1. ASSESSMENT OF BREAST SYMPTOMS/LUMPS Professor P Grantley Gill Specialists Without Borders Seminar in Surgery Rwanda, September 2010

2. SIGNS AND SYMPTOMS AT PRESENTATION Palpable mass Thickening, Pain Mass or pain in the axilla Nipple discharge Oedema or erythema of the skin www.specialistswithoutborders.org

3. CAUSES OF BREAST LUMPS – Fibroadenoma – Cyst – Fibrocystic change – Cancer – Duct ectasia – Fat necrosis – Haematoma www.specialistswithoutborders.org

4. BREAST CANCER RISK FACTORS – Age – History of breast cancer – Family history of breast cancer, especially in first degree relatives – Specific genetic mutations e.g. BRCA-1, BRCA-2 – Benign breast “cancer” atypical hyperplasia – Early menarche, late menopause – Late first pregnancy/no pregnancy – Exogenous oestrogens – Radiation – Diet, alcohol www.specialistswithoutborders.org

5. EXAMINATION OF BREAST – Inspection – Palpation – Lymph node basins (axilla, neck) – Contralateral breast www.specialistswithoutborders.org

6. INSPECTION www.specialistswithoutborders.org

7. NIPPLE RETRACTION www.specialistswithoutborders.org

8. SKIN DIMPLING www.specialistswithoutborders.org

9. PAGET’S DISEASE www.specialistswithoutborders.org

10. PAGET’S DISEASE www.specialistswithoutborders.org

11. TRIPLE ASSESSMENT OF A BREAST LUMP – Clinical – Imaging Mammography Ultrasound – Pathology Fine needle aspiration cytology (FNAC) Core biopsy www.specialistswithoutborders.org

12. PALPABLE LYMPH NODES www.specialistswithoutborders.org

13. MAMMOGRAPHIC STAGING – Masses – Asymmetry Architectural distortion – Calcification – Skin changes www.specialistswithoutborders.org

14. NORMAL FATTY REPLACEMENT

15. www.specialistswithoutborders.org NORMAL INVOLUTION

16. DENSE BREASTS www.specialistswithoutborders.org

17. DENSE BREASTS – RETROAREOLAR TISSUE LEFT www.specialistswithoutborders.org

18. DENSE BREASTS +++ ALL OF LIFE www.specialistswithoutborders.org

19. ULTRASOUND A: Fibroadenoma B: Carcinoma www.specialistswithoutborders.org

20. FINE NEEDLE ASPIRATION CYTOLOGY (FNAC) www.specialistswithoutborders.org

22. FNAC INTERPRETATION AND ACTION www.specialistswithoutborders.org INTERPRETATONACTION Unsatisfactory for diagnosisRepeat or core Cellular, benignAccept if consistent with imaging; repeat or core if not Cellular, some atypiaCore biopsy Open biopsy SuspiciousCore biopsy Open biopsy MalignantTreatment

23. TRIPLE ASSESSMENT OUTCOME www.specialistswithoutborders.org ASSESSMENTCONCORDANTDISCORDANT Clinical Accept results benign or malignant Core biopsy Open biopsy Imaging Cytology

24. CONCLUSION – Confirm malignancy in ≥90% by triple assessment – Open biopsy if not possible www.specialistswithoutborders.org