Professional Documents
Culture Documents
Disease
Supervisor: Ms. Vysa
Presenters:
Dr. Neoh Ping Sern
Dr. Vikkineshwaran Siva Subramaniam
Dr. Nadzirah Afiqah
Contents
• Benign Breast Diseases
• Breast Abscess
• Mastitis
• Fibroadenoma
• Nipple discharge
• Breast Cancer
• Diagnosis
• Risk factors
• Staging
• Management
• Screening
Benign Breast Diseases
Topics
• Mastitis
• Breast abscess
• Nipple discharge
• Fibroadenoma
Mastitis
• Inflammation of breast -> If complicates with a
localized collection of pus = Breast abscess
• May or may not be associated with infection
• Noninfective in origin:
• Breast cyst
• Features of malignancy?
• Consider breast carcinoma
Risk factors
• Incomplete breast drainage (difficulty
in attachment, infrequent feedings,
cleft palate)
• Engorgement/ oversupply of milk
• Blocked nipple/milk ducts
• Trauma to breast or nipples, cracked
or excoriated nipples
• History taking :
• Acute presentation
• Fever
• Preceded by inflammation/breast tenderness
• Painful lump
• Lactation?
• Recent surgical procedure (breast injection?)
• Constitutional symptoms
• Frequent expression of breast milk, apply warm compress prior to feeding to aid milk let-down
• Symptomatic relieve
• Analgesia for pain (paracetamol)
• Topical mupirocin in cases of traumatized nipples (cracked/fissured during breastfeeding) for superficial skin infection
• Remove and reapply after each feeding
• Risk factors :
• Diabetes mellitus
• Smoking
• Lactation, progress from puerperal mastitis
• History of injection?
• History taking :
• Acute presentation
• Fever
• Preceded by inflammation/breast tenderness
• Painful lump
• Lactation?
• Recent surgical procedure (breast injection?)
• Constitutional symptoms
• History of the lump
• Site
• Single or multiple?
• How was it noticed? (sudden pain?)
• Any overlying skin changes
• Erythema, warmth
• Swelling
• Skin cracks -> Pus or blood discharge?
• Dimpling?
• Breast asymmetry?
• Duration since 1st noticed
• Nipple retraction?
• Nipple discharge?
• Well defined, fluctuant lump
• Blood stained
• Carcinoma? Correlate with history and clinical findings
• Ductal ectasia?
• History taking -> Family history of breast cancer, details on menstrual history
• Usually 1-5cm
• Women in teens or early 20s may not need a biopsy if lump goes
away on its own (lump <1cm)
• If lump is doesn’t disappear and has increased in size..
• USG guided FNAC for definite diagnosis -> Histopathology examination
• Fibroadenomas are benign
• https://www.researchgate.net/publication/6470168_Aspiration_of_B
reast_Abscess_Under_Ultrasound_Guidance_Outcome_Obtained_an
d_Factors_Affecting_Success
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3900741/
• http://www.myhealth.gov.my/en/fibroadenoma-2/
Breast Cancer
Risk factors
Diagnosis
Staging
Management
Screening
Risk Factors
• Gender- Female has higher risk.
• 42.6 per 100,000 women years vs 1.15 per 100,000 men years
• Age- increases from 40 y/o (pre menopausal) & 50 y/o (post menopausal)
• Lifestyle
• A BMI > 25 has an increase risk to develop breast cancer with higher death rate
• Small waist and waist-hip ratio (WHR) give a significant protection (pre-
menopausal)
• Reproductive Factors
• First full-term pregnancy >30 years old
• Nulliparity
• OCP use poses a mild increase of risk if it is used before the first full term
pregnancy and lower with low dose preparation
• Unopposed estrogen use in hysterectomised women mildly increases the risk of
breast cancer and only after longer term use (>15 years)
• Combination hormone replacement therapy has a mild risk for breast cancer
• Age at menopause of more than 55 years old
• Age at menarche less than 12 years old
• Breastfeeding for a duration >12 months is protective of breast cancer
Stratifications of Risk Factors
Low Risk (RR 1.0-1.4) Moderate Risk (RR 1.5-2.0) High Risk (RR>2.0)
Alcohol consumption Increasing age from 40 years old Personal history of invasive breast cancer
Obesity Benign breast disease with proliferation Benign breast disease with atypical
without atypia hyperplasia
Dense breast Ionising radiation from treatment of
breast cancer, Hodgkin’s disease, etc.
