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EVERYTHING YOU NEED TO KNOW ABOUT BREAST Shazia Here’s whatwedo: ■ Weekly tutorialsopento all! ■ Focussed oncore presentationsand teaching diagnostictechnique If you’re new here… ■ By medical students, for medical students Welcome to ■ Reviewed by doctorsto ensure accuracy Teaching ■ We’ll keepyouupdatedabout our Things! upcoming events viaemail and groupchats!BREAST Shazia All ofbreast: Hyperplasia Lumps, bumps & Breastfeeding Malignancy Discharge pains Sclerosing Fibroadenomas Raynaud's disease Ductal &lobular Intraductal adenosis Fibroadenosis ofthenipple Invasive& insitu papilloma Radialscar Cyclical mastalgia Lactational mastitis Inflammatory Duct ectasia Epithelial Fat necrosis Breast abscess breastcancer Nipplecandidiasis hyperplasia Periductal mastitis Engorgement Paget’sdisease Galactorrhoea Mondor’sdisease Galactocele Phyllodes Implantrupture All ofbreast: Hyperplasia Lumps, bumps & Breastfeeding Malignancy Discharge pains Sclerosing Fibroadenomas Raynaud's disease Ductal &lobular Intraductal adenosis Fibroadenosis ofthenipple Invasive& insitu papilloma Radialscar Cyclical mastalgia Lactational mastitis Inflammatory Duct ectasia Epithelial Fat necrosis Breast abscess breastcancer Nipplecandidiasis hyperplasia Periductal mastitis Engorgement Paget’sdisease Galactorrhoea Mondor’sdisease Galactocele Phyllodes Implantrupture What we’ll do today: Hyperplasia Lumps, bumps & Breastfeeding Malignancy Discharge pains Sclerosing Fibroadenomas Raynaud's disease Ductal &lobular Intraductal adenosis Fibroadenosis ofthenipple Invasive& insitu papilloma Radialscar Cyclical mastalgia Lactational mastitis Inflammatory Duct ectasia Epithelial Fat necrosis Breast abscess breastcancer Nipplecandidiasis hyperplasia Periductal mastitis Engorgement Paget’sdisease Galactorrhoea Mondor’sdisease Galactocele Phyllodes ImplantruptureBenign lumps and pains Case1:19Ysingle,painlesslump Case2: 38Ymultiple,painful lumps bilaterally Case3:23Y bilateral breast painwithout any lumpBenign lumps and pains Let’s startby askingif thereis anychangeduringmenstruation –whatdo we expect? Case1:19Ysingle,painlesslump Case2: 38Ymultiple,painful lumps bilaterally Case3:23Y bilateral breast painwithout any lumpBenign lumps and pains Let’s startby askingif thereis anychangeduringmenstruation –whatdo we expect? Case1:19Ysingle,painlesslump No changeduring period Case2: 38Ymultiple,painful lumps bilaterally Case3:23Y bilateral breast painwithout any lumpBenign lumps and pains Let’s startby askingif thereis anychangeduringmenstruation –whatdo we expect? Case1:19Ysingle,painlesslump No changeduring period Case2: 38Ymultiple,painful lumps bilaterally Worse duringperiod Case3:23Y bilateral breast painwithout any lumpBenign lumps and pains Let’s startby askingif thereis anychangeduringmenstruation –whatdo we expect? Case1:19Ysingle,painlesslump No changeduring period Case2: 38Ymultiple,painful lumps bilaterally Worse duringperiod Case3:23Y bilateral breast painwithout any lump Worse duringperiodBenign lumps and pains Howdothey feel? Case1:19Ysingle,painlesslump No changeduring period Case2: 38Ymultiple,painful lumps bilaterally Worse duringperiod Case3:23Y bilateral breast painwithout any lump Worse duringperiodBenign lumps and pains Howdothey feel? Case1:19Ysingle,painlesslump No changeduring period Verymobile, rubbery &non-tender Case2: 38Ymultiple,painful lumps bilaterally Worse duringperiod Case3:23Y bilateral breast painwithout any lump Worse duringperiodBenign lumps and pains Howdothey feel? Case1:19Ysingle,painlesslump No changeduring period Verymobile, rubbery &non-tender Case2: 38Ymultiple,painful lumps bilaterally Worse duringperiod Fluctuant,mobile&fluid filled Case3:23Y bilateral breast painwithout any lump Worse duringperiodBenign lumps and pains Howdothey feel? Case1:19Ysingle,painlesslump No changeduring period Verymobile, rubbery &non-tender Case2: 38Ymultiple,painful lumps bilaterally Worse duringperiod Fluctuant,mobile&fluid filled Case3:23Y bilateral breast painwithout any lump Worse duringperiod No focal pointoftendernessBenign lumps and pains Whatis it? Case1:19Ysingle,painlesslump No changeduring period Verymobile, rubbery &non-tender Case2: 38Ymultiple,painful lumps bilaterally Worse duringperiod Fluctuant,mobile&fluid filled Case3:23Y bilateral breast painwithout any lump Worse duringperiod No focal pointoftendernessBenign lumps and pains Whatis it? Fibroadenoma Breast mouse: mobile, firm, painless& unilateral Case1:19Ysingle,painlesslump Benign clumps of breast tissue during development No changeduring period Most common breast lump: >60% of breast lumps between Verymobile, rubbery &non-tender 18-25 Case2: 38Ymultiple,painful lumps bilaterally Worse duringperiod Fluctuant,mobile&fluid filled Case3:23Y bilateral breast painwithout any lump Worse duringperiod No focal pointoftendernessBenign lumps and pains Whatis it? Breast mouse: mobile, firm, painless& unilateral No change with period Case1:19Ysingle,painlesslump Benign clumps of breast tissue during development No changeduring period 18-25common breast lump: >60% of breast lumps between Verymobile, rubbery &non-tender Fibroadenosis Case2: 38Ymultiple,painful lumps bilaterally Fibrocystic disease: bilateral, pain and Worse duringperiod Changes with period Fluctuant,mobile&fluid filled Lumpy breasts Most common cause ofbreast pain in middle aged aged women Case3:23Y bilateral breast painwithout any lump Worse duringperiod No focal pointoftendernessBenign lumps and pains Whatis it? Fibroadenoma No change with period firm, painless& unilateral Case1:19Ysingle,painlesslump Benign clumps of breast tissue during development No changeduring period Most common breast lump: >60% of breast lumps between Verymobile, rubbery &non-tender 18-25 Fibroadenosis Fibrocystic disease: bilateral, pain and Case2: 38Ymultiple,painful lumps bilaterally fluctuant Worse duringperiod Changes with period Fluctuant,mobile&fluid filled Lumpy breasts Most common cause ofbreast pain in middle aged aged women Case3:23Y bilateral breast painwithout any lump Worse duringperiod No focal pointoftenderness Benign cyclical mastalgia Bilateral with no lump Young females No focal point of tendernesscycleBenign lumps and pains Let’s investigate! Case1:19Ysingle,painlesslump No changeduring period Verymobile, rubbery &non-tender Case2: 38Ymultiple,painful lumps bilaterally Worse duringperiod Fluctuant,mobile&fluid filled Case3:23Y bilateral breast painwithout any lump Worse duringperiod No focal pointoftendernessBenign lumps and pains Let’s investigate! Case1:19Ysingle,painlesslump No changeduring period Verymobile, rubbery &non-tender USS/mammogram: oval,lobulated, circumscribed Case2: 38Ymultiple,painful lumps bilaterally Worse duringperiod Fluctuant,mobile&fluid filled Case3:23Y bilateral breast painwithout any lump Worse duringperiod No focal pointoftendernessBenign lumps and pains Let’s investigate! Case1:19Ysingle,painlesslump No changeduring period USS/mammogram: oval,lobulated, circumscribed Verymobile, rubbery &non-tender Case2: 38Ymultiple,painful lumps bilaterally Worse duringperiod Fluctuant,mobile&fluid filled USS/mammogram: halo appearance, fluid filled Aspiration Case3:23Y bilateral breast painwithout any lump Worse duringperiod No focal pointoftendernessBenign lumps and pains Let’s investigate! Case1:19Ysingle,painlesslump No changeduring period Verymobile, rubbery &non-tender USS/mammogram: oval,lobulated, circumscribed Case2: 38Ymultiple,painful lumps bilaterally Worse duringperiod USS/mammogram: halo appearance, fluid filled Fluctuant,mobile&fluid filled Aspiration Case3:23Y bilateral breast painwithout any lump Worse duringperiod No focal pointoftenderness USS/mammogram: no focal lesionsBenign lumps and pains Management Case1:19Ysingle,painlesslump No changeduring period Verymobile, rubbery &non-tender Case2: 38Ymultiple,painful lumps bilaterally Worse duringperiod Fluctuant,mobile&fluid filled Case3:23Y bilateral breast painwithout any lump Worse duringperiod No focal pointoftendernessBenign lumps and pains Management Case1:19Ysingle,painlesslump No changeduring period Wide excision