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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?
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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
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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.
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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.
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What should be your next step?
Cytology
Mammograghy
Us
Ductogram
Biopsy
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History:
spontaneous
characteristic (bloody, milky , purulent , green to yellow )
uni or bilateral
lactation ( duration and time of weaning)
pain
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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 .
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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.
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Guaiac Test
Positive guaiac test shown on right Negative on left
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Nipple Discharge
• Causes (in order of frequency)
• Physiological
• Duct papilloma
• Duct ectasia
• Periductal mastitis
• Cancer
• Galactorrhoea
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Expressing of discharge
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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.
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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.
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Investigation
Cytologic examination
recommended for guaiac positive or bloody discharge.
useful for differentiating between proliferative lesions and inflammatory
lesions.
Mammography and ultrasound
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Ductography
It can often identify intraluminal lesions, Cytology can also be
obtained at the time of the ductogram.
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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(.
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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.
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Nipple discharge
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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.
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-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 .
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Breast Screening
Aim Of Screening:
-The early detection of cancer
-Any mass < 2 cm is not palpable
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Clinical presentation of breast lesion
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When should Done ?
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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.
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Screening Introduction OutCome
Incidence for women > 50 yrs (rate per 100.000)
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Screening Introduction OutCome
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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
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Radiological Sign
•irregular border , 90% of such lesion is invasive carcinoma
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Well Circumscribed Mass D.D
) Fibroadenoma Fibrocystic Changes (
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Multiple Clusters Of Small , Irregular Calcifications In A Segmental DistributionThe suspicious Calcification Should Be Biopsied
20% to 30% is DCIS
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Reading the MammogramReading the MammogramWhere is the
suspecious lesion???
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Medically proven malignancy.
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A benign microcacification
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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.
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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)
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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
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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.
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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.
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Mammography revealed a small cluster of
calcifications around a small mass.
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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?
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Stereotactic Biopsy
orneedle-localization excisional biopsy
Depends on the site of the lesion and/or patient preference
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Case Discussion
What are stereotactic core biopsy and needle localization core biopsy?
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Stereotactic core biopsy: biopsies are taken as directed with computer-assisted techniques. (For non palpable mass) and has 2% to 4% “miss rates”
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Case Discussion
• If FNA cytology detecting benign cells, so either continue routine screening, (or close follow-up in non-certain cytological analysis) .
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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
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Case Discussion• The tissue biopsy come back and diagnosed as
DCIS.
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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
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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.
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MiscellaneousMiscellaneous
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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
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Nipple Laceration
• Keep clean and dry.• Stop breastfeeding that side and allow to heal• Antibiotics usually not necessary
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Supernumerary Breasts
Relatively common
Found along “milk line”
Most identified during pregnancy/lactation
Most common in axilla
Not dangerous
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Supernumerary Nipples
More common than supernumerary breasts
Found along milk line
May darken during pregnancy
Not dangerous
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Mondor’s disease
thrombophlebitis of lateral thoracic vein.
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Male breast Carcinoma
•Risk factor are:
1 -gynecomastia
2 -BRCA 2
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