A 34year-old woman has been having bloody nipple discharge from the right nipple, on and off for...

A 34year-old woman has been having bloody nipple discharge from the right nipple, on and off for several months. There are no palpable masses .

Intraductal papllioma

What is the diagnosis?

INTRADUCTAL PAPILLOMA

• It is a benign, solitary polypoid lesion involving epithelium-lined major subareolar ducts.

Presents as • bloody nipple discharge in premenopausal women.. • Major differential diagnosis is between intraductal papilloma

and invasive papillary carcinoma

Management:• Cancer should be ruled out , Ductogram can help• Excision of involved duct (microdochectomy) after localization

by physical examination

A 43 -year- old women presents with blood tinged discharge from her right nipples. She indicates that this problem has been occurring intermittently over the past several weeks. Her past medical history is significant for hypothyroidism . Her medication consist of OCP and levothyroxine.

On examination , she is found to have fibrocystic changes in both breast . there is evidence of thickening in the right retroareolar region . there is no evidence of nipple discharge or adominant

mass in the left breast.

A 43 -year- old women presents with blood tinged discharge from her right nipples. She indicates that this problem has been occurring intermittently over the past several weeks. Her past medical history is significant for hypothyroidism . Her medication consist of OCP and levothyroxine.

On examination , she is found to have fibrocystic changes in both breast . there is evidence of thickening in the right retroareolar region . there is no evidence of nipple discharge or adominant

mass in the left breast.

What should be your next step?

Cytology

Mammograghy

Us

Ductogram

Biopsy

History:

spontaneous

characteristic (bloody, milky , purulent , green to yellow )

uni or bilateral

lactation ( duration and time of weaning)

pain

Types of DischargeMilky white discharge

galactorrhe (bilateral)Pregnancy common afterLactation (as long as twoyears(

Straw-colored, transparent discharge due to a papilloma. The resulting increase in vascular pressure causes a transudate to form

in the duct .

Types of Discharge

Grossly bloody discharge 1/3 due to an intraductal carcinoma, 1/3 due to

bleeding papillomata, and 1/3 from fibrocystic changes with an active intraductal component.

Guaiac positive discharge Nipple secretion that is not grossly bloody, but is

guaiac positive. causes: intraductal pathologies or plasma cell

mastitis with duct ectasia.

Guaiac Test

Positive guaiac test shown on right Negative on left

Nipple Discharge

• Causes (in order of frequency)

• Physiological

• Duct papilloma

• Duct ectasia

• Periductal mastitis

• Cancer

• Galactorrhoea

Expressing of discharge

Bilateral multiductal secretion

is usually normal and tests negative on the guaiac card

)i.e. Not bloody (regardless of colortreatment is reassurance and endocrinological follow-up if abnormalHowever, prolactin and

TSH concentration should be measured.

UNILATERAL DISCHARGE

-multiductal unilateral discharge is unlikely to represint significant disease and should be investigated similarly to

bilateral discharge .

Uniductal dischargeis more likely to

represent underlying pathology.

Investigation

Cytologic examination

recommended for guaiac positive or bloody discharge.

useful for differentiating between proliferative lesions and inflammatory

lesions.

Mammography and ultrasound

Ductography

It can often identify intraluminal lesions, Cytology can also be

obtained at the time of the ductogram.

    Ductoscopy Ductoscopy is increasingly employed as

a minimally invasive method for evaluation and treatment of nipple discharge.

)It involves placing a small (outer diameter 0.625 cm) fiberoptic cannula in the offending duct; the procedure can be done in the office or in the operating room. Ductoscopic biopsy is also possible in some cases and obviates the

need to excise the surgical duct(.

TREATMENT

An isolated papilloma is benign, but diffuse papillomatosis is associated with an increased risk of breast cancer. In both cases, surgery is necessary to treat the nipple discharge and confirm the diagnosis.

All guaiac positive and/or bloody nipple discharge without imaging correlate should be resected by a terminal duct excision.

Nipple discharge

KEY POINTS

-Nipple discharge is common and usually of benign origin .

-Bilateral and multiductal nipple discharge are almost always due to benign processes.

-Discharge characteristics associated with a higher risk of underlying malignancy are spontaneous, persistent, unilateral discharge; discharge limited to one duct;

presence of a breast mass; and bloody fluid.

-A straw-colored, transparent, sticky discharge is characteristic of an intraductal papilloma.

-Cytology should be performed only when nipple

discharge is grossly bloody or guaiac positive. Surgical excision is warranted after imaging for

grossly bloody or guaiac positive discharge .

- -Cytology may be useful for differentiating between proliferative lesions and inflammatory lesions in women with guaiac positive discharge.

Both processes require excision .

Breast Screening

Aim Of Screening:

-The early detection of cancer

-Any mass < 2 cm is not palpable

Clinical presentation of breast lesion

When should Done ?

When should Done?

