BREAST LUMPSBREAST LUMPS

DR AMBREEN MUNIRFRCS, BAPRAS Fellowship Breast, PG-D Bioethics

Associate Professor Surgery

INTRODUCTIONINTRODUCTIONOf all breast disorders, palpable

breast lump is 2nd most common presentation, pain being the first

Generally a breast lump in adolescents and young female is nearly always regarded as benign at first instance and patient may falsely be reassured with the result she refrain from further consultation

INTRODUCTIONINTRODUCTIONOn the other hand, all lumps are

not cancers; however the possibility of cancer must always be considered, as approximately 10% of all breast lumps are finally diagnosed as cancer.

Case scenarioCase scenario

A 25 year old School teacher came to you and she is worried about a lump she just found in her right breast.

Additional HistoryAdditional HistoryHistory of traumaIs lump painful?Nipple DischargeAny other lump? Axilla

Otherwise she is healthyHer weight is stableShe is marriedShe takes OCPHer menstrual cycle is regularNo family history of cancer

Breast ExaminationBreast ExaminationInspection- sitting position

symmetry, level of both breasts, Contour, skin changes Ask her to lift arms, put arms against waist

Palpate the axilla in sitting position

Palpate supraclavicular lymph nodes

Palpation of breast- supine position with hands above head

Examine both breastsNormal firstExamine with the flat of the hand

to avoid pinching up tissue

Four quadrants in clockwise direction

Nipples & areolaIf you have difficulty finding a

discrete lump, ask the patient to demonstrate it for you

About LumpAbout LumpSite - describe the location of the

lump as a position on a clockface i.e. 'A firm mass is felt at 2 o'clock'.  

SizeShapeSurface/ Overlying skinTendernessConsistency

Mobility and attachmentIf you are unable to move the

skin over the lump it implies fixation or tethering

If patient mentioned nipple discharge ask her to squeeze nipple for a sample of the discharge

Examination FindingsExamination FindingsSolitary 1.5 cm mass of right

breast, upper outer quadrant at 10 oclock

Mass is non-tenderLesion is freely movable No obvious skin changes over

the lesionNo nipple dischargeNo axillary masses

PossibilitiesPossibilitiesFibroadenomaFibrocystic diseaseSimple cystFat necrosisCancer

Benign Breast diseasesBenign Breast diseasesANDIInfectionsTrauma

FibroadenomaFibroadenoma

• Benign overgrowth of one lobule of the breast, usually isolated, may be multiple or giant• Composed of both stromal and epithelial elements in the breast •Well-defined, mobile, painless, discrete• Common in younger women, and is most common tumor in women younger than age 30 years

Fibrocystic diseaseFibrocystic disease

Combination of localized fibrosis, inflammation, cyst formation and hormone driven breast pain

Occurs almost exclusively between menarche and menopause

Causing cyclical pain and swelling, lumpy breasts, multiple breast cysts

CystsCysts• Fluid-filled, epithelium-lined cavities often associated with FBD • Common after age 35, and rare before 25• Round symmetrical lumps, may be discrete or multiple, occasionally painful• Three types Simple cyst, clear or green fluid and is benign.

Milk-filled cyst, called galactocele and is benign.

Bloody cyst is a cause of concern for malignancy.

Infections & Infections & InflammationsInflammationsLactational Mastitis

Due to acute staphylococcal infection of mammary ducts

Breast AbscessWhen infection progress

Infections & Infections & InflammationsInflammationsMammary duct ectasia

Due to dilated, scarred, chronically inflammed subareolar mammary ductsRecurrent yellow green nipple discharge or recurrent breast abscess

Mondor’s diseasePhlebitis of the thoracoepigastric veinPalpable, visible, tender cord along lower quadrants

Fat NecrosisFat Necrosis

• Associated with trauma or radiation therapy to breast • There is organization of acute traumatic injury by fibrosis, organized haematoma & occasionally calcification • Can simulate cancer with mass or skin retraction

Next step in assessmentNext step in assessmentImaging- choice of imaging modality depends on specific characteristics of the patient e.g. age, and findings on clinical examination

