Breast Benign CA Upcm4 Lec Nonotes 08sept22

Benign and Malignant Conditions of the Breast

Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg

Orlino Bisquera, MD

September 22, 2008

Overview of the Breast Health Problem

Benign Conditions of the Breast


UPM Centennial Professorial Chair (2008)

September 22, 2008

Malignant Conditions of the Breast

Orlino Bisquera, MD

September 22, 2008

Complementary Reading Material


Module – Self-instructional ProgramStudy Guide


General Learning Objectives

– To describe and discuss the more common benign lesions of the breast, pathophysiology, and corresponding treatment.

– To familiarize with the different malignancies arising the breast, its diagnosis, and management.






September 22, 2008

Specific Learning Objectives

– Enumerate at least 10 more common breast disorders seen in the Philippines.

– Classify the breast disorders into benign and malignant conditions.



– Categorize the breast disorders by primary causes • malignant neoplasms • benign neoplasms• aberration of normal development and involution or

ANDI • infection



– Identify the most probable breast disorder present in patients presenting with a set of symptoms and signs referable to the breast.



– Enumerate at least 4 more common paraclinical diagnostic procedures being done for patients with possible breast disorders.

– Identify the usual indications for the different diagnostic procedures commonly used in patients for possible breast disorders.


Specific Learning Objectives– Identify which breast disorders can be

monitored and which should be actively treated.


Specific Learning Objectives– Given a pretreatment diagnosis of a breast

disorder with the stage of the disorder,

indicate the usual goal of treatment and its corresponding recommended primary treatment.



– Advice patients with nonspecific mastalgia or mastalgia secondary to hormonal changes.

– Identify at least two general indications for referral to a breast specialist.


RJOSON’s Session

Are the learning objectives

clear?enough?

Want to add more?

OVERVIEW OF BREAST HEALTH PROBLEM

CONCEPT MAP OF

WELLNESS & ILLNESS

AS INFLUENCED BY

THE BREAST CONDITION

CONCEPT MAP OF WELLNESS & ILLNESS


BIOPSYCHOSOCIAL WELLNESS

HOMEOSTASIS

BREAST

FAILURE OF HOMEOSTASIS

ILLNESS

Stimuli / insults

Genetic/congenitalNutritional

Endocrine/metabolicInfectious

Psychosocial

DevelopmentalDifferentiationMaladaptationFailure of coping



ILLNESS

MANIFESTATION OF ILLNESSSYMPTOMS / SIGNS

PATHOPHYSIOLOGY

BIOPSYCHOSOCIAL ASSESSMENTDIFFERENTIALS

DIAGNOSTIC AIDS

DIAGNOSIS



DIAGNOSIS

THERAPEUTICS & MANAGEMENT

MEDICAL / SURGICAL

CHRONIC ILLNESSHEALTH

BIOPSYCHOSOCIAL WELL-BEINGDEATH

REPAIR / RECOVERY

QUALITY OF DYING

QUALITY OF LIFE

FAILURE OF REPAIR / RECOVERY

QUALITY OF LIFE

BREAST HEALTH PROBLEM

Any condition on the breast

that affects the

biopsychosocial well-being

of an individual

can be considered as a

“breast health problem”

BREAST HEALTH PROBLEM

Three categories:

• breast feeding problem

• breast sexuality problems

• breast disorders

Learning Objectives

– Enumerate at least 10 more common breast disorders seen in the Philippines.


COMMON BREAST DISORDERS IN PHILIPPINES

1. Breast cancer

2. Fibroadenoma

3. Macrocyst

4. Galactocoele

5. Mastitis and breast abscess

COMMON BREAST DISORDERS IN PHILIPPINES

6. Intraductal papilloma

7. Benign cystosarcoma phyllodes or phyllodes tumor

8. Tuberculosis of the breast

9. Paget’s disease of the nipple (a type of breast cancer)

10. Mammomegaly (virginal hypertrophy in females; gynecomastia in males)

Learning Objectives

– Classify the breast disorders into benign and malignant conditions.

