1 / 61

Breast Presentations in General Practice

Breast Presentations in General Practice. Dr Therese Ryan GP Discipline Academic Supervisor Bundaberg Rural Clinical School. Nipple discharge Mastalgia Gynaecomastia Breast lumps Breast cancer. Learning Objectives. Physiological – yellow, milky or green does not occur spontaneously

melva
Download Presentation

Breast Presentations in General Practice

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Breast Presentations in General Practice Dr Therese Ryan GP Discipline Academic Supervisor Bundaberg Rural Clinical School

  2. Nipple discharge • Mastalgia • Gynaecomastia • Breast lumps • Breast cancer Learning Objectives

  3. Physiological – • yellow, milky or green • does not occur spontaneously • can be seen originating from multiple ducts • Pathological – • spontaneous & unrelated to pregnancy or lactation • unilateral • localised to a single duct • clear or blood-stained Nipple Discharge

  4. Aetiology • Duct ectasia • Intraductal papilloma • Nipple eczema • Breast cancer • Paget’s disease • Hyperprolactinaemia – pituitary/thyroid disease • Drugs – anti-HT; GI agents; hormones; opiates; psychotropic agents Nipple Discharge

  5. Investigation • Detailed history • Clinical examination – to exclude other signs • Express discharge – ask patient to do this • Mammography/ breast ultrasound – focus on retro-areolar region • Nipple discharge cytology – limited accuracy • Ductography Nipple Discharge

  6. Management • Physiological discharge requires no specific treatment. • Spontaneous, blood stained, single duct discharge that can be reproduced on clinical examination MUST be referred for microdochectomy. Nipple Discharge

  7. Cyclical • most breast pain • occurs in the second half of the menstrual cycle & resolves with the onset of menses • usually affects UOQ’s • usually symmetrical • described as “dull”, “heavy” or “aching” • may be accompanied by swelling/lumpiness • usually occurs in younger women & abates after menopause Mastalgia

  8. Non-Cyclical • may occur at any stage of cycle • not influenced by the cycle • occurs in older women • descriptors – “tight”, “burning” or “sore” • more likely than cyclical mastalgia to be associated with breast pathology • medications – digoxin; frusemide; spironolactone; some SSRIs Mastalgia

  9. Non-Breast • abdominal – gallstones; oesophagitis • cardiac (red flag) • respiratory - pneumonia • chest wall – e.g. Tietze’s syndrome; intercostal muscles; ribs Mastalgia

  10. Investigations • thorough history • clinical examination • investigate significant symptoms – mammography/ultrasound dependent on age & clinical findings Mastalgia

  11. Management • chronic condition - set realistic expectations • reassurance – may improve symptoms in up to 85% • appropriate bra • adjust oral hormones – e.g. COCP • analgesia prn • prescription medication – e.g. danazol, tamoxifen • lifestyle/complementary – low fat diet; caffeine reduction; EPO; vitamins B/E Mastalgia

  12. Lifestyle Modification • Caffeine reduction – anecdotal evidence only • Low fat diet – few well-conducted studies Complementary Therapies • EPO – no consistent evidence • Vitamins B/E – placebo-controlled trials do not support the efficacy Mastalgia

  13. Most patients are asymptomatic • Symptomatic – breast/nipple pain or tenderness; breast enlargement; breast lump Gynaecomastia

  14. Causes Physiological(25%) • Infancy – transient; 60 – 90% infants • Puberty – transient; 30 – 60% boys; should have resolved by age 17 • Aging Gynaecomastia

  15. Causes (cont.) Pathological(75%) • Therapeutic drugs– androgens; anabolic steroids; cyproterone; cimetidine; digoxin; spironolactone; metronidazole; metoclopramide; calcium channel blockers • Recreational drugs – alcohol; amphetamines; heroin; marijuana • Herbal agents – lavender; tea tree oil; dong quai; soy protein • Medical conditions – cirrhosis; hypo-gonadism; chronic renal failure; hyperthyroidism; obesity; primary adrenal/testicular/PRL secreting tumour; tumours with ectopic hormone production; Kleinfelter’s syndrome • Idiopathic (25%) Gynaecomastia

  16. RED FLAGS • > 2 years • Nipple discharge • Breast skin changes • Rapid breast enlargement • Firm breast mass • Testicular mass • Weight loss Gynaecomastia

  17. Management • Observation • Medical management • Surgical management – prolonged, severe, refractory cases Gynaecomastia

