1. BONDOC BORJA BUENAVENTE BUSTAMANTE BUTI CABANAG CALAQUIAN CALAYAN
BENIGN BREAST CASE
BONDOC
BORJA
BUENAVENTE
BUSTAMANTE
BUTI
CABANAG
CALAQUIAN
CALAYAN

2. The Cases
Three females with ages 23, 35, and 55 years, respectively, went to see you for consult. All have a mass in one of their breasts.

3. A. What important general data from the patients do you think are important to be able to guide you in your diagnosis? Explain.

4. Breast Cancer diagnoses
AGE
Breast cancer risk increases with aging.
Breast Cancer diagnoses
Age
18%
40s
77%
>50 5%
<40

5. B. In the Physical Examination, differentiate a benign from a malignant lesion.

6. Benign vs. Malignant Lesion
BENIGN (e.g. Fibrocystic Changes, Fibroadenoma)
MALIGNANT (Cancer)
Occurrence
Usually bilateral
Usually unilateral
Number
Multiple or single
Single
Shape
Round or discoid
Irregular or stellate
Consistency
Soft to firm; tense; rubbery
Hard, stonelike
Mobility
Mobile
Fixed
Determining if a mass is present by physical examination can be difficult, as all breasts have variable combinations of glandular tissue, fibrosis, and fat. True masses are generally asymmetrical in relation to the other breast, distinct from the surrounding tissues, and three-dimensional. A typical cancer may be firm, have indistinct borders, and have attachments to the skin or deep fascia with dimpling or nipple retraction. Benign lesions typically have discrete, well-defined margins and are mobile. Cysts cannot reliably be distinguished from solid breast masses by palpation. In one study, only 58% of 66 palpable cysts were correctly identified by physical examination. Significant disagreement among experienced examiners may occur. In another study, four surgeons performed physical examination independently and agreed on the need for biopsy of only 73% of 15 masses subsequently proven malignant.

7. Benign vs. Malignant Lesion
BENIGN (e.g. Fibrocystic Changes, Fibroadenoma)
MALIGNANT (Cancer)
Retraction signs
(-)
(+)
Tenderness
Tender or non-tender
nontender
Borders
Well delineated (smooth)
Poorly delineated; irregular
Variation with menses
(+) or (-)
Because many breast masses may not exhibit distinctive physical findings, an imaging evaluation is necessary in almost all cases to characterize the palpable lesion and screen the remainder of each breast for additional lesions.

8. Visible Signs and Symptoms of Malignancy
Retraction Signs
1. Skin Dimpling
2. Abnormal Contours
3. Nipple Retraction and Deviation
Edema of the skin
-- a sign of subdermal lymphatic involvement
-- aka peau d’orange sign
-- thickened skin with enlarged pores seen on the lower portion of the breast
Retraction Signs – as breast cancer advances, it causes fibrosis. Shortening of the fibrotic tissue produces retraction signs, including dimpling, changes in contour, and retraction or deviation of the nipple. Other causes of retraction include fat necrosis and mammary duct ectasia.
Skin Dimpling
Edema of the skin
- produced by lymphatic blockade
3. Abnormal contours
- Look for any variation in the normal convexity of each breast, and compare one side with the other.
4. Nipple retraction and deviation
- A retracted nipple is flattened or pulled inward. It may also be broadened, and feels thickened.
Diagnosing Breast Cancer
In 33% of breast cancer cases, the woman discovers a lump in her breast. Other less frequent presenting signs and symptoms of breast cancer include (1) breast enlargement or asymmetry; (2) nipple changes, retraction, or discharge; (3) ulceration or erythema of the skin of the breast; (4) an axillary mass; and (5) musculoskeletal discomfort. However, up to 50% of women presenting with breast complaints have no physical signs of breast pathology. Breast pain usually is associated with benign disease.

9. Visible Signs and Symptoms of Malignancy
Nipple Discharge
Axillary Mass
Musculoskeletal Discomfort

10. Case
23-year old, with a 2x2x2 cm, firm, mobile, well- circumscribed non-tender mass on her L breast

11. Salient features 23-year old
Early reproductive years: age 15 to 25 years
2 X 2 X 2cm, firm, mobile, well-circumscribed non-tender mass
Most probably benign

12. Diagnosis Fibroadenoma
Most common cause of benign breast mass in female patients younger than 25 years.
These arise from the terminal duct lobular unit and appear clinically as singular, firm, rubbery, smooth, mobile, painless masses ranging in size from 1-5 cm.
Small fibroadenomas
1 cm in size or less = Normal
Larger fibroadenomas
up to 3 cm = Disorder
Giant fibroadenomas; Multiple fibroadenomas (very uncommon)
larger than 3 cm; more than five lesions in one breast = Disease

