Seminar>Sameer S. Sawaed

1. Theobjectivesof thisTheobjectivesof this
seminar:seminar:
By : Sameer S. SawaedBy : Sameer S. Sawaed
MAIN SYMPTOMS OF BREAST
DISORDERS
Breast cancer
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2. Why to care about breast CA?
Most common malignancy in women
Second most common cause of cancer death after
lung C, causing 458,503 deaths worldwide in 2008
Life time risk for women is raised from 1 in 12 (2007)
to 1 in 7 (2012)
50% of women will have benign breast lesion in their
life time.

3. Breast cancer in Jordan:
Breast cancer is the most common cancer
overall as well as the most common malignancy
afflicting Jordanian women.
According to the latest statistics from the
Jordan National Cancer Registry, 864
females and 9 males were diagnosed with breast
cancer in 2008, accounting for 18.8% of the
total new cancer cases & accounting for 36.7%
of all female cancers,
the leading cause of cancer deaths among
Jordanian women.

4. Median age (51) Vs (65) western countriesMedian age (51) Vs (65) western countries
Incidence rates are increasing at 3% per yearIncidence rates are increasing at 3% per year
Presentation:Presentation:
according to jordan cancer registry at king hussien cancer center:according to jordan cancer registry at king hussien cancer center:
23.8 % stage 123.8 % stage 1
31.6 % stage 231.6 % stage 2
21.2 % stage 321.2 % stage 3
13.7 % stage 413.7 % stage 4

5.  The Jordan Breast Cancer Program (JBCP) is
a nation-wide initiative for the development and
provision of comprehensive services for the
early detection and screening of breast cancer
for all women in Jordan for the purpose of.
 JBCP has a multidimensional approach
covering the provision of screening services,
education of females, capacity building of health
professionals and quality assurance.
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6. Reducing morbidity and mortality from
breast cancer by early detection and
screening.
Shifting the current state of diagnosis
of breast cancer from its late stages (III-
IV), to diagnosing breast cancer at its
earlier stages (0-II) where :-
- the disease is most curable,
- survival rates are highest,
- and treatment costs are lowest.
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7. Early
Detection
&
Screening
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8. Survival rates and the early detection of breast cancer
are directly connected; yet unfortunately, public
awareness in Jordan regarding this fact is minimal and
inadequate.
The best way to protect yourself against breast cancer
is by maintaining routine checkups.
The most appropriate course of action will depends on
age & risk factors.
8

9. Women at normal risk can follow the Early
Detection Plan below, which summarizes the
National recommendations in Jordan:
9
Screening/
Age
20-29 30-39 40-49 50+
Self Breast
Exam
Monthly Monthly Monthly Monthly
Clinical
Breast Exam
Once every
1-3 years
Once every
1-3 years
Annually Annually
Mammogram -------------- ------------ Every two
years
Annually
If the women are at increased risk, they must have the
annual mammography earlier, and they will have more
frequent clinical breast examination

10. What are the Risk Factors?What are the Risk Factors?
Advanced age >40
Family history
 Family history of ovarian cancer in
women <50y
Personal history
Positive BRCA1/BRCA2 mutation
Breast biopsy with atypical hyperplasia
Breast biopsy with LCIS or DCIS
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11. Reproductive history
Early age at menarche (<12 y)
Late age of menopause
Late age of first term pregnancy (>30 y)/nulliparity
Use of combined estrogen/progesterone HRT
Current or recent use of oral contraceptives
Lifestyle factors
Adult weight gain
Sedentary lifestyle
Alcohol consumption
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12. Presentation
Asymptomatic
Breast Mass
◦ Usually Hard, UOQ in 60%
Skin changes (skin tethering)
Nipple (Discharge ,retraction, inversion)
Pain(mastalgia) or Prickling sensation
Symptoms of Mets. (back ache, pathological fx,
Respiratory symptoms, jaundice, skin lesions,
and general symptoms of cancer ..etc)

13. Red Flags Suggestive of Breast CancerRed Flags Suggestive of Breast Cancer
Symptom Characteristics
Pain Unilateral, noncyclic
Nipple discharge Unilateral
Watery, serous,
serosanguineous, bloody
Breast mass Unilateral
Hard, immobile
Noncystic
History Postmenopausal
Personal history of breast cancer
Family history of breast cancer
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14. Triple assessment
1- Detailed history and physical
examination
2- Diagnostic imaging by Mammography
and/or Ultrasound scanning
3- Cytology or Histology
Positive Predictive Value of this
combination should exceed 99.9%
 Ref. Bailey and Love’s 24th
ed. P.826

