Differential Diagnosis

1. Differential Diagnosis

2. L breast has a 2 X 2 cm. hard, non-tender, & movable mass with irregular margins underneath the nipple Fibroadenoma • Fibroadenomas are the second most common solid tumor after breast cancer and the most common benign tumor in women • composed of stromal and epithelial elements (Benign fibroepithelial neoplasm) • commonly seen in young women(20-30 yr) • Presents as a mass • Usually 2-3 cm in size; well-defined • Single in 80% • Related to estrogen • Not premalignant • The prevalence of fibroadenomas is approximately 8-10% in women older than 40 years.   • oval, freely mobile, rubbery masses that may be nonpalpable or palpable. • size varies from smaller than 1 cm in diameter to as large as 15 cm in diameter in the giant forms. • The typical case is the presence of a painless, firm, solitary, mobile, slowly growing lump in the breast of a woman of childbearing years.

3. L breast has a 2 X 2 cm. hard, non-tender, & movable mass with irregular margins underneath the nipple Fibrocystic Change • Result of prolonged cyclic stimulation of repeated menstrual cycle • 35-50 (premenopausal) • Presentation is tenderness • Pain with multiple cystic lesions/single dominant mass • Not premalignant except those with atypical hyperplasia

4. L breast has a 2 X 2 cm. hard, non-tender, & movable mass with irregular margins underneath the nipple Phylloides Tumor • Previously called CystosarcomaPhylloides • predominantly benign tumor • invasive- malignant • Mesenchymaland epithelial components • Rapid growth • Rarely metastasizes to the axillary lymph nodes • Phyllodes tumor is the most commonly occurring nonepithelial neoplasm of the breast, although it represents only about 1% of tumors in the breast • It has a smooth, sharply demarcated texture and typically is freely movable. • It is a relatively large tumor, with an average size of 5 cm. However, lesions of more than 30 cm have been reported. • can occur in people of any age; however, the median age is the fifth decade of life.

5. L breast has a 2 X 2 cm. hard, non-tender, & movable mass with irregular margins underneath the nipple Phylloides Tumor • Patients typically present with a firm, mobile, well-circumscribed, nontender breast mass. • A small mass may rapidly increase in size in the few weeks before the patient seeks medical attention. • Tumors rarely involve the nipple-areola complex or ulcerate to the skin. • Tends to involve the left breast more commonly than the right one. • Overlying skin may display a shiny appearance and be translucent enough to reveal underlying breast veins.

6. L breast has a 2 X 2 cm. hard, non-tender, & movable mass with irregular margins underneath the nipple Breast Carcinoma • 2nd leading site for both sexes combined; 1st among women • Incidence starts rising steeply at age 30 • 14,043 new cases in 2005 among women • 3rd leading cause of cancer deaths (6,357 breast cancer deaths) • Median survival among females is 60 months. • Clustered microcalcifications – more common here in the Philippines

7. L breast has a 2 X 2 cm. hard, non-tender, & movable mass with irregular margins underneath the nipple Breast Carcinoma • Hard, solitary, non-tender mass with irregular margins • 40—60 y/o • 40-50% are located in the upper outer quadrant • Since this area contains greater breast volume, including theaxillarytail of Spence • 80% of the time, there are also lesions in the other quadrants • Most common cause of this discharge is breast CA • Bloody nipple discharge • Skin retraction • Involvement of the ligament of Cooper) • Peaud’ orange

8. Work-ups

9. Mammography • Examinations of an indeterminate mass that presents as a solitary lesion suspicious of CA • 10% to 50% of cancers detected mammographically are not palpable, 10% to 20% of palpable tumors not detectablemammographically • Although sensitive, not specific • 25% of non-palpable lesions detected are found to be malignant at biopsy • Sine qua non (hallmark): Spiculated density with ill-defined margins (If seen in mammography, consider as a malignancy until proven otherwise) • Features that are suggestive but not diagnostic of cancer includes: • Clustered microcalcifications – more common here in the Philippines • Asymmetric density • Ductalasymmetry • Distortion of skin, nipple & normal breast architecture

10. Fine Needle Aspiration Biopsy • definitive diagnosis • determination of histopathology

11. Role of the following? 1. FNAB 2. Mammography 3. Chest x-ray 4. Ultrasound 5. CT scan 6. Bone scan

12. FNAB • Fine needle aspiration is the easiest and fastest method of obtaining a breast biopsy, and is very effective for women who have fluid filled cysts. • However, the pathological evaluation can be incomplete because the tissue sample is very small. When used alone, about 10% of breast cancers may be missed.