13. Diagnosis Fibroadenoma
They may grow to a large size, thereby affecting the contours of the overlying skin and overall shape of the breast.
Fibroadenomas appear as multiple masses in 10– 15% of patients.
precise etiology of adolescent breast hypertrophy is unknown

14. Imaging Ultrasonography Distinguish solid from cystic structures
Direct needle aspiration for abscess drainage
Simple cysts - round or oval with sharply defined margins and posterior acoustic enhancement. 
Complex cysts - significant solid component, septations, lobulations, varied wall thickness, and the presence of internal debris. 
Abscesses - ill-defined masses and have central hypoechoic areas with either septations or low-level internal echoes, and posterior enhancement

15. Management
Removal of all fibroadenomas has been advocated irrespective of patient age or other considerations,
Solitary fibroadenomas in young women are frequently removed to alleviate patient concern
Self-limiting; Many go undiagnosed - more conservative approach
Patient is counseled concerning the biopsy results, and excision of the fibroadenoma may be avoided.

16. Management
Careful ultrasound examination with core- needle biopsy - accurate diagnosis
Not an emergency
Timely follow-up care is essential
mammography
involvement of primary physician and surgeon
Provide reassurance that not all breast masses are malignant - finding a breast mass can be stressful for patients

17. Case
How will you approach the 35-year old, with a 2x2x2 cm, firm, mobile, well-circumscribed non-tender mass on her R breast?

18. 1. Role of imaging modality? Choice?

19. Imaging Modalities
The role of imaging in detecting breast masses are important.
The morphological appearance of the lesion can be a clue to whether the tumor is benign or malignant.
Needs histology to confirm.

20. Modality of Choice Mammography
The aim of interpreting mammograms is to find:
asymmetric densities
mostly circular or stellate lesions
parenchymal contour changes
architectural distortion and microcalcifications with or without associated tumor, which may indicate breast malignancy.

21. Modality of Choice Ultrasound the main indications
differentiation between cystic and solid lesions
evaluation of a palpable lesion
evaluation of a lesion detected at mammography or mammographic asymmetry
detection of an abscess in an infectious breast
evaluation after breast cancer treatment and breast augmentation
evaluation of axillary lymph nodes
guidance for interventional procedures

22. 2. A mammogram was taken as seen in the picture
2. A mammogram was taken as seen in the picture. Is this benign or malignant?
BENIGN CYST

23. Benign cyst: Imaging Mammography Ultrasound
To screen the normal surrounding breast tissue and the opposite breast for non-palpable cancers
Ultrasound
to differentiate solid from cystic masses
to provide guidance for interventional breast procedures such as cyst aspiration or core biopsy
useful when a palpable mass is partially or poorly seen on a mammogram, especially in young women

24. 3. Differentiate radiologically a benign lesion from a malignant one.

25. Radiologic difference between a benign and malignant mass
Smooth contour
Grow significantly
Well-circumscribed
Stellate or star-bust shaped that extends in all directions
Encapsulated
Calcifications
With “halo sign”
Will not change much in shape or size

26. Difference in ultrasound findings
BENIGN
MALIGNANT
intense uniform hyperechogenicity
Irregular/spiculated borders (“Silhouette sign”)
ellipsoid or wider-than-tall (parallel) orientation along with a thin, echogenic capsule
taller-than-wide orientation
2 or 3 gentle lobulations and a thin, echogenic capsule
angular margins
marked hypoechogenicity
posterior acoustic shadowing
punctate calcifications
duct extension
branch pattern
Microlobulation

27. 4. Should the patient have a mother who is a breast cancer survivor, how would that information change your management?

28. Breast Cancer Screening Tests
HIGH RISK
annual mammogram beginning at an age that is 5 to 10 years younger than the youngest member of the family with breast cancer
Mammogram
is the best tool available for early breast cancer detection
can often identify cancer before symptoms appear and can reveal calcium deposits in the breast, which may be an early sign of cancer

29. Breast Cancer Screening Tests
Clinical breast exam
HIGH RISK: recommended every 6 to 12 months
Self breast exam
performed monthly, about one week after the end of your period
Breast MRI
For extremely dense breast tissue that make mammograms difficult to interpret
thorough physical examination of the breasts done by a physician or nurse practitioner
identify breast abnormalities and should be

30. Case
How will you approach the 55 year old menopausic, with 2 cm diameter, mobile, firm non tender mass on the right breast?