33
Triple Assessment
36
57. Corsetti et al. Eur J of Ca. 2008
Diagnostic Accuracy of Ultrasound
42
45
47
Early Breast Cancer
Definition:
• Cancer that has not spread beyond the
breast or axillary lymph nodes
• Includes ductal carcinoma in situ, stage 1,
stage IIA and stage IIB
48
Early Breast Cancer
50
whether
61. NZGG, 2009
FDG-PET or bone scintigraphy is
superior in detecting bone metastases from
Early Breast Cancer
• Another retrospective study (n = 221)
with operable breast cancer
• Result :
• Routine pre-operative staging with bone scan and
liver ultrasound were not helpful
• Bone scan has a 12 % FP and 19 % PPV
• Liver ultrasound has 3% FP and 33% PPV
• Conclusion:
• These investigations should be reserved for
patients with symptoms suggestive of metastases,
abnormal blood test and high risk patients
52
negative (Grade C)
Advanced Breast Cancer
Definition:
Locally advanced breast cancer (LABC)
includes cancers with large primary
tumours > 5 cm or those with skin and /or
chest wall involvement with or without
regional node involvement ( Stage 3a, 3b
and 3c)
54
Advanced Breast Cancer
• If advanced breast cancer is suspected
either clinically or on imaging, the routine
practice is to confirm the diagnosis and
assess the extent of the metastatic disease
with more imaging (staging)
lesions
54. NICE guidelines, 2009
Advanced Breast Cancer
56
54. NICE guideline, 2009
Recommendation
• In patients presenting with clinically advanced
breast cancer, further imaging modalities such
as chest x-ray, liver ultrasound, and/or CT scan
should be offered to assess the extent of disease
depending on the available resources. (Grade
C)
C)
Positron Emission Tomography
(PET) or PET/CT in Staging
• FDG labelled with positron emitting flourine
provides functional information
59
54. NICE guidelines, 2009
Positron Emission Tomography (PET) or
PET/CT in Staging
New Zealand guidelines:
60
61. NZGG, 2009
Positron Emission Tomography (PET) or
PET/CT in Staging
Belgian guidelines:
• PET scan is not indicated in the diagnosis of
breast cancer, axillary staging and in the
follow-up of breast cancer.
61
55. Belgian guidelines , 2007
Positron Emission
Tomography (PET) or
PET/CT in Staging
Other studies:
• Diagnostic accuracy of FDG-PET/CT nearly
equal to AUS in detecting axillary lymph node
metastases primary operable breast cancer 67,
level III
67. Ueda et.al., BMC Cancer, 2008; 68. Kumar et. al., Nucl Med Commun. 2006; 69. Taira N et. al.,
Jpn J Clin Oncol. 2008
Positron Emission Tomography
(PET) or PET/CT in Staging
Other studies:
• PET/CT is superior to PET or CT alone for
the diagnosis of tumour recurrence and
for the definition of extent of disease 70, level
III, 71, level III
66
Fine Needle Aspiration
Cytology
67
Core Biopsy (CB)
68
Core Biopsy (CB) in
combination with Fine Needle
Aspiration Cytology (FNAC)
69
RECOMMENDATION
• Fine needle aspiration cytology may be
considered as the initial method of
pathological assessment for palpable breast
lumps where facility and expertise are
available. (Grade C)
70
Human Epidermal Growth
Factor Receptor 2 (HER-2)
Testing In Breast Cancer
71
IMMUNOHISTOCHEMISTRY
• A technology review based on 10 studies
looking at Human Epidermal Growth Factor
Receptor 2 (HER-2) testing showed that
the most cost-effective testing strategy is
to screen all breast cancer cases with IHC,
followed by FISH or CISH or SISH for
Immunohistochemistry( of 2+ and 3+) 81, level
III
75
Silver-enhanced in-situ
hybridization (SISH).
