APPROACH TO

BREAST DISEASE
PRESENTERS :
SIVARANI KASIRAJA MBBS0919244
NAQIB
IZZUL MBBS0919224
 CONTENT

1- INTRODUCTION

2- CASE SCENARIO & DISCUSSION

3- COMMON CONDITION IN BREAST LUMP

ANATOMY
● Lies in superficial fascia pectoral region.
● Breast is generally described as overlying the 2nd - 6th ribs,
extending from lateral border of the sternum to the anterior
axillary line.
● Modified sweat gland and accessory organ of female
reproductive system.
● Nipple ; at the level of 4th intercostal spaces, pierced by 15 to
20 lactiferous ducts.
● It contains circular and longitudinal smooth muscle fibers.
● Areola ; pigmented skin around nipple.
INVESTIGATIONS
 1) MAMMOGRAPHY
⬡ Mammography is a radiographic modality to detect breast pathology
and cancer.
⬡ Soft tissue radiographs are taken by placing the breast in direct
contact with ultra sensitive film and exposing it to low voltage, high
amperage x-rays.
⬡ Sensitivity in women > 50 years old. 98% fatty breast because of this
masses are easy to seen on mammogram, unlike younger females their
breasts are more dense fibroglandular and difficult to see.
⬡ When we want to see lesion we should see in the 2 views ( CC, MLO ) to
determine in which quadrants.
 2) BREAST ULTRASOUND

● US is particularly used in young women with dense breasts.

● It can also be used to localise impalpable areas of breast
● Imaging characteristics : size, shape,border definition, internal
echogenicity, posterior enhancement and any architectural changes.
 3) MAGNETIC RESONANCE IMAGING
● Breast MRI is currently the most sensitive detection technique for breast cancer
diagnosis.
● The patient is placed in prone position with the breasts in the cups of the coil.
● Patient comfortable is vital, as the breast examination can last 30 minutes or
longer.
 4) NEEDLE BIOPSY/CYTOLOGY

● Histology can be obtained under local anaesthesia using spring

loaded core needle biopsy device.
● Cytology is obtained using a 21G or 23G needles and 10mL syringe
with multiple passes through the lump.
● The aspirate is then smeared on to a slide, which is air dried or
fixed.
● FNAC is least invasive technique of obtaining a cellular diagnosis
and is rapid and very accurate.
BREAST INCISIONS
1. Inframammary incisions
- incisions is made at the breast crease where breast meets the ribs
- Gives best visualisation of the tissues
- Scars are hidden in the lower crease of the breast.

2. Periareolar incision
- made around the nipple.
- This incision allows the surgeons to easily access the internal breast tissues.
- Few visible scars
- Best to correct nipple inversion, to remove lumps nearer to areola around 5cm,
abscess near areola.
- Difficulty in breast feedings.

