E.Naghshineh M.D 1

IN THE NAME OF GOD

BREAST DISEASE

E.Naghshineh M.D 2

- Most common cancer in women- Lifetime risk of breast cancer: 12.5% (1 in 8)- Lifetime risk of death :3.6% (1 in 28 )

- Decrease if : screening- ( G.P ) or ( ob . Gyn )

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Risk factors

- Age (most important)-family history ( BRCA1 – BRCA 2 ) 5-10 % all breast cancer .

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- personal history Atypical Ductal hyperplasia

Atypical lobular Hyperplasia

Lobular carcinoma insitu

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Contra lateral breast cancer 0.5-1% /year

Ipsilateral recurrence (lumpectomy –Radiation ) 10 % or more in 10 year

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-Reproduction history Early menarche Late menopause Nulliparity

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Age at first pregnancy (<30 yrs---30%, <20 yrs---50%)

breast – feeding (>24 months)

Bilateral oophorectomy

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-HRT HRT increase risk ( 10 %) HRT > 10 year increased Risk (E+P: highest risk) HRT smaller , less aggressive Breast cancer, lower mortalityHRT Not recommended for primary nor secondary prevention of heart disease

Not recommended for prevention of osteoporosis

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-prior exposure to radiation therapy

-7-10 yrs after radiotherapy-breast cancer risk in 40

years: 35%

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Other factor Jewish Black women Japanese Asian Diet (animal fat )

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Alcohol (dose dependent)

-BRCA1 , BRCA 2 -45 % Early onset in Breast cancer

-90 % hereditary Ovarian cancer

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History & Physical

Exam Family History MenarchePrevious pregnancies Breast – feeding HRT

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Trauma Surgery nipple discharge Breast mass

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Breast self Examination•Bilateral Exam after menses & before ovulation

•Supraclavicular -axilla

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Inflammatory appearance After Antibiotic therapy: Biopsy

Mammography (screening & fallow up )

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Mammography Screen of Asymptomatic patient Diagnose of breast cancer in

early stage mediolatenal Oblique (MLO),

Craniocaudal(CC) views Radiation Dose<0.1 Rad per study

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Negative mammogram not R/O Breast cancer

False Negative 10-15% If clinically positive Biopsy Screening mammography at 40 years 20-30 % Mortality

After 40 years: every 1-2 yrs

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BI-RADS CLASSIFICATION

0:Need Additional imaging evaluation Assessment is incomplete1:Negative2:Benign finding3:Probably benign finding Short interval follow-up suggested4:Suspicious abnormality Biopsy should be considered5:Highly suggestive of malignancy Appropriate action should be taken

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Breast ultrasoundD.Dx of Solid from cystic lesion

Guide for biopsyNo screening use( Not micro-calcification Dx)

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Ultrasound complement mammography in a young patient with dense Breast

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MRI•No role in cancer screening•High sensitivity(86-100%)•Low specificity(37-97%)•Expensive

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MRI Rupture of Breast implant pectoralis extension in

extensive breast cancer Post lumpectomy fibrosis Dense breast screening ?

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FNA Palpable thickening – mass DDx solid & cystic mass 21-25 needle,10 cc,3cc False negative 3-35% Atypical cells Biopsy False positive < 0.1 %

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Fibrocystic

change Most common Benign

breast disease 20-50 year Mastodynia – bilateral –

pre menstrual phase DDx: neuralgia, myalgia,

chronic costochondritis

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•Etiology: ? Methylgesantins

•cAMP, cGMP increase•No risk for breast cancer

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Fibro

Adenoma Second common Most common < 25 ys

Smooth, mobile, painless, Palpable mass

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Dx:-Physical exam -sonography –Mammography - FNA- Surgery if : Become Larger – atypia in FNA – patient desire

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Mastitis Breast feedingStaph Oreos – strep Continue Breast feedingTx:Dicloxacillin– Penicillin G If not cure: Biopsy R/O inflammatory carcinoma

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Ductectasia Pre-post menopause Hard erythematous mass adjacent to the areola with burning . itching – sensation of pulling in the nipple area .

Tx: Excisional Biopsy

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Fat Necrosis Benign, uncommonTraumaHard mass – irregular - skin retraction

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Multiple calcification in mammography

No increase risk of breast cancer

DDx : carcinoma

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Nipple

discharge 10-15% Benign, 2.5- 3 % malignant(milky – green – bloody – serous- cloudy – purulent ) bilateral- unilateral

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If nipple discharge : •Unilateral•Single duct•Menopause •Mass increase risk of cancer

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Breast cancer Most common: sup-lat (38.5%)

Most metastases: axilla, same side

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Ductal carcinoma Paget Disease Lobular carcinoma insitu Invasive ductal carcinoma Infiltrating lobular carcinoma Inflammatory carcinoma Metastases from

Extramammary tumors (lung,ovary,uterus,…)

Pathology

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Treatment Mastectomy Breast conservation therapy

Chemotherapy Radiation therapy

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