15. Proper HxProper Hx
Age?
The risk of breast cancer increases with age.
Postmenopausal women presenting with a mass are much more
likely to have cancer than premenopausal women.
A breast mass in a woman younger than age 30 rarely (2%)
represents cancer, whereas a woman of 70 years or older with
a mass will have cancer more than 85% of the time.
Where? How long? How was it discovered? Painful,
painless?
Associated Sx.( pain, discharge, Wt loss, bone pain)
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16. Family Hx for BC
First-degree relative increases the risk about two to three
folds.
If two first-degree relatives have been affected, the risk
increases up to six-folds.
Hx of pregnancy after the age of 30.
Menarche
Menopause.
Use of any hormonal therapies
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17. Self Breast Exam
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18. 18

19. Performance of Self breast exam must be done
at the end of menstrual cycle.
Step one: In front of a mirror
Look for any abnormal changes and check the
shape, size, color & texture of the
breasts in four different positions:
Arms at your side.
Hands pressed on your hips while tightening your chest
muscles.
Arms held over your head.
Upper body bent forward with your hands on your
hips.
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20. Step 2: Lying Down
Lie down on your back with a pillow under your right
shoulder.
Using the finger pads of the middle three fingers of your left
hand, examine your right breast for the presence of any
lumps.
Press gently but firmly using variable pressure (light, medium,
and deep) to each area examined.
Follow overlapping circular motions and cover the entire
breast including underarm area.
Repeat on your left breast using your right hand.
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21. Clinical breast
exam
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22. CBE can be helpful in detecting a breast mass,
particularly among women at normal risk under
the age of 40 for whom mammography is not
recommended.
For women aged 40 years and older, clinical
breast exams are an important complement –
not substitute – to mammography.
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23. Physical ExaminationPhysical Examination
The physical exam should be done in a private
and comfortable room, in the presence of a
chaperone, Should include:
inspection and palpation of both breasts.
palpation of the axillary and supraclavicular
lymph node regions.
Recognize any skin changes.
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24. Mammography
1- Screening:
it is the most successful widely-available screening tool
that can detect breast cancer at its earliest stages.
2- Diagnostic:
 Low dosage of X-ray, Safe.
 Diagnostic mammography is used to evaluate a patient
with abnormal clinical findings—such as a breast lump
 contraindicated in pregnant women .
 There are two types of mammograms available world-
wide:
standard mammography (film-screen mammography)
Digital mammography.

25. Mammograms are quick and easy. Patient
stand in front of an X-ray machine. The
person who takes the X-rays places the
breast between two plastic plates. The
plates press the breast and make it flat.
This may be uncomfortable to the patient
but it helps get a clear picture. Then the
process repeated to the other breast.
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26. Mammography view:-
Craniocaudal Mediolateral oblique

27. Mammography
*The sensitivity of the mammogram is in the 90%
range.
**the sensitvity increase with age
***Cancers missed by mammography are
in the range of 10-30%.
Causes include:
1- Observer error.
2- Dense tissue.
3- Lobular cancer ( growth patterns
indistinguishable from normal breast tissue).

28. Remember..
A normal Mammogram in the
presence of a palpable Mass does
not exclude malignancy and further
workup should be performed with
an US, MRI, and/or Biopsy.
An interval of 2 weeks between a
mammogram and cyst aspiration is
recommended because aspiration can
sometimes result in hematoma formation,
which could confuse mammographic
interpretation.

29. Mammogram Interpretation:Mammogram Interpretation:
Categories and the ACR/BI-Categories and the ACR/BI-
RADSRADS
The American College of Radiology (ACR) has established the Breast Imaging
Reporting and Database System (BI-RADSTM
) to guide the breast cancer
diagnostic routine. Radiologists sometimes refer to each BI-RADSTM
category
as a "level."
Category 0 Need Additional Imaging
Evaluation
Category 1 Negative
Category 2 Benign Finding
Category 3 Probably Benign Finding – Short
Interval Follow-Up Suggested
Category 4 Suspicious Abnormality – Biopsy
Should Be Considered
Category 5 Highly Suggestive of Malignancy –
Appropriate Action Should Be
Taken

30. MAIN SYMPTOMS OF BREASTMAIN SYMPTOMS OF BREAST
DISORDERS :DISORDERS :
Breast Mass
Skin Changes
Breast Pain (Mastalgia)
Nipple (Discharge, Inversion, Skin changes)

31.  The presentation of a woman with a breast mass is one of
the most common problems facing a primary care physician
 It may occur at any age after adolescence
 A systematic, thorough approach to the workup of any
breast mass -- including a careful history, clinical breast
examination, and documentation -- is crucial plus a careful
and systematic clinical investigation.
 distinguishing the cyst from the solid mass is the most
important tasks facing the clinician
 Although breast cancer is often not an easy diagnosis to
make , it is the explicit duty of the physician to rule out this
diagnosis.

