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Management of Breast Disease

Breast Disease. Reproductive HealthDiagnosisTreatmentCancer Screening. Role of Primary Care Physician. Breast Anatomy. SkinFatGlandConnective TissueVessels. COMPONENTS. Breast Anatomy. BodyTailNipple Complex. TOPOGRAPHY. Breast Anatomy. 10 ? 20 DuctsDuct Drains LobeLobe Contains 20 ? 40 L

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Management of Breast Disease

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    1. Management of Breast Disease Joseph A. Lucci III, M.D. Department of Obstetrics and Gynecology Division of Gynecologic Oncology

    2. Breast Disease Reproductive Health Diagnosis Treatment Cancer Screening

    3. Breast Anatomy Skin Fat Gland Connective Tissue Vessels

    4. Breast Anatomy Body Tail Nipple Complex

    5. Breast Anatomy 10 – 20 Ducts Duct Drains Lobe Lobe Contains 20 – 40 Lobules Lobule Contains 10 – 100 Alveoli

    6. Breast Anatomy Camper’s Fascia Pectoral Fascia Cooper’s Ligaments

    7. Breast Anatomy ARTERIAL Internal Mammary Lateral Thoracic LYMPHATICS Drainage Nodal Levels

    8. Breast Anatomy Level I – Lateral Pectoralis Minor Level II – Deep Pectoralis Minor Level III – Medial Pectoralis Minor

    10. Breast Cancer Location

    11. Components of Appropriate Screening Program Professional Physical Examination Breast Self Examination (BSE) Mammography

    12. Breast Exam OBSERVE Mass Effect Arm Position PALPATE Breast Nodes

    13. Breast Exam Positioning Palpation Discharge

    15. Breast Disease Benign 88% Malignant 12%

    16. Nipple Discharge Galactorrhea Intraductal papilloma Duct ectasia Carcinoma

    17. Screening Recommendations Professional Breast Exam

    18. Screening Recommendations Breast Self Exam (BSE) Recommended monthly for all women over the age of 20

    19. Breast Disease MAMMOGRAPHY 2 Views Magnification ULTRASOUND

    20. Carcinoma

    21. Comedo Carcinoma

    22. Ductal Carcinoma

    23. Breast Cancer Mammographic Screening

    24. Absolute Indications for Breast Biopsy Biopsy any suspicious palpable lesions. Biopsy any suspicious area seen on mammogram, but not palpable

    26. Breast Mass Presumed Benign

    27. 50 – 80% of all women Etiology Diagnosis Treatment FIBROCYSTIC CHANGES

    28. FIBROCYSTIC CHANGES Diagnosis Palpation Mammography Ultrasound Aspiration Biopsy

    29. Fibrosystic Changes OCP’S Methylxanthines Nicotine Vitamin E Hormones Bromocriptine

    30. Fibrosystic Changes Extent of Proliferative Changes Variable

    31. Proliferative Breast Disease

    32. Sclerosing Lesions Fibrocystic Changes Small, Irregular Resembles CA DX: FNA TX: Excision

    33. Sclerosing Duct Hyperplasia

    34. Adenoma Age: 20 – 30 yrs Groups Tubular Lactating DX: FNA TX: Observe, Excision

    35. Fibro-adeno-lipoma

    36. Lipoma

    37. Fibroadenoma Age 20 – 49 yrs Firm, Painless Bilateral 15 – 25% DX: FNA TX: Observe, Excise

    38. Fibroadenoma

    39. Phylloides Tumor Age: 30 – 55 yrs Slow Growing Epithelial and Stromal 10% Sarcoma DX: FNA TX: Excision

    40. Cystosarcoma Phylloides

    41. Intraductal Papilloma Age: 45 – 50 yrs Bloody Discharge Unilateral, small TX: Excision CA Risk: Rare, Multiple Lesions

    42. Intraductal Papilomatosis

    43. Intraductal Papillomatosis

    44. Ductal Ectasia Age: Perimenopausal Bilateral Sticky, Thick, Green Discharge DX: Exam TX: ABX, Excision CA Risk: Rare

    45. Breast Cancer US Statistics, 2000 182,800 new cases in women 40,800 deaths in women 1:8 women will develop breast cancer in lifetime

    46. Cancer Incidence 1998

    47. Breast Cancer Five Year Survival (1989-95)

    48. Breast Cancer Incidence has plateaued since 1987 Mortality rates have been stable or declining 5 year survival for localized disease has improved

    49. Presentation of Breast Cancer (744 Patients)

    50. Breast Cancer Sex Parity Menses Socioeconomic Race Diet Weight

    51. Breast Cancer Risk Assessment Modified Gail Model Age Family history of breast cancer Age at first live birth, if any Number of breast biopsies History of atypical hyperplasia Age at menarche Race

    54. Breast Cancer Family History

    55. Breast Cancer Risk Factors

    56. Breast Cancer Early Pregnancy Castration Exercise Avoid ETOH

    57. Chemical Structure of Estradiol and Selected SERMs

    59. BCPT Objectives Primary End Point Incidence of invasive breast cancer Secondary End Points Breast cancer mortality Incidence of cardiovascular events Incidence of bone fractures

    61. BCPT Results: Invasive Breast Cancer

    62. BCPT Results: Invasive Breast Cancer Cases by Previous Pathology

    65. BCPT QOL: Symptoms Reported at Least Once Over 36 Months

    68. Raloxifene and Breast Cancer Prevention Trials MORE Trial Breast Cancer risk not specifically addressed at entry 70% reduction at 33 months 9 trials – 10,575 patients Mean follow-up = 40 months 67 breast cancer events 55% reduction in relative risk

    69. Carcinoma

    70. Breast Cancer Evaluation H&P CXR Bone Scan Labs TNM

    71. Breast Cancer Surgery Radiation Chemotherapy Hormones

    72. Breast Cancer In SITU Location Tumor Size Breast Size Patient Age Patient Preference Mammographic Appearance

    73. Breast Cancer Breast Conservation Lumpectomy Sentinal Node(s) Modified Radical Mastectomy and Papillary Node Disection

    74. Breast Cancer Size Nodes Stage Grade Ploidy S – Phase Necrosis HER-2/neu

    75. Breast Cancer Premenopausal – Chemo Postmenopausal – Hormones

    76. Breast Cancer Regimens CMF CAF AC 6 – 12 Cycles

    77. Breast Cancer All Breast Concerving Surgical Therapies High Risk Patients When After Chemo Middle of Chemo

    78. Breast Cancer Tamoxifen x 5 years All Patients Ovarian Ablation

    79. Breast Cancer Survival Rate According to AJCC Stage

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