Benign and Malignant Conditions of the Breast Reynaldo

Benign and Malignant Conditions of the Breast Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg Orlino Bisquera, MD 2014

Overview of the Breast Health Problem Benign Conditions of the Breast Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg UPM Centennial Professorial Chair (2008) Retiree (2014) – Clinical Faculty (2014) 2014

Malignant Conditions of the Breast Orlino Bisquera, MD 2014

Complementary Reading Material Benign and Malignant Conditions of the Breast Module – Self-instructional Program Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg

Benign and Malignant Conditions of the Breast General Learning Objectives – To familiarize with the more common benign lesions of the breast, pathophysiology, diagnosis and corresponding treatment. – To familiarize with the different malignancies arising the breast, its diagnosis, and management.

Benign and Malignant Conditions of the Breast Specific Learning Objectives – Enumerate at least 10 more common breast disorders seen in the Philippines. – Classify the breast disorders into benign and malignant conditions.

Benign and Malignant Conditions of the Breast Specific Learning Objectives – Categorize the breast disorders by primary causes • • malignant neoplasms benign neoplasms aberration of normal development and involution or ANDI infection

Benign and Malignant Conditions of the Breast Specific Learning Objectives – Identify the most probable breast disorder present in patients presenting with a set of symptoms and signs referable to the breast.

Benign and Malignant Conditions of the Breast Specific Learning Objectives – Enumerate at least 4 more common paraclinical diagnostic procedures being done for patients with possible breast disorders. – Identify the usual indications for the different diagnostic procedures commonly used in patients for possible breast disorders.

Benign and Malignant Conditions of the Breast Specific Learning Objectives – Identify which breast disorders can be monitored and which should be actively treated.

Benign and Malignant Conditions of the Breast Specific Learning Objectives – Given a pretreatment diagnosis of a breast disorder with the stage of the disorder, indicate the usual goal of treatment and its corresponding recommended primary treatment.

Benign and Malignant Conditions of the Breast Specific Learning Objectives – Advice patients with nonspecific mastalgia or mastalgia secondary to hormonal changes. – Identify at least two general indications for referral to a breast specialist.

RJOSON’s Session Are the learning objectives clear? enough? Want to add more?

OVERVIEW OF BREAST HEALTH PROBLEM

BREAST HEALTH PROBLEM Any condition on the breast that affects the biopsychosocial well-being of an individual can be considered as a “breast health problem”

BREAST HEALTH PROBLEM Three categories: • breast feeding problem • breast sexuality problems • breast disorders

Benign and Malignant Conditions of the Breast Learning Objectives – Enumerate at least 10 more common breast disorders seen in the Philippines.

MORE COMMON BREAST DISORDERS IN PHILIPPINES 1. Breast cancer 2. Fibroadenoma 3. Macrocyst 4. Galactocoele 5. Mastitis and breast abscess

MORE COMMON BREAST DISORDERS IN PHILIPPINES 6. Intraductal papilloma 7. Benign cystosarcoma phyllodes or phyllodes tumor 8. Tuberculosis of the breast 9. Paget’s disease of the nipple (a type of breast cancer) 10. Mammomegaly (virginal hypertrophy in females; gynecomastia in males)

MOST COMMON BREAST CONDITION (NOT DISEASE / DISORDER) IN PHILIPPINES Fibrocystic Breast Condition Fibrocystic Breast Changes Fibrocystic Changes Lumpiness of the breast with / without pain Hormonal changes Normal

Benign and Malignant Conditions of the Breast Learning Objectives – Classify the breast disorders into benign and malignant conditions. – Categorize the breast disorders by primary causes • • malignant neoplasms benign neoplasms aberration of normal development and involution or ANDI infection

Classification and Causes – Breast Disorders CONDITIONS Benign (non-malignant) CAUSES ANDI* INFECTION DISORDERS BENIGN NEOPLASM Malignant MALIGNANT NEOPLASM Breast Cancer Fibroadenoma Macrocyst Galactocoele Mastitis and breast abscess *ANDI – Aberration of normal development and involution

