Breast lumps/mass

Young Pt with breast lump; next step after History & Examination……….. US.

Old pts >40 with breast lump; next step after History & Examination…… Mammography.

1^st inv of solid mass: core biopsy.

Best inv of solid mass: excision.

1^st inv of cystic mass: FNABC.

Asymptomatic mass in young female, hypoechoic on US: FIBROADENOMA.

TTT of fibroadenoma: surgery.

Young pt with breast Pain, swelling which fluctuate with menses: fibro-cystic disease of breast (fibro-adenosis).

TTT of fibro-adnosis: analgesic& tight fitting bra 1^st, if no response: OCPs.

TTT of Severe fibro-adenosis not respond to OCPs: danazole.
MCC of bloody discharge of breast: intra-ductal papilloma.

TTT of Lactating female with mastitis: continues breast feeding.

1^st: Breast feeding from affected side and then, from the other side.

If mastitis complicated by breast abscess: continues breast feeding from affected side 1^st.

Gynecomastia in infant: passage of maternal hormones…… reassure.

Gynecomastia in puberty with pain& induration…………….. reassure.

Gyenecomastia in young athlete……………………………………. Steroid abuse.

Senile gynecomastia………………………………………………………… testosterone replacement.

Pt with viscid secretion (serous or creamy discharge) from breast: mammary duct ectasia.

Most common cause of bleeding per nipple…….duct papilloma

Mutation of BRCA1, BRCA2 gene increases risk of breast& ovarian cancer.

Old female with any change in her breast, skin overlying it, nipple, nipple discharge… most probable diagnosis is breast cancer (whatever other choices).

Screening of breast cancer: mammography (cancer appears as micro-calcification).

Mammography is done every 2 ys to all female from age 50

When to do mammo before 50 ys? if she asks or if FH of breast cancer in 1^st degree <50 ys.

Why are Australian females are scared of mammo? pain.

Routine self breast examination is NO longer recommended.

Female with strong positive FH of breast, ovarian cancer… do gene assesment.

Female with one relative has brca mutation… do gene assesment.

Before doing BRCA1, BRCA2 test: do counseling about the test 1^st.

After TTT of Women with breast cancer in one side, she develops breast cancer in the other side; the most probable cause is: 1ry cancer (not metastases from the other part).

Most imp prognostic factor of breast cancer: LN.

Main line of management of breast hematoma: excision.

N.B: for breast

Haw to deal with breast mass:

• First step  …. Hestory & examination
• 2^nd step ………. Imagin
  • If young ……. U/S
  • Old ..  mammografy
• If solid mass: …… core biopsy …..initial step
  • Exisional biopsy … invest of choise
• F cystic lesion ……… aspiratin
• Fibroadenoma : young female with breast mass … invest. U/S
• Fibroadenosis : painfull swelling in breast increased befor period

     TTT : analgesics ,  If failed : Danazol

• Intraductal papilloma : most common cause of bleeding discharge per nipple.
• Mastitis and Acute breast abscess :

         TTT: antibiotics

                  Incision and drainage for B. abscess

            Continue breast feeding from affected breast and start wit it 1^st

If suction for milk she can feed the baby from it

• Gynecomastia : ask for steroids and anabolic hormons in young atheletic male.
• Mamary ductectasia : yellow serous or creemy white discharg.
• Breast cancer:

…General role: any old female with any breast abnormality … cancer breast untill prove other wise.

-Duct carcinoma ….. most common.

-Lobular carcinoma ….. bilateral.

-BRCA1 , BRCA2 : done if there is strong 1^st degree +ve family history.

• Screeaning for breast cancer :

Mammography : all female 50-74 y every 2 years

Age 40-49 :

1-if she asked

2-if 1^st degree +ve family history of breast cancer <50 y and do it annually.

• Pagets disease : old woman with unilateral nipple discharge.
• Breast hematoma : hard some times painfull mass with history of truma …. TTT : excision.
• Women with history of cancer breast at one side now come with cancer in other side ….. primary cancer not metastasis.
• Why female in aust. Scared from mammograohy…..pain.

How to deal with breast lump??????

First step………….history and examination

Imaging:

If young…………US

If old………mammography

if solid mass:   1^st inv………….Core biopsy

                             Best inv……..excision

If cystic lesion………1^st inv………aspirate

Fibroadenoma

Fibroadenosis(mammary dysplasia)

Hormone related disorder

Age 30-50

Pain, tenderness and swelling

Increased symptoms premenstrual

Fluctuation in the size of the mass….vvv imp

Nodular feeling and possible obvious lump

Inv………mammography and needle biopsy

If cyst………needle aspiration

Treatment………….  Analgesics 

                                      Tight bra

                                       ocp

severe cases……..danazol……vvvvvvv imp  

 Intraductal papilloma

Most common cause of bloody discharge per nipple

Inv: mammography…exclude cancer

TTT…..duct excision 

 Mastitis

Acute breast abscess

Severe and throbbing pain

Hectic fever

Marked systemic manifestation

Fluctuation

TTT…… incision under anesthesia

              Leave a drain

             Antibiotics

            Continue breast feeding from affected side 1^st

GYNECOMASTIA

Mammary ducat ectasia

Pagets disease:

Clinical picture of breast cancer:

Usually painless breast mass

Breast…..enlargement, asymmetry

Skin…..dimpling, ulceration or nodules

Nipples….retraction or change of direction

Lymph nodes/……enlargement

Paeu de orange…..advanced stage, non pitting edema due to obstruction of skin lymphatics

Investigation:

Imaging of choice………Mammography

Cancer appears with microcalcification and speculated appearance

Biopsy:

Core biopsy……………… initial

Excisional…………………..Best

When to do BRCA1 OR BRCA2 test?

First step…….counselling about the test

Positive family history (less than 50 years) breast or ovarian

Breast and ovarian cancer in the same female

Family history of male breast cancer

Is breast self exam routinely advised??….noooo

Has no effect on mortality rate

Best diagnostic screening tool decreasing mortality in whole preventive medicine……mammography

Screening for breast cancer:VVVVVVVVV IMP

Tool……..MAMMOGRAPHY

Routine:

All females from 50-74 every 2 years

Age 40-49…….1-only if she asked

                              2-1^st degree less than 50 ys with breast cancer→( annually)

Age more than 74.…..only if she asked

When to screen at young age??

1. One first degree relative with breast cancer in age younger than 50 years
2. 2-   2- two first degree relatives with breast cancer at any age
3. 3-   3- two second degree relatives less than 50
4. 4-   2 first or second degree with the following:

Breast cancer less than 40 years

Bilateral breast cancer

Breast and ovarian cancer in the same female

Male breast cancer

Breast hematoma:

History of trauma or operations

Cp…….hard and some times painful mass

Breast biopsy…..fat globules

TTT..

EXCISION…..vvvvvvvvvvvvvvv imp

N:B:

Women with cancer breast in one side ….now has breast cancer on the other side ……what is the most probability………primary cancer not metastasis

Most imp prognostic factor of breast cancer……..LN

Why females in Australia are scared from mammograpgy…..pain…vvvvvvvvvvvvvv imp