1. BREAST LUMPS DR AMBREEN MUNIR
FRCS, BAPRAS Fellowship Breast, PG-D Bioethics
Associate Professor Surgery

2. INTRODUCTION
Of all breast disorders, palpable breast lump is 2nd most common presentation, pain being the first
Generally a breast lump in adolescents and young female is nearly always regarded as benign at first instance and patient may falsely be reassured with the result she refrain from further consultation

3. INTRODUCTION
On the other hand, all lumps are not cancers; however the possibility of cancer must always be considered, as approximately 10% of all breast lumps are finally diagnosed as cancer.

4. Case scenario
A 25 year old School teacher came to you and she is worried about a lump she just found in her right breast.

5. Additional History History of trauma Is lump painful? Nipple Discharge
Any other lump? Axilla

6. Otherwise she is healthy
Her weight is stable
She is married
She takes OCP
Her menstrual cycle is regular
No family history of cancer

7. Triple Assessment
Examination
Imaging
Cytology/ Biopsy

8. Breast Examination Inspection- sitting position
symmetry, level of both breasts, Contour, skin changes
Ask her to lift arms, put arms against waist
Palpate the axilla in sitting position
Palpate supraclavicular lymph nodes

9. Palpation of breast- supine position with hands above head
Examine both breasts
Normal first
Examine with the flat of the hand to avoid pinching up tissue

10. Four quadrants in clockwise direction
Nipples & areola
If you have difficulty finding a discrete lump, ask the patient to demonstrate it for you

11. About Lump
Site - describe the location of the lump as a position on a clockface i.e. 'A firm mass is felt at 2 o'clock'.  
Size
Shape
Surface/ Overlying skin
Tenderness
Consistency

12. Mobility and attachment
If you are unable to move the skin over the lump it implies fixation or tethering
If patient mentioned nipple discharge ask her to squeeze nipple for a sample of the discharge

14. Examination Findings
Solitary 1.5 cm mass of right breast, upper outer quadrant at 10 oclock
Mass is non-tender
Lesion is freely movable
 No obvious skin changes over the lesion
No nipple discharge
No axillary masses

15. Possibilities Fibroadenoma Fibrocystic disease Simple cyst
Fat necrosis
Cancer

16. Benign Breast diseases
ANDI
Infections
Trauma

17. Fibroadenoma
Benign overgrowth of one lobule of the breast, usually isolated, may be multiple or giant
Composed of both stromal and epithelial elements in the breast
Well-defined, mobile, painless, discrete
Common in younger women, and is most common tumor in women younger than age 30 years

18. Fibrocystic disease
Combination of localized fibrosis, inflammation, cyst formation and hormone driven breast pain
Occurs almost exclusively between menarche and menopause
Causing cyclical pain and swelling, lumpy breasts, multiple breast cysts

19. Cysts
Fluid-filled, epithelium-lined cavities often associated with FBD
Common after age 35, and rare before 25
Round symmetrical lumps, may be discrete or multiple, occasionally painful
Three types
Simple cyst, clear or green fluid and is benign.
Milk-filled cyst, called galactocele and is benign.
Bloody cyst is a cause of concern for malignancy.

20. Infections & Inflammations
Lactational Mastitis
Due to acute staphylococcal infection of mammary ducts
Breast Abscess
When infection progress

21. Infections & Inflammations
Mammary duct ectasia
Due to dilated, scarred, chronically inflammed subareolar mammary ducts
Recurrent yellow green nipple discharge or recurrent breast abscess
Mondor’s disease
Phlebitis of the thoracoepigastric vein
Palpable, visible, tender cord along lower quadrants

22. Fat Necrosis Associated with trauma or radiation therapy to breast
There is organization of acute traumatic injury by fibrosis, organized haematoma & occasionally calcification
Can simulate cancer with mass or skin retraction

23. Next step in assessment
Imaging- choice of imaging modality depends on specific characteristics of the patient e.g. age, and findings on clinical examination
Ultrasound scan or Mammography
MRI of breast