No controversy: all women aged 50 and older should have a mammogram (CDC recommendation) , (Grade 1A), every 1-2 year (Grade 2A)

Also clinical breast examination (Grade 1B)

Women aged 40 to 49 (Grade 2B)

In high risk group The decision depends on individual risk.

Screening Introduction OutCome

Incidence for women > 50 yrs (rate per 100.000)

Screening Introduction OutCome

Number of women needing to be screened to detect one new breast

cancer Age Group no. needed• 20 to 24 67,000 • 30 to 34 4,000 • 40 to 44 850 • 50 to 54 375 • 60 to 64 275 • 70 to 74 210 • 80 to 84 210

Radiological Sign

•irregular border , 90% of such lesion is invasive carcinoma

Well Circumscribed Mass D.D

) Fibroadenoma Fibrocystic Changes (

Multiple Clusters Of Small , Irregular Calcifications In A Segmental DistributionThe suspicious Calcification Should Be Biopsied

20% to 30% is DCIS

Reading the MammogramReading the MammogramWhere is the

suspecious lesion???

Medically proven malignancy.

A benign microcacification

Reading the MammogramReading the Mammogram

Best if read by radiologist Best if read by radiologist specializing in mammography.specializing in mammography.

Using Category of American College Using Category of American College Of Radiology.Of Radiology.

Category of American College Of Category of American College Of RadiologyRadiologyBioRads Assessment

Category 0Needs Additional Imaging Evaluation

Category 1Negative (5/10,000 risk of breast cancer)

Category 2Benign Finding (5/10,000 risk of breast cancer)

Category 3Probably Benign Finding: Short Interval Follow up Suggested (generally 6

months)

Category 4Suspicious Abnormality-Biopsy Should be considered (risk cancer 25-

50%)

Category 5Highly suggestive of malignancy- Appropriate Action should be taken

(obvious cancer: 75-100%risk)

Limitation of Mammogram

Mammogram is best method of detecting breast cancer at an

early stage, but is it perfect??

There is No perfect test , screening mammogram lead to over-diagnosis and subsequent problem of false positive

CASE PRESENTATION

A 59-year-old Woman Comes into your office for health maintenance examination.

Her PMH is remarkable for mild hypertension controlled on thiazide. Her PSH is

unremarkable .

On exam. her vitals within normal range thyroid is norm. to palpation. The breasts are nontender and without masses. Pelvic exam. Is unremarkable.

CASE PRESENTATION

A 59-year-old Woman Comes into your office for health maintenance examination.

Her PMH is remarkable for mild hypertension controlled on thiazide. Her PSH is

unremarkable .

On exam. her vitals within normal range thyroid is norm. to palpation. The breasts are nontender and without masses. Pelvic exam. Is unremarkable.

Mammography revealed a small cluster of

calcifications around a small mass.

What Is Your Next Step?

U.S guided FNAC vs. U.S guided core biopsy,

Unfortunately the lesion not seen by ultra sound

Then what is your next step?

Stereotactic Biopsy

orneedle-localization excisional biopsy

Depends on the site of the lesion and/or patient preference

Case Discussion

What are stereotactic core biopsy and needle localization core biopsy?

Stereotactic core biopsy: biopsies are taken as directed with computer-assisted techniques. (For non palpable mass) and has 2% to 4% “miss rates”

Case Discussion

• If FNA cytology detecting benign cells, so either continue routine screening, (or close follow-up in non-certain cytological analysis) .

Case Discussion

If FNA cytology detecting malignant cells, so Needle localization core-biopsy should be obtained as many as 50% of such a case will reveal a (DCIS). ACS surgery

principle and practice 2006

(Nowadays they use iodine-125 seed localizing biopsy in some center to avoid needle placement) a called emerging technique

Case Discussion• The tissue biopsy come back and diagnosed as

DCIS.

Case Discussion

What is the management ?

1 -wide excision →→ assess the margins once negative →→ +/- irradiate breast and follow

up.

2 – If margins are positive, patient worried of recurrence and/or lesion > 5 cm →→ simple

mastectomy +/- reconstruction

Lobular Carcinoma in SituLCIS

• Rare , occurs in young women

• Always almost incidental finding in biopsy for other reason.

• found bilaterally in 25% of cases

• Marker of increased risk for invasive carcinoma

• Treatment either close follow up or prophylactic simple mastectomy.

MiscellaneousMiscellaneous

Studies evaluating Breast Self Examination

• No difference in breast cancer mortality

• No difference in stage of cancer at diagnosis

• More provider visits: 8% vs. 4%

• More benign biopsies

Nipple Laceration

• Keep clean and dry.• Stop breastfeeding that side and allow to heal• Antibiotics usually not necessary

Supernumerary Breasts

Relatively common

Found along “milk line”

Most identified during pregnancy/lactation

Most common in axilla

Not dangerous

Supernumerary Nipples

More common than supernumerary breasts

Found along milk line

May darken during pregnancy

Not dangerous

Mondor’s disease

thrombophlebitis of lateral thoracic vein.

Male breast Carcinoma

•Risk factor are:

1 -gynecomastia

2 -BRCA 2