Classification and Causes – Breast Disorders CONDITIONS Benign (non-malignant) CAUSES ANDI INFECTION DISORDERS BENIGN NEOPLASM Intraductal papilloma Phyllodes tumor MALIGNANT NEOPLASM Tuberculosis of the breast Paget’s disease of the nipple Mammomegaly Malignant *ANDI – Aberration of normal development and involution

Classification and Causes – Breast Condition / Disorders CONDITIONS Benign (non-malignant) CAUSES ANDI DISORDERS Fibrocystic Breast Condition Fibroadenoma Macrocyst Galactocoele Mammomegaly INFECTION BENIGN NEOPLASM Malignant MALIGNANT NEOPLASM *ANDI – Aberration of normal development and involution

Benign and Malignant Conditions of the Breast Learning Objectives – Identify the most probable breast disorder present in patients presenting with a set of symptoms and signs referable to the breast.

CLINICAL PRESENTATION and DIAGNOSIS OF BREAST DISORDERS BREAST DISORDER MANIFESTATIONS (SYMPTOMS AND SIGNS) Processes Pattern Recognition Prevalence CLINICAL DIAGNOSIS

How to formulate a clinical diagnosis using processes of pattern recognition and prevalence Pattern Recognition - realization that patient’s presentation (signs and symptoms) conforms to a previously learned picture or pattern of disease. Prevalence - choice of diagnosis is based on frequency of occurrence of disease in a certain locality, certain age and sex group, and in affected organ and system.

Breast Complete Physical Exam • Inspection • Palpation • Squeezing the nipple for discharge • Axillary palpation

Breast Physical Exam • Inspection of the breast – Look for gross abnormality!

Gross Abnormalities of the Breast • • Unilateral gigantic breast Erosions of the nipple Skin retraction Ulcerations Fungating mass Erythema Nipple discharge

Breast Physical Exam • Palpation of the breast – Ask before palpating!

Palpation of the Breast • Look for pathologic lumps! – Dominant lumps • Take note of fibrocystic changes! – Hormonal changes – Lumpy breast substance

Pathologic Breast Lump Data needed • Size (in cm in its greatest diameter) • Nature (solid or cystic) • Consistency (hard or not hard – firm/ soft) • Tumor border (well-defined or ill-defined) • Tenderness (presence or absence) • Mobility (movable or fixed – overlying / underlying tissue)

Breast Physical Exam • Gently squeeze the nipple for any discharge. • Take note of color of discharge!

Breast Physical Exam • Axillary palpation – Search for palpable lymph nodes

Algorithm for clinical diagnosis of breast mass Signs of Inflammation Positive Negative Signs of Malignancy Positive Negative Signs of Benignity

Diagnostic Process Diagnosis Look for signs of inflammation • Pus • Erythema • Warmth • Tenderness Presence of erythema is enough basis to suspect inflammation! Take note though of “Inflammatory breast cancer”!

Breast Abscess Gram +; Staph aureus Inflammatory breast cancer

Diagnostic Process Diagnosis Look for signs of malignancy • Hard consistency • Ill-defined border • Local invasion • Fixation • Regional spread • Distant spread Presence of ONE sign of malignancy is enough basis to suspect malignancy!

Signs of Malignancy Peau d’ orange Inflammatory carcinoma Carcinoma en cuirasse

Diagnostic Process Diagnosis Look for signs of benignity • Cystic nature of mass

Fibrocystic Changes Macrocyst

Algorithm for clinical diagnosis of breast mass Signs of Inflammation Positive Negative Signs of Malignancy Positive Negative Signs of Benignity

Breast Abscess

Mastitis

TB of the Breast

Galactocoele

Fibrocystic Changes Macrocyst

Nipple discharge due to nonspecific cause or fibrocystic changes

Intraductal papilloma Sanguinous discharge No mass

Intraductal Papilloma

Gynecomastia

Fibroadenoma

Fibrocystic Changes Lumpy breast – no dominant mass

Mammomegaly

Reduction Mammoplasty

Fibroadenoma vs Phyllodes Tumor

Phyllodes Tumor

Nipple retraction

Breast Cancer

Infiltrative Breast Mass

Peau d’orange (orange peel)

Paget’s Disease of the Nipple – areolar erosions

Contact dermatitis, nipple

Benign Conditions of the Breast

Time-out / Recap For questions and comments, • pls. text and send to 0918 -804 -03 -04 • or email: rjoson 2001@yahoo. com

Benign and Malignant Conditions of the Breast Learning Objectives – Enumerate at least 4 more common paraclinical diagnostic procedures being done for patients with possible breast disorders. – Identify the usual indications for the different diagnostic procedures commonly used in patients for possible breast disorders.