– Categorize the breast disorders by primary causes • malignant neoplasms • benign neoplasms• aberration of normal development and involution or

ANDI • infection


Classification and Causes – Breast Disorders

CONDITIONS Benign (non-malignant) Malignant

CAUSES

DISORDERS

ANDI* INFECTION BENIGN NEOPLASM

MALIGNANT NEOPLASM

Breast Cancer

Fibroadenoma

Macrocyst

Galactocoele

Mastitis and breast abscess

*ANDI – Aberration of normal development and involution

Classification and Causes – Breast Disorders

CONDITIONS Benign (non-malignant) Malignant

CAUSES

DISORDERS

ANDI INFECTION BENIGN NEOPLASM

MALIGNANT NEOPLASM

Intraductal papilloma

Phyllodes tumor

Tuberculosis of the breast

Paget’s disease of the nipple

Mammomegaly

*ANDI – Aberration of normal development and involution

Time-out / Recap

For questions and comments,

• pls. text and send to

0918-804-03-04

• or email:

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Learning Objectives

– Identify the most probable breast disorder present in patients presenting with a set of symptoms and signs referable to the breast.


CLINICAL PRESENTATION and DIAGNOSIS OF BREAST DISORDERS

BREAST DISORDER

MANIFESTATIONS (SYMPTOMS AND SIGNS)

CLINICAL DIAGNOSIS

Processes

Pattern RecognitionPrevalence

How to formulate a clinical diagnosis using processes of pattern recognition and

prevalence

Clinical diagnosis - diagnosis derived from symptoms and signs or diagnosis based on history and physical examination

How to formulate a clinical diagnosis using processes of pattern recognition and

prevalence

Pattern Recognition - realization that patient’s presentation (signs and symptoms) conforms to a previously learned picture or pattern of disease.

Prevalence - choice of diagnosis is based on frequency of occurrence of disease in a certain locality, certain age and sex group, and in affected organ and system.

CLINICAL BREAST EXAM

• Examination done by a physician on a patient consulting with a breast complaint or for a breast check

vs• Breast self-examination

– Examination by a person on her/his own breasts– The “person” includes physicians who may be a

patient now or in the future



Breast Complete Physical Exam

• Inspection

• Palpation

• Squeezing the nipple for discharge

• Axillary palpation

BreastPhysical Exam

• Inspection of the breast

– Look for gross abnormality!

Gross Abnormalities of the Breast

• Unilateral gigantic breast

• Erosions of the nipple

• Skin retraction

• Ulcerations

• Fungating mass

• Erythema

• Nipple discharge

BreastPhysical Exam

• Palpation of the breast

–Ask before palpating!

Palpation of the Breast

• Look for pathologic lumps!– Dominant lumps

• Take note of fibrocystic changes!– Hormonal changes

– Lumpy breast substance

Pathologic Breast Lump

Data needed• Size (in cm in its greatest diameter)• Nature (solid or cystic)• Consistency (hard or not hard – firm/ soft)• Tumor border (well-defined or ill-defined)• Tenderness (presence or absence)• Mobility (movable or fixed – overlying /

underlying tissue)

BreastPhysical Exam

• Gently squeeze the nipple for any discharge.

• Take note of color of discharge!

BreastPhysical Exam

• Axillary palpation– Search for palpable lymph

nodes

Algorithm for clinical diagnosis of breast mass

Signs of Inflammation

Positive Negative

Signs of Malignancy

Signs of Benignity

Positive Negative

Diagnostic Process

Diagnosis

Look for signs of inflammation

•Pus•Erythema•Warmth•Tenderness

Presence of erythema is enough basis to suspect inflammation!

Take note though of “Inflammatory breast cancer”!

Breast Abscess

Inflammatory breast cancer

Diagnostic Process

Diagnosis

Look for signs of malignancy•Hard consistency•Ill-defined border•Local invasion•Fixation•Regional spread•Distant spread

Presence of ONE sign of malignancy is enough basis to suspect malignancy!