32. Risk factorsRisk factors
1)early onset of menstruation,
2)late onset of menopause,
3)childbirth after age 30,
4)nulliparity,
5)lactation for less than 2 years,
6)alcohol ingestion,
7)obesity,
8)low socioeconomic status,
9)particular ethnicity,
10)hormone replacement therapy (HRT),
11) family history,
12)radiation exposure, and
13)prior history of proliferative breast disease or breast cancer.
14) smoking
15) inheritance of mutation in the BRCA-1 or BRCA-2 genes

33. Etiologies:Etiologies:
There are 4 common etiologies of a
breast "lump":
1) Fibroadenoma,
2) Cyst,
3) Benign fibrocystic masses,
4) Cancer.

35. Fibrocystic MassFibrocystic Mass
Fibrocystic changes are very common in
premenopausal women, primarily as a
result of the influence of ovarian hormones
on the physiology of breast tissue.
Fibrocystic masses may also appear in some
postmenopausal women being treated with
HRT
it is not possible for physical examination or
radiological studies to definitively distinguish
a fibrocystic from a malignant mass.

36. FibroadenomaFibroadenoma
Benign mass that occurs most frequently
in young women, beginning in
adolescence
They are usually quite mobile on
physical examination and represent a
benign proliferation of connective tissue
that is encapsulated and incorporates
epithelial cells

37. CystCyst
 Is a benign, fluid-filled structure found mostly in
perimenopausal women. It is uncommon to find
cysts in women younger than age 35.
 May develop in postmenopausal women, but
this is distinctly uncommon unless the woman is
taking HRT.
 They could be present with variable
consistencies varying from soft & cystic to a
hardness equal to cancer which makes them
difficult to distinguish, by palpation, from solid
abnormalities.

38. CancerCancer
 Usually firmer than the other
 In addition, breast cancer is often painless
 Exceptions to the usual firmness and
painlessness of cancerous masses make
reliance on such descriptors for diagnosis
very hazardous
“Postmenopausal women who present with
a breast mass should be presumed to
have cancer until it is proven otherwise”

39. Traumatic fat necrosis : it
affects middle aged female.
Caused by a trauma to the breast fatty
tissues ( ex : seatbelt , direct trauma ,
RTA) which will cause a painless lump
that mimic carcinoma.
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40. Taking historyTaking history
Systematic Approach to Breast Mass Workup
Triple assessment
 Location Ask the woman to point to the area of concern with 1
finger.
 Document this area on the physical examination record pictorially
with an "X."
 Method of Discovery Establish how familiar the woman is with
her own breast examination.
 How often does the woman perform breast self-examination
(BSE)?
 Did she discover the lump during BSE or by accident?
 Was the lump found when the patient was in the supine position,
standing in the shower, or in a different position?
 Size How big is the lump currently? Liken the size to familiar
items, such as a pea, a grape, or a walnut.

41.  Duration When was the lump first found?
 Has it changed since first date of discovery?
 Hormonal Influences What is the woman's
ovulatory status?
 When was her last menstrual period?
 Is she premenopausal? If so, does the mass change
depend on the phase of her ovulatory cycle?
 Is she on hormone replacement therapy? If so, what
are the drug names and dosages?
 Tenderness Is the mass tender?
 If the patient is premenopausal, does the tenderness
change with the ovulatory cycle?
 Associated Sx.( pain, discharge, Wt loss, bone pain)

42.  4 essential elements to consider when taking a risk factor
history:
 Age. Before age 25, it is rare to consider breast cancer as
a possible etiology of a breast mass; after age 25, the
incidence rises incrementally.
 Personal history of breast cancer. It is important to
have a clear estimate of cancer risk to the contralateral
breast when a woman has been diagnosed with breast
cancer
 Personal history of proliferative breast disease.
 Family history of breast cancer.((1) Lack of a family
history is by no means protective; (2) A large majority of
women diagnosed with breast cancer do not have a family
history of the disease.)

43. 43

44. FNA-FNABFNA-FNAB
 Simple FNA is often used when a mass can be
palpated to distinguish a cyst from a solid mass
 a 2-week interval should be allowed between
FNA and mammography or ultrasound. This is
because small hematomas from the needle
aspiration may cause false-positive results .
 If a mass is solely cystic, it will disappear following
a complete aspiration.
 If a mass is solid, 3 characteristics will typically
make this distinction: (1) no fluid will be aspirated
into the syringe barrel; (2) if there is any aspirate,
it will be solid; and (3) the mass will persist
following aspiration, then we do FNAB

