Evaluation of Breast Problems

Points to evaluate in Breast Mass

& Benign Breast Disease - Site → most common site: upper outer quadrant
Surgery II - Shape
Dr. Fernandez - Size → important: the bigger it is the more chance of
January 17, 2007 malignancy
- Borders → malignancy have ill-defined borders
- Consistency → Benign conditions → rubbery like balls of
hand; Malignancy → hard like knuckles of hand
- Mobility → Benign: mobile; Malignancy: fixed
- Tenderness (not a sign of cancer)

Orange Peel → late sign of malignancy; a sign of subdermal

lymphatic involvement

Breast Imaging
- Most women who present to a surgeon for evaluation of a
- Mammography, ultrasonography, and ductography: the proven
breast problem do not have cancer
breast imaging methods
- For both patient and physician faced with any breast problem,
- MRI and PET: promising methods
differentiation between benign or malignant disease is the
- Imaging methods are complements to, not substitutes for, a
most important issue
thorough history and PE
- History and PE can already give

In mammography → breast have to compressed as thin as

Usually 80-90% of cases are benign, malignancy is not that
possible
common
Mammography
Age
- Indications:
- Breast cancer risk increases with age
- Indeterminate mass suspicious of cancer
- Indeterminate mass that can not be considered a dominant
Incidence of Cancer
nodule
- In a study of 951 breast biopsies performed in young women
- Prerequisite before BCT (Breast Conservation Technique)
<21 y/o 0%
- Since we have to check for other lesions, presence of
21-25 y/o 1.3% which indicates that BCT cannot be done
26-30 4.0% - Follow up of patients following BCT
- Follow up of contralateral breast
Family History - Since the greatest risk for breast cancer is a history of
- Institute of Public health UK cancer on the other breast
Relative Risk of Cancer - Huge breasts → only for Caucasians
2nd degree relative 1.5
BCT Have parallel
1st degree 2.1
Radical Mastectomy → gold standard result
Mother 2.0 - Although sensitive, this is not specific
Sister 2.3 - 25% of nonpalpable lesions detected are found to be malignant
Mother and Sister 3.6 at biopsy
- Sine qua non: Spiculated density with ill-defined margins →
almost 100% cancer
Reproduction and Menstrual History - Features that are suggestive but not diagnostic of cancer
- Breast cancer risk increases with early menarche and late includes:
menopause - Clustered microcalcifications
- Early full term pregnancy is protective → pregnancy allows a - Asymmetric density
9 month rest from monthly estrogen cycles - Ductal asymmetry
- Breast feeding is protective → prolactin: menstruation stops - Distortion of skin, nipple, normal breast architecture
- Multigravida is protective → longer rest from exposure
- Nulligravida is a risk Guidelines (ACS)
- Therefore high incidence of cancer in nuns - Self-Breast Examination (SBE) at 20 years old

Factor here is Estrogen Exposure - Consultation Breast Examination (CBE) every year after 30

What is important is the periodic estrogen exposure years old
- Baseline mammography at 40 years old
Other Risk Factors - Consult doctor for need of regular mammographic screening
- Obesity (fatty diet) → due to estrogen from peripheral between 40-50 years old
conversion of fat - Annual mammography thereafter → earlier if individual is at
- Radiation exposure higher risk: history of breast cancer, obesity
- Hormone replacement therapy for menopausic women Note:
- Oral contraceptives
10% to 50% of cancers detected mammographically are not
palpable.
Self-Breast Examination
10% to 20% of palpable tumors not detectable mammographically.
- Look for asymmetry, retractions
- Palpation can be from outside to in inwards or vice-versa

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Digital Mammography Nipple Discharge
- Lesser pressure - 10 to 15% of benign breast disease
- Can have 3D view - 2.5 to 3% of women with breast cancer
- Classification: Physiologic vs pathologic
Needle Localization Technique - Most common condition: Intraductal papilloma
- Uses needle with hook - When mass is associated cancer must be considered
- Patient has to be awake and upright during the procedure
Bloody nipple discharge → most common reason is a benign
- Able to get cancer at an early stage condition; also intraductal papilloma
- Procedure: mammogram → insert needle to serve as guide
→ surgery → excise around the guide → send to histopath Nipple Discharge
→ if borders still have malignant lesions → reoperate
Benign Malignant
Ultrasound
- The most useful feature is its ability to distinguish between
cystic and solid masses
- Cystic → benign Physiologic Duct Duct
- Solid → malignant Papilloma Ectasia
- It is not an effective screening test for cancer (cannot detect
microcalcifications or small lesions) Management of Nipple Discharge
- May help to confirm the diagnosis of a cyst or support a clinical Nipple Discharge
impression of fibroadenoma

Cheap and not painful

Common Breast Problems Physiologic Pathologic

- Tenderness
- Mass
Compression
Spontaneous
- Nipple Discharge
Clear, white,
Bloody with a
yellow or dark mass
Breast Tenderness green
Unilateral
- Most common reason for consultation
Bilateral
Single duct
- More common in premenopausal (reproductive age)→ breast
Multiple duct
are full and edematous prior to menstruation; however subject
to individual difference
- Estrogen (monthly cycles) → inflammation of breast →
Spontaneous e.g. upon removal of brassiere
withdrawal of estrogen → scarring → fibrocystic change
- Rarely a symptom of cancer Management of Nipple Discharge
- Etiology is unknown

Tenderness Physiologic Pathologic

Localization of affected
Normal Fibrocystic Abscess > 35 years old duct mammography for
variant change nonpalpable mass or
calcifications
Mammogram
Do history and physical
examination