Signs of Malignancy

Diagnostic Process

Diagnosis

Look for signs of benignity

•Cystic nature of mass

Fibrocystic ChangesMacrocyst

Algorithm for clinical diagnosis of breast mass

Signs of Inflammation

Positive Negative

Signs of Malignancy

Signs of Benignity

Positive Negative

Breast Abscess

Mastitis

TB of the Breast

Galactocoele

Fibrocystic ChangesMacrocyst

Nipple discharge due to nonspecific cause or fibrocystic changes


Sanguinous discharge

No mass

Intraductal Papilloma

Gynecomastia

Gynecomastia

Fibroadenoma

Fibrocystic Changes

Lumpy breast – no dominant mass

Mammomegaly

Reduction Mammoplasty

Fibroadenoma vs Phyllodes Tumor

Phyllodes Tumor

Nipple retraction

Breast Cancer

Infiltrative Breast Mass

Peau d’orange (orange peel)

Paget’s Disease of the Nipple

Nipple – areolar erosions

Contact dermatitis, nipple


Time-out / Recap



0918-804-03-04

• or email:


Learning Objectives

– Enumerate at least 4 more common paraclinical diagnostic procedures being done for patients with possible breast disorders.

– Identify the usual indications for the different diagnostic procedures commonly used in patients for possible breast disorders.


Learning Objectives– Identify which breast disorders can be

monitored and which should be actively treated.


CLINICAL PRESENTATION AND RECOGNITION OF BREAST DISORDERS

• CLINICAL DIAGNOSIS– Differential diagnoses

• Primary • Secondary

• PARACLINICAL DIAGNOSTIC PROCEDURES

(ANCILLARY DIAGNOSTIC PROCEDURES)

INDICATIONS FOR PARACLINICAL DIAGNOSTIC PROCEDURE

• DEGREE OF CERTAINTY OF CLINICAL DIAGNOSIS

• MANAGEMENT PLAN – Differences in mgt of primary and secondary

diagnoses– Will the diagnostic procedure affect

significantly your management?

COMMON PARACLINICAL DIAGNOSTIC PROCEDURES FOR BREAST DISORDERS

• Monitoring (observation) and constant analysis

• Biopsy (needle evaluation or open biopsy)

• Mammography

• Ultrasound

INDICATION FOR MONITORING

If on initial evaluation, based on clinical findings, chances are,

• breast disorder is of a nature that it is NOT malignant and

• treatment is usually by monitoring and observation where no active treatment is needed

Example: Fibrocystic changes

Needle Aspiration+/- Biopsy

Galactocoele

Open Biopsy

Mammography

Ultrasound of the Breast

• Solid vs cystic

• Cystic – implication of benignity

• Solid per se – no diagnostic implication – may be benign or malignant

• Complex mass – combination of cystic and solid component

Selection of Paraclinical Diagnostic Procedures – A Process

Options Benefit Risk Cost Availability

1 ++ ++++ +++++ NA

2 + +++ ++ A

3 ++++ ++ ++ RA

Selection of Paraclinical Diagnostic Procedures


Needle evaluation and biopsy

Open biopsy

Mammography

Ultrasound



Needle evaln & biopsy

Direct exam and sampling

Yield > 90%

Open biopsy Direct exam and sampling

Yield > 98%

Mammo Indirect exam – imaging

Malignant calcifications

Ultrasound Indirect exam – imaging

cystic vs solid





Yield > 90%

Pain

Hematoma

No scar


Yield > 98%

Pain / Hematoma

Scar

Anesthesia – side effect



Pain on compression

Radiation


cystic vs solid

Painless





Yield > 90%

Pain

Hematoma

No scar

P1.5T


Yield > 98%

Pain / Hematoma

Scar


P8T



Pain on compression

Radiation

Plain - P2T

Scinti –

P5T Ultrasound Indirect exam –

imaging

cystic vs solid

Painless P1.5T





Yield > 90%

Pain

Hematoma

No scar

P1.5T

RA


Yield > 98%

Pain / Hematoma

Scar


P8T RA



Pain on compression

Radiation

Plain - P2T

Scinti –

P5T

RA

NRA


cystic vs solid

Painless P1.5T RA

Breast Mass

Needle Aspiration+/- Biopsy

Time-out / Recap



0918-804-03-04

• or email:


Learning Objectives– Given a pretreatment diagnosis of a breast

disorder with the stage of the disorder,

indicate the usual goal of treatment and its corresponding recommended primary treatment.

