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7/29/2019 Recent Advances in Breast Diseases
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DR.MATHISEKARAN
RECENT
ADVANCES IN
BENIGN BREAST
DISEASES
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INTRODUCTION:
Majority of patients presenting to a breast clinic do not havebreast cancer.
A range of benign breast condition pose a diagnostic
challenge.
This presentation describes the recent changes in both Dx
and Rx of
Gynaecomastia
Mastalgia
Nipple discharge
Breast sepsis
Benign lesions.
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GYNAECOMASTIA:
A BENIGN ENLARGEMENT OF MALE BREAST TISSUE. HYPERPLASIA OF STROMAL AND DUCTAL TISSUE.
ONLY EXCESS FAT WITHOUT STROMAL OR DUCTAL
CHANGES IS CALLED PSEUDOGYNEMCOMASTIA.
INCIDENCE-PEAKS IN ADOLESCENCE AND IN OLD AGE.
IMBALANCE BETWEEN OESTROGEN AND ANDROGEN
LEVELS OR ALTERED RESPONSIVENESS OF BREAST TO
THESE HORMONES.
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GYNAECOMASTIA:
CAUSES: PHYSIOLOGICAL
PATHOLOGICAL
DRUG INDUCED/IDIOPATHIC.
KLINEFELTERS SYNDROME
TESTICULAR FEMINISATION
HERMAPHRODITISM
ADRENAL CARCINOMA
HEPATIC DISEASE
1* OR 2* HYPOGONADISM
TESTICULAR TUMORS
HYPERTHYROIDISM RENAL DISEASES
MALNUTRITION.
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GYNAECOMASTIA:
SIMONS GRADINGGRADE CLINICAL APPEARANCE
1 SMALL BUT VISIBLE BREAST DEVELOPMENT WITH
LITTLE REDUNDANT SKIN
2A MODERATE BREAST DEVELOPMENT WITH NO
REDUNDANT SKIN
2B MODERATE BREAST DEVELOPMENT WITH REDUNDANT
SKIN
3 MARKED BREAST DEVELOPMENT WITH MUCH
REDUNDANT SKIN
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-IMAGING MODALITY:
-MAMMOGRAPHY (95%)
-USG (89%)
-CORE NEEDLE BIOPSY
-BLOOD SCREENINGRFT/ LFT/ FSH/ LH/ TSH/ LDH/ PROLACTIN/ AFPb-HCG OESTRADIOL/ TESTOSTERONE
ADOLESCENTS
ENDOCRINE DYSFUNCTION
TUMOURS
ALCOHOL EXCESS
LONG TERM MEDICAL TT
INVESTIGATIONS:
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Underlying cause corrected.
Other treatment modalities branch as
Management:
MEDICAL(acute phase) SURGICAL(SIMONS 2B and 3)
DANAZOL(licensed in
UK)
WEBSTER TECHQ (interareolar incision)
TAMOXIFEN LETTERMAN TECHQ(skin resection +nipple
transposition)
CLOMIFENE En Bloc resection (Massive gynecomastia)
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Liposuction
Ultrasonic liposuction
Arthroscopic shaver
Vacuum-assisted core biopsy device.
The above mentioned tech are very effective in fatty breast.
Minimally invasive techniques
Combined approach is advocated:
Liposuction for fatty tissue
Surgical removal of glandular tissue
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MASTALGIA
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Experienced by most women at sometime.
True pain Referred pain
-cyclical -not cyclical
-worse before menstruation -often unilateral
-Relieved following -associated with activities
menstruation
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Causes:Breast related musculoskeletal miscellaneous
Benign breasttumors
Cervical andthoracic
spondylosis
Cholelithiasis
Breast Ca Chest wall trauma Angina/coronary art dz
Breast trauma Costochondritis/
tietze sydrome
Gastroesophageal reflux
mastitis Fibromyalgia Medication eg.OCP
Sclerosing
adenosis
Herpes zoster Peptic ulcer dz
Thrombophlebitis/
Mondors syd
Shoulder pain Pericarditis
Pleurisy
pregnancy
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The cause of true mastalgia is unknown.
Some research suggests imbalance in prolactin and
oestrogen.
Physical examination:
To exclude discrete breast mass,chest wall
pain,costochondritis.