Normal variant: normal palpation Negative Positive Biopsy

Fibrocystic change: due to estrogen stimulation; scarring; palpation
would give a “mongo seed” feel/bumpiness

Abscess: with signs of inflammation
Reassurance Benign Malignant
Evaluation and Management of Breast Pain
Breast Pain Intraductal Papilloma
- Cannulate 1 opening and inject contrast medium
- “filling defect” on xray
History and PE: Normal
Breast Masses
- Diagnosis, work-ups and treatment dependent upon the age at
presentation
Patient’s age <35 years Patient’s age ≥ 35 years - Postmenopausal women
- Patients most prone to carcinoma
- Evaluation relatively straightforward
Reassurance Mammogram - After obtaining bilateral mammograms (to screen for
concurrent, clinically unappreciated lesions) → biopsy of
the palpable mass is indicated
Persisting Pain
Cannot observe only
Normal
- For women younger than 30 years of age
- A well-circumscribed discrete breast mass suggests the
Pain relievers presence of a simple cyst, fibroadenoma, or fibrocystic
changes
- Ultrasound can confirm the diagnosis of a simple cyst or
Danazol
support a diagnosis of fibroadenoma

Danazol → anti-follicle stimulating hormone - Either lesion may be followed safely in a young patient

Highest percentage is 4% for malignancy

Most common lesions are benign

Observe only!!!

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 - In a study of 951 breast biopsies performed in young Treatment
women Incidence of cancer: - Below 25 y/o: observation
- 0% <21 y/o - Age 25-35 y/o: observation/excision
- 1.3% 21 to 25 y/o - Above 35 y/o: excision
- 4.0% 26 to 30 y/o
- Premenopausal (“Gray Area”) B. Fibrocystic Change
- Evaluation of breast masses between age 30 and - 35-50 (premenopausal)
menopause is problematic (presence of functional, cycling - Presentation is tenderness
glandular tissue combined with a progressively increasing - To differentiate from premenstrual pain → age: fibrocystic
incidence of cancer) change tends to occur in older women
- Bilateral mammograms to look for concurrent nonpalpable - Pain with multiple cystic lesions/single dominant mass
disease - Result of prolonged cyclic stimulation of repeated menstrual
- Definitive diagnostic procedure cycle
- Not premalignant except those with atypical hyperplasia
Algorithm for Evaluating A Discrete Breast Mass Diagnosis
- History
1. Localization followed by biopsy - Physical examination
- Mammography
- Biopsy
Treatment
- Reassurance → since it is not malignant/premalignant
- Pain management
- Aspiration of cystic lesion
- 3 Treatments shown by RCT to be effective:
1. Caffeine free diet
2. Abstinence from smoking
3. Danazol

Usually presents as nevus on breast; like birthmark

Stops when menstruation stops e.g. pregnancy

Biopsy
A. Palpable mass
1. Fine needle aspiration biopsy → most common
2. Trucut biopsy → uses a big needle; ABBI
3. Incisional biopsy → for big lesions
4. Excisional biopsy → for small lesions; gold standard
B. Non-palpable mass
- Localization followed by biopsy
C. Phylloides Tumor
- Previously called Cystosarcoma Phylloides → since it is not
sarcoma
- Mesenchymal and epithelial components
- Rapid growth
- Benign: if local invasive → obviously malignant
- Rarely metastasizes to the axillary lymph nodes
Treatment
- Wide local excision → with normal rim of tissue while
small, if big sometimes would need mastectomy
- Axillary dissection usually not necessary → since there is
not lymph node involvement

Sometimes it can grow to enormous proportions → to differentiate
from malignancy: look at axillary lymph nodes → usually there is no
involvement in phylloides tumor

FNAB → 22-23 gauge needle

Core → 21 gauge needle

Mammotome → uses vacuum

For both patient and physician faced with any breast problem,
differentiation between benign or malignant is the most important
issue.

Once it has been established that the patient does not have cancer,
definition of the precise histology is less important that provision of
symptomatic relief.

Benign Diseases of the Breast

A. Fibroadenoma
- Benign fibroepithelial neoplasm
- 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

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D. Intraductal Papilloma
- Unilateral bloody nipple discharge
- Nonpalpable
- If mass is present, think of cancer
- Solitary involvement of the duct

E. Physiologic Gynecomastia
- Neonatal
- Adolescence
- Senescence
Causes:
1. Estrogen excess state
2. Androgen deficiency states
3. Drug-related
4. Systemic diseases

F. Acute Mastitis
- Staphylococcus aureus/Streptococcus
- Usually related to lactation
- From cellulitis to frank abscess formation

G. Chronic Mastitis
- Recurrent abscess formation
- Draining sinuses
- In the Philippines → think of TB

Summary
- Most common: pain, discharge, mass
- Most of these women have benign disease
- Breast pain alone is rarely a cancer symptom and imaging
should be reserved for those that fall within the usual
screening guideline
- Nipple discharges are physiologic or pathologic
- Pathologic discharge is an indication for terminal duct biopsy
- Dominant mass requires histologic diagnosis
- Breast cyst can be diagnosed and treated by aspiration.
- The management of solid mass depends on the degree of
clinical suspicion and the patient’s age

Transcribed by: Fred Monteverde

Denise Zaballero
Notes from: Emy Onishi
Charlene Santos
Pictures from: Angel Mejia
Powerpoint from: Mitzel Mata

Fred Monteverde
Emy Onishi
Mitzel Mata
Cecile Ong
Regina Luz
Mae Olivarez
Section C 2009