– Advice patients with nonspecific mastalgia or mastalgia secondary to hormonal changes.


Learning Objectives– Identify at least two general indications for

referral to a breast specialist.


Breast DisordersBasic Principles of Management

Goal of management:

Resolution of the problem in such a way that the patient

- does NOT end up dead,- with disability, - with complication, and

in such a manner that the patientis satisfied and does NOT file a medicolegal suit.

PRIMARY GOALS AND MODALITIES OF TREATMENT OF BREAST DISORDERS

Breast disorders based on causation

Primary goals in treatment

Primary modalities of treatment

Aberrations of normal development and involution

To allay anxiety and fear that the breast condition is cancer

Advice and tempered assurance

Monitoring and observation

Analgesics, if needed

Aspiration for cysts

Excision for solid mass as a last resort

Infections To resolve the infection

Antibiotics

Drainage / debridement

PRIMARY GOALS AND MODALITIES OF TREATMENT OF BREAST DISORDERS

Breast disorders based on causation

Primary goals in treatment

Primary modalities of treatment

Benign neoplasms To resolve the mass Excision

Monitoring and observation for small fibroadenomas

Malignant neoplasms

To control the cancer Surgery, radiotherapy, chemotherapy, hormonal therapy, singly or in combination

Treatment of Breast Condition / Disorder

Condition

Disorder

Observe

Monitor

Surgery Drugs (Chemotx

Hormonal

Antibiotics)

Radiotx

Breast cancer & Paget’s disease

(subtotal / total / modified radical

mastectomy)

Fibrocystic Changes

Macrocyst (aspiration)

Galactocoele (aspiration)

Fibroadenoma (excision)


Condition

Disorder

Observe

Monitor


Hormonal

Antibiotics)

Radiotx

Mastitis and breast abscess

(aspiration /

incision - drainage)

TB of the breast

(aspiration /

incision - drainage)


Condition

Disorder

Observe

Monitor


Hormonal

Antibiotics)

Radiotx


(excision)

Phyllodes tumor

(wide excision)

Mammomegaly

(reduction mammoplasty)

Learning Objectives– Advice patients with nonspecific mastalgia or

mastalgia secondary to hormonal changes.


Nonspecific Mastalgia (Nonspecific Breast Pain)Operational definition

Pain in/on the breast in which the cause cannot be exactly established and

chances are it is NOT due to a pathologic condition / disorder (there is no pattern indicative of a definite breast disorder.)

Usually, hormone-induced, cyclical or noncyclical

Nonspecific Mastalgia (Nonspecific Breast Pain)Operational definition

If a definite cause is identified, then the diagnostic label should be mastalgia secondary to …….example, trauma, mastitis, etc.)

Nonspecific Mastalgia (Nonspecific Breast Pain)CLINICAL DIAGNOSIS

No palpable dominant mass on both breasts, no palpable lymph nodes on axillae and supraclavicular areas (but may have clinical findings consistent with fibrocystic changes)

No gross abnormality on the breasts

No recognizable pattern for a known breast disorder

No known definite precipitating events – such as trauma to the breast, breast injection

Mastalgia may be unilateral or bilateral

Mastalgia may be related (cyclical) or not related to mense (non-cyclical)

Nonspecific Mastalgia (Nonspecific Breast Pain)Recommendation on PARACLINICAL PROCEDURES

No technical paraclinical diagnostic procedures needed

Just monitoring / check-up (breast self-examination and clinical breast examination) at planned intervals (1 mo , then 3 mos – 6 mos – 9 mos – 12 mos)