24. Indications of U/S
To evaluate the breast in patients who are under the age of 35 years
To differentiate solid and cystic lesions
Women who are pregnant and cannot have mammography
To complement mammography
 To guide fine needle aspiration and core biopsies

25. Next step in this case

26. Solid lesions- have internal echoes
Benign tumours have isoechoic or hypoechoic patterns, smooth well defined borders
Malignant tumours have hypoechoic areas,interspersed between brighter echoes, irregular edges
Cysts- Smooth walls, sharp anterior and posterior borders, black hypoechoic centres without internal echoes

27. U/S report in this case is benign solid lesion U2

28. To complete the triple assessment, this lesion needs to be biopsied
There are a number of different types of biopsy( cytological or histopathological)

29. Fine needle aspiration (FNA)

30. Core biopsy

31. FNA-Sensitivity is 80-98%, specificity 100%
False negatives are 2-10%
Core Biopsy-More tissue, however still possibility of false negative and could represent sampling error
Incisional biopsy- For large (>4 cm) lesions for whom pre-op chemotherapy or radiation will be desirable
Excisional biopsy-Removal of entire lesion and a margin of normal breast parenchyma

32. Triple Assessment gives confident diagnosis in 95% of cases
On other hand, Triple assessment is not always needed to investigate breast lumps, as it would be viable to diagnose a breast cyst purely on ultrasound
A solid lump will require a core biopsy to confirm its benign or malignant state

33. Treatment
Most benign breast lumps will not require treatment. This is especially true of small fibroadenomas,If they are increasing in size they may be removed
FNA is used for simple and recurrent cysts. In this case FNA would be used as a treatment rather than a diagnostic tool. Complete resolution, follow up to ensure it does not recur,Incomplete resolution treat as breast mass and excise

34. Treatment Mondor’s disease
Treatment self-limited, can use NSAIDs if necessary
Antibiotics can be used to treat infections of the breast and abscesses are treated by incision & drainage

35. Treatment Mondor’s disease
Treatment self-limited, can use NSAIDs if necessary
Antibiotics can be used to treat infections of the breast and abscesses are treated by incision & drainage

36. BREAST CANCER DR AMBREEN MUNIR
FRCS, BAPRAS Fellowship Breast, PG Diploma Bioethics
Associate Professor Surgery

37. Overview The most common form of cancer among women
The second most common cause of cancer related mortality
One out of nine Pakistani women is likely to suffer from Breast Cancer at some point of life

38. Overview Highest incidence of Breast cancer in the Asia
At Least 90,000 Women Suffer From Breast Cancer In Pakistan Every Year
40,000 Deaths Per Year, Which Is Alarming

39. Risk factors Female Aging First degree Relative Menstrual history
early onset
late menopause
Child birth
After the age of 30

40. Risk Factors Hormonal replacement therapy(HRT)
30% increased risk with long term use
Oral Contraceptives(OC)
risk slight
risk returns to normal once the use of OC’s has been discontinued
Radiation exposure

41. Risk Factors Breast disease Atpyical Hyperplasia
Intraductal carcinoma in situ
Intralobular carcinoma in situ
Obesity
Diet
Fat
Alcohol

42. Genetic Risk Factors
BRCA-1
BRCA-2
P53
Her-2/neu

43. Because of enhanced Public awareness, number of patients reporting with complaints of breast diseases has increased in recent years

44. Breast diseases are common in females because of more complex structure of female breast, greater volume and influence of various hormones
Subjected to constant physiological changes throughout reproductive life and beyond.
These changes lead to a number of conditions

45. Mostly these conditions are benign e. g
Mostly these conditions are benign e.g. bilateral nodularity, tender lumpy breasts
Our aim should be to exclude cancer
That aim is achieved through proper assessment