Benign and Malignant Conditions of the Breast Learning Objectives – Identify which breast disorders can be monitored and which should be actively treated.

CLINICAL PRESENTATION AND RECOGNITION OF BREAST DISORDERS • CLINICAL DIAGNOSIS – Differential diagnoses • Primary • Secondary • PARACLINICAL DIAGNOSTIC PROCEDURES (ANCILLARY DIAGNOSTIC PROCEDURES)

INDICATIONS FOR PARACLINICAL DIAGNOSTIC PROCEDURE • • DEGREE OF CERTAINTY OF CLINICAL DIAGNOSIS MANAGEMENT PLAN – Differences in mgt of primary and secondary diagnoses – Will the diagnostic procedure affect significantly your management?

COMMON PARACLINICAL DIAGNOSTIC PROCEDURES FOR BREAST DISORDERS • • Monitoring (observation) and constant analysis Biopsy (needle evaluation or open biopsy) Mammography Ultrasound

INDICATION FOR MONITORING If on initial evaluation, based on clinical findings, chances are, • • breast disorder is of a nature that it is NOT malignant and treatment is usually by monitoring and observation where no active treatment is needed Example: Fibrocystic changes

Needle Aspiration+/- Biopsy

Galactocoele

Open Biopsy

Mammography

Ultrasound of the Breast • Solid vs cystic • Cystic – implication of benignity • Solid per se – no diagnostic implication – may be benign or malignant • Complex mass – combination of cystic and solid component

Ultrasound of the Breast

Selection of Paraclinical Diagnostic Procedures – A Process Options Benefit Risk Cost Availability 1 ++++ ++ +++++ NA 2 ++ + ++ RA 3 +++ ++ +++ RA

Selection of Paraclinical Diagnostic Procedures Options Needle evaluation and biopsy Open biopsy Mammography Ultrasound Benefit Risk Cost Availability

Selection of Paraclinical Diagnostic Procedures Options Benefit Needle evaln Direct exam & biopsy and sampling Yield > 90% Open biopsy Direct exam and sampling Yield > 98% Mammo Indirect exam – imaging Malignant calcifications Ultrasound Indirect exam – imaging cystic vs solid Risk Cost Availability

Selection of Paraclinical Diagnostic Procedures Options Benefit Risk Needle evaln Direct exam & biopsy and sampling Yield > 90% Pain Hematoma No scar Open biopsy Direct exam and sampling Yield > 98% Pain / Hematoma Scar Anesthesia – side effect Mammo Indirect exam – Pain on compression imaging Radiation Malignant calcifications Ultrasound Indirect exam – Painless imaging cystic vs solid Cost Availa bility

Selection of Paraclinical Diagnostic Procedures Options Benefit Risk Cost Needle evaln Direct exam & biopsy and sampling Yield > 90% Pain Hematoma No scar P 2 T Open biopsy Direct exam and sampling Yield > 98% Pain / Hematoma Scar Anesthesia – side effect P 8 T Mammo Indirect exam – Pain on compression imaging Radiation Malignant calcifications P 2 T Ultrasound Indirect exam – Painless imaging cystic vs solid P 1 T Availa bility

Selection of Paraclinical Diagnostic Procedures Options Benefit Risk Cost Availa bility Needle evaln Direct exam & biopsy and sampling Yield > 90% Pain Hematoma No scar P 2 T RA Open biopsy Direct exam and sampling Yield > 98% Pain / Hematoma Scar Anesthesia – side effect P 8 T RA Indirect exam – Pain on compression imaging Radiation Malignant calcifications P 2 T RA Indirect exam – Painless imaging cystic vs solid P 1 T Mammo Ultrasound NRA RA

Breast Mass

Needle Aspiration+/- Biopsy

Time-out / Recap For questions and comments, • pls. text and send to 0918 -804 -03 -04 • or email: rjoson 2001@yahoo. com

Benign and Malignant Conditions of the Breast Learning Objectives – Given a pretreatment diagnosis of a breast disorder with the stage of the disorder, indicate the usual goal of treatment and its corresponding recommended primary treatment. – Advice patients with nonspecific mastalgia or mastalgia secondary to hormonal changes.