Ultrasound scan or MammographyMRI of breast

Indications of U/S Indications of U/S To evaluate the breast in patients

who are under the age of 35 yearsTo differentiate solid and cystic

lesionsWomen who are pregnant and

cannot have mammographyTo complement mammography To guide fine needle aspiration and

core biopsies

Next step in this caseNext step in this case

Solid lesions- have internal echoesBenign tumours have isoechoic or hypoechoic patterns, smooth well defined bordersMalignant tumours have hypoechoic areas,interspersed between brighter echoes, irregular edges

Cysts- Smooth walls, sharp anterior and posterior borders, black hypoechoic centres without internal echoes

U/S report in this case is benign solid lesion U2

To complete the triple assessment, this lesion needs to be biopsied

There are a number of different types of biopsy( cytological or histopathological)

Fine needle aspiration Fine needle aspiration (FNA)(FNA)

Core biopsyCore biopsy

• FNA-Sensitivity is 80-98%, specificity 100%

False negatives are 2-10%

• Core Biopsy-More tissue, however still possibility of false negative and could represent sampling error

• Incisional biopsy- For large (>4 cm) lesions for whom pre-op chemotherapy or radiation will be desirable

• Excisional biopsy-Removal of entire lesion and a margin of normal breast parenchyma

Triple Assessment gives confident diagnosis in 95% of cases

On other hand, Triple assessment is not always needed to investigate breast lumps, as it would be viable to diagnose a breast cyst purely on ultrasound

A solid lump will require a core biopsy to confirm its benign or malignant state

TreatmentTreatmentMost benign breast lumps will not

require treatment. This is especially true of small fibroadenomas,If they are increasing in size they may be removed

FNA is used for simple and recurrent cysts. In this case FNA would be used as a treatment rather than a diagnostic tool. Complete resolution, follow up to ensure it does not recur,Incomplete resolution treat as breast mass and excise

TreatmentTreatment

•Mondor’s diseaseTreatment self-limited, can use

NSAIDs if necessary• Antibiotics can be used to treat infections of the breast and abscesses are treated by incision & drainage

TreatmentTreatment

• Mondor’s diseaseTreatment self-limited, can use NSAIDs if necessary

• Antibiotics can be used to treat infections of the breast and abscesses are treated by incision & drainage

BREAST CANCERBREAST CANCER

DR AMBREEN MUNIRFRCS, BAPRAS Fellowship Breast, PG Diploma Bioethics

Associate Professor Surgery

OverviewOverview

The most common form of cancer among women

The second most common cause of cancer related mortality

One out of nine Pakistani women is likely to suffer from Breast Cancer at some point of life

OverviewOverview

Highest incidence of Breast cancer in the Asia

At Least 90,000 Women Suffer From Breast Cancer In Pakistan Every Year

40,000 Deaths Per Year, Which Is Alarming

Risk factorsRisk factors

Female AgingFirst degree Relative Menstrual history

◦early onset◦late menopause

Child birth◦After the age of 30

Risk FactorsRisk FactorsHormonal replacement

therapy(HRT)30% increased risk with long

term use • Oral Contraceptives(OC)risk slightrisk returns to normal once the

use of OC’s has been discontinuedRadiation exposure

Risk FactorsRisk FactorsBreast disease

◦Atpyical Hyperplasia◦Intraductal carcinoma in situ◦Intralobular carcinoma in situ

ObesityDiet

◦Fat◦Alcohol

Genetic Risk FactorsGenetic Risk FactorsBRCA-1BRCA-2P53 Her-2/neu

Because of enhanced Public awareness, number of patients reporting with complaints of breast diseases has increased in recent years

Breast diseases are common in females because of more complex structure of female breast, greater volume and influence of various hormones

Subjected to constant physiological changes throughout reproductive life and beyond.