13. Mammography • Most cost-effective approach for breast cancer screening, however, the sensitivity (67.8%) and specificity (75%) are not ideal. • An X-ray technique that looks for changes in the breast. These appear as changes in the shape of the breast or calcifications. • demonstrated to be an effective tool for the prevention of advanced breast cancer in women at average risk • Mammography often reveals a lesion before it is palpable by clinical breast examination and, on average, 1-2 years before noted by breast self-examination.  • Two-view mammography (ie, craniocaudal and oblique) is the imaging method of choice for breast screening

14. Mammography • Investigation of choice for detecting and classifying microcalcification. • Benign microcalcification is characterized by diffuse scattering and crescentic "tea-cupping." Malignant microcalcification is characterized by isolated clusters, punctate of varying sizes, and a branching or linear pattern. • Mammography is also efficient for helping detect larger patterns of calcification, such as the outlining of calcified arterioles or the coarse patchy calcification of long-standing fibroadenomata.

15. Chest X-ray • Before treatment begins, a chest x-ray may be done to rule out metastasis of breast cancer the lungs • May be used to assess the heart and lungs before receiving general anesthesia or chemotherapy. • During treatment for breast cancer, chest x-rays may be used in the following situations: • If a person has advanced breast cancer that has spread to the lungs, a chest x-ray is used to check on how the disease is responding to treatment. • For people who develop a fever during chemotherapy, chest x-rays are used to check for the presence of pneumonia. • If a person experiences new shortness of breath in the first few months after radiation therapy, with or without a cough, her doctor may order a chest x-ray to see if the radiation caused any inflammation of the lungs.

16. Ultrasound • not used on its own as a screening test for breast cancer • used to complement other screening tests. • If an abnormality is seen on mammography or felt by physical exam, ultrasound is the best way to find out if the abnormality is solid (such as a benign fibroadenoma or cancer) or fluid-filled (such as a benign cyst). • cannot determine whether a solid lump is cancerous, nor can it detect calcifications. • guide biopsy needles precisely to suspicious areas in the breast.

17. Ultrasound • Ultrasonographic features of malignancy include the following: • Poorly defined borders • Heterogeneous internal echoes • Disruption of the tissue layers • Irregular shadowing • Superficial echo enhancement • Depth greater than height • High vascular density and flow rates on Doppler images • Features of benign lesions include the following: • Cyst - Absence of internal echoes, marked deep enhancement • Fibroadenoma - Well-defined borders, well-defined internal echoes, and displacement of tissue planes • Lymph node - Well-defined peripheral blood flow on Doppler images

18. CT Scan • With contrast, CT scans can help specify lesions with high vascularity. CT scan is also useful for helping detect lung and brain metastases and high axillary and intrathoraciclymphadenopathy. • Right now, CT scans are not used routinely to evaluate the breast • Assess whether or not the cancer has moved into the chest wall. This helps determine whether or not the cancer can be removed with mastectomy. • Examine other parts of the body where breast cancer can spread, such as the lymph nodes, lungs, liver, brain, and/or spine • Generally, CT scans wouldn’t be needed for early-stage breast cancer. • After treatment, CT scans may be used if there is reason to think the breast cancer has spread or recurred outside the breast • May also be used to guide biopsy

19. Bone Scan • Also called bone scintigraphy, is an imaging test used to determine whether breast cancer has traveled to the bones • a small quantity of radioactive dye is injected into a vein, and a special X-ray is then taken to see if the cancer has gone to bone. • Breast cancer has a predilection to go to bone, where it may lie dormant for many years. A "baseline" scan is obtained for any invasive cancer, to make later scans easier to compare and interpret. • during and after treatment, if patient experiences persistent bone and joint pain, or if a blood test suggests the possibility that the breast cancer has traveled to the bones • If "something" is seen on a bone scan, it may or may not be cancer. Old fractures, inflammation, or infections can make bone scans "light up" in those areas.

20. If FNAB is negative, what will you do?

21. Lumpectomy • Excision is diagnostic and therapeutic. • Best suited for the benign or indeterminate lesion where patient preference is removal rather than biopsy with observation