if >3cm Verymobile, rubbery &non-tender Case2: 38Ymultiple,painful lumps bilaterally Worse duringperiod Fluctuant,mobile&fluid filled Case3:23Y bilateral breast painwithout any lump Worse duringperiod No focal pointoftendernessBenign lumps and pains Management Case1:19Ysingle,painlesslump Wide excision if >3cm No changeduring period Verymobile, rubbery &non-tender Case2: 38Ymultiple,painful lumps bilaterally Worse duringperiod Conservative measures: simple analgesia & supportive Fluctuant,mobile&fluid filled measures Non-symptomatic: self-massage & safety net Symptomatic:aspiration of recurrent cysts,follow up, ?COCP Case3:23Y bilateral breast painwithout any lump Worse duringperiod No focal pointoftendernessBenign lumps and pains Management Case1:19Ysingle,painlesslump Wide excision if >3cm No changeduring period Verymobile, rubbery &non-tender Case2: 38Ymultiple,painful lumps bilaterally Worse duringperiod Conservative measures: simple analgesia & supportive Fluctuant,mobile&fluid filled measures Non-symptomatic: self-massage & safety net Symptomatic:aspiration of recurrent cysts,follow up, ?COCP Case3:23Y bilateral breast painwithout any lump Worse duringperiod No focal pointoftenderness Supportive bra Oral/topical No response to conservative measuresafter 3 ?COCPs: hormonal agentse.g.bromocriptine,28Y 17 days post-delivery with bilateral breast pain28Y 17 days post-delivery with bilateral breast pain Whatshould weask?28Y 17 days post-delivery with bilateral breast pain Whatshould weask? Otherwisewell Slight feverine Breastsfeel hot, red, swollenand tender with improvementonfeeding28Y 17 days post-delivery with bilateral breast pain Whatshould weask? Otherwisewell Baby doing fine Slight fever Breastsfeel hot, red, swollenand tender with improvementonfeeding Differentials?28Y 17 days post-delivery with bilateral breast pain Whatshould weask? Otherwisewell Slight feverine Breastsfeel hot, red, swollenand tender with improvementonfeeding Lactational Mastitis Breastengorgement28Y 17 days post-delivery with bilateral breast pain Whatshould weask? Otherwisewell Slight feverine Breastsfeel hot, red, swollenand tender with improvementonfeeding Lactational Mastitis Breastengorgement Inflammation of breast during breastfeedimilkproductionblood and fluid in breast due to28Y 17 days post-delivery with bilateral breast pain Whatshould weask? Otherwisewell Baby doing fine Slight fever Breastsfeel hot, red, swollenand tender with improvementonfeeding Lactational Mastitis Breastengorgement Inflammation of breast during breastfeedingCongestion of blood and fluid in breast due to milkproduction No change after feeding Symptomsimprove on feeding General malaise and pyrexia May be slight fever28Y 17 days post-delivery with bilateral breast pain Whatshould weask? Otherwisewell What’s this? Baby doing fine Slight fever Breastsfeel hot, red, swollenand tender with improvementonfeeding Lactational Mastitis Breastengorgement Inflammation of breast during breastfeedingCongestion of blood and fluid in breast due to milkproduction No change after feeding Symptomsimprove on feeding General malaise and pyrexia May be slight fever28Y 17 days post-delivery with bilateral breast pain Whatshould weask? Otherwisewell Engorgement! Baby doing fine Slight fever Breastsfeel hot, red, swollenand tender with improvementonfeeding Lactational Mastitis Breastengorgement Inflammation of breast during breastfeedingCongestion of blood and fluid in breast due to milkproduction No change after feeding Symptomsimprove on feeding General malaise and pyrexia May be slight fever28Y 17 days post-delivery with bilateral breast pain Whatshould weask? Otherwisewell Engorgement Baby doing fine Treatment? Slight fever Breastsfeel hot, red, swollenand tender with improvementonfeeding Lactational Mastitis Breastengorgement Inflammation of breast during breastfeedingCongestion of blood and fluid in breast due to milkproduction No change after feeding Symptomsimprove on feeding General malaise and pyrexia May be slight fever28Y 17 days post-delivery with bilateral breast pain Whatshould weask? Otherwisewell Engorgement Baby doing fine Conservative: handexpression ofmilk Slight fever Breastsfeel hot, red, swollenand tender with improvementonfeeding Lactational Mastitis Breastengorgement Inflammation of breast during breastfeedingCongestion of blood and fluid in breast due to milkproduction No change after feeding Symptomsimprove on feeding General malaise and pyrexia May be slight fever32Y 34 days post-delivery with breast mass Stopped feedingasreturning to office Massis painless,fluctuantandmobile Otherwiseweller32Y 34 days post-delivery with breast mass Stopped feedingasreturning to office Massis painless,fluctuantandmobile Otherwiseweller What’s going on?32Y 34 days post-delivery with breast mass Stopped feedingasreturning to office Massis painless,fluctuantandmobile Otherwiseweller Galactocele–justbuild-up ofmilk inductswhenstoppingbreastfeeding32Y 34 days post-delivery with breast mass Stopped feedingasreturning to office Massis painless,fluctuantandmobile Slightly tender Otherwisewell Galactocele–justbuild-up ofmilk inductswhenstoppingbreastfeeding Whatdo we do?32Y 34 days post-delivery with breast mass Stopped feedingasreturning to office Massis painless,fluctuantandmobile Otherwiseweller Galactocele–justbuild-up ofmilk inductswhenstoppingbreastfeeding Non-symptomatic:self-massageandsafety net Symptomatic:aspiration Follow up and imaging32Y 34 days post-delivery with breast mass Stopped feedingasreturning to office Massis painless,fluWhatto doiflady wishes to stop Otherwiseweller producing milk? Galactocele–justbuild-up ofmilk inductswhenstoppingbreastfeeding Non-symptomatic:self-massageandsafety net Symptomatic:aspiration Follow up and imaging32Y 34 days post-delivery with breast mass Stopped feedingasreturning to office Massis painless,fluctuaStopping lactationreflex Otherwiseweller Well supported bra Cabergoline(dopamine agonist) Galactocele–justbuild-up ofmilk inductswhenstoppingbreastfeeding Non-symptomatic:self-massageandsafety net Symptomatic:aspiration Follow up and imaging28Y 17 days post-delivery with breast pain General malaiseand fever Painful,tenderright breast No improvementonfeeding28Y 17 days post-delivery with breast pain General malaiseand fever Mastitis Painful,tenderright breast 10% of breastfeeding Hot and red women No improvementonfeeding28Y 17 days post-delivery with breast pain Mastitis General malaiseand fever 10% of breastfeeding Painful,tenderright breast No improvementonfeeding women st 1 line:28Y 17 days post-delivery with breast pain Mastitis General malaiseand fever 10% of breastfeeding Painful,tenderright breast No improvementonfeeding women st 1 line:continuebreastfeeding,warm compresses, milk expression,analgesia28Y 17 days post-delivery with breast pain General malaiseand fever Mastitis Painful,tenderright breast 10% of breastfeeding Hot and red women No improvementonfeeding Whento give antibiotics?28Y 17 days post-delivery with breast pain General malaiseand fever Mastitis Painful,tenderright breast 10% of breastfeeding Hot and red women No improvementonfeeding Whento give antibiotics? F(L)APS Fissure Attempted conservative already Positive culture Systemically unwell28Y 17 days post-delivery with breast pain General malaiseand fever Mastitis Painful,tenderright breast 10% of breastfeeding Hot and red women No improvementonfeeding Whento give antibiotics? – 10-14 daysPO flucloxacillin F(L)APS Fissure Attempted conservative already Positive culture Systemically unwell28Y 17 days post-delivery with breast pain Mastitis General malaiseand fever 10% of breastfeeding Painful,tenderrigSkinissues:try fluclox if in doubt! No improvementonfeeding women (erythro ifallergic) Whento give antibiotics? – 10-14 daysPO flucloxacillin F(L)APS Fissure Attempted conservative already Positive culture Systemically unwellSame lady back after 2 days Ongoingmastitis symptomsbut now tender, fluctuant mass Ongoing,worseningmalaiseand pyrexiaSame lady back after 2 days Ongoingmastitis symptomsbut now tender, fluctuant mass Ongoing,worseningmalaiseand pyrexia What’s going on?Same