Nonspecific Mastalgia (Nonspecific Breast Pain)Recommendation on TREATMENT

•Give advice – as clear AND convincing as possible to allay fear of cancer and to develop trust and confidence

•Secure informed consent on your recommendations

•Give stand-by prescription of a safe and affordable analgesics, such as paracetamol, if needed (in case of intolerable pain at home)

•No need for antibiotics (a common practice)

Nonspecific Mastalgia (Nonspecific Breast Pain)Recommendation on TREATMENT

•Give advice – as clear AND convincing as possible to allay fear of cancer and to develop trust and confidence

Clinical diagnosis of a NONSPECIFIC MASTALGIA (not due to cancer) with quantification of degree / percentage of certainty – may be as high as 98%

No need for technical paraclinical diagnostic procedures

Importance / necessity of monitoring and check-up

NONSPECIFIC MASTALGIA (Nonspecific Breast Pain)

Sample of Advice and Informed

Consent

FIBROCYSTIC BREAST

CHANGES

Sample of Advice and Informed Consent

Learning Objectives– Identify at least two general indications for

referral to a breast specialist.

• NOT certain of diagnosis• Certain that a breast specialist is in the best

position to manage the patient• Possible breast cancer diagnosis• Patient needs treatment more than a prescription of

analgesics and antibiotics


Time-out / Recap



0918-804-03-04

• or email:




vs• Breast self-examination

– Examination by a person on her/his own breasts– The “person” includes physicians who may be a

patient now or in the future

Breast Self-Examination

A Primer

Reynaldo O. Joson, MD


The best and most practical and the most economical way of detecting

breast cancer rests in a health habit called Breast Self-Examination

(BSE).


Examine your own breast regularly at least once a month to become

familiar with usual appearance and usual feel of breast.


Familiarity makes it easier to notice any change.

Early discovery of a change from what is “normal”

main idea behind

BSE


Time to do BSE:

- while taking a bath

- anytime at your convenience


Time to do BSE:

For menstruating women -

one week after menstrual period

breasts least likely to be tender and swollen


Time to do BSE:

For postmenopausal women -

1st day of the month

or

last day of the month

How to Do Breast Self-Examination

How to do BSE

INSPECTION

How to do BSEINSPECTION

Look for anything unusual!

If present, consult breast specialist ASAP! Don’t delay!



Visibly unequal breasts




Markedly unequal breasts

If present, consult breast specialist ASAP! Don’t delay further!



Change in contour




Visible lumps




Nipple erosions




Nipple retraction




Nipple discharge





How to do BSEPALPATION


Palpate for lump or thickening!


Palpate as illustrated by pressing and rotating fingers against breast and chest wall to look for lumps!

Do NOT grab breast with fingers!


Explore breast

FIRMLY, CAREFULLY, & THOROUGHLY!

Make sure to cover the entire 2 breasts!


Up to armpit!

Breast MassDifferent Sizes on

DetectionThe Smaller The Better

Breast MassDifferent Sizes on

DetectionThe Smaller The Better

Don’t wait for lumps to grow to these sizes!

TOO LATE! HOPELESS!


Palpate for lump or thickening!

If you palpate something unusual, consult breast specialist ASAP! Don’t delay!


Gently squeeze nipple!

How to do BSE

Nipple discharge


PALPATION

Gently squeeze nipple!


If you find

something unusual or abnormal,

consult a breast specialist ASAP!

Don’t delay consult!

PALPATIONINSPECTION


Most breast lumps are NOT serious.

But all should come to a breast specialist’s attention for expert opinion.


Only a breast specialist can make sure of the diagnosis.

So, see a breast specialist right away and give yourself a peace of mind!


If it is cancer,

chances you have discovered it early!

With early treatment,

you can save your life!


A breast check

so simple

yet so important

that requires practically NO time!


A breast check

so simple

costs nothingyet so important

and life-saving!

Time-out / Recap



0918-804-03-04

• or email:






September 22, 2008

Documents

Breast Benign CA Upcm4 Lec Nonotes 08sept22