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Approach to Breast Disease

Approach to Breast Disease. DR C A BENN. INTRODUCTION. Ultimate goal as doctors Surgical evolution versus “revolution”. BACKROUND. INCIDENCE BENIGN INCIDENCE MALIGNANT DISEASE AFRICAN AMERICAN EXPERIENCE OLD SERVICES OFFERED A NEW BEGINNING. Screening in Breast Cancer-an update

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Approach to Breast Disease

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  1. Approach to Breast Disease DR C A BENN

  2. INTRODUCTION • Ultimate goal as doctors • Surgical evolution versus “revolution”

  3. BACKROUND • INCIDENCE BENIGN • INCIDENCE MALIGNANT DISEASE • AFRICAN AMERICAN EXPERIENCE • OLD SERVICES OFFERED • A NEW BEGINNING

  4. Screening in Breast Cancer-an update Breast cancer screening in Europe- current status Bad press???? Poor technology???? Wrong test??? Overly aggressive clinicians??? Fault is breast cancer????

  5. How patients present…….. • Mass • Pain • Discharge • Basic management

  6. INTRODUCTION • INCREASING AWARENESS OF CANCER • POSSIBILITY THAT MASTALGIA IS INDICATIVE OF DISEASE • PHYSICIANS ARE INADEQUATELY TRAINED FOR TREATING THIS CONDITION…..

  7. HELP !

  8. ACADEMICS • CYCLIC MASTALGIA (67%) • NONCYCLIC MASTALGIA (26%) • CHEST WALL PAIN (7%)

  9. FACT…... • >90% OF PATIENTS WITH CYCLIC MASTALGIA AND 64% OF PATIENTS WITH NONCYCLIC MASTALGIA OBTAIN RELIEF FROM A COMBINATION OF NONPRESCRIPTION AND PRESCRIPTION DRUGS

  10. HISTORY • IS THIS BREAST PAIN ?

  11. EXCLUDE.. • Cardiac • Respiratory • Gastrointestinal • Dermatological • Musculoskeletal • Endocrine • Gynaecological • Haematological • Habits

  12. THOROUGH EXAMINATION SPECIFICALLY THE BREASTS FINDINGS • NORMAL SMALL, MEDIUM OR LARGE BREASTS • BREASTS WITH A MASS, NIPPLE DISCHARGE OR THICKENING

  13. ASSESSMENT…. • Normal breast pain • Extent to which it disrupts the patient’s life [work, sleep, sex, ….]* • Provide the patient with a breast pain chart and a symptom chart *Check diet and drugs

  14. INVESTIGATIONS.. GENERAL • Blood tests (HIV, Prolactin) and other tests depending on clinical suspicion SPECIFICALLY • Sonar and mammogram depending on the age of the patient

  15. FIBROCYSTIC CHANGE IS NOT DISEASE • ANDI CLASSIFICATION

  16. THEORIES OF CAUSATION

  17. MANAGEMENT OF MASTALGIA There is a long list of suggested modalities for the treatment of an entity that is ubiquitous; has an unknown aetiology, and a poorly understood relationship to fibrocystic disease and cancer.

  18. MASTALGIA MANAGEMENT SUMMARY • THOROUGH HISTORY • PHYSICAL EXAMINATION • MAMMOGRAPHY AND /OR SONAR • ABNORMALITIES…….BIOPSY • CLASSIFY • REASSURANCE

  19. MASTALGIA MANAGEMENT SUMMARY • ABSTENTION FROM CERTAIN MEDICATIONS AND FOOD • EVENING PRIMROSE OIL • DRUGS

  20. NIPPLE DISCHARGE • HISTORY & EXAMINATION one duct, multiple ducts, one breast or both clear, blood stained, green,yellow black etc INVESTIGATIONS • pus swab mc&s • mammogram, sonar • ductogram • bloods: BHCG, prolactin

  21. Nipple Discharge • Introduction • Clinical features • Investigations • Treatment Plan • General Comments

  22. Clinical features of MDAIDS • Nipple Discharge • Breast Pain and tenderness • Nipple Retraction and Subareolar mass • Subareolar breast abscess and recurrent abscess • Periareolar Mammary duct Fistula