lady back after 2 days Ongoingmastitis symptomsbut now tender, fluctuant mass Ongoing,worseningmalaiseand pyrexia Breastabscess Mostcaused bystaph aureus infection dueto mastitis Systemic/localinfectionSame lady back after 2 days Ongoingmastitis symptomsbut now tender, fluctuant mass Ongoing,worseningmalaiseand pyrexia Swinging pyrexia/spiking fevercommon Breastabscess inabscesses ofany location Mostcaused bystaph aureus infection dueto mastitis Systemic/localinfectionSame lady back after 2 days Ongoingmastitis symptomsbut now tender, fluctuant mass Ongoing,worseningmalaiseand pyrexia Breastabscess Mostcaused bystaph aureus infection dueto mastitis Systemic/localinfection Whatdo we do?Same lady back after 2 days Ongoingmastitis symptomsbut now tender, fluctuant mass Ongoing,worseningmalaiseand pyrexia Breastabscess Mostcaused bystaph aureus infection dueto mastitis Systemic/localinfection USS guided aspirationand antibiotics Incisionand drainage Surgicaldebridementifoverlying necrosis If inGP–urgentreferraltohospital breastteamWhat’shappening?What’shappening? Raynaud’s diseaseofthenipple Sameideaasinrheum– vasospasm of breast tissue during breastfeeding Intermittent pain during and after feeding Blanching,cyanosis,erythemaof nippleWhat’shappening? Raynaud’s diseaseofthenipple Sameideaasinrheum– vasospasm of breast tissue during breastfeeding Intermittent pain during and after feeding Blanching,cyanosis,erythemaof nipple What to do: Conservative:What’shappening? Raynaud’s diseaseofthenipple Sameideaasinrheum– vasospasm of breast tissue during breastfeeding Intermittent pain during and after feeding Blanching,cyanosis,erythemaof nipple What to do: Conservative:avoidcold, heat packs, nosmokingWhat’shappening? Raynaud’s diseaseofthenipple Sameideaasinrheum– vasospasm of breast tissue during breastfeeding Intermittent pain during and after feeding Blanching,cyanosis,erythemaof nipple What to do: Conservative:avoidcold, heat packs, nosmoking Specialist:What’shappening? Raynaud’s diseaseofthenipple Sameideaasinrheum– vasospasm of breast tissue during breastfeeding Intermittent pain during and after feeding Blanching,cyanosis,erythemaof nipple What to do: Conservative:avoidcold, heat packs, nosmoking Specialist:POnifedipine31Y with painful red breast Red,tender, hot breast Painful Pyrexiaandmalaise Nulliparous Areolar/periareolar skinchanges31Y with painful red breast Red,tender, hot breast Painful Pyrexiaandmalaise Nulliparous Areolar/periareolar skinchanges What’s likelyin her social history?31Y with painful red breast Red,tender, hot breast Painful Pyrexiaandmalaise Nulliparous Areolar/periareolar skinchanges Causes damageof subareolar ducts thatbecomeinfected Can also beimplants,piercings,injury etc.31Y with painful red breast Red,tender, hot breast Painful Pyrexiaandmalaise Areolar/periareolar skinchanges Causes damageof subareolar ducts thatbecomeinfected Can also beimplants,piercings,injury etc. What’s going on?31Y with painful red breast Red,tender, hot breast Pyrexiaandmalaise Nulliparous Areolar/periareolar skinchanges Smoking! Causes damageof subareolar ducts thatbecomeinfected Can also beimplants,piercings,injury etc. Periductal mastitis Inflammationand dilationof mammary ducts with infection31Y with painful red breast Periductal mastitis Inflammationand dilationof mammary ducts with infection Howdowetreat?31Y with painful red breast Periductal mastitis Inflammationand dilationof mammary ducts with infection Howdowetreat? Sameaslactational mastitis –warmcompressesand analgesia Stopsmoking But should we: 1. Giveeveryoneantibiotics 2.Only giveif F(l)APS31Y with painful red breast Periductal mastitis Inflammationand dilationof mammary ducts with infection Howdowetreat? Sameaslactational mastitis –warmcompressesand analgesia Stopsmoking But should we: 1.Giveeveryoneantibiotics –wedon’twanttowaitas highchanceof complications 2.Only giveif F(l)APS31Y with painful red breast Periductal mastitis Inflammationand dilationof mammary ducts with infection Speakingofcomplications –whatcangowrong? Sameaslactational mastitis -31Y with painful red breast Periductal mastitis Inflammationand dilationof mammary ducts with infection Speakingofcomplications –whatcangowrong? Sameaslactational mastitis –abscess!31Y with painful red breast Periductal mastitis Inflammationand dilationof mammary ducts with infection Speakingofcomplications –whatcangowrong? Sameaslactational mastitis –abscess! Treatment?31Y with painful red breast Periductal mastitis Inflammationand dilationof mammary ducts with infection Speakingofcomplications –whatcangowrong? Sameaslactational mastitis –abscess! Refer tobreastinhospital,aspiration,antibiotics etc.Discharging nipples Ductectasia Intraductal papillomaDischarging nipples Ductectasia Intraductal papilloma Benign proliferation inside a milkductDischarging nipples Ductectasia Intraductal papilloma Benign proliferation inside a milkductDischarging nipples Ductectasia Intraductal papilloma Wideningand thickeningof milkductsin breastsdue to Benign proliferation inside a celldeath milkductDischarging nipples Ductectasia Intraductal papilloma Wideningand thickeningof milkductsin breastsdue to Benign pmilkducttion inside a celldeath Can be normal part ofageing in~25% ofpwomenenopausalDischarging nipples Ductectasia Intraductal papilloma Wideningand thickeningof milkductsin breastsdue to Benign pmilkducttion inside a celldeath Can be normal part ofageing in~25% ofpost-menopausal womenDischarging nipples Ductectasia Intraductal papilloma Wideningand thickeningof milkductsin breastsdue to Benign proliferation inside a celldeath milkduct Can be normal part ofageing Mostcommon in pre- in~25% ofpost-menopausal menopausalwomen 30-55 womenDischarging nipples Ductectasia Intraductal papilloma Wideningand thickeningof Benign proliferation inside a milkductsin breastsdue to milkduct celldeath Can be normal part ofageing in~25% ofpost-menopausal Mostcommon in pre- women menopausalwomen 30-55 Smokingisarisk factorDischarging nipples Ductectasia Intraductal papilloma Wideningand thickeningof Benign proliferation inside a milkductsin breastsdue to milkduct celldeath Can be normal part ofageing in~25% ofpost-menopausal Mostcommon in pre- women menopausalwomen 30-55 Smokingisarisk factorDischarging nipples Ductectasia Intraductal papilloma Wideningand thickeningof Benign proliferation inside a milkductsin breastsdue to milkduct celldeath Can be normal part ofageing in~25% ofpost-menopausal Mostcommon in pre- women menopausalwomen 30-55 Bilateral, clear/blood-stained Smokingisarisk factor dischargeDischarging nipples Ductectasia Intraductal papilloma Wideningand thickeningof Benign proliferation inside a milkductsin breastsdue to milkduct celldeath Can be normal part ofageing in~25% ofpost-menopausal Mostcommon in pre- women menopausalwomen 30-55 Smokingisarisk factor Bilateral, clear/blood-stained dischargeDischarging nipples Ductectasia Intraductal papilloma Wideningand thickeningof milkductsin breastsdue to Benign proliferation inside a celldeath milkduct Can be normal part ofageing Mostcommon in pre- in~25% ofpost-menopausal menopausalwomen 30-55 women Smokingisarisk factor Unilateral, thickgreen discharge Bilateral, clear/blood-stained dischargeDischarging nipples Duct e ctasia Intraductal papill o ma Wideningand thickeningof milkductsin breastsdue to Benign proliferation inside a celldeath milkduct Can be normal part ofageing Mostcommon in pre- in~25% ofpost-menopausal menopausalwomen 30-55 women Smokingisarisk factor Unilateral, thiceern Bilateral, cleaoobd- discharge staineddischargeDischarging nipples Ductectasia Intraductal papilloma Wideningand thickeningof Benign proliferation inside a milkductsin breastsdue to milkduct celldeath Can be normal part ofageing Investigations etc. later in~25% ofpost-menopausalomuch more than remove affectedducte.g.,Mostcommon in pre- women microdochectomy/ excision menopausalwomen 30-55 Smokingisarisk factor Unilateral, thickgreen Bilateral, clear/blood-stained discharge discharge1. 26Y breastfeedingwithtenderlump, feverandmalaise A.USSshowshaloappearance andfluid 2. 