31. Postmenopausal Clinical PE and History Bilateral mammography Biopsy

32. Diagnosis Cyst/Fibrocystic change
A cyst is a fluid-filled sac that develops in the breast tissue.
typically occur in women between the ages of 35 and 50
Cysts are rarely malignant and may be caused by a blockage of breast glands.
result of prolonged cyclic stimulation of repeated menstrual cycle
not premalignant except those with atypical hyperplasia

33. Role of imaging modality in this case?
Mammography
breast tissue undergoes fatty replacement with age and masses are more easily visible
young women have more fibrous tissue making mammogram harder to interpret
the primary purpose of the mammogram is to screen the normal surrounding breast and the opposite breast for non-palpable cancers
Ultrasound
The most useful feature is its ability to distinguish between cystic and solid masses
not an effective screening test for cancer( cannot detect microcalcifications or small lesions)
confirm the diagnosis of a cyst or support a clinical impression of fibroadenoma
more helpful in older women because

34. FNAc revealed NEGATIVE FOR MALIGNANT CELLS
FNAc revealed NEGATIVE FOR MALIGNANT CELLS. How will you manage the patient?
Annual mammography
clinically suspicious mass
excisional biopsy
( distinct mass - should be removed and sent for examination for malignancy because mammograms and cytologic needle biopsies can have falsely negative results and can miss cancer)

35. Treatment of Fibrocystic Change
Reassurance
Pain management
Aspiration of cystic lesion
3 Treatments shown by RCT to be effective
Caffeine free diet
Abstinence from smoking
Danazol

36. Case 2 43-year old female Chief complaint: rapidly growing L breast
(-) palpable axillary lymph nodes

37. Fibroadenoma Phyllodes Tumor
Fibrocystic disease
20-30 yrs. old
2-3cm
firm, rubbery, painless, movable, well-circumscribed mass
epithelial elements and connective tissue stroma
usually bilateral
Rapid growth but not premalignant
Any age
>5cm
firm, mobile, well- circumscribed, nontender mass
epithelial elements and connective tissue stroma (more cellular, more pleomorphic and mitotically more active)
Usually on Left
tendency to grow rapidly and aggressively
35-50 y/o (premenopausal)
Lumpy breast with premenstrual tenderness and heaviness
multiple cysticlesions/single dominant mass
not premalignant except those with atypical hyperplasia
result of prolonged cyclic stimulation of repeated menstrual cycle

38. Phyllodes Tumor
most commonly occurring nonepithelial neoplasm of the breast
history of sudden enlargement of a previously stable mass
Overlying skin may display a shiny appearance and be translucent enough to reveal underlying breast veins.
Lungs - the most common metastatic site
followed by the skeleton, heart, and liver.

39. Behavior of Phyllodes Tumor
Benign
Borderline
Malignant
Local Recurrence (%) 15 25 30
Distant Metastases (%) 5 20
rarely metastasize in axillary lymph nodes
a lobulated lump with finger-like processes
stromal overgrowth and hypercellularity associated with elongated and compressed ducts
Axillary lymph node enlargement occurs mainly due to ulceration and infection of the lump, but almost never due to metastasis.

40. Phyllodes Tumor Benign Borderline Malignant Pushing boundary Yes
Usually
Not usually
Stromal/epithelial balance
Even
Uneven
Stromal cellularity
High
Variability of stromal cellularity
Yes ++
Stromal mitoses /10 hpf
< 5
5 - 10
>10

41. Surgical Treatment wide local excision, with a rim of normal tissue.
No absolute rules on margin.
2 cm margin for small (<5 cm) tumors
5 cm margin for large (>5 cm) tumors

42. SURGICAL
Lesion should not be "shelled out," (as in fibroadenoma) or the recurrence rate will be unacceptably high.

43. SURGICAL ALTERNATIVES:
Total mastectomy, with or without reconstruction.
High tumor to breast ratio
satisfactory cosmetic result by segmental excision
More radical procedures are not generally warranted.
Axillary lymph node dissection
for clinically suspicious nodes.
Virtually all of these nodes are reactive and do not contain malignant cells.

44. ADJUVANT THERAPY
POOR response to chemotherapy and radiotherapy for recurrences and metastases
UNSUCCESFUL Hormonal manipulation has been documented.

45. Case
A 55-year old female consults because of bloody nipple discharge.

46. PHYSIOLOGIC vs. PATHOLOGOC NIPPLE DISCHARGE

47. PATHOLOGIC PHYSIOLOGIC Frequently bilateral
Characterized by discharge only with compression
Multiple duct involvement
More viscous
Milky to yellow, gray, brown, or dark green
Usually unilateral
Spontaneous, bloody or associated with a mass
Confined to one duct
Watery consistency
Usually serous, bloody or clear
Nipple discharges are classified as pathologic if they are spontaneous, bloody or associated with a mass. Pathologic discharges are usually unilateral and confined to one duct. Physiologic discharges are characterized by discharge only with compression and by multiple duct involvement. These discharges are frequently bilateral. With either type, the discharge fluid may be clear, yellow, white or dark green.
PHYSIOLOGIC
Exogenous or endogenous hormones, medications, stress, direct stimulation, or endocrine abnormalities can cause physiologic nipple discharge.
In cases where a hormonal influence is pathologic, as is the case with prolactinoma, the ductal system itself has no abnormality so the resultant discharge is classified as physiologic
Causes of Physiologic discharge Hormonal variation Pregnancy/Post lactational Mechanical stimulation Galactorrhea Duct ectasia /periductal mastitis Infection Fibrocystic change Medications
Medications causing nipple discharge Oestrogens/Progestrogen Long term opiates Antidepressants Antipyschotics Metachlopramide Cimetidine
PATHOLOGIC
abnormality of the duct epithelium
The fluid produced by the lesion collects in the dilated duct and is subsequently released when the plug is removed or the duct is compressed.