46. Triple Assessment Clinical History Examination Imaging Ultrasound
Mammography
Histopathology
FNAC
Trucut Biopsy

47. History
Age
Family history of breast and other cancers with emphasis on gynaecological cancers

48. History Reproductive history age at menarche age at first delivery
number of pregnancies, children and miscarriages
age at onset of menopause
history of hormonal use including:
contraceptive pills (type and duration)
hormonal replacement therapy (type and duration)

49. Signs/Symptoms Any new discrete breast lump
Any new lump in a pre-existing nodularity
Recurrent breast cysts
Unilateral axillary lump
Unusual increase in the size of one breast

50. Signs/Symptoms Persistent or unilateral breast pain
Pain associated with a lump

51. Signs/Symptoms Nipple discharge other than breast milk Blood stained
Single duct
Bilateral troublesome discharge
in more than 50 years
New nipple retraction
Nipple eczema if not elsewhere or unresponsive to steroids

52. Signs/Symptoms A puckering of skin of breast
Skin irritation or dimpling
Redness, scaling or thickening of skin of breast
Swelling of arm

54. Clinical Examination Annually for women over 40
At least every 3 years for women between 20 and 40
More frequent examination for high risk patients

55. Clinical examination Breast Sitting Supine
Both Axillae & Supraclavicular fossae
Local examination of possible metastatic sites

57. Mammography
Not recommended under the age of 35 unless there is a strong clinical suspicion of cancer
Mammography allows for efficient diagnosis of breast cancers at an earlier stage
Normal mammogram does not rule out possibility of cancer completely

58. Mammogram
Two of the most important mammographic indicators of breast cancers
Masses
Microcalcifications: Tiny flecks of calcium – like grains of salt – in the soft tissue of the breast that can sometimes indicate an early cancer.

59. Malignant masses have a more spiculated appearance

63. Calcifications show up as white spots on a mammogram
Round well-defined, larger calcifications are more likely benign
Tight cluster of tiny, irregularly shaped calcifications may indicate cancer

65. Breast Ultrasound To see whether the lump is solid or cystic
Margins, complexity
For aspiration or biopsy

66. Histopathology Fine needle aspiration cytology
performed with 5 cc disposable needle as outpatient procedure
Trucut biopsy
performed with core cut needle under local anaesthesia

67. Treatment Based on many factors
Varies from reassurance to radical Surgery

68. TNM Staging TX: primary tumor cannot be assessed
T0: no evidence of tumor
Tis: carcinoma in situ
T1: tumor <2 cm
T2: tumor 2-5 cm
T3: tumor >5 cm
T4: direct extension to chest wall or skin

69. TNM staging NX:regional nodes cannot be assessed
N0: negative lymph nodes
N1: metastases to moveable ipsilateral
axillary lymph nodes
N2: metastases to fixed ipsilateral
N3: metastases to ipsilateral internal
mammary nodes

70. TNM staging MX: distant sites cannot be assessed
M0: no distant metastases
M1: distant metastases

71. Breast cancer treatment
Breast Conserving surgery
Mastectomy
Axillary sampling( Sentinel node biopsy)
Axillary clearance
Chemotherapy
Radiotherapy
Hormone Therapy

72. Oncoplastic Surgery
The combination of reconstructive surgery in cancer surgery. 
Immediate breast reconstruction following partial or total Mastectomy

73. Oncoplastic Tumours smaller than 3 cm Nodal status-N0, N1
Peripheral tumors
Large breasts

74. Conclusion
The diagnosis of breast cancer is devastating for most women and is compounded by mental anguish associated with the anticipated changes in their appearance

75. Conclusion
As clinical breast examination (CBE) may play a positive role in detecting cancer earlier, especially in reducing tumour size from 5 cm to 2 cm at presentation in developing countries without a mammography screening programme, the practice of CBE by doctors and trained nurses should be encouraged.

76. Conclusion
If breast cancer patients are offered breast oncoplasty procedures, more women are likely to come forward for treatment at an early stage.