32Y with bloody, unilateral nipple discharge B. Most common cause ofbenign breast lumps C. Causedby stoppingbreastfeedingandmanagedwith 3. 24Y with bilateral, painful, lumpy breasts handexpression 4. 19Y with painfulbreasts with nolumps D.Antibiotics given toall patients 5. 21Y with single, non-painfullumponbreast E. Urgentreferral tohospitalfordrainage 6. 33Y pyrexicbreastfeedingwithpainfulbreastw/olump F. Likelytovary inintensity by menstrualcycle 7. 51Y smoker with unilateral discharge G. Wouldwait for antibiotics until complicationsor conservative managementattempted 8.34Ybreastfeeding with painless, non-tenderlump H. Causedby benign proliferation within milk ducts 9. 3Y nulliparawith painful, hotbreastandfever I. Mostlikely todescribe greenish discharge1.26Ybreastfeeding withtenderlump,feverandmalaise A.USSshowshaloappearance andfluid 2. 32Y with bloody, unilateral nipple discharge B. Most common cause ofbenign breast lumps C. Causedby stoppingbreastfeedingandmanagedwith 3. 24Y with bilateral, painful, lumpy breasts handexpression 4. 19Y with painfulbreasts with nolumps D.Antibiotics given toall patients 5. 21Y with single, non-painfullumponbreast E. Urgentreferral tohospital for drainage 6. 33Y pyrexicbreastfeedingwithpainfulbreastw/olump F. Likelytovary inintensity by menstrualcycle 7. 51Y smoker with unilateral discharge G. Wouldwait for antibiotics until complicationsor conservative managementattempted 8.34Ybreastfeeding with painless, non-tenderlump H. Causedby benign proliferation within milk ducts 9. 3Y nulliparawith painful, hotbreastandfever I. Mostlikely todescribe greenish discharge1.26Ybreastfeeding withtenderlump,feverandmalaise A.USSshowshaloappearance andfluid 2. 32Y withbloody, unilateral nipple discharge B. Most common cause ofbenign breast lumps C. Causedby stoppingbreastfeedingandmanagedwith 3. 24Y with bilateral, painful, lumpy breasts handexpression 4. 19Y with painfulbreasts with nolumps D.Antibiotics given toall patients 5. 21Y with single, non-painfullumponbreast E. Urgentreferral tohospital for drainage 6. 33Y pyrexicbreastfeedingwithpainfulbreastw/olump F. Likelytovary inintensity by menstrualcycle 7. 51Y smoker with unilateral discharge G. Wouldwait for antibiotics until complicationsor conservative managementattempted 8.34Ybreastfeeding with painless, non-tenderlump H. Causedbybenignproliferationwithinmilkducts 9. 3Y nulliparawith painful, hotbreastandfever I. Mostlikely todescribe greenish discharge1.26Ybreastfeeding withtenderlump,feverandmalaise A. USS shows haloappearance andfluid 2. 32Y withbloody, unilateral nipple discharge B. Most common cause ofbenign breast lumps C. Causedby stoppingbreastfeedingandmanagedwith 3.24Ywithbilateral, painful, lumpybreasts handexpression 4. 19Y with painfulbreasts with nolumps D.Antibiotics given toall patients 5. 21Y with single, non-painfullumponbreast E. Urgentreferral tohospital for drainage 6. 33Y pyrexicbreastfeedingwithpainfulbreastw/olump F. Likelytovary inintensity by menstrualcycle 7. 51Y smoker with unilateral discharge G. Wouldwait for antibiotics until complicationsor conservative managementattempted 8.34Ybreastfeeding with painless, non-tenderlump H. Causedbybenignproliferationwithinmilkducts 9. 3Y nulliparawith painful, hotbreastandfever I. Mostlikely todescribe greenish discharge1.26Ybreastfeeding withtenderlump,feverandmalaise A. USS shows haloappearance andfluid 2. 32Y withbloody, unilateral nipple discharge B. Most common cause ofbenign breast lumps C. Causedby stoppingbreastfeedingandmanagedwith 3.24Ywithbilateral, painful, lumpybreasts handexpression 4.19Ywithpainful breastswithnolumps D.Antibiotics given toall patients 5. 21Y with single, non-painfullumponbreast E. Urgentreferral tohospital for drainage 6. 33Y pyrexicbreastfeedingwithpainfulbreastw/olump F.Likely tovaryinintensity bymenstrual cycle 7. 51Y smoker with unilateral discharge G. Wouldwait for antibiotics until complicationsor conservative managementattempted 8.34Ybreastfeeding with painless, non-tenderlump H. Causedbybenignproliferationwithinmilkducts 9. 3Y nulliparawith painful, hotbreastandfever I. Mostlikely todescribe greenish discharge1.26Ybreastfeeding withtenderlump,feverandmalaise A. USS shows haloappearance andfluid 2. 32Y withbloody, unilateral nipple discharge B.Mostcommoncause of benignbreastlumps C. Causedby stoppingbreastfeedingandmanagedwith 3.24Ywithbilateral, painful, lumpybreasts handexpression 4.19Ywithpainful breastswithnolumps D.Antibiotics given toall patients 5.21Ywithsingle, non-painfullumponbreast E. Urgentreferral tohospital for drainage 6. 33Y pyrexicbreastfeedingwithpainfulbreastw/olump F.Likely tovaryinintensity bymenstrual cycle 7. 51Y smoker with unilateral discharge G. Wouldwait for antibiotics until complicationsor conservative managementattempted 8.34Ybreastfeeding with painless, non-tenderlump H. Causedbybenignproliferationwithinmilkducts 9. 3Y nulliparawith painful, hotbreastandfever I. Mostlikely todescribe greenish discharge1.26Ybreastfeeding withtenderlump,feverandmalaise A. USS shows haloappearance andfluid 2. 32Y withbloody, unilateral nipple discharge B.Mostcommoncause of benignbreastlumps C. Causedby stoppingbreastfeedingandmanagedwith 3.24Ywithbilateral, painful, lumpybreasts handexpression 4.19Ywithpainful breastswithnolumps D.Antibiotics given toall patients 5.21Ywithsingle, non-painfullumponbreast E. Urgentreferral tohospital for drainage 6.33Y pyrexicbreastfeedingwithpainful breastw/o lump F.Likely tovaryinintensity bymenstrual cycle 7. 51Y smoker with unilateral discharge G. Wouldwaitfor antibioticsuntilcomplicationsor conservative managementattempted 8.34Ybreastfeeding with painless, non-tenderlump H. Causedbybenignproliferationwithinmilkducts 9. 3Y nulliparawith painful, hotbreastandfever I. Mostlikely todescribe greenish discharge1.26Ybreastfeeding withtenderlump,feverandmalaise A. USS shows haloappearance andfluid 2. 32Y withbloody, unilateral nipple discharge B.Mostcommoncause of benignbreastlumps C. Causedby stoppingbreastfeedingandmanagedwith 3.24Ywithbilateral, painful, lumpybreasts handexpression 4.19Ywithpainful breastswithnolumps D.Antibiotics given toall patients 5.21Ywithsingle, non-painfullumponbreast E. Urgentreferral tohospital for drainage 6.33Y pyrexicbreastfeedingwithpainful breastw/o lump F.Likely tovaryinintensity bymenstrual cycle 7.51Y smoker withunilateraldischarge G. Wouldwaitfor antibioticsuntilcomplicationsor conservative managementattempted 8.34Ybreastfeeding with painless, non-tenderlump H. Causedbybenignproliferationwithinmilkducts 9. 3Y nulliparawith painful, hotbreastandfever I.Mostlikely todescribe greenishdischarge1.26Ybreastfeeding withtenderlump,feverandmalaise A. USS shows haloappearance andfluid 2. 32Y withbloody, unilateral nipple discharge B.Mostcommoncause of benignbreastlumps C.Causedby stoppingbreastfeeding andmanagedwith 3.24Ywithbilateral, painful, lumpybreasts handexpression 4.19Ywithpainful breastswithnolumps D.Antibiotics given toall patients 5.21Ywithsingle, non-painfullumponbreast E. Urgentreferral tohospital for drainage 6.33Y pyrexicbreastfeedingwithpainful breastw/o lump F.Likely tovaryinintensity bymenstrual cycle 7.51Y smoker withunilateraldischarge G. Wouldwaitfor antibioticsuntilcomplicationsor conservative managementattempted 8.34Ybreastfeedingwithpainless, non-tenderlump H. Causedbybenignproliferationwithinmilkducts 9. 3Y nulliparawith painful, hotbreastandfever I.Mostlikely todescribe greenishdischarge1.26Ybreastfeeding withtenderlump,feverandmalaise A. USS shows haloappearance andfluid 2. 