3. Transaxillary incisions
- incisions made in the folds of the armpit, and a channel is cut to the breast.
- Commonest incision for breast implant.
 HISTORY OF PRESENT
ILLNESS
History taking
Case scenario
● a 40 years old Malay housewife with underlying right breast carcinoma post mastectomy
with axillary clearance, was electively admitted for 4th cycle of chemotherapy.
➔ History of present ilness ( HOPI)
● In mid Nov 2018, She started to notice lump over right breast, outer quadrant, about the
● size of a marble, mobile and sometimes causing discomfort/ painless.
● went to KK and was reffered to hospital. USG was done and showed abnormal/ atypical
● cells present with suspected of malignancy. USG was repeated five times.
● biopsy was done and confirmed carcinoma.
● Mammogram showed features of malignancy in right breast. otherwise left breast is
● normal.
● right mastectomy with axillary clearance was done on 8.9. 2019. CT TAP ( 28.1.2019)
● showed lungs metastasize and probable in thyroid.
● Further evaluation by USG of neck was done however patient could not recall the result.
 Systemic Review
● General : NO Fever or chills, Poor appetite since Nov 2018, but no changes in
● weight, NO night sweats
● HEENT: NO Headache, NO changes in vision, hearing or smell and NO difficulty
● in swallowing.
● CVS: NO palpitation or chest pain
● Respiratory: NO shortness of breath or cough.
● Gastroenterology: NO constipation or diarrhoea, NO bleeding or change in color.
● Genitourinary: NO blood or foul smell or burning sensation.
● Dermatology ( breast): NO discoloration fo skin over right breast, no nipple
● discharge, no ulceration, no skin changes and nipple was normal as left breast.
● Musculoskeletal: NO pain / swelling/ stiffness in muscle / joint/back.
● CNS: NO numbness or weakness. NO nausea.
● Endocrine: No hot or cold intolerance. No loss or gain of weight.
 Previous gynecological history
menarche at age of 16 and had menopause at 56 years old.
She denies taking any hormonal therapy and breast fed all her children up to 2 years.
Past Medical History
➔ Bronchial Asthma
➔ diagnosed at age of 9. Last attack was in March 2019 requiring one time nebulizer at A&E.
Currently
on Salbutamol PRN, seratide accuhaled 2 puffs BD.
➔ HTN
➔ Diagnosed post partum 31 years ago, Currently on T. Felodipine. Patient is moderarely
compliant to
her medications.
➔ Cholecystitis
➔ On conservative treatment. Not keen for cholecystectomy.
➔ DM
➔ Dignosed post partum 31 years ago. only on diet control.
➔ Thyroid
➔ Inoperable due to attachement to trachea. Stridor and horseness of voice. sweating and
mood
swings.No dysphagia or dyspnea. Not on medications.
 Past surgical history
● undergone bilateral tubal ligation 31 years ago while she was diagnosed
with stillbirth.
Family History
● Father deceased at age of 72 years old ( due to stroke secondary to
● hypertension)
● Mother (86 years old) with no known medical illness and still alive.
● present of family history of malignancy associated with breast cancer
which was her late brother ( colon carcinoma that metastasize to his
liver)
● Her daughter has lumpectomy.
● One siblings has cardiac disease and was undegone pacemaker
implantation.
● Other siblings have no known medical illness.
Physical examination
General examination
General appearance
⬡ alert
⬡ lying supine position
⬡ not in distress
⬡ obese
Vital signs
⬡ Tempt: 36.9 C
⬡ PR: 70 BPM
⬡ BP:146/72 mmHg
⬡ RR: 18 breaths per minute
⬡ O2: 98%
Hands
⬡ no clubbing
⬡ no peripheral cyanosis
⬡ no palmar erythema
⬡ normal sensation
 Head and neck
● no swelling
● slightly pallor
● no jaundice
● no central cyanosis
● no mouth ulcers
Legs
● no pitting edema
● no swelling
● no redness
● normal sensation
 Local examination
Upper breast examination
Right breast.
● horizontal scar over right chest extending from parasternum to
anterior axillary line. scar is well healed ( no keloid or hypertrophic
formation)
● no ulceration, no visible mass, no skin changes, no palpable mass in
both breast.
● Hyperpigmentation of skin over right chest ( probably due to
chemotherapy)
Left breast
● was normal
● No visible mass, No ulceration, no skin changes or discoloration.
● Nipple was normal, no discharge, no distended vein over both sides
of chest.
 Lymph node examination -> No lymphadenopathy
Lungs and spine -> normal
Neck examination
● Midline swelling measuring 3cmX3cm, round shape, non
tender, no ulceration, moves with deglutition, can pinch,
surface is smooth, soft in consistency, no discoloration.
Abdominal examination
● No hepatosplenomegaly
● Abdomemen is soft non tender.
● Midline incisional scar infraumbilical to suprapubic
● measuring 20 cm. Scar is well healed and no keloid/
hypertrophic scar formation.
● No organomegaly
 Provisional diagnosis
⬡ Right breast carcinoma post mastectomy
⬡ reasons:
⬡ painless lump in right breast.
⬡ age ( elderly +35)
⬡ loss of appetite ( distant recurrance)
⬡ had done USG previously and it showed atypical cells with suspected
malignancy.
⬡ family history of breast cancer.
⬡ obesity ( higher risk for recurrence)
 Differential diagnosis
⬡ Cyst
- age 30-35 ⬡ Phyllodes Tumor
- painless/ painful
- smooth surface, well defined edges ⬡ Area of fibroadenosis
- soft,firm, fluctuant consistency
- mobile
-
⬡ Fibroadenoma
- below 30 years old
- Painless
- smooth surface, bosselated margins
- firm rubbery consistency
- very mobile
Investigations and Management
for Breast Carcinoma
 INVESTIGATION
⬡ Triple assessment
- clinical examination
- A radiological assessment (mammory / ultrasound)
- A histopathological assessment (cytology/ biopsy)

