MANAGEMENT OF BREAST DISORDERS. By Dr. L.D.Lugaria

• Introduction

• Painful Breast.

• Inflammatory Diseases of the Breast.

• Benign Breast Disease.

• Cancer of the Breast.

MANAGEMENT BREAST DISORDERS.

• History: Common symptoms -Discrete abnormality, -Premenstrual discomfort, -Nipple discharge/retraction, -Previous breast complaints/invest., -marital status -Obs/Gyn: Menarche, LMP, Deliveries & Breastfeeding.

MANAGEMENT OF BREAST DISORDERS.

• P/E: -Inspection: Asymmetry, Lumps, Flattening, Tethering, Abnormal fixation, Nipple retraction/altered position. -Palpation: Tenderness, Lumps, LNs (pectoral, axillary, supraclavicular). –Lumps: Position, Consistency, discretness/fixity. –Nipple Discharge: Type, Blood, Clinitest, cytology.

MANAGEMENT OF BREAST DISORDERS….

• INVESTIGATIONS: -FNA –Mammography (High resolution and X-ray of low penetration). –CXR. –Biopsy (Trucut needle or incisional/excition).

• TREATMENT: Cause dependent.• PAINFUL BREAST: -Cyclical (predominantly premenestrual

or hormonal related). –Noncyclical (inflammatory or Duct actasia). –Invest. Mammography (>35yrs). –Treatment: -severe pain-Bromocryptin 2.5mg BD or clamizol or Tamoxifen. –Cysts :Aspirate -Fibrous nodules: Excision. –Normal –Reassure/psychological support.

INFLAMMATORY DISEASE OF THE BREAST.

• Acute : -Mastitis- Antibiotics. –Breast Abscess –I/D +Antibiotics.

• Chronic:

BENIGN BREAST LESIONS

• Fibroadenoma - soft -excision - giant – complete local excision.

• Phyloides tumour (cystosarcoma phylloides) - Rapidly growing unilateral breast mass, common in 40-50yr. - Sarcomatous degeneration occurs in 10%. –Treat: small-wide margin excision; Large- mastectomy with axillary LN sampling.

BENIGN BREAST LESIONS

• Cystic Disease and Epethelial Hyperplasia –Cystic disease of the breast lobules :Duct Actasia (dilatation of the duct system); common in late menopause.

• Benign Epithelial Hyperplasia -Non neoplastic change of the glandular elements= focal increase in epithelial cell layers (>3layers). -May be mild, mod, severe. -Atypical hyperplasia= Borderline between benign & ca in situ. -Diagnosis: Clinical - Diffuse cystic ds =heavy thickened lumpy breast + pain; Mammography curvilinear shadows) ; FNA ;Biopsy.

BENIGN DISEASE OF THE DUCTS

• Nipple Discharge, Duct actasia, Duct Papilloma.• Nipple Discharge: -

History: –PE: –INVEST: Microscopy, Cytology, Mammography & Biopsy. –Treatment: -None if cytology & mammography are normal. -Surgery for profuse discharge, patient concern or multiple lesions.

DUCT ACTASIA

• Def: Dilatation of major breast ducts which fill with inspissated creamy secretion & associated periductal inflammation.

• Pathophysiology: -Dil.+ leakage of secretion= inflammation. –prim inflammation, destruction of breast elasticity, dilatation.

• Presentation: asymptomatic or symptomatic –Symptoms: Discharge (Bloody, serous or creamy); Nipple retraction/involution; Acute inflammation in breast segment +/- non lactating abscess or fistula; localized /segmental inflammation.

• Treatment: Excision of the involved ducts &surrounding breast tissue; Plastic surgery to restore nipple contour.

DUCT PAPILLOMA

• Defn. Growth arising from the main duct epithelium (usually within 1cm of the nipple).

• Symptoms: Bleeding from a single point of the nipple.

• PE: -Small nodule at the nipple. –Discharge on pressure.

• INVEST: Mammography; Ductography (filling defect).

• Treatment: Surgical Excision.

CARCINOMA OF THE BREAST.

• PREDISPOSING FACTORS: -Environmental: Dietary (especially fat) & social class (high). –Sex –Female has higher incidence; Functioning ovaries; Increased risk with Early menarche ,late menopause, nulliparity & Late 1st pregnancy. –Age: Peak at 50-60 years. -Genetic:1st degree relatives (autosomal dominance trait chromosome 17).

CARCINOMA OF THE BREAST…

• TYPES OF BREAST CANCER: -Carcinoma in situ =confined to ducts or acini & within the basement membrane. It has good prognosis but transforms to invasive ca with delayed treatment. –Invasive carcinoma: Ductal (90%) Lobular(10%). –Ductal ca: Medullary (better progn.); Tubular & Mucoid. –Lobular Ca: Cribriform; Solid & Tubular.

CARCINOMA OF THE BREAST…

• BIOLOGICAL BEHAVIOUR. -Spread: Lymphatic/Haematogenous. –Lymphatic: Axillary (lower, apical, supraclavicular). –Blood :Bone, Lungs, Liver, Brain, Ovaries, Peritonium.

• FACTORS INFLUENCING PROGNOSIS (Tumour, LNs & Mets). –Tumour: Size, Contour, Histological type,Grade of differentiation, DNA ploidity (diploid), Degree of elastosis, Presence of necrosis, Oestrogen receptor. Poor prognosis: undifferentiated, aneuploid,ER negative- -LNs: Tumour involvement, No involved & Reactive changes. –Distant Metastases.

CARCINOMA OF THE BREAST…

• CURABILITY: <40% with surgery; <20% all cases.• DIAGNOSIS:

-History: Painless lump in the Breast; Tingling sensation. –PE: Asymmetry, Nipple fixity/scaling, Dimpling/Peau derange; Examine both breasts & compare. –Lump: Site, Mobility/fixity, Skin ulceration; LNs (size, mobility, matted, fixity). –INVESTIGATION: FNA, Mammography (sensitivity>95%), True cut biopsy.

TNM STAGING

TREATMENT

• Surgery – Breast Conserving: Lumpectomy; Quadrantectomy. -Mastectomy.

• Chemotherapy.

• DXT

• Combination.

• Palliative Treatment.

PREVENTION

• Predisposing Factors

• Early Detection and Treatment: -Education: -Self palpation &Treatment –Mammography, U/S, FNA