recent advances in breast diseases

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

recent advances in breast diseases

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