These changes lead to a number of conditions

Mostly these conditions are benign e.g. bilateral nodularity, tender lumpy breasts

Our aim should be to exclude cancer

That aim is achieved through proper assessment

Triple AssessmentTriple AssessmentClinical History

Examination

ImagingUltrasoundMammography

HistopathologyFNACTrucut Biopsy

HistoryHistory

Age

Family history of breast and other cancers with emphasis on gynaecological cancers

HistoryHistoryReproductive history

age at menarcheage at first deliverynumber of pregnancies, children

and miscarriagesage at onset of menopausehistory of hormonal use including:

contraceptive pills (type and duration)

hormonal replacement therapy (type and duration)

Signs/SymptomsSigns/Symptoms

Any new discrete breast lumpAny new lump in a pre-existing

nodularityRecurrent breast cystsUnilateral axillary lumpUnusual increase in the size of

one breast

Signs/SymptomsSigns/Symptoms

Persistent or unilateral breast pain

Pain associated with a lump

Signs/SymptomsSigns/SymptomsNipple discharge other than breast

milk Blood stainedSingle ductBilateral troublesome dischargein more than 50 years

New nipple retractionNipple eczema if not elsewhere or

unresponsive to steroids

Signs/SymptomsSigns/Symptoms

A puckering of skin of breastSkin irritation or dimplingRedness, scaling or thickening of

skin of breastSwelling of arm

Clinical ExaminationClinical ExaminationAnnually for women over 40At least every 3 years for women

between 20 and 40More frequent examination for

high risk patients

Clinical examinationClinical examinationBreast

SittingSupine

Both Axillae & Supraclavicular fossae

Local examination of possible metastatic sites

MammographyMammographyNot recommended under the age

of 35 unless there is a strong clinical suspicion of cancer

Mammography allows for efficient diagnosis of breast cancers at an earlier stage

Normal mammogram does not rule out possibility of cancer completely

MammogramMammogram

Two of the most important mammographic indicators of breast cancers

MassesMicrocalcifications: Tiny flecks of calcium – like grains of salt – in the soft tissue of the breast that can sometimes indicate an early cancer.

Malignant masses have a more spiculated appearance

Calcifications show up as white spots on a mammogram

Round well-defined, larger calcifications are more likely benign

Tight cluster of tiny, irregularly shaped calcifications may indicate cancer

Breast UltrasoundBreast Ultrasound

To see whether the lump is solid or cystic

Margins, complexity For aspiration or biopsy

HistopathologyHistopathologyFine needle aspiration cytology

performed with 5 cc disposable needle as outpatient procedure

Trucut biopsy performed with core cut needle

under local anaesthesia

TreatmentTreatment

Based on many factorsVaries from reassurance to

radical Surgery

TNM StagingTNM StagingTX: primary tumor cannot be

assessedT0: no evidence of tumor Tis: carcinoma in situT1: tumor <2 cm T2: tumor 2-5 cm T3: tumor >5 cm T4: direct extension to chest wall

or skin

TNM stagingTNM stagingNX:regional nodes cannot be

assessedN0: negative lymph nodesN1: metastases to moveable

ipsilateral axillary lymph nodes

N2: metastases to fixed ipsilateral axillary lymph nodes

N3: metastases to ipsilateral internal mammary nodes

TNM stagingTNM staging

MX: distant sites cannot be assessed

M0: no distant metastasesM1: distant metastases

Breast cancer treatmentBreast cancer treatmentBreast Conserving surgeryMastectomyAxillary sampling( Sentinel node

biopsy)Axillary clearanceChemotherapyRadiotherapyHormone Therapy

Oncoplastic SurgeryOncoplastic Surgery

The combination of reconstructive surgery in cancer surgery. 

Immediate breast reconstruction following partial or total Mastectomy

OncoplasticOncoplastic

Tumours smaller than 3 cm Nodal status-N0, N1Peripheral tumorsLarge breasts

ConclusionConclusionThe diagnosis of breast cancer is

devastating for most women and is compounded by mental anguish associated with the anticipated changes in their appearance

ConclusionConclusion As clinical breast examination

(CBE) may play a positive role in detecting cancer earlier, especially in reducing tumour size from 5 cm to 2 cm at presentation in developing countries without a mammography screening programme, the practice of CBE by doctors and trained nurses should be encouraged.

ConclusionConclusionIf breast cancer patients are

offered breast oncoplasty procedures, more women are likely to come forward for treatment at an early stage.