  23. CONCLUSION • Antibiotics: • Surgery for complicated disease Intractable pain Recurrent discharge not responding to antibiotics Abscess Fistula

  24. MANAGEMENT • DUCT ECTASIA • medical antibiotics • surgery for complications fistula, abscess, intractable pain and recurrent discharge non responsive with antibiotics DUCT PAPILLOMA surgical excision Physiological discharge Medication and Conservative management

  25. HISTORY APPROACH TO ABREAST MASS

  26. APPROACH TO BREAST MASS

  27. BREAST MASSES REQUIRE A TISSUE DIAGNOSIS REGARDLESS OF THE AGE OF THE PATIENT

  28. ALL BREAST MASSES TO GET A TISSUE DIAGNOSIS • WHY? • CANCER IN YOUNG WOMEN • UNUSUAL DIAGNOSIS • LYMPHOMA • TUBERCULOSIS • HOW? • FINE NEEDLE ASPIRATE • CORE/TRUCUT BIOPSY • SONAR GUIDED FNA OR CORE • MAMMOGRAM GUIDED • HOOK WIRE • LAST RESORT EXCISIONAL DIAGNOSIS

  29. 95% of all patients should have the diagnosis made prior to surgery

  30. From benign to malignant…. • Large variety of benign lesions • Broad terms used (FCD; BBD) used for convenience • Transition theory : benign, hyperplasia, cellular atypia, carcinoma in situ. • What is the breast cancer risk and at what stage should a lesion be considered malignant ?

  31. The Evolution of Breast Cancer Florid hyperplasia Lobular carcinoma in situ • Normal breast Proliferative Changes Atypical epithelium (mild to moderate ductal lobular or ductal or lobular hyperplasia) hyperplasia DCIS Nonproliferative changes (fibroadenoma, duct ectasia, cysts Papillomatosis fibrosis, apocrine metaplasia, stromal sclerosis) Invasive cancer

  32. Lobular Carcinoma In Situ Epidemiology • young women (44 - 47yrs) Pathology • “Busy Bosom” • ipsilateral multicentricity / contralateral / bilateral / ……in almost every case • homogenous, slow growth, low nuclear grade

  33. Prognosis and Management of LCIS • Risk applies equally to both breasts • Incidence variable [1% per year, lifetime 5% ( 4-13%), 37% of cases] • Malignancies arising (50-65%) are ductal • From bilateral mastectomy to ipsilateral mastectomy and blind contralateral biopsy to non operative close observation

  34. DCIS: More Ominous Epidemiology • Females and Males • Occurs between the age of presentation of LCIS and Ca Pathology • Historically 4 histological types: Papillary and micropapillary, cribriform and solid. • Comedo versus Non Comedo

  35. Applying a relative risk reduction to treatment decisions • Individual treatment algorythm Family history of Breast /other cancer Age at diagnosis Tumour necrosis and Nuclear Grade Resection margins

  36. STAGING • TNM CLASSIFICATION • MANCHESTER • A BIOLOGICAL CLASSIFICATION

  37. Breast Cancer management • Multimodal Approach • Surgical • Radiation therapy • Chemotherapy

  38. Surgery • Breast conservation or mastectomy with immediate/delayed reconstruction • Size of the breast • Size of the tumour • Patients wishes • Axilla • Clearance (> 7 lymph nodes) • Sentinel node biopsy if trained

  39. Radiation Therapy Breast • All breast conserving surgery • Mastectomy with margins <1cm • Locally advanced breast cancer Axilla • 4 or more nodes positive

  40. Chemotherapy • Tumours >1,5cm • All lymph node positive tumours • All receptor negative tumours • Tumours with poor prognostic indicators her2neu, lymph vascular invasion

  41. Breast conserving procedures are being employed with increasing frequency... • How strong is the justification for the changes that have occurred? • Why have they come about? • Has science played a role? • Is this few tampering with tradition? • Is this consumer pressure?

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