32Y withbloody, unilateral nipple discharge B.Mostcommoncause of benignbreastlumps C.Causedby stoppingbreastfeeding andmanagedwith 3.24Ywithbilateral, painful, lumpybreasts handexpression 4.19Ywithpainful breastswithnolumps D. Antibiotics giventoallpatients 5.21Ywithsingle, non-painfullumponbreast E. Urgentreferral tohospital for drainage 6.33Y pyrexicbreastfeedingwithpainful breastw/o lump F.Likely tovaryinintensity bymenstrual cycle 7.51Y smoker withunilateraldischarge G. Wouldwaitfor antibioticsuntilcomplicationsor conservative managementattempted 8.34Ybreastfeedingwithpainless, non-tenderlump H. Causedbybenignproliferationwithinmilkducts 9.3Ynullipara withpainful,hotbreastand fever I.Mostlikely todescribe greenishdischargeBreast CancerTypes 1.Lobularor Ductal –Invasiveor In situ 2.BRCA1or 2 3.ER,PR, PDL1or HER2 +Types 1.Lobularor Ductal –Invasiveor In situ Most common: Most likely topresent without lump: Most likely tometastasise: 2.BRCA1or 2 3.ER,PR, PDL1or HER2 +Types 1.Lobularor Ductal –Invasiveor In situ Most common:IDC – presentwith lump! Most likely topresent without lump: lobular – presents with skin changes DCIS >LCIS tometastasise 2.BRCA1or 2 3.ER,PR, PDL1or HER2 +Types 1.Lobularor Ductal –Invasiveor In situ Most common:IDC Most likely topresent without lump: lobular DCIS >LCIS tometastasise 2.BRCA1or 2 3.ER,PR, PDL1or HER2 + Poorest prognosis?Types 1.Lobularor Ductal –Invasiveor In situ Most common:IDC Most likely topresent without lump: lobular DCIS >LCIS tometastasise 2.BRCA1or 2 3.ER,PR, PDL1or HER2 + Poorest prognosis withtriplenegative,thenHER2+Types 1.Lobularor Ductal –Invasiveor In situ Most common:IDC Most likely topresent without lump: lobular DCIS >LCIS tometastasise 2.BRCA1or 2 Lifetimerisk of breast or ovarianifeitherpresent? 3.ER,PR, PDL1or HER2 + Poorest prognosis withtriplenegative,thenHER2+Types 1.Lobularor Ductal –Invasiveor In situ Most common:IDC Most likely topresent without lump: lobular DCIS >LCIS tometastasise 2.BRCA1or 2 50%lifetimeriskof breast or ovarian cancer in autosomal dominant inheritance BRCA1 = TOP= triplenegativebreast, ovarian,pancreatic, prostate BRCA2 = POPS= positive(ER/PR)breast,ovarian,pancreatic, prostate, skin 3.ER,PR, PDL1or HER2 + Poorest prognosis withtriplenegative,thenHER2+Types 1.Lobularor Ductal –Invasiveor In situ Most common:IDC Most likely topresent without lump: lobular DCIS >LCIS tometastasise 2.BRCA1or 2 Riskfactors BRCAor non-BRCA: Non-BRCAonly: 3.ER,PR, PDL1or HER2 + Poorest prognosis withtriplenegative,thenHER2+Types 1.Lobularor Ductal –Invasiveor In situ Most common:IDC Most likely topresent without lump: lobular DCIS >LCIS tometastasise 2.BRCA1or 2 Riskfactors BRCAor non-BRCA: HRT/COCP,smoking,obesity Non-BRCAonly:nulliparity,early menarche, latemenopause,not breastfeeding –whatdoesthis basically mean? 3.ER,PR, PDL1or HER2 + Poorest prognosis withtriplenegative,thenHER2+Types 1.Lobularor Ductal –Invasiveor In situ Most common:IDC Most likely topresent without lump: lobular DCIS >LCIS tometastasise 2.BRCA1or 2 Riskfactors BRCAor non-BRCA: HRT/COCP,smoking,obesity Non-BRCAonly:nulliparity,early menarche, latemenopause,not breastfeeding –moreovulations! 3.ER,PR, PDL1or HER2 + Poorest prognosis withtriplenegative,thenHER2+Types 1.Lobularor Ductal –Invasiveor In situ Most common:IDC Most likely topresent without lump: lobular DCIS >LCIS tometastasise 2.BRCA1or 2 Riskfactors BRCAor non-BRCA: HRT/COCP,smoking,obesity Non-BRCAonly:nulliparity,early menarche, latemenopause,not breastfeeding –moreovulations! 1 pregnancy at > 30years:breasts grow during pregnancy 3.ER,PR, PDL1or HER2 + Poorest prognosis withtriplenegative,thenHER2+Criteria for genetic testing st 1 degreeonly: Additive:Criteria for genetic testing 1 degreeonly: 1 FD breast <40 1 FD malebreast 1FD bilateral breast <50 Additive: 1FD + 1SD breast 1FD/SD breast + 1 FD/SD ovarian 3 FD/SD breastCriteria for genetic testing st 1 degreeonly: 1 FD breast <40 1FD bilateral breast <50 Mum has ovarian cancer(1FD ovarian)and dad’s sister has breastcancer(1SD ovarian) Additive: Willshe qualify? 2 FD breast 1FD + 1SD breast 1FD/SD breast + 1 FD/SD ovarian 3 FD/SD breastCriteria for genetic testing st 1 degreeonly: 1 FD breast <40 1FD bilateral breast <50 Mum has ovarian cancer(1FD ovarian)and dad’s sister has breastcancer(1SD ovarian) Additive: No!Difference sides of family notadditive! 2 FD breast 1FD + 1SD breast 1FD/SD breast + 1 FD/SD ovarian 3 FD/SD breastTriple assessment 1. 2. 3.Triple assessment 1. Physical examination 2. 3.Triple assessment 1. Physical examination 2. Imaging > 40: mammogram Compression x-ray in 2 dimensions USS for all for axilla screening 3.Triple assessment 1. Physical examination > 40: mammogram < 40: USS as tissue too dense Compression x-ray in 2 dimensions USS for all for axilla screening 3.Biopsy for everyone?Triple assessment 1. Physical examination > 40: mammogram < 40: USS as tissue too dense Compression x-ray in 2 dimensions USS for all for axilla screening 3.Biopsy If <3for exam/imaging: only doneif>25Yor discordantresultsTriple assessment 1. Physical examination > 40: mammogram < 40: USS as tissue too dense Compression x-ray in 2 dimensions USS for all for axilla screening 3.Biopsy If <3for exam/imaging: only doneif>25Yor discordantresults FNAC: Coreneedlebiopsy:Triple assessment 1. Physical examination > 40: mammogram < 40: USS as tissue too dense Compression x-ray in 2 dimensions USS for all for axilla screening 3.Biopsy If <3for exam/imaging: only doneif>25Yor discordantresults FNAC: fineneedleaspirationof cellsfor cytology underUSS Coreneedlebiopsy: coretissuesamplefor histology under USS Can determine invasivetumours &marginsTriple assessment 1. Physical examination Otherstaging/grading: 1. Grading: 1-3 depending onhistologicaland > 40: mammogram pathologicalstatus of cells < 40: USS as tissue too enseogicalstaging: metastasisallowingTNM Compression x-ray in 2 dimensions staging USS for all for axilla screening 3.Biopsy If <3for exam/imaging: only doneif>25Yor discordantresults FNAC: fineneedleaspirationof cellsfor cytology underUSS Coreneedlebiopsy: coretissuesamplefor histology under USS Can determine invasivetumours &marginsTriple assessment 1. Physical examination 2. Imaging > 40: mammogram Cancersmost likely tometastasise tobones? < 40: USS as tissue too dense USS for all for axilla screenings 3.Biopsy If <3for exam/imaging: only doneif>25Yor discordantresults FNAC: fineneedleaspirationof cellsfor cytology underUSS Coreneedlebiopsy: coretissuesamplefor histology under USS Can determine invasivetumours &marginsTriple assessment 1. Physical examination 2. Imaging BaldKids LearnTo Persevere! > 40: mammogram BreastKidney LungThyroid Prostate < 40: USS as tissue too dense USS for all for axilla screenings 3.Biopsy If <3for exam/imaging: only doneif>25Yor discordantresults FNAC: fineneedleaspirationof cellsfor cytology underUSS Coreneedlebiopsy: coretissuesamplefor histology under USS Can determine invasivetumours &marginsManagement Surgical: Pharmaceutical:Management Surgical: Pharmaceutical: 1. Large tumour insmall breast/ multifocal/DCIS >4cm: 2.Small tumour inlargebreast/solitary tumour/DCIS <4cm:Management Surgical: Pharmaceutical: 1. Large tumour insmall breast/ multifocal/DCIS >4cm: mastectomy 2.Small tumour inlargebreast/solitary tumour/DCIS <4cm: excision/lumpectomyManagement Surgical: Pharmaceutical: 1. Large tumour insmall breast/ multifocal/DCIS >4cm: mastectomy 2.Small tumour inlargebreast/solitary tumour/DCIS <4cm: excision/lumpectomy What about radiotherapy?Management Surgical: Pharmaceutical: 1. Large tumour insmall breast/ multifocal/DCIS >4cm: mastectomy 2.Small tumour inlargebreast/solitary tumour/DCIS <4cm: excision/lumpectomy Excision:All Mastectomy: only ifT3/T4tumour OR >4positive axillary nodesManagement Surgical: Pharmaceutical: Axillary nodes Sentinelnode?Management Surgical: Pharmaceutical: Axillary nodes whichcancer cell aremostlikely to spread fromtheprimary tumourManagement Surgical: Pharmaceutical: Axillary nodes Sentinelnode:firstlymph nodeto whichcancer cell aremostlikely to spread fromtheprimary tumour Onexamination palpable lymphadenopathy observed:Management Surgical: Pharmaceutical: Axillary nodes Sentinelnode:firstlymph nodeto whichcancer cell aremostlikely to spread fromtheprimary tumour Onexamination palpable lymphadenopathy observed:clear all axillarynodes insurgeryManagement Surgical: Pharmaceutical: Axillary nodes Sentinelnode:firstlymph nodeto whichcancer cell aremostlikely to spread fromtheprimary tumour lymphadenopathy observed:clear all axillarynodes insurgery Otherwise,preoperativeaxillary USS: Sentinelnodebiopsy atsurgeryif still negativeManagement Surgicalcomplications: Pharmaceutical: Armlymphedemaand function impairment:axillary nodeclearance Axillary web syndrome/coding: Fibrouscordsfrom axillato hand Sensationof tightness and pullingin chest area Seroma:localised accumulation offluid beneathskinsurfaceManagement Surgicalcomplications: Pharmaceutical: Armlymphedemaand function ER+: impairment:axillary nodeclearance Pre-menopause: Post menopause: Axillary web syndrome/coding: Fibrouscordsfrom axillato hand HER 2+: Sensationof tightness and pullingin chest area Triplenegative: Seroma:localised accumulation offluid Axillary nodedisease: beneathskinsurfaceManagement Surgicalcomplications: Pharmaceutical: Armlymphedemaand function ER+: impairment:axillary nodeclearance Pre-menopause: Tamoxifen(SERM) Post menopause:Anastrozole Axillary web syndrome/coding: (aromataseinhibitor) Fibrouscordsfrom axillato hand Sensationof tightness and pullingin HER 2+: Herceptin(trastuzumab) chest area (biologic) Seroma:localised accumulation offluid Triplenegative: chemotherapy=/- beneathskinsurface immunotherapy Axillary nodedisease: FEC-DManagement Surgicalcomplications: Pharmaceutical: ER+: Armlymphedemaand function Pre-menopause: Tamoxifen(SERM) impairment:axillary nodeclearance Sideeffects? Post menopause:Anastrozole Axillary web syndrome/coding: (aromataseinhibitor) Fibrouscordsfrom axillato hand Sideeffects? Sensationof tightness and pullingin chest area HER 2+: Herceptin(trastuzumab) (biologic) Seroma:localised accumulation offluid Contraindication and side effect? beneathskinsurface Triplenegative: chemotherapy=/- immunotherapy Axillary nodedisease: FEC-DManagement Surgicalcomplications: Pharmaceutical: Armlymphedemaand function ER+: impairment:axillary nodeclearance Pre-menopause: Tamoxifen (SERM) Post menopause: Anastrozole Axillary web syndrome/coding: (aromatase inhibitor) Fibrouscordsfrom axillato hand HSP, hypercholesterolemia, DEXA scan before starting Sensationof tightness and pullingin chest area HER 2+: Herceptin (trastuzumab) (biologic) Seroma:localised accumulation offluid Heart disorders and cardiomyopathy beneathskinsurface Triple negative: chemotherapy =/- immunotherapy Axillary node disease: FEC-DWhat’shappening?What’shappening? Eczematoid changes of nipple Most causedby DCIS Starts atnipple and spreads outwardsWhat’shappening? Paget’sdisease Eczematoid changes of nipple Most causedby DCIS Starts atnipple and spreads outwards Eczema starts atareolar and spreadstonippleWhat’shappening?What’shappening? Inflammatory breastcancer Caused by IDC Most commoninyoung Rare Rapidly progressing,swollen,red breasts Peaud’orangeskin Triplenegative Poor prognosis Almost alwaysneeds neoadjuvant chemo45Y with unilateral, firm, irregular lump that has grown BMI29.5r symptomse.g.weight loss, pain,axillary lymphadenopathy Onethingthatwouldmakecancer unlikely?45Y with unilateral, firm, irregular lump that has grown BMI29.5r symptomse.g.weight loss, pain,axillary lymphadenopathy Trauma!45Y with unilateral, firm, irregular lump that has grown No other symptomse.g.weight loss, pain,axillary lymphadenopathy BMI29.5 Trauma! Typicallypresentsup to 1.5 yearsafter traumae.g.seat belt incaraccident Commoninobesewomenwithlarge breasts Who are you 2WW vsnon-urgent referral? 1. 38 unexplained unilateral breast lump 2. 57discharge from right nipple only 3. 28 mastitisnotresolving in 3days 4. 27 unexplainedbilateralbreast lumps 5. 61 discharge from both nipples 6. 45skin changesin and around nipple left nipple only 7. 26 unexplained single axillary lump 8. 41 unexplainedsingle axillary lump Who are you 2WW vsnon-urgent referral? 1. 38 unexplained unilateral breast Mastitiswithout improvement 2WW lump Skin changes 2. 57discharge from right nipple Unilateral bloody/clear only discharge 3. 28 mastitisnotresolving in 3days 4. 27 unexplainedbilateralbreast > 30 2WW lumps Unexplained breastor 5. 61 discharge from both nipples axillalump 6. 45skin changesin and around nipple left nipple only < 30 Nonurgent 7. 26 unexplained single axillary lump 8. 41 unexplainedsingle axillary > 50+ unilateral nipple 2WW lump rinversion)(not Who are you 2WW vsnon-urgent referral? Mastitiswithout improvement 1. 38 unexplained unilateral breast Skin changes suggestive of lump ibreastcancer 2WWW Unildischargoody/clear 2. 57discharge from right nipple Unilateral bloody/clear only discharge 3. 28 mastitisnotresolving in 3days > 330 2W2WW 4. 27 unexplainedbilateralbreast lumps Unexplalump breastorraxilla 5. 61 discharge from both nipples axillalump 6. 45skin changesin and around nipple left nipple only < 330 Nonurgentent 7. 26 unexplained single axillary lump 8. 41 unexplainedsingle axillary > 50 +unilateralnipple >retraction(not inversion) 2WWW lump retraction (not inversion) Who are you 2WW vsnon-urgent referral? Mastitiswithout improvement 1. 38 unexplained unilateral breast Skin changes suggestive of lump ibreastcancer 2WWW Unildischargeody/clear 2. 57discharge from right nipple Unilateral bloody/clear only discharge 3. 28 mastitisnotresolving in 3days > 330 2W2WW 4. 27 unexplainedbilateralbreast lumps Unexplalump breastorraxilla 5. 61 discharge from both nipples axillalump 6. 45skin changesin and around nipple left nipple only < 330 Nonurgentent 7. 26 unexplained single axillary lump 8. 41 unexplainedsingle axillary > 50 +unilateralnipple >retraction(not inversion) 2WWW lump retraction (not inversion) Who are you 2WW vsnon-urgent referral? Mastitiswithout improvement 1. 38 unexplained unilateral breast Skin changes suggestive of lump ibreastcancer 2WWW Unildischargeody/clear 2. 57discharge from right nipple Unilateral bloody/clear only discharge 3. 28 mastitisnotresolving in 3days > 330 2W2WW 4. 27 unexplainedbilateralbreast lumps Unexplalump breastorraxilla 5. 61 discharge from both nipples axillalump 6. 45skin changesin and around nipple left nipple only < 330 Nonurgentent 7. 26 unexplained single axillary lump 8. 41 unexplainedsingle axillary > 50 +unilateralnipple >retraction(not inversion) 2WWW lump retraction (not inversion) Who are you 2WW vsnon-urgent referral? Mastitiswithout improvement 1. 38 unexplained unilateral breast Skin changes suggestive of lump ibreastcancer 2WWW Unildischargeody/clear 2. 57discharge from right nipple Unilateral bloody/clear only discharge 3. 28 mastitisnotresolving in 3days > 330 2W2WW 4. 27 unexplainedbilateralbreast lumps Unexplalump breastorraxilla 5. 61 discharge from both nipples axillalump 6. 45skin changesin and around nipple left nipple only < 330 Nonurgentent 7. 26 unexplained single axillary lump 8. 41 unexplainedsingle axillary > 50 +unilateralnipple >retraction(not inversion) 2WWW lump retraction (not inversion) Who are you 2WW vsnon-urgent referral? Mastitiswithout improvement 1. 38 unexplained unilateral breast Skin changes suggestive of lump – 2WW ibreastcancer 2WWW Unildischargeody/clear 2. 57discharge from right nipple Unilateral bloody/clear only discharge 3. 28 mastitisnotresolving in 3days > 330 2W2WW 4. 27 unexplainedbilateralbreast lumps Unexplalump breastorraxilla 5. 61 discharge from both nipples axillalump 6. 45skin changesin and around nipple left nipple only < 330 Nonurgentent 7. 26 unexplained single axillary lump 8. 41 unexplainedsingle axillary > 50 +unilateralnipple >retraction(not inversion) 2WWW lump retraction (not inversion) Who are you 2WW vsnon-urgent referral? Mastitiswithout improvement 1. 38 unexplained unilateral breast Skin changes suggestive of lump – 2WW ibreastcancer 2WWW Unildischargeody/clear 2. 57discharge from right nipple Unilateral bloody/clear only – non-urgent discharge 3. 28 mastitisnotresolving in 3days > 330 2W2WW 4. 27 unexplainedbilateralbreast lumps Unexplalump breastorraxilla 5. 61 discharge from both nipples axillalump 6. 45skin changesin and around nipple left nipple only < 330 Nonurgentent 7. 26 unexplained single axillary lump 8. 41 unexplainedsingle axillary > 50 +unilateralnipple >retraction(not inversion) 2WWW lump retraction (not inversion) Who are you 2WW vsnon-urgent referral? Mastitiswithout improvement 1. 38 unexplained unilateral breast Skimprovementsuggestive of lump – 2WW Unilateralbloody/clear 2WWW 2. 57discharge from right nipple discharge Uniladischargeody/clear only – non-urgent 3. 28 mastitisnotresolving in 3days – 2WW > 330 2W2WW 4. 