Breast

Hend almalki

Station 1a young lactating female she gave a history of 24 hr tenderness and redness

a) The pic. show ?? b) the causative organism is ? c) DDx ?d ) list 2 Rx ?e) the affected parts r ??? nipple & the areola ???!!

a- what dose the picture show?Swelling ,redness, pus discharge of the breastB- what is the causative organism?Staphylococcus aureus C- what is the differential diagnosis? Breast abscess proceeded by early phase acute mastitis D- what is the treatment?Antibiotic (dicloxacillin)needle aspiration with culture taken and if large abscess incision and drainage should be done E- what are the affected parts?Breast lobule will be affected via the nipple ,duct system and circulation

Station 2A- name the abnormality that you see in the picture?

B- what is your DDx?

c- what is the 1st underlying structure that will concern us if it get attached to this lesion?

D- what maneuver that done to make this lesion more clear ?

E- list the groups of axillary Lymph node?

f- what is the different between benign and malignant breast cancer?

A- name the abnormality that you see in the picture?Skin dimpling caused by tetheringnote :puckering is multiple dimpling of the skin(this note is from doc kurdi session)

B- what is your Dx?Breast cancer

c- what is the 1st underlying structure that will concern us if it get attached to this lesion? The fibrous septa (cooper`s ligament) that separate breast lobule which may block the lymphatic that run alongside them causing edema of the breast and peau d` orange apperance

D- what maneuver that done to make this lesion more clear ?

Ask the patient to raise the hand above the head

E- list the groups of axillary Lymph node?

There are six groups can be easily remembered by the acronym 'APICAL' -anterior, posterior,infraclavicular, central,apical and lateral :1- anterior or medial (pectoral)2- posterior or inferior (subscapular)3- lateral ( humeral)4-(central) or intermediate ( they drain from ant , post and lat then efferents drain into apical)5- ( infraclavicular or subclavicular)6-( apical) : the final group , receives its afferents from all other groups and from the mammary tail and its efferents form the subclavian trunk.That was the anatomical classificationSurgically, axillary lymph nodes r classified into 3 levels going from lateral to medial in relation to pectoralis minor p.m. muscle: level 1 : lat to p.m. ( mainly ant , post & lat groups) , level 2 : behind p.m. Mainly ( central and some apical nodes) , level 3 : medial to p.m. ( mainly infraclavicular group+ some apical )

f- what is the different between benign and malignant breast cancer?

Benign Malignant

Anywhere Commonly in the axillary tail

presnted as smooth, rubbery, discrete, well-circumscibed brest mass, non-tender, mobile,

hormone dependent

Solid mass ,painless , roughly spherical breast mass, fixed , not mobile

Age <40 Age > 40

none Nipple(discharge, rash , retraction) skin dimpling,edema

Axillary ,supraclavicular lymph node

-Mammogram - US - FNA to R/O solid lesion

Triple assement (history & examination, imaging: mammogram-US,pathology)

Metastatic screen(chest,liver,bone ,brain)

Benign Malignant

Generally conservative – serial observation

-Excision if: mass rapidly growing, if >5cm in size or if Pt. wants

Stage I,IIBCS ( breast conservative surgery):Lumpectomy with free margin+radiation+/- Axillary clearance (ALND) +/- chemotherapyIf there is any contraindication of

conservative as to radiation (skin excoriation , pregnancy , CTD )we go for non conservative

Stage III, IVModified radical mastectomy

(MRMSimple mastectomy (it’s MRM

without LN dissection)+Chemotherapy

Nowadays all breast cancer pt receive chemotherapy except for pt who can`t tolerate it as old women who can die by post chemo infection we give her tamoxifen if ER receptor +ve

Benign Malignant

Circumscribed mass Spiculated mass

Fat-containing lesion Architectural distortion with no history of prior surgery

Macrocalcifications :Widely scattered

Microcalcifications (<0.5 mm) :Tightly clustered

Round, uniform density, large, coarse

Linear, branching, pleomorphic, casting

Long axis of the lesion is along the normal tissue planes

Lesion is taller than it is wide

Homogeneous internal echotexture

Decreased hyperechogenicity

Hyperechogenicity Marked acoustical shadowing

Smoothly marginated Spiculation

Finding in mammogram:

Station 3*describe what u see.?

*Dx?

*give 3D.Dx for bloody discharge from nipple?

A- describe what you see?Retracted nipple

b- what is your differential diagnosis?Congenital retraction, duct ectasia, carcinoma

C- give3 differential diagnosis for bloody discharge from nipple?Intraductal Carcinoma ,Intraductal papillomaPaget’s disease

Station 4Q. describe Q. mention 3 important points that you should ask about in the Hx (risk factors) ?Q. what is the most proper diagnosis ?

A- describe what you see?Bilateral breast enlargement

b- mention 3 important points that you should ask about in the Hx (risk factors) ?*Drugs(antihistamine ,cimetidine , anabolic steroid, diuretics spironolactone,estrogen for prostatic cancer ,digoxindecreased testosterone)sign and symptoms of* liver cirrhosis or * bronchial carcinoma

D -what is the most proper diagnosis ? gynaecomastia

NBCommon Breast Lumps:Young Women: Fibroadenoma / AbscessPregnant : Galactocoele / abscessMiddle aged and elderly women: Cancer higher up the differential diagnosis list.

Galactocele:a cystic tumour containing milk or a milky substanceGalactocele is usually round and freely mobile

Needle aspiration is the choice for diagnosis and treatment with large gauge needle as the content of a galactocele is thick and creamy

Surgery is performed when needle aspiration is not possible or when it becomes infected.

Thank you