45.  If the cyst has recurred, mammography and excisional
biopsy should be recommended.
 If any of the components of the diagnostic triad of CBE,
mammography, and FNA are suspicious or consistent
with malignancy, the mass should be biopsied.
 If All three results are negative, the mass can be closely
followed with CBE by the same examiner every 3
months for two visits, then again in 6 months to
determine if it is stable.
 Benign breast masses may spontaneously resolve over
time
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46. Don’t ForgetDon’t Forget
The cardinal signs of a late cancer of the
breast:
Hard, non-tender, irregular lump.
Tethering or fixation of the lump.
Palpable axillary lymph nodes
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47. Skin ChangesSkin Changes
 Puckering
Skin is pulled by an underlying cancer.
Fat necrosis after an injury.
 Peau d’orange
Edema caused by obstruction of skin lymphatics by cancer cells.
 Nodules
Usually they are secondary to a tumor
E.g: Benign breast lumps “diffuse nodularity”.
 Discolouration
 Ulceration
Due to the invasion of the carcinoma to the skin.
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48. Breast PainBreast Pain
Breast pain can be separated into two main
groups, cyclical and Non- cyclical.
Two thirds of women have cyclical pain other
third is Non- cyclical,
The causes for noncyclical breast pain are
very varied and hard to establish. Noncyclical
pain has frequently its root cause outside the
breast.

49. Non-cyclicalNon-cyclical
mean age 43
the pain is often localized and described
as a “burning” or Prickling sensation
Cyclical breast pain is very often associated
with fibrocystic breast changes or
duct ectasia and believed to be caused by
aberrations in dynamic hormonal changes

50. Cyclical mastalgiaCyclical mastalgia
 average age is 34
 discomfort, fullness, and heaviness of the breast
during the 3-7 days before each period
 breast being tender to touch
 pain improving at menstruation
 The pain varies in severity from cycle to cycle but
can persist for many years.
 Cyclical mastalgia is relieved by the menopause
 pregnancy, oral contraceptives & parity do not
affect its course.

51. TreatmentTreatment
Cyclical breast painCyclical breast pain
 There are presently three drugs that can be prescribed for
cyclical mastalgia.
 trial of treatment should last at least four months
1) Gamolenic acid
Mild nausea
Slow response to treatment
2) Danazol
Weight gain
Acne
Hirsutism
3)Bromocriptine
Nausea
Dizziness

52. TreatmentTreatment
Non-Cyclical breast painNon-Cyclical breast pain
local anaesthetic and steroid injection
some women respond to the drugs used
for cyclical mastalgia

53. Bacterial mastitisBacterial mastitis
 Most common in lactational females.
 Caused by staph aureus which lives in the
oropharynx of the baby.
 Stasis of the milk due to lactiferous duct blockage 
good media for bacteria.
 Treatment by antibiotics , and if it didn’t treated it
will complicated to abscess formation.
 Malaise , fever , throbbing pain Breast
abscess  don’t wait  incision and drainage.

54. The nipplesThe nipples
Nipple discharge.
Nipple inversion.
Nipple retraction.
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55. Nipple dischargeNipple discharge
Nipple discharge is a common complaint in
women who are not pregnant or breastfeeding,
especially during the reproductive years. Nipple
discharge is not necessarily abnormal, even
among postmenopausal women.
Nipple discharge can be serous (yellow),
mucinous (clear and watery), milky, sanguineous
(bloody), purulent, multicolored and sticky, or
serosanguineous (pink). It may occur
spontaneously or only in response to breast
manipulation.
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56. EtiologyEtiology
Most frequently, nipple discharge has a benign
cause. Cancer (usually intraductal carcinoma or
invasive ductal carcinoma) causes < 10% of cases.
The rest result from benign ductal disorders (eg,
intraductal papilloma, mammary duct ectasia,
fibrocystic changes), endocrine disorders, or
breast abscesses or infections.
Intraductal papilloma is probably the most
common; it is also the most common cause of a
bloody nipple discharge without a breast mass.
56

57. 57

58. Nipple inversionNipple inversion
This condition is frequently associated
with significant diseases and always need
full assessment.
The commonest cause by far are Duct
ectasia, but it is a regular presentation of
breast cancer with or without palpable
lump.

59. Paget disease of the nipple:Paget disease of the nipple:
Caused by cancer cells spreading around
ductal system from a carcinoma situated
deeply in the breast, which is in early stages
DCIS.
The presence of carcinoma cells in the skin
of the nipple produces a clinical appearance
similar to that of eczema , patches of skin
first become red and then encrusted and
oozy, but they do not itchy, later the nipple
is destroyed and replaced by a malignant
ulcer. 59

60. eczema Paget disease
bilateral unilateral
Common at lactation Occurs at menopause
itchy Not itchy
vesicles No vesicles
nipple intact Nipple destroyed
No lumps May be an underlying lump
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61. Duct ectasiaDuct ectasia
 Dilatation of breast ducts followed by periductal inflammation.
 Has strong association with smoking.
 Symptoms :
- nipple inversion "transverse slit"
- purulent nipple discharge.
- Subareolar mass. (tender)
- Periductal abscess & may rupture resulting in
Mammillary fistula.
 Treatment:
- Stop smoking.
- Antibiotics.
- Surgery.

62. Thank you