27 unexplainedbilateralbreast Unexplained breastoraxilla lumps Unexaxillalumpeastor 5. 61 discharge from both nipples < 330 Nonurgentent 6. 45skin changesin and around nipple left nipple only 7. 26 unexplained single axillary lump >retraction(not inversion) 2WWW 8. 41 unexplainedsingle axillary retraction (not lump inversion) Who are you 2WW vsnon-urgent referral? Mastitiswithout improvement 1. 38 unexplained unilateral breast Skimprovementsuggestive of lump – 2WW Unilateralbloody/clear 2WWW 2. 57discharge from right nipple discharge Uniladischargeody/clear only – non-urgent 3. 28 mastitisnotresolving in 3days – 2WW > 330 2W2WW 4. 27 unexplainedbiWhy?ralbreast Unexplained breastoraxilla lumps Unexaxillalumpeastor 5. 61 discharge from both nipples < 330 Nonurgentent 6. 45skin changesin and around nipple left nipple only 7. 26 unexplained single axillary lump >retraction(not inversion) 2WWW 8. 41 unexplainedsingle axillary retraction (not lump inversion) Who are you 2WW vsnon-urgent referral? Mastitiswithout improvement 1. 38 unexplained unilateral breast Skimprovementsuggestive of lump – 2WW Unilateralbloody/clear 2WWW 2. 57discharge from right nipple discharge Uniladischargeody/clear only – non-urgent 3. 28 mastitisnotresolving in 3days – 2WW > 330 2W2WW 4. 27 unexplainedInflammatorybreast cancer!Unexplained breastoraxilla lumps Unexaxillalumpeastor 5. 61 discharge from both nipples < 330 Nonurgentent 6. 45skin changesin and around nipple left nipple only 7. 26 unexplained single axillary lump >retraction(not inversion) 2WWW 8. 41 unexplainedsingle axillary retraction (not lump inversion) Who are you 2WW vsnon-urgent referral? Mastitiswithout improvement 1. 38 unexplained unilateral breast Skimprovementsuggestive of lump – 2WW Unilateralbloody/clear 2WWW 2. 57discharge from right nipple discharge Uniladischargeody/clear only – non-urgent 3. 28 mastitisnotresolving in 3days – 2WW > 330 2W2WW 4. 27 unexplainedbilateralbreast Unexplained breastoraxilla lumps – non-urgent Unexaxillalumpeastor 5. 61 discharge from both nipples < 330 Nonurgentent 6. 45skin changesin and around nipple left nipple only 7. 26 unexplained single axillary lump >retraction(not inversion) 2WWW 8. 41 unexplainedsingle axillary retraction (not lump inversion) Who are you 2WW vsnon-urgent referral? Mastitiswithout improvement 1. 38 unexplained unilateral breast Skimprovementsuggestive of lump – 2WW Unilateralbloody/clear 2WWW 2. 57discharge from right nipple discharge Uniladischargeody/clear only – non-urgent 3. 28 mastitisnotresolving in 3days – 2WW > 330 2W2WW 4. 27 unexplainedbilateralbreast Unexplained breastoraxilla lumps – non-urgent Unexaxillalumpeastor 5. 61 discharge from both nipples – < 330 Nonurgentent non-urgent 6. 45skin changesin and around nipple left nipple only 7. 26 unexplained single axillary >retraction(not inversion) 2WWW lump retraction (not 8. 41 unexplainedsingle axillary inversion) lump Who are you 2WW vsnon-urgent referral? Mastitiswithout improvement 1. 38 unexplained unilateral breast Skimprovementsuggestive of lump – 2WW Unilateralbloody/clear 2WWW 2. 57discharge from right nipple discharge Uniladischargeody/clear only – non-urgent 3. 28 mastitisnotresolving in 3days – 2WW > 330 2W2WW 4. 27 unexplainedbilateralbreast Unexplained breastoraxilla lumps – non-urgent Unexaxillalumpeastor 5. 61 discharge from both nipples – < 330 Nonurgentent non-urgent 6. 45skin changesin and around leftnipple only – 2WW 7. 26 unexplained single axillary >retraction(not inversion) 2WWW lump retraction (not 8. 41 unexplainedsingle axillary inversion) lump Who are you 2WW vsnon-urgent referral? Mastitiswithout improvement 1. 38 unexplained unilateral breast Skimprovementsuggestive of lump – 2WW Unilateralbloody/clear 2WWW 2. 57discharge from right nipple discharge Uniladischargeody/clear only – non-urgent 3. 28 mastitisnotresolving in 3days – 2WW > 330 2W2WW 4. 27 unexplainedbiWhy?ralbreast Unexplained breastoraxilla lumps – non-urgent Unexaxillalumpeastor 5. 61 discharge from both nipples – < 330 Nonurgentent non-urgent 6. 45skin changesin and around leftnipple only – 2WW 7. 26 unexplained single axillary >retraction(not inversion) 2WWW lump retraction (not 8. 41 unexplainedsingle axillary inversion) lump Who are you 2WW vsnon-urgent referral? Mastitiswithout improvement 1. 38 unexplained unilateral breast Skimprovementsuggestive of lump – 2WW Unilateralbloody/clear 2WWW 2. 57discharge from right nipple discharge Uniladischargeody/clear only – non-urgent 3. 28 mastitisnotresolving in 3days – 2WW > 330 2W2WW 4. 27 unexplainedPage ’s!lbreast Unexplained breastoraxilla lumps – non-urgent Unexaxillalumpeastor 5. 61 discharge from both nipples – < 330 Nonurgentent non-urgent 6. 45skin changesin and around leftnipple only – 2WW 7. 26 unexplained single axillary >retraction(not inversion) 2WWW lump retraction (not 8. 41 unexplainedsingle axillary inversion) lump Who are you 2WW vsnon-urgent referral? Mastitiswithout improvement 1. 38 unexplained unilateral breast Skimprovementsuggestive of lump – 2WW Unilateralbloody/clear 2WWW 2. 57discharge from right nipple discharge Uniladischargeody/clear only – non-urgent 3. 28 mastitisnotresolving in 3days – 2WW > 330 2W2WW 4. 27 unexplainedbilateralbreast Unexplained breastoraxilla lumps – non-urgent Unexaxillalumpeastor 5. 61 discharge from both nipples – < 330 Nonurgentent non-urgent 6. 45skin changesin and around leftnipple only – 2WW 7. 26 unexplained single axillary >retraction(not inversion) 2WWW lump – non-urgent retraction (not 8. 41 unexplainedsingle axillary inversion) lump Who are you 2WW vsnon-urgent referral? Mastitiswithout improvement 1. 38 unexplained unilateral breast Skimprovementsuggestive of lump – 2WW Unilateralbloody/clear 2WWW 2. 57discharge from right nipple discharge Uniladischargeody/clear only – non-urgent 3. 28 mastitisnotresolving in 3days – 2WW > 330 2W2WW 4. 27 unexplainedbilateralbreast Unexplained breastoraxilla lumps – non-urgent Unexaxillalumpeastor 5. 61 discharge from both nipples – < 330 Nonurgentent non-urgent 6. 45skin changesin and around leftnipple only – 2WW 7. 26 unexplained single axillary >retraction(not inversion) 2WWW lump – non-urgent retraction (not 8. 41 unexplainedsingle axillary inversion) lump – 2WW Who are you 2WW vsnon-urgent referral? Mastitiswithout improvement 1. 38 unexplained unilateral breast Skimprovementsuggestive of lump – 2WW Unilateralbloody/clear 2WWW 2. 57discharge from right nipple discharge Unildischargeoody/clear only – non-urgent Remember: everyone needsassessment! 3. 28 mastitisnotresolving in 3days – 2WW Could be clearly afat necrosis, adenoma orcys> 330 2W2WW everyone gets assessed! 4. 27 unexplainedbilateralbreast Unexplained breastoraxilla lumps – non-urgent Unexaxillalumpeastor 5. 61 discharge from both nipples – < 330 Nonurgentgent non-urgent 6. 45skin changesin and around leftnipple only – 2WW 7. 26 unexplained single axillary >retraction(not inversion) 2WWW lump – non-urgent retraction (not 8. 41 unexplainedsingle axillary inversion) lump – 2WWLastly- screening: A. 55-80 every 5yearswithUSS B. 50-65every5 years withmammogram C. 25-49every 5years & 50-64every 3 years with mammogram D. 50-75every 3 years withUSS E. 50-70 every 3 years withmammogramLastly- screening: 55-80 every 5yearswithUSS 50-65every5 years withmammogram 25-49every 5years &50-64every 3 years with mammogram 50-75every 3 years withUSS 50-70 every 3 years withmammogramLastly- screening: 55-80 every 5yearswithUSS 50-65every5 years withmammogram 25-49every 5years &50-64every 3 years with mammogram 50-75every 3 years withUSS 50-70 every 3 years withmammogram Ifcancer surgery <50 years: 5yearly mammogram until screeningage1.25F currently breastfeeding presents to GP with sorenessand redness in both breasts for 2 days. Mild pyrexia. Mum andbabysystemically well. O/E: erythematous breasts, hot to touch,no masses.Small, tender slit is present on the left nipple. She is allergic to penicillin. What is the most appropriate management? Reassure and discharge with advice tocontinue breastfeeding, warm compress, analgesia Refertohospitalbreast team urgently Prescribe POflucloxacillin 10-14 days Prescribe POerythromycin 10-14 days Prescribe POco-amoxiclav 10-14 days1.25F currently breastfeeding presents to GP with sorenessand redness in both breasts for 2 days. Mild pyrexia. Mum andbabysystemically well. O/E: erythematous breasts, hot to touch,no masses.Small, tender slit is present on the left nipple. She is allergic to penicillin. What is the most appropriate management? Reassure and discharge with advice tocontinue breastfeeding, warm compress, analgesia Refertohospitalbreast team urgently Prescribe POflucloxacillin 10-14 days Prescribe POerythromycin 10-14 days Prescribe POco-amoxiclav 10-14 days2. 