mr mike puttick - gp cme north/sat_plenary_1710_puttick... · 2018. 6. 9. · bia-alcl •breast...
TRANSCRIPT
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Mr Mike PuttickGeneral Surgeon
Auckland City Hospital
Breast Associates
17:10 - 17:30 Managing Common Breast Disease in Primary Care
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Managing Common Breast Diseases in Primary Care
Michael PuttickConsultant Oncoplastic Breast Surgeon
Auckland City Hospital & Breast Associates
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Managing Common Breast Diseases in Primary Care
Michael PuttickConsultant Oncoplastic Breast Surgeon
Auckland City Hospital & Breast Associates
Disorders
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Nomenclature- is unhelpful
Clinical Entity Exclusion of Cancer
Much of breast “disease” is normality
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Who should you refer….....….and who can you manage?
•Lumps
•Pain
•Family History
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When is a lump not a lump?
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When is a lump not a lump?
Discrete Persistent
Fixed Growing
Suspicious
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When is nodularity a lump?
When Dominant or Persistent1. Examine both breasts2. Confirm or refute with US3. Biopsy if necessary4. Review 6-8 weeks
Could be● Prominent fat lobules● Prominent rib● Intramammary node● Accessory breast tissue● Edge of a biopsy site
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MoH High Suspicion Criteria
• Discrete, hard breast lump with fixation (with or without skin tethering)
• Discrete breast lump that presents in women with one or more of the following: • age 40 years or older, and persists after her next period or presents after
menopause
• aged younger than 40 years and the lump is increasing in size or where there are other risk factors, such as strong family history
• with previous breast cancer or ovarian cancer
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MoH High Suspicion Criteria
• Discrete, hard breast lump with fixation (with or without skin tethering)
• Discrete breast lump that presents in women with one or more of the following: • age 40 years or older, and persists after her next period or presents after
menopause
• aged younger than 40 years and the lump is increasing in size or where there are other risk factors, such as strong family history
• with previous breast cancer or ovarian cancer
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Lumps need Triple Assessment• Clinical Assessment
• History• Examination
• Radiology• USS• Mammograms• (MRI)
• Biopsy• FNA• Core Biopsy
KEY = Concordance
1. Normal / non-diagnostic
2. Benign
3. Probably benign
4. Probably malignant
5. Malignant
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What Imaging?
• Mammogram > 35yrs
• Tomosynthesis of dense tissue
• USS <35yrs
• Characterize lumps
• Targeted
• MRI• Should be in a breast clinic
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Which Biopsy?
• Core Biopsy
• FNA for benign lumps
• Cysts
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44 year old
Sudden onset lump UOQ L breastApprox 3cmTenderPersisted after her period
What is it?
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Breast Cysts• Commonest discrete benign breast mass
• 7-10% of ♀• Simple cysts can be aspirated• Recurrent cysts can be aspirated• Standard breast screening is appropriate follow-up in most cases
“.....if US not available, the first investigation of an easily palpable lump in the breast should be the insertion of a needle….”
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Typical Breast Cyst Fluid
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Mastalgia
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Mastalgia
Breast pain is an uncommon symptom in breast cancer, but it does not exclude the diagnosis
Cyclical changes of menstruation
Cyclical mastalgiaIncapacitating
mastalgia
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33 year old
Painful breasts 3 monthsL>RSome cyclical variationNeeding occasional paracetamolCousin had breast cancer aged 47
What would you do?
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Mastalgia Management
1. Exclude Cancer
2. Reassurance
3. Define Pattern1. Cyclical; start with EPO2. True Non-cyclical; EPO
4. Define musculo-skeletal pain
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Mastalgia – who needs imaging?
• Risk factors for breast cancer
• History/exam ≠ classical cyclical painE.g. sudden onset focal pain, nipple discharge
• Focal pain without a mass
• Breast lump (discrete or general lumpiness)
• Patient/doctor needs reassurance
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Family History of Breast Cancer….
….what should I do?
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Family History of Breast Cancer….
….what should I do?
Stratify Risk• High
• Medium
• Low
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Family History of Breast Cancer….
….what should I do?
Stratify Risk• High
• Medium
• Low
1. Screening
2. Risk reducing strategies
3. Genetic Testing
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BIA-ALCL
• Breast Implant Associated Anaplastic Large Cell Lymphoma
• Rare• 1 in 60,000
• Associated with certain textured implants
• Curable
• Do NOT need surveillance
• Changes should be investigated
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Summary
• Spectrum of Normal
• Triple Assessment for lumps
• Aspirate cysts
• Mastalgia: reassurance +/- imaging
• Family History
• BIA-ALCL
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Thank you