Women >35 yrs:
Mammogram to exclude malignancy
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Management of mastalgia:
2.7% of patients found to have Ca breast. Most of the other cases-reassurance alone is enough
(simple analgesia with well fitted bra)
NON-CYCLICAL BREAST PAIN:
Oral or topical NSAIDS
Cut caffeine
Low fat diet scientific evidences poor
Stopping smoking
IN 2002, THE UK MEDICINES AND HEALTHCAREPRODUCTS
REGULATORY AGENCY withdrew its license for EVENING
PRIMOSE OIL due to lack of evidence regarding its
effectiveness.
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MAYO CLINIC:
A double-blind study showed EPO alone or with
combination with VitE may be benificial.
MAY BE OF BENEFIT:
Starflower oil
Phytoestrogens
Agnus castus.
Prescribed medicines is for severe breast pain:
danazol and tamoxifen -3 months
(tamoxifen being superior)
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One study states
DOUBLE BLIND STUDY,RANDOMISED CONTROLLED
STUDIES PROVED HIGHER DOSE OF TAMOXIFEN
SHOWED THAT 72% REMAINED PAIN FREE AT ONE
YEAR END.
Danazol Tamoxifen37% pain free 53% pain free
META ANALYSIS OF RANDOMISED CONTROL TRAILS
CONCLUDED:
TAMOXIFEN IS ASSOCIATED WITH LESS SIDE EFFECTS
SHOULD BE THE DRUG OF FIRST CHOICE
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SIDE EFFECTS PROFILE:
DANAZOL TAMOXIFEN
AMENORRHEA HOT FLUSHES
DEEPENING OF VOICE DVT
ACNE VAGINAL BLEEDING
HIRSUITISM RISK OF ENDOMETRIAL CA
WEIGHT GAIN
SOME OF THE EFFECTSOFTAMOXIFEN CAN BE MITIGATED BY
USE OF TOPICAL PREPERATION-SHOWED PROMISE IN PHASE 2 TRIAL
YET TAMOXIFEN IS NOT LICENSED-DANAZOL IS A
LICENSED ALTERNATIVE IN UK
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NIPPLE DISCHARGE
NIPPLE DISCHARGE:
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NIPPLE DISCHARGE:
ACCOUNTS FOR 5%OF BREAST CLINIC REFERALS
OF THIS 5% IS MALIGNANT.
DUCT ECTASIA
DUCT PAPILLOMA
DISCHARGE GALACTORRHOEA
DCIS
INVASIVE CANCER- rare
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IMPORTANT FEATURES TO ASSESS:
FREQUENCY OF DISCHARGE
BLOOD STAINING
SPONTANEOUSITY
UNILATERAL/BILATERAL
SINGLE OR MULTIPLE DUCTS
DUCTAL PATHOLOGY INDICATED BY:
SINGLE DUCT SPONTANEOUS
PERSISTANT
BLOOD STAINED / SEROSANGUINOUS / WATERY
GALACTORHOEA:
BILATERAL, COPIOUS,WHITE DISCHARGE AND CAN OCCURS
LONG TIME AFTER CESSATION OF BREAST FEEDING.
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DUCT ECTASIA:
-MULTIDUCT
-OFTEN COLOURED
-B/L DISCHARGE.
INVESTIGATIONS:
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INVESTIGATIONS:
PROLACTIN LEVEL:
>1000 mlU/L = PITUTARY TUMOUR OR MEDICATION
MAMMOGRAPHY:
IN WOMEN MORE THAN 35 YRS.
USG:
DIPSTICK FOR Hb IN DISCHARGE:
NIPPLE DISCHARGE CYTOLOGY: low sensitivity in detectingmalignancy.
DUCTOGRAPHY: not done routinely.
DUCTOSCOPY: Involves passage of microendoscope into respective duct,
visualize and do tissue sampling.
Avoids unnecessary surgery.
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Management of nipple discharge
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Management of nipple discharge
NO ABNORMALITY IN EXAMINATION AND IMAGING:
-simple reassurance and observation.
PAPPILOMA:
-If suitable: vacuum-assisted core biopsy and percutaneous
removal
OR
- needle biopsy followed by image guided excision.
- If still no cause found SURGERY.IN PREMENOPAUSAL PATIENTS:
MICRODOCHECTOMY IS OFTEN SUFFICIENT.