28F breastfeedingpresentswitha 1-weekhxof a tender, red, hot left breast. Slight fever. OE: tenderness anderythema ina wedge-shaped area at the4 o'clock position in theleft breast. Theaffected areafeels firmand hot. What isthemost likely diagnosis? Fibroadenoma Breastabscess Puerperalmastitis Breastcyst Inflammatorybreast disease2. 28F breastfeedingpresentswitha 1-weekhxof a tender, red, hot left breast. Slight fever. OE: tenderness anderythema ina wedge-shaped area at the4 o'clock position in theleft breast. Theaffected areafeels firmand hot. What isthemost likely diagnosis? Fibroadenoma Breastabscess Puerperalmastitis Breastcyst Inflammatorybreast disease3.27FpresentstoGP with2 weekhx oflumpy, painful, heavybreasts. Her motherwasrecently diagnosed with breast cancerat67.She has nochildrenand normally hasregularmenstrualperiods.Whatis your firststep aftercompletingexamination? Perform aurine pregnancy test Referforgenetictesting USSaspirationof alllumps 2WW pathwayreferral Non-urgentreferralfortriple assessment3.27FpresentstoGP with2 weekhx oflumpy, painful, heavybreasts. Her motherwasrecently diagnosed with breast cancerat67.She has nochildrenand normally hasregularmenstrualperiods.Whatis your firststep aftercompletingexamination? Perform aurine pregnancy test Referforgenetictesting USSaspirationof alllumps 2WW pathwayreferral Non-urgentreferralfortriple assessment4. 27Fpresents toGP with2 week hx of lumpy,painful,heavy breasts. Her motherwasrecently diagnosed with breast cancerat67.She has nochildrenand normally hasregularmenstrualperiods.A pregnancy test isnegative.Whatis the most likely diagnosis? Fibroadenoma Cyclicalmastalgia Fibroadenomas Fatnecrosis DCIS4. 27Fpresents toGP with2 week hx of lumpy,painful,heavy breasts. Her motherwasrecently diagnosed with breast cancerat67.She has nochildrenand normally hasregularmenstrualperiods.A pregnancy test isnegative.Whatis the most likely diagnosis? Fibroadenoma Cyclicalmastalgia Fibrocysticdisease Fatnecrosis DCIS5.22Fpresents to GPwithcnewbreastlump.She hasrecently hada triple assessmentinvolvinga needlebiopsy ofanewlumpconfirmed to bebenign. Sincethen,shehas found asecondlump near the biopsy site.OE: lumpis irregular,firmto touch,andimmobile. Thereis no painor overlyingskin changes.Whichof thefollowingis the bestinitial managementplan? Urgent2WW referral Advice analgesia andsupportive bras Non-urgentreferralfortriple assessment Wide local excisionof lump Reassurance, discharge and safety net5.22Fpresents to GPwithcnewbreastlump.She hasrecently hada triple assessmentinvolvinga needlebiopsy ofanewlumpconfirmed to bebenign. Sincethen,shehas found asecondlump near the biopsy site.OE: lumpis irregular,firmto touch,andimmobile. Thereis no painor overlyingskin changes.Whichof thefollowingis the bestinitial managementplan? Urgent2WW referral Advice analgesia andsupportive bras Non-urgentreferralfortriple assessment Wide local excisionof lump Reassurance, discharge and safety net6. 70F has undergonesurgery for aninvasive, nodenegative, non- metastaticbreast cancer. Post-operativeadjuvant radiotherapy hasalso beencompleted.Nosignificant PMHxand NKA. Thehistology results: HER2+, ER+ positive and PR+. What is themost suitablemanagement? Goserelin Anastrozole Oestradiolwith progesterone Tamoxifen Doxorubicin6. 70F has undergonesurgery for aninvasive, nodenegative, non- metastaticbreast cancer. Post-operativeadjuvant radiotherapy hasalso beencompleted.Nosignificant PMHxand NKA. Thehistology results: HER2+, ER+ positive and PR+. What is themost suitablemanagement? Goserelin Anastrozole Oestradiolwith progesterone Tamoxifen Doxorubicin7.45Fpresentsfor afollow upappointmentafter investigation for a breast lump.Histology:5cm(T4) peripherallesion inthe upper outer quadrantof her rightbreast.Cytology: abnormal cellsareconfinedtotheductal tissue inthe breastand havenotspreadintothesurroundingbreasttissue. Whatis thebestmanagementoptionfor this patient? Palliative care Mastectomy Wide local excisionwith radiotherapy Wide local excisionwithout radiotherapy Cytotoxicchemotherapy7.45Fpresentsfor afollow upappointmentafter investigation for a breast lump.Histology:5cm(T4) peripherallesion inthe upper outer quadrantof her rightbreast.Cytology: abnormal cellsareconfinedtotheductal tissue inthe breastand havenotspreadintothesurroundingbreasttissue. Whatis thebestmanagementoptionfor this patient? Palliative care Mastectomy Wide local excisionwith radiotherapy Wide local excisionwith radiotherapy Cytotoxicchemotherapy8.53FpresentstoGP witha 1-week hx of bloodydischarge from her left nipple.No PMHx.She ispost-menopausal.No othersymptoms. O/E:normal breastswithnolumps or skinchanges. Which of the following isthe nextbeststep in hermanagement? Non-urgentreferralforclinicalassessment, mammographyand biopsy 2WW forclinicalassessment, mammographyand biopsy 2WW forclinicalassessment, USSandbiopsy Reassure, discharge and safety net Non-urgentreferralforclinicalassessment, USSand biopsy8.53FpresentstoGP witha 1-week hx of bloodydischarge from her left nipple.No PMHx.She ispost-menopausal.No othersymptoms. O/E:normal breastswithnolumps or skinchanges. Which of the following isthe nextbeststep in hermanagement? Non-urgentreferralforclinicalassessment, mammographyand biopsy 2WW forclinicalassessment, mammographyand biopsy 2WW forclinicalassessment, USSandbiopsy Reassure, discharge and safety net Non-urgentreferralforclinicalassessment, USSand biopsyLastly - important things to ask in breast history taking: Differential based historytaking - thinkof your differential andaskquestionsto ruleout!Lastly - important things to ask in breast history taking: Differential based historytaking - thinkof your differential andaskquestionsto ruleout! Lumps: changes with menstruation, unilateral or bilateral pain, tenderness, multiple, mobile, fluctuant, tethered, rubbery, irregular, axilla changes, trauma, skin and nipple changes Constitutional symptoms: Bone pain, fever, weight loss Presence of discharge: bilateral or unilateral, type, consistency, colour Family history: age of onset, relation and side of family, ovarian, male, bilateral, pancreatic, prostate and skin cancerLastly - important things to ask in breast history taking: Differential based historytaking - thinkof your differential andaskquestionsto ruleout! Lumps: changes with menstruation, unilateral or bilateral pain, tenderness, multiple, mobile, fluctuant,tethered, rubbery, irregular, axilla changes, trauma, skin andnipple changes Constitutional symptoms: Bone pain, fever, weight loss Presence of discharge: bilateral or unilateral, type, consistency, colour Family history: age of onset, relation andside of family,ovarian, male, bilateral,pancreatic, prostate and skincancerLastly - important things to ask in breast history taking: Differential based historytaking - thinkof your differential andaskquestionsto ruleout! Breastfeeding: exclusivity, mass, fissure,fever and duration, pain, fluctuancy Gynaecology history: age of menarche, age of menopause, period regularity, number of children, age of first child Drugs: COCP, HRT Social: SmokingLastly - important things to ask in breast history taking: Differential based historytaking - thinkof your differential andaskquestionsto ruleout! Breastfeeding: exclusivity, mass,fissure, fever and duration,pain, fluctuancy Gynaecology history: age of menarche,age of menopause, period regularity,numberof children, age of firstchild Drugs: COCP, HRT Social: Smoking THANKS FOR WATCHING! Pleasefill outthe feedback form on Medall and see you next week! Tutorname: Shazia