  18. http://canceraustralia.gov.au/sites/default/files/publications/ibs-investigation-of-new-breast-symptoms_504af03719a75.pdfhttp://canceraustralia.gov.au/sites/default/files/publications/ibs-investigation-of-new-breast-symptoms_504af03719a75.pdf Breast symptoms

  19. Pathology • Nodule of benign breast tissue • Fibroadenoma • Simple cyst • Abscess • Fat necrosis • Breast cancer Breast lumps

  20. Investigations • History & clinical breast examination PLUS • Medical imaging: mammography &/or ultrasound PLUS • Non-excision biopsy: fine needle aspiration cytology (FNAC) &/or core biopsy = TRIPLE TEST Breast lumps

  21. Triple Test • The triple test is positive if any component is indeterminate, suspicious or indicates malignancy. • A negative result on all 3 components of the triple test gives good reassurance that the symptom is not due to breast cancer. Breast lumps

  22. 2mm core of tissue which is submitted for histological analysis Requires local anaesthetic Complications: 1. bleeding 2. bruising 3. infection 4. pneumothorax Core Biopsy

  23. What investigations and where? Women with breast symptoms must be referred for diagnostic assessment rather than being referred to a breast screening service. Breast lumps Ref: NBOCC The investigation of a new breast symptom - a guide for general practitioners. February 2006

  24. What investigations? • In women < 35 years of age: ultrasound is recommended as the initial imaging modality. • Mammography should be added if the clinical findings are suspicious or the ultrasound findings are not consistent with the clinical findings. Breast lumps

  25. Risk Factors • being female! • increasing age • family history • inheritance of mutations in the genes BRCA2, BRCA1 and CHEK2 • exposure to female hormones (natural & administered) • obesity (poor diet & inadequate exercise) • excess alcohol consumption - > 3 drinks per day Breast Cancer

  26. Family History • multiple relatives affected by breast (male or female) or ovarian cancer • young age at cancer diagnosis in relatives • relatives affected by both breast & ovarian cancer • relatives affected by bilateral cancer • Ashkenazi Jewish ancestry Breast Cancer Ref: NBOCC - Advice about familial aspects of breast cancer and epithelial ovarian cancer - a guide for health professionals December 2010

  27. Breast cancer is the malignancy most often cited in delayed diagnosis claims against GPs. Breast Cancer

  28. Breast Cancer

  29. Symptoms • lump or thickening in the breast or axillary tail • nipple discharge • nipple changes – inversion; deviation; skin changes • dimpling of the skin of the breast • peau d’orange • pain alone (rare) Breast Cancer

  30. Investigation Triple test Breast Cancer

  31. Mammogram Histology Breast Cancer

  32. Management • Surgical - wide local excision (WLE) - surgery to the axilla - mastectomy (+/- reconstruction) • Radiotherapy • Chemotherapy • Hormonal therapies – hormone receptor positive tumours; e.g. tamoxifen; anastrozole • Targeted therapies – e.g. trastuzumab Breast Cancer

  33. Accounts for <1% of all breast cancers Most common risk factors are: • Age - occurs more commonly in those aged ≥50 years; • A strong family history Signs of breast cancer in men: • Painless lump – most common symptom • Discharge from the nipple/shape change of breast • Any unusual pain/swollen axillary lymph nodes Men and Breast Cancer

  34. Definition of Screening The presumptive identification of unrecognised disease or defects by means of tests, examinations, or other procedures. (modified from WHO, 1968) Breast Cancer Screening Ref: Population Based Screening Framework - www.cancerscreening.gov.au

  35. Eligibility • Specifically designed to target women 50 to 69 years as this is the age group most at risk of developing breast cancer. • Also accept women in their 40s or ≥70 years. • Women < 40 are not routinely screened: • no current evidence that screening mammography is effective in detecting early stages of breast cancer in this age group; • concerns about the effect of regular mammograms on young breast tissue; & • young breasts generally have denser tissue which may make it difficult to see breast cancer. Breast Cancer Screening

  36. Why a specific age group? • All women are at risk of developing breast cancer. However, the risk increases with age. • 75% of women diagnosed with breast cancer are over 50. • Research to date has found that women in the 50 to 69 years age group are at the most risk of developing breast cancer. This is also the age group in which the benefit of breast cancer screening has been shown to be the greatest. Breast Cancer Screening Source: BreastScreen Queensland

More Related