting MRI due to anxiety regarding breast cancer and difficulty examining her breasts Well lady, nulliparous, premenopausal, previously used OCP 10 years No significant PMH and no medications
36 Examination Bilaterally nodular breasts Right UOQ 15 mm area of discrete nodularity with benign characteristics Investigations? Mammogram? US? MRI?
37 Investigations Mammogram: 50% parenchymal density Localised increased stroma left LIQ which dispersed on further views Stable as compared to the previous year Ultrasound: Scattered small cysts bilaterally, no solid lesion 5mm simple cyst right UOQ in area of palpable abnormality Happy? Further investigation? MRI?
38 Failed Triple Assessment! 5mm cyst would not adequately explain a 15mm palpable lesion Needs pathology to complete the triple assessment dfna: benign ductal cells MRI not indicated Discharge to BSWA for annual mammography (mother BC at 47)
39 Case 5 Ms P Ms P, 29 year old presents with a tender, weeping, red periareolar area right breast present 3 weeks. Past history of two similar episodes, settled with antibiotics Nil trauma No FH, nulliparous, smoker PMH depression Medications SSRI and OCP
40 Examination Right breast NAD Right breast periareolar region, 2cm reddened tender fluctuant area with small purulent discharge Nil other masses noted Afebrile Thoughts? Investigations?
41 Case 6 Ms C Mrs C, 50 year old Malaysian woman, 3 to 4 week history of non cyclical left breast pain associated with a tender lump in left breast No FH First of 2 children at 27, breast fed No significant PMH, no medications No breast imaging dfna benign ductal cells only
42 Right breast 20mm smooth well defined mobile mass in UOQ Examination Left breast 25mm irregular concerning mass in LOQ, no palpable LN What next? Are you happy to accept the left breast FNA?
43 Investigations Mammogram and Ultrasound Lesion1) Left LOQ 22mm stellate opacity, seen on US as solid and irregular. Lesion 2) Axillary LN possibly pathological Lesion 3) Right UOQ 20mm well defined solid mass with benign characteristics Lesion 4) Right UIQ 40mm widespread pleomorphic calcifications What next?
44 Further investigations and results Core biopsy Left mass: Grade 2 Invasive Duct Carcinoma FNA LN: benign lymphoid tissue Core biopsy Right mass: benign Fibroadenoma Core biopsy Right calcifications: low to intermediate grade Ductal carcinoma in situ (DCIS) without evidence of invasion
45 Management WLE vs Mastectomy, SNB vs ANC Left breast suitable for breast conserving surgery, lymph node sampling, followed by radiotherapy Right breast mastectomy required as 40mm and small breasts. Offered immediate reconstruction FA incidental benign finding Patient chose bilateral mastectomy without reconstruction.
46 Case 7 Mrs V Mrs V 65 year old grandmother 6 month unresolved bruise right breast following accident whilst gardening More recently noted changes to her nipple and skin overlying her breast On closer questioning aware of palpable mass being evident much longer
47 History (cont) FH breast cancer sister at 70 PMH: NIDDM, hypercholesterolaemia, hypertension, cholecystectomy, appendicectomy and depression Medications: Aspirin, Lipitor, Micardis and Zoloft Nil allergies
48 Examination Nil abnormality left breast Right breast tender to examination and almost totally involved with malignant change Nipple retraction and peau d orange No ulceration Palpable LN Thoughts? What next?
49 Investigations Mammogram: only left could be performed due to pain. NAD Ultrasound: Left NAD. Right breast revealed multiple irregular masses involving the majority of the breast. The dominant mass measured in excess of 60 mm. Multiple pathological axillary LN. Nipple and skin involvement. Core biopsy for histology and receptor status plus FNA of LN
50 LOCALLY ADVANCED BREAST CANCER Locally advanced (large mass, lymphadenopathy) Staging investigations Blood tests (FBC, U&E, Creat, LFTs, Ca) CT chest/abdomen/pelvis Bone scan Multidisciplinary management including surgery, medical and radiation oncology. Mrs V referred for neoadjuvant chemotherapy
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