The objectives of this The objectives of this seminar:seminar:By : Sameer S. SawaedBy : Sameer S. Sawaed

MAIN SYMPTOMS OF BREAST DISORDERS

Breast cancer

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Why to care about breast CA?Most common malignancy in women

Second most common cause of cancer death after lung C, causing 458,503 deaths worldwide in 2008

Life time risk for women is raised from 1 in 12 (2007) to 1 in 7 (2012)

50% of women will have benign breast lesion in their life time.

Breast cancer in Jordan:Breast cancer is the most common cancer

overall as well as the most common malignancy afflicting Jordanian women.

According to the latest statistics from the Jordan National Cancer Registry, 864 females and 9 males were diagnosed with breast cancer in 2008, accounting for 18.8% of the total new cancer cases & accounting for 36.7% of all female cancers,

the leading cause of cancer deaths among Jordanian women.

Median age (51) Vs (65) western countriesMedian age (51) Vs (65) western countries

Incidence rates are increasing at 3% per yearIncidence rates are increasing at 3% per year

Presentation: Presentation:

according to jordan cancer registry at king hussien cancer center:according to jordan cancer registry at king hussien cancer center:

23.8 % stage 123.8 % stage 131.6 % stage 231.6 % stage 221.2 % stage 321.2 % stage 313.7 % stage 413.7 % stage 4

The Jordan Breast Cancer Program (JBCP) is a nation-wide initiative for the development and provision of comprehensive services for the early detection and screening of breast cancer for all women in Jordan for the purpose of.

JBCP has a multidimensional approach covering the provision of screening services, education of females, capacity building of health professionals and quality assurance.

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Reducing morbidity and mortality from breast cancer by early detection and screening.

Shifting the current state of diagnosis of breast cancer from its late stages (III- IV), to diagnosing breast cancer at its earlier stages (0-II) where :-

- the disease is most curable, - survival rates are highest, - and treatment costs are lowest.

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Early Detection

& Screening

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Survival rates and the early detection of breast cancer are directly connected; yet unfortunately, public awareness in Jordan regarding this fact is minimal and inadequate.

The best way to protect yourself against breast cancer is by maintaining routine checkups.

The most appropriate course of action will depends on age & risk factors.

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Women at normal risk can follow the Early Detection Plan below, which summarizes the National recommendations in Jordan:

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Screening/ Age

20-29 30-39 40-49 50+

Self Breast Exam

Monthly Monthly Monthly Monthly

Clinical Breast Exam

Once every 1-3 years

Once every 1-3 years

Annually Annually

Mammogram -------------- ------------ Every two years

Annually

If the women are at increased risk, they must have the annual mammography earlier, and they will have more frequent clinical breast examination

What are the Risk Factors?What are the Risk Factors?Advanced age >40

Family history   Family history of ovarian cancer in

women <50y

Personal history   Positive BRCA1/BRCA2 mutation  Breast biopsy with atypical hyperplasia  Breast biopsy with LCIS or DCIS

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Reproductive history  Early age at menarche (<12 y)  Late age of menopause  Late age of first term pregnancy (>30 y)/nulliparity Use of combined estrogen/progesterone HRT Current or recent use of oral contraceptives

Lifestyle factors Adult weight gain Sedentary lifestyle Alcohol consumption

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PresentationAsymptomaticBreast Mass ◦ Usually Hard, UOQ in 60%

Skin changes (skin tethering)Nipple (Discharge ,retraction, inversion)Pain(mastalgia) or Prickling sensationSymptoms of Mets. (back ache, pathological fx,

Respiratory symptoms, jaundice, skin lesions, and general symptoms of cancer ..etc)

Red Flags Suggestive of Breast CancerRed Flags Suggestive of Breast Cancer

Symptom Characteristics

Pain Unilateral, noncyclic

Nipple discharge UnilateralWatery, serous, serosanguineous, bloody

Breast mass UnilateralHard, immobileNoncystic

History PostmenopausalPersonal history of breast cancerFamily history of breast cancer

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Triple assessment 1- Detailed history and physical

examination2- Diagnostic imaging by Mammography

and/or Ultrasound scanning3- Cytology or Histology

Positive Predictive Value of this combination should exceed 99.9%

Ref. Bailey and Love’s 24th ed. P.826

Proper HxProper HxAge?

The risk of breast cancer increases with age.Postmenopausal women presenting with a mass are much more likely to have cancer than premenopausal women.A breast mass in a woman younger than age 30 rarely (2%) represents cancer, whereas a woman of 70 years or older with a mass will have cancer more than 85% of the time.