IN POSTMENOPAUSAL PATIENTS:
MAJOR DUCT EXCISION MAY BE REQUIRED.
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BREAST SEPSIS
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COMMON CHILD BEARING AGE GROUPWOMEN
LACTATIONAL NON-LACTATIONAL
First 6 weeks of breast smoking
feeding DM
Staph aureus RA
floxacilin Steroids
staph aureus
Co-amoxyclav(anaer-cover)
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Symptoms PAIN
ERYTHEMA
SWELLING
PYREXIA
LEUCOCYTOSIS
NOTE:
COMEDO NECROSIS WITH IN DCIS CAN PRESENT AS
NON-LACTATIONAL ABSCESS
SO PATIENTS AGED >35YRS MAMMOGRAMONCE INFLAMMATION SETTLED
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MANAGEMENT:
LACATATIONAL ABSCESS SKIN IS NECROSED MINI INCISION AND DRAINAGE SKIN IS NORMAL ASPIRATION BREAST FEEDING CONTINUED
IF DIFFICULT USE BREAST PUMP
NON-LACTATIONAL ABSCESS
AVOID SMOKING
DRAINAGE 1/3PATIENTS DEVELOP FISTULA OFTEN IDC MAY UNDERLIE
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PERCUTANEOUS
MANAGEMENT OF BENIGNBREAST LESIONS
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Image guided core biopsy standard procedure whenlesion visible on mammography or USG.
14-gauge device typically used
Larger bore used in vacuum-assisted biopsy/
mammotomy devices(VAB/VAM)
In recent years large bore biopsy has been established as
Safe
Cost-effective alternative to surgery.
USEFULNESS OF VAB:
BENIGN PAPILLARY LESION
RADIAL SCARS
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VACUUM-ASSISTED MAMMOTOMY
SYSTEMS
FOUR COMMERCIALLY AVAILABLE SYSTEMS: MAMMOTOME
ATEC
EnCOR
VACORA
ALLOWS SAMPLING THROUGH 360 DEGREE.
-VACORA USES 10G
-ATEC 9G
-MAMMOTOME 8G
-EnCOR 7G
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Lesions measuring upto 20-30 mm-VAM
EnCOR and ATECremoves lesions upto 50-60mm in
diameter
These procedures are done under LA.
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SINGLE LARGE-CORE BIOPSY
SYSTEM
LARGE-CORE RADIOFREQUENCY BIOPSY SYSTEM INTACT BREAST LESION EXCISION SYSTEM(BLES).
RF CUTTING WITH VACUUM TO REMOVE A COMPLETE
LESION.
ADVANTAGES:
Intact BLES may be considered superior to VAM systems as
the architecture of both the lesion and surrounding tissues
are retained.
LIMITATIONS:
RF functions limits its use in small breasts and for lesions
close to skin or chest wall.
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TECHNIQUE:
6-8 mm skin incision under LA.
A probe is introduced and advanced to the periphery.
Cutting RF wire is activated to cut and ensnare the target
Single specimen is removed.
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RADIOLOGICAL EXCISION OF
FIBROADENOMAS
Lesions upto 2.5-3 cmscompletely removed using 7 8 gauge needle for nodules 1 cm > larger.
Success rates- 75 100%
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RADIOLOGICAL EXCISION OF
PAPILLOMAS
Vacuum-assisted excision under USG guidance is now
considered an appropriate alternative approach with
subsequent surgical excision only in cases where atypia
or malignancy are found .
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RADIOLOGICAL EXCISION OF RADIAL
SCARS
Vacuum-assisted excision may also have a role in themanagement of radial scars in which no atypia has been
demonstrated on multiple VAB.
Scars >10 mm in size requires diagnostic surgical
excision biopsy.
Vacuum-assisted biopsy devices can be
safely used as an alternative to surgical
excision of solitary breast papillomas, smallfibroadenomas and radial scars under 10 mm
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CONCLUSION:
TAMOXIFEN is considered the most effective medication for severe breastpain, although this is not a licensed use in UK.Danazol is a licensed alternative.
Unilateral,single duct, spontaneous persistant or blood-stained,serosanguinous or watery nipple discharge are less likely to be physiologicaland need investigation.
Liposuction : gynaecomastia
USG Aspiration :breast sepsis
Radiological excision : benign breast diseases