48. Suspicious nipple discharges
Nipple discharges that are usually benign
Suspicious nipple discharges

49. LOCALIZATION OF THE INVOLVED DUCT

50. CONTRAST DUCTOGRAM MAMMOGRAPHY
Preferred examination especially in women older than 40 years,
For visualization and localization of involved duct and lesion
Retrograde injection of contrast medium into a discharging duct
Mammographic imaging of the breast in at least 2 planes
A contrast ductogram mammography will help image and localize the area from which the discharge originates. This can only be done when there is an active discharge and is done only when the discharge occurs from a single duct. The most common causes of occult blood in nipple discharge are, in order of frequency, intraductal papilloma, duct ectasia, "fibrocystic change," and carcinoma.
Glyptography (also called ductogram) -- contrast mammogram's obtained by injecting a radio-opaque dye into the discharging duct -- is the diagnostic procedure of choice in patients with a suspicious nipple discharge. This technique allows the clinician to visualize and localize the involved duct and lesion.  
Galactography involves the retrograde injection of water-soluble radiopaque contrast material into a discharging duct, with subsequent mammographic imaging.
 not indicated unless the nipple discharge is spontaneous, unilateral, and expressed from a single pore. If discharge cannot be expressed at the time of galactography, the affected duct cannot be identified or cannulated.

51. ADJUVANT: Ultrasonography, CT, nuclear medicine study, and MRI.
In younger patients
increased breast density may mask small cancers
additional tests such as ultrasonography, nuclear medicine study, and MRI may be useful.

52. Diagnosis Intraductal Papilloma
a small, noncancerous (benign) tumor that grows in a milk duct of the breast
occurs most often in women ages 35 – 55
causes and risk factors unknown
most common cause of spontaneous nipple discharge from a single duct
outcome is excellent for people with one tumor
People with many tumors, or who get them at an early age may have an increased risk of developing cancer, particularly if they have a family history of cancer or there are abnormal cells in the biopsy.

53. Intraductal Papilloma
Signs and Symptoms
Breast enlargement
Breast lump - might feel a small lump beneath the nipple, but this lump cannot always be felt (palpable)
Breast pain
Nipple discharge: clear, sticky or bloody
The health care professional might feel a small lump beneath the nipple, but this lump cannot always be felt (palpable). A mammogram often does not show papillomas. Ultrasound may be helpful.
Other tests include:
A breast biopsy to rule out cancer
An examination of the discharge to see if the cells are cancerous (malignant)
An x-ray with contrast dye injected into the affected duct (ductogram

54. Treatment
the involved duct is surgically removed (and the cells are checked for cancer)

55. Case
Two ladies aged 20 and 48 years, respectively, consulted because of bilateral breast tenderness.

56. Fibroadenoma Fibrocystic change
In the 20 year old, what is your foremost consideration?
Fibroadenoma
In the 48 year old, what is your foremost consideration?
Fibrocystic change

57. How do you differentiate the diagnosis in #1 from that of #2?
Fibroadenoma
Fibrocystic Change
15-30 y/o
Firm, round, smooth, rubbery, and movable
May feel tender, especially right before menstruation, due to hormonal changes
On US, appears as a dark area, with a definite outline, homogeneous, round or oval, and may have smooth-edged bumps
> 35 y/o (premenopausal)
Dense with an irregular area of thicker tissue with a lumpy or ridge-like surface
May feel tender, swollen and full with a dull, heavy pain
Prolonged cyclic stimulation of repeated menstrual cycle

58. How will you manage the 20 yr old?
If small, painless, remains the same size, and a biopsy shows no problems- no further treatment, but may have follow-up ultrasounds
If large (more than 3cm), painful, growing, or a biopsy results in atypical (very active) cells- surgical excision

59. The 48-year old undergoes surgery showing the gross finding below, what is your treatment?

60. Management Pain relievers- acetaminophen, NSAIDS
Supportive bra to provide firm support
Caffeine free diet -can decrease water retention and may help to alleviate the discomfort.
Abstinence from smoking
Danazol- for severe cases