All 3 must be concordant for benign to have >99% specificity to relate to

malignancy
1) Breast Imaging Mammography
⬡ most sensitive.
⬡ performed in asymptomatic older women (>40YO) but >35 YO in symptomatic
women.
⬡ 2 views:
- Craniocaudal ( CC)
- Right/ left
70% tumors of lateral quadrant ( upper)
⬡ Mediolateral oblique ( MLO)
- captures the tail
- Right/ left
- 80% tumors in oblique milky way.
- can look at axilla -> any enlarged lymph nodes
Malignant mammographic findings
⬡ New / spiculated masses
⬡ Clustered micro- calcifications in linear or
⬡ branching way
⬡ architecture distortion

Benign Mammographic findings

⬡ Radial scar
⬡ Fat necrosis
⬡ milk of calcium
BI-RADS ( Breast Imaging Reporting and Data System)
Classification
 Ultrasound
⬡ 1st investigation in young patients (<35 YO), pregnant, lactating patient
⬡ NOT gold standard for screening
⬡ sensitivity -> 98.4%, negative predictive value -> 99.5%
Uses
⬡ diff. both palpable and mammographic lesions as either cystic or solid
⬡ Subsequent characterization and classification fo solid nodules
⬡ guide procedures
⬡ evaluation fo palpable mass with a negative mammogram
⬡ evaluation of mammographically-difficult areas
Pitfalls:
⬡ Operator dependent, non standardised technique, poor resolution
⬡ unable to detect most micro calcifications
 Malignancy features
⬡ borders = spiculation, microlobulation, angular margins
⬡ Internal calcification
⬡ Taller > wide
⬡ Central vascularity/ compressibility
⬡ hypoechoic nodule / posterior acoustic shadowing
Benign features
⬡ smooth margins, well circumscribed
⬡ Thin echogenic capsule
⬡ Ellipsoid shape ( wide > deep)
⬡ Macrolobulation
⬡ Hyperechogenicity
 MRI of breast
⬡ Expensive but good soft tissue definition without radiation
( >90% sensitivity)
Indications
⬡ occult lesions: Axillary LAD but Mammography & US -ve
⬡ determine extent of the disease
⬡ assessment of response to neoadjuvant chemotherapy
when planning for breast conservation surgery
⬡ screening in high risk patients
3) Breast Biopsy
options available
fine needle aspiration/ cytology ( FNAC)
Core biopsy ( Trucut/ mammotome)
Incisional / excisional biopsy
 Management ( Therapeutic options)
A. Loco-regional control
• surgery
• radiotherapy

B. Systemic treatment
• chemotherapy
• hormonal therapy
• targeted therapy
Surgery

1. Preparing for operation

• anasthesia workup and necessary imaging. mark out the site
• psychological counselling, consent taking, discuss breast
reconstruction]

2. Wide excision
• removal of tumor with clear margins, with good cosmetic result
• Criteria :
• <T2: tumor size <5cm in size, no skin or chest wall involvement
• only 1 tumor, not multicentric/ multiple DCIS/ LCIS unless same quadrant
• no metastatic disease
• appropriate tumor size-to-breast ratio
• patient must agree to post-operative radiotherapy
• result -> overall survival at 25 years, with slightly higher local reccurance
rates