Where? How long? How was it discovered? Painful, painless?

Associated Sx.( pain, discharge, Wt loss, bone pain)

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Family Hx for BCFirst-degree relative increases the risk about two to three folds.If two first-degree relatives have been affected, the risk increases up to six-folds.

Hx of pregnancy after the age of 30.

Menarche

Menopause.

Use of any hormonal therapies

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Self Breast Exam

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Performance of Self breast exam must be done at the end of menstrual cycle.

Step one: In front of a mirrorLook for any abnormal changes and check the shape, size, color & texture of the breasts in four different positions:

Arms at your side. Hands pressed on your hips while tightening your chest muscles. Arms held over your head. Upper body bent forward with your hands on your hips.

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Step 2: Lying Down

Lie down on your back with a pillow under your right shoulder.

Using the finger pads of the middle three fingers of your left hand, examine your right breast for the presence of any lumps.

Press gently but firmly using variable pressure (light, medium, and deep) to each area examined.

Follow overlapping circular motions and cover the entire breast including underarm area.

Repeat on your left breast using your right hand.

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Clinical breast exam

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CBE can be helpful in detecting a breast mass, particularly among women at normal risk under the age of 40 for whom mammography is not recommended.

For women aged 40 years and older, clinical breast exams are an important complement – not substitute – to mammography.

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Physical ExaminationPhysical ExaminationThe physical exam should be done in a private and comfortable room, in the presence of a chaperone, Should include:inspection and palpation of both breasts.

palpation of the axillary and supraclavicular lymph node regions.

Recognize any skin changes.

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Mammography1- Screening: it is the most successful widely-available screening tool

that can detect breast cancer at its earliest stages.

2- Diagnostic:Low dosage of X-ray, Safe. Diagnostic mammography is used to evaluate a patient

with abnormal clinical findings—such as a breast lumpcontraindicated in pregnant women .There are two types of mammograms available world-

wide:standard mammography (film-screen mammography)Digital mammography.

Mammograms are quick and easy. Patient stand in front of an X-ray machine. The person who takes the X-rays places the breast between two plastic plates. The plates press the breast and make it flat. This may be uncomfortable to the patient but it helps get a clear picture. Then the process repeated to the other breast.

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Mammography view:-

Craniocaudal Mediolateral oblique

Mammography*The sensitivity of the mammogram is in the 90%

range.**the sensitvity increase with age***Cancers missed by mammography are

in the range of 10-30%.Causes include:1- Observer error.2- Dense tissue.3- Lobular cancer ( growth patterns

indistinguishable from normal breast tissue).

Remember..A normal Mammogram in the

presence of a palpable Mass does not exclude malignancy and further workup should be performed with an US, MRI, and/or Biopsy.

An interval of 2 weeks between a mammogram and cyst aspiration is recommended because aspiration can sometimes result in hematoma formation, which could confuse mammographic interpretation.

Mammogram Interpretation: Mammogram Interpretation: Categories and the ACR/BI-Categories and the ACR/BI-RADSRADS

The American College of Radiology (ACR) has established the Breast Imaging Reporting and Database System (BI-RADSTM) to guide the breast cancer diagnostic routine. Radiologists sometimes refer to each BI-RADSTM category as a "level."

Category 0 Need Additional Imaging Evaluation

Category 1 Negative

Category 2 Benign Finding

Category 3 Probably Benign Finding – Short Interval Follow-Up Suggested

Category 4 Suspicious Abnormality – Biopsy Should Be Considered

Category 5 Highly Suggestive of Malignancy – Appropriate Action Should Be Taken

MAIN SYMPTOMS OF BREAST MAIN SYMPTOMS OF BREAST DISORDERS :DISORDERS :

Breast MassSkin Changes

Breast Pain (Mastalgia) Nipple (Discharge, Inversion, Skin changes)

The presentation of a woman with a breast mass is one of the most common problems facing a primary care physician

It may occur at any age after adolescence A systematic, thorough approach to the workup of any

breast mass -- including a careful history, clinical breast examination, and documentation -- is crucial plus a careful and systematic clinical investigation.

distinguishing the cyst from the solid mass is the most important tasks facing the clinician

Although breast cancer is often not an easy diagnosis to make , it is the explicit duty of the physician to rule out this diagnosis.