76
RECOMMENDATION
• Age
• Tumour histology (lymphovascular invasion, grade, extensive in-situ
component and tumour type such as lobular carcinoma)
• Which margin is approximated by tumour (smaller margins may be
acceptable for deep and superfcial margins)
• Extent of cancer approaching the margin
AXILLARY SURGERY IN EARLY BREAST CANCER
• Axillary lymph node dissection (ALND) comprises of removal of one,
two or three level of nodes relative to the pectoralis minor muscle.
Typically 10 - 15 lymph nodes are retrieved and at least one section
from each assessed by standard haematoxylin and
eosin (H&E).
AXILARY SURGERY
INDICATIONS FOR SENTINEL LN BIOPSY (SLNB) IN BREAST CANCER
1. Women with tumors > 3cm
2. Women with multicentric / multifocal tumors
3. Women with clinically positive nodes
4. Pregnant or breastfeeding women
5. Women with known allergies to radioisotopes or blue dye
6. Women with previously treated breast cancer or axillary surgery
on the affected side
MANAGEMENT OF LOCALLY ADVANCED
BREAST CANCER
• Locally advanced breast cancer is invasive breast cancer that has one
or more of the following features:
• large (typically bigger than 5 cm)
• spread to several lymph nodes in the axilla or other areas near the
breast
• spread to several lymph nodes in the axilla such as the skin, muscle
or ribs.
However, there are no signs that the cancer has spread beyond the
breast region or
to other parts of the body.
SURGICAL MANAGEMENT IN EARLY BREAST
CANCER
MASTECTOMY
• REMOVAL OF THE WHOLE
BREAST.
1. ‘SIMPLE’ OR ‘TOTAL’
MASTECTOMY
2. MODIFIED RADICAL
MASTECTOMY
3. RADICAL MASTECTOMY
4. PARTIAL MASTECTOMY
5. SUBCUTANEOUS (NIPPLE
SPARING) MASTECTOMY
FOUR BOUNDARIES FOR A MASTECTOMY
• Clavicle- superior boundary
• Inframammary fold (above
rectus sheath)- inferior
boundary
• Sternum (midline)- medial
boundary
• Latissimus dorsi (anterior
border)- lateral boundary
MASTECTOMY + BREAST RECONSTRUCTION
• IMMEDIATE OR DELAYED RECONSTRUCTION
• According to NICE guideline, there is no difference in recurrence and
survival following
mastectomy with immediate reconstruction compared to mastectomy
with no reconstruction.
• The aim of immediate breast reconstruction is to improve well-being
and quality of life for women undergoing mastectomy for breast
cancer.
CHEMOTHERAPY
Treatement with cancer-killing drugs that may be given intravenously
(injected into vein) or by mouth. Occasionally, chemo may be given
directly into spinal fluid which surrounds the brain and spinal cord.
NEO-ADJUVANT CHEMOTHERAPY IN LOCALLY
ADVANCED BREAST CANCER
• neo-adjuvant chemotherapy can be given to downsize the tumour
in an attempt for BCS or enable subsequent surgery for initially
inoperable breast cancer.
• The most common drugs used for adjuvant and neo adjuvant
chemo include:
1. Anthracyclines, such as doxorubicin (Adriamycin) and epirubicin
(Ellence)
2. Taxanes, such as paclitaxel (Taxol) and docetaxel (Taxotere)
3. 5-fluorouracil (5-FU)
4. Cyclophosphamide (Cytoxan)
5. Carboplatin (Paraplatin)
• Most often, combination of 2-3 of these drugs are used
POST MASTECTOMY RADIOTHERAPY
• Radiotherapy is a treatment for cancer that uses carefully measured and
controlled
high energy x-rays.
• In primary breast cancer it aims to destroy any cancer cells that may be
left behind in the breast area after surgery.
• Radiotherapy has the greatest effect on cancer cells but also affects
healthy tissue in the area being treated – however, this is generally able to
recover and repair itself.
• In high risk patients who have had mastectomy, there is a significant risk of
loco-regional relapse. Radiotherapy has been shown to improve loco-
regional control but controversy existed regarding the survival benefit until
recently.
FOLLOW UP
• Minimum 3 years
• First year: every 3 months
• Next 5 years : 6-monthly
• Subsequent years: annual review
• Annual mammography and regular physical examination were
recommended