3. Simple Mastectomy
• removal of breast tissue, nipple-areolar complex and
overlying skin
• lower rates of local recurrance
4. Axillary clearance
5. Palliative surgery
6. Breast Reconstruction
Radiotherapy
1. Adjuvant
2. Palliative

Chemotherapy

1. Neoadjuvant
• given in stage 3 to shrink tumor before surgical resection.
• 20% achieve complete clinical response and further 20% will achieve
complete
pathological response.
2. Adjuvant
• typical regimen : 6-8 cycle of FEC ( all 3 drugs injected on first day of
each 3 week cycle)
• preferred for premenopausal patients.

3. Palliative
• Anthracycline and Taxanes are the mainstay.
• help reduce load of disease to alleviate symptoms, increase surviva
 Hormonal Therapy

⬡ used in adjuvant setting to eradicate micrometastases.

⬡ for ER/PR +ve -> 90% response
⬡ preferred for postmenopausal women.
⬡ reduces risk in contralateral breast.
⬡ Classes:
⬡ Selective Oestrogen receptor modulators ( SERMS): Tamoxifem
⬡ Aromatase Inhibitors: Lanastrazole, Ietrozole, Exemastane

Targeted Therapy ( Herceptin)

⬡ administed IV monthly for 12 months

⬡ targets Her-2-neu/ C-erbB2
⬡ used in C-erB2 positive tumors.
 Management ( Tumor Stage)
1. Ductal Carcinoma In Situ ( non -invasive)
- Surgical excision ( partial mastectomy/ total
mastectomy) with margin >10mm with adjuvant
radiation

2. Lobular Carcinoma in Situ

- life-long surveillance
- bilateral total mastectomies with immediate reconstruction ( high risk
patients)
- Prophylaxis with Tamoxifen/ Raloxifene ( for post-M women)
3. Stage 1 and Stage 2 Early invasive breast cancer
• Curative intent - lcear surgically with adequate margins
• Breast conservation therapy ( BCT)
• Neoadjuvant chemotherapy or hormonal therapy
• Partial mastectomy with SLNB
• Non conservative therapy ( Mastectomy)
• Immediate reconstruction

4. Stage 3 locally advanced breast cancer ( non inflammatory)

• Neoadjuvant chemotherapy
• Neoadjuvant Herceptin
• Surgical Excision
5. Locally Advanced breast cancer
• investigate with skin punch biopsy
• approx. 30% have distant mets at time of diagnosis
• Agressive multimodular therapy ( early 4 cycles of FAC) -
fluorouracil + doxorubicin +cyclophosphanamide then
followed by additional 4 cycles of FAC then adjuvant
radiation therapy.

6. Stage 4 Invasive advanced breast cancer

• Intention : Palliative, aim to disease control.
• systemic therapy is the main stay of treatment - CT, HT or
TT.
COMMON CONDITIONS
OF BREAST LUMPS
1. BREAST CYST
- fluid filled sacs inside the breast.
- Usually non cancerous.
- One/multiple breast cysts.
- Common in pre menopause women.
- smooth, movable.
- presented with breast pain & tenderness .
- Nipple discharge - clear, yellow, straw coloured or brown.

2. BREAST FIBROADENOMA
- solid, non cancerous.
- most common benign breast in young women.
- Painless
- Firm or rubbery
-
3. FAT NECROSIS
- lump of dead or damaged breast tissue that appears after breast surgery, radiation
or another trauma.
- Harmless and doesn’t increase risk of cancer.
- older women with large breast are at increased risk.
- Firm lump or mass on the breast.
- Usually painless, but can be tender
- Redness, can feel the same as breast cancer ; to differentiate?

4. INTRADUCTAL PAPILLOMA
- smalL benign tumour that forms a milk duct in the breast.
- Present of breast enlargement, lumps & niple discharge, some might have pain or
discomfort in breast.
THANK YOU