Benign and Malignant Conditions of the Breast Learning Objectives – Identify at least two general indications for referral to a breast specialist.

Breast Disorders Basic Principles of Management Goal of management: Resolution of the problem in such a way that the patient does NOT end up - dead, - with disability, - with complication, and in such a manner that the patient is satisfied and does NOT file a medicolegal suit.

PRIMARY GOALS AND MODALITIES OF TREATMENT OF BREAST DISORDERS Breast disorders based on causation Primary goals in treatment Aberrations of normal To allay anxiety and development and fear that the breast involution condition is cancer ANDI is NOT cancer ANDI does NOT lead to cancer! Infections To resolve the infection Primary modalities of treatment Advice and tempered assurance Monitoring and observation Analgesics, if needed Aspiration for cysts Excision for solid mass as a last resort Antibiotics Drainage / debridement

PRIMARY GOALS AND MODALITIES OF TREATMENT OF BREAST DISORDERS Breast disorders based on causation Primary goals in treatment Primary modalities of treatment Benign neoplasms To resolve the mass Excision Monitoring and observation for small fibroadenomas Malignant neoplasms To control the cancer Surgery, radiotherapy, chemotherapy, hormonal therapy, singly or in combination

Treatment of Breast Condition / Disorder Condition Disorder Observe Monitor Breast cancer & Paget’s disease Surgery Drugs (Chemotx Hormonal Antibiotics) Radiotx (subtotal / modified radical mastectomy) Fibrocystic Changes Macrocyst (aspiration) Galactocoele (aspiration) Fibroadenoma (excision)

Treatment of Breast Condition / Disorder Condition Disorder Observe Monitor Surgery Drugs (Chemotx Hormonal Antibiotics) Mastitis and breast abscess (aspiration / incision - drainage) TB of the breast (aspiration / incision - drainage) Radiotx

Treatment of Breast Condition / Disorder Condition Disorder Observe Monitor Surgery Intraductal papilloma (excision) Phyllodes tumor (wide excision) Mammomegaly (reduction mammoplasty) Drugs (Chemotx Hormonal Antibiotics) Radiotx

Benign and Malignant Conditions of the Breast Learning Objectives – Advice patients with nonspecific mastalgia or mastalgia secondary to hormonal changes.

Nonspecific Mastalgia (Nonspecific Breast Pain) Operational definition Pain in/on the breast in which the cause cannot be exactly established and chances are it is NOT due to a pathologic condition / disorder (there is no pattern indicative of a definite breast disorder. ) Usually, hormone-induced, cyclical or noncyclical

Nonspecific Mastalgia (Nonspecific Breast Pain) Operational definition If a definite cause is identified, then the diagnostic label should be mastalgia secondary to ……. example, trauma, mastitis, etc. )

Nonspecific Mastalgia (Nonspecific Breast Pain) Recommendation on PARACLINICAL PROCEDURES No technical paraclinical diagnostic procedures needed Just monitoring / check-up (breast self-examination and clinical breast examination) at planned intervals (1 mo , then 3 mos – 6 mos – 9 mos – 12 mos)

Nonspecific Mastalgia (Nonspecific Breast Pain) Recommendation on TREATMENT • Give advice – as clear AND convincing as possible to allay fear of cancer and to develop trust and confidence • Secure informed consent on your recommendations • Give stand-by prescription of a safe and affordable analgesics, such as paracetamol, if needed (in case of intolerable pain at home) • No need for antibiotics (a common practice)

Nonspecific Mastalgia (Nonspecific Breast Pain) Recommendation on TREATMENT • Give advice – as clear AND convincing as possible to allay fear of cancer and to develop trust and confidence Clinical diagnosis of a NONSPECIFIC MASTALGIA (not due to cancer) with quantification of degree / percentage of certainty – may be as high as 98% No need for technical paraclinical diagnostic procedures Importance / necessity of monitoring and check-up