Risk factorsRisk factors 1)early onset of menstruation, 2)late onset of menopause, 3)childbirth after age 30, 4)nulliparity, 5)lactation for less than 2 years, 6)alcohol ingestion, 7)obesity, 8)low socioeconomic status, 9)particular ethnicity, 10)hormone replacement therapy (HRT), 11) family history, 12)radiation exposure, and 13)prior history of proliferative breast disease or breast cancer. 14) smoking 15) inheritance of mutation in the BRCA-1 or BRCA-2 genes

Etiologies:Etiologies:There are 4 common etiologies of a

breast "lump": 1) Fibroadenoma, 2) Cyst, 3) Benign fibrocystic masses, 4) Cancer.

Fibrocystic MassFibrocystic MassFibrocystic changes are very common in

premenopausal women, primarily as a result of the influence of ovarian hormones on the physiology of breast tissue.

Fibrocystic masses may also appear in some postmenopausal women being treated with HRT

it is not possible for physical examination or radiological studies to definitively distinguish a fibrocystic from a malignant mass.

FibroadenomaFibroadenomaBenign mass that occurs most frequently

in young women, beginning in adolescence

They are usually quite mobile on physical examination and represent a benign proliferation of connective tissue that is encapsulated and incorporates epithelial cells

CystCyst Is a benign, fluid-filled structure found mostly in

perimenopausal women. It is uncommon to find cysts in women younger than age 35.

May develop in postmenopausal women, but this is distinctly uncommon unless the woman is taking HRT.

They could be present with variable consistencies varying from soft & cystic to a hardness equal to cancer which makes them difficult to distinguish, by palpation, from solid abnormalities.

CancerCancer Usually firmer than the other In addition, breast cancer is often painless Exceptions to the usual firmness and

painlessness of cancerous masses make reliance on such descriptors for diagnosis very hazardous

“Postmenopausal women who present with a breast mass should be presumed to

have cancer until it is proven otherwise”

Traumatic fat necrosis : it affects middle aged female.

Caused by a trauma to the breast fatty tissues ( ex : seatbelt , direct trauma , RTA) which will cause a painless lump that mimic carcinoma.

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Taking historyTaking historySystematic Approach to Breast Mass Workup

Triple assessment Location Ask the woman to point to the area of concern with 1

finger. Document this area on the physical examination record pictorially

with an "X." Method of Discovery Establish how familiar the woman is with

her own breast examination. How often does the woman perform breast self-examination

(BSE)? Did she discover the lump during BSE or by accident? Was the lump found when the patient was in the supine position,

standing in the shower, or in a different position? Size How big is the lump currently? Liken the size to familiar

items, such as a pea, a grape, or a walnut.

Duration When was the lump first found? Has it changed since first date of discovery? Hormonal Influences What is the woman's

ovulatory status? When was her last menstrual period? Is she premenopausal? If so, does the mass change

depend on the phase of her ovulatory cycle? Is she on hormone replacement therapy? If so, what

are the drug names and dosages? Tenderness Is the mass tender? If the patient is premenopausal, does the tenderness

change with the ovulatory cycle? Associated Sx.( pain, discharge, Wt loss, bone pain)

4 essential elements to consider when taking a risk factor history:

Age. Before age 25, it is rare to consider breast cancer as a possible etiology of a breast mass; after age 25, the incidence rises incrementally.

Personal history of breast cancer. It is important to have a clear estimate of cancer risk to the contralateral breast when a woman has been diagnosed with breast cancer

Personal history of proliferative breast disease. Family history of breast cancer.((1) Lack of a family

history is by no means protective; (2) A large majority of women diagnosed with breast cancer do not have a family history of the disease.)

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FNA-FNABFNA-FNAB

Simple FNA is often used when a mass can be palpated to distinguish a cyst from a solid mass

a 2-week interval should be allowed between FNA and mammography or ultrasound. This is because small hematomas from the needle aspiration may cause false-positive results .

If a mass is solely cystic, it will disappear following a complete aspiration.

If a mass is solid, 3 characteristics will typically make this distinction: (1) no fluid will be aspirated into the syringe barrel; (2) if there is any aspirate, it will be solid; and (3) the mass will persist following aspiration, then we do FNAB

If the cyst has recurred, mammography and excisional biopsy should be recommended.

If any of the components of the diagnostic triad of CBE, mammography, and FNA are suspicious or consistent with malignancy, the mass should be biopsied.

If All three results are negative, the mass can be closely followed with CBE by the same examiner every 3 months for two visits, then again in 6 months to determine if it is stable.