NONSPECIFIC MASTALGIA (Nonspecific Breast Pain) Sample of Advice and Informed Consent

FIBROCYSTIC BREAST CHANGES Sample of Advice and Informed Consent

Benign and Malignant Conditions of the Breast Learning Objectives – Identify at least two general indications for referral to a breast specialist. • • NOT certain of diagnosis Certain that a breast specialist is in the best position to manage the patient • • Probable breast cancer diagnosis Patient needs treatment more than a prescription of analgesics and antibiotics

Time-out / Recap For questions and comments, • pls. text and send to 0918 -804 -03 -04 • or email: rjoson 2001@yahoo. com

CLINICAL BREAST EXAM • Examination done by a physician on a patient consulting with a breast complaint or for a breast check vs • Breast self-examination – Examination by a person on her/his own breasts – The “person” includes physicians who may be a patient now or in the future

Breast Self. Examination A Primer Reynaldo O. Joson, MD

Breast Self-Examination The best and most practical and the most economical way of detecting breast cancer rests in a health habit called Breast Self-Examination (BSE).

Breast Self-Examination Examine your own breast regularly at least once a month to become familiar with usual appearance and usual feel of breast.

Breast Self-Examination Familiarity makes it easier to notice any change. Early discovery of a change from what is “normal” main idea behind BSE

Breast Self-Examination Time to do BSE: - while taking a bath - anytime at your convenience

Breast Self-Examination Time to do BSE: For menstruating women one week after menstrual period breasts least likely to be tender and swollen

Breast Self-Examination Time to do BSE: For postmenopausal women 1 st day of the month or last day of the month

How to Do Breast Self-Examination

How to do BSE INSPECTION

How to do BSE INSPECTION Look for anything unusual! If present, consult breast specialist ASAP! Don’t delay!

How to do BSE INSPECTION Look for anything unusual! Visibly unequal breasts If present, consult breast specialist ASAP! Don’t delay!

How to do BSE INSPECTION Look for anything unusual! Markedly unequal breasts If present, consult breast specialist ASAP! Don’t delay further!

How to do BSE INSPECTION Look for anything unusual! Change in contour If present, consult breast specialist ASAP! Don’t delay further!

How to do BSE INSPECTION Look for anything unusual! Visible lumps If present, consult breast specialist ASAP! Don’t delay further!

How to do BSE INSPECTION Look for anything unusual! Nipple erosions If present, consult breast specialist ASAP! Don’t delay further!

How to do BSE INSPECTION Look for anything unusual! Nipple retraction If present, consult breast specialist ASAP! Don’t delay further!

How to do BSE INSPECTION Look for anything unusual! Nipple discharge If present, consult breast specialist ASAP! Don’t delay!

How to do BSE INSPECTION Look for anything unusual! If present, consult breast specialist ASAP! Don’t delay!

How to do BSE PALPATION

How to do BSE PALPATION Palpate for lump or thickening!

How to do BSE PALPATION Palpate as illustrated by pressing and rotating fingers against breast and chest wall to look for lumps! Do NOT grab breast with fingers!

How to do BSE PALPATION Explore breast FIRMLY, CAREFULLY, & THOROUGHLY! Make sure to cover the entire 2 breasts!

How to do BSE PALPATION Up to armpit!

Breast Mass Different Sizes on Detection The Smaller The Better

Don’t wait for lumps to grow to these sizes! TOO LATE! HOPELESS!

How to do BSE PALPATION Palpate for lump or thickening! If you palpate something unusual, consult breast specialist ASAP! Don’t delay!

How to do BSE PALPATION Gently squeeze nipple!

How to do BSE PALPATION Gently squeeze nipple! Nipple discharge If present, consult breast specialist ASAP! Don’t delay!

Breast Self-Examination INSPECTION PALPATION If you find something unusual or abnormal, consult a breast specialist ASAP! Don’t delay consult!

Breast Self-Examination Most breast lumps are NOT serious. But all should come to a breast specialist’s attention for expert opinion.

Breast Self-Examination Only a breast specialist can make sure of the diagnosis. So, see a breast specialist right away and give yourself a peace of mind!