Benign breast masses may spontaneously resolve over time

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Don’t ForgetDon’t ForgetThe cardinal signs of a late cancer of the

breast:

Hard, non-tender, irregular lump.Tethering or fixation of the lump.Palpable axillary lymph nodes

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Skin ChangesSkin Changes Puckering

Skin is pulled by an underlying cancer.Fat necrosis after an injury.

Peau d’orangeEdema caused by obstruction of skin lymphatics by cancer cells.

Nodules Usually they are secondary to a tumorE.g: Benign breast lumps “diffuse nodularity”.

Discolouration

UlcerationDue to the invasion of the carcinoma to the skin.

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Breast PainBreast Pain

Breast pain can be separated into two main groups, cyclical and Non- cyclical.

Two thirds of women have cyclical pain other third is Non- cyclical,

The causes for noncyclical breast pain are very varied and hard to establish. Noncyclical pain has frequently its root cause outside the breast.

Non-cyclicalNon-cyclical

mean age 43the pain is often localized and described

as a “burning” or Prickling sensation

Cyclical breast pain is very often associated with fibrocystic breast changes or duct ectasia and believed to be caused by aberrations in dynamic hormonal changes

Cyclical mastalgiaCyclical mastalgia average age is 34 discomfort, fullness, and heaviness of the breast

during the 3-7 days before each period breast being tender to touch pain improving at menstruation The pain varies in severity from cycle to cycle but

can persist for many years. Cyclical mastalgia is relieved by the menopause pregnancy, oral contraceptives & parity do not

affect its course.

TreatmentTreatmentCyclical breast painCyclical breast pain There are presently three drugs that can be prescribed for

cyclical mastalgia. trial of treatment should last at least four months1) Gamolenic acid Mild nausea Slow response to treatment2) Danazol Weight gain Acne Hirsutism3)Bromocriptine Nausea Dizziness

TreatmentTreatmentNon-Cyclical breast painNon-Cyclical breast pain

local anaesthetic and steroid injectionsome women respond to the drugs used

for cyclical mastalgia

Bacterial mastitis Bacterial mastitis

Most common in lactational females.

Caused by staph aureus which lives in the oropharynx of the baby.

Stasis of the milk due to lactiferous duct blockage good media for bacteria.

Treatment by antibiotics , and if it didn’t treated it will complicated to abscess formation.

Malaise , fever , throbbing pain Breast abscess don’t wait incision and drainage.

The nipplesThe nipples

Nipple discharge.Nipple inversion.Nipple retraction.

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Nipple dischargeNipple dischargeNipple discharge is a common complaint in

women who are not pregnant or breastfeeding, especially during the reproductive years. Nipple discharge is not necessarily abnormal, even among postmenopausal women.

Nipple discharge can be serous (yellow), mucinous (clear and watery), milky, sanguineous (bloody), purulent, multicolored and sticky, or serosanguineous (pink). It may occur spontaneously or only in response to breast manipulation.

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EtiologyEtiology

Most frequently, nipple discharge has a benign cause. Cancer (usually intraductal carcinoma or invasive ductal carcinoma) causes < 10% of cases. The rest result from benign ductal disorders (eg, intraductal papilloma, mammary duct ectasia, fibrocystic changes), endocrine disorders, or breast abscesses or infections.

Intraductal papilloma is probably the most common; it is also the most common cause of a bloody nipple discharge without a breast mass.

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Nipple inversionNipple inversionThis condition is frequently associated

with significant diseases and always need full assessment.

The commonest cause by far are Duct ectasia, but it is a regular presentation of breast cancer with or without palpable lump.

Paget disease of the nipple:Paget disease of the nipple:

Caused by cancer cells spreading around ductal system from a carcinoma situated deeply in the breast, which is in early stages DCIS.

The presence of carcinoma cells in the skin of the nipple produces a clinical appearance similar to that of eczema , patches of skin first become red and then encrusted and oozy, but they do not itchy, later the nipple is destroyed and replaced by a malignant ulcer. 59

eczema Paget disease

bilateral unilateral

Common at lactation Occurs at menopause

itchy Not itchy

vesicles No vesicles

nipple intact Nipple destroyed

No lumps May be an underlying lump60

Duct ectasia Duct ectasia Dilatation of breast ducts followed by periductal inflammation. Has strong association with smoking. Symptoms : - nipple inversion "transverse slit" - purulent nipple discharge. - Subareolar mass. (tender)

- Periductal abscess & may rupture resulting in Mammillary fistula.

Treatment: - Stop smoking. - Antibiotics. - Surgery.

Thank you