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Dr Daniella Soussi Breast Lecture 8th October 2024 Daniella.soussi1@nhs.netSESSION STRUCTURE Aetiology History Presentation Investigations Management History Taking • Common presenting complaints • Pain • Lump • Nipple discharge • Risk factors • Significant (Age, Obesity, Alcohol intake, Previous breast • cancer, FH/gene carrier) • contraception, menopause)che, children/breastfeeding, • General condition Breast PACES • 5 minutes (3 minutes for examination + 2 minutes for questions) • Simulated patient • Usually combined with Vascular station • Approach, confidence and fluency • Watch videos (Medlearn/geeky medics) • Palpation technique – choose your preference • Use quadrant method • No nipple squeezing • Go to a one stop breast clinic! Breast PACES • Introduction and explanation • Inspection – sitting up and on movement • Palpation – lying at 45 degrees with a reasonable technique. Ask patient to put their arm to their head. • Axillary lymph nodes - approach • “o complete my examination, I would like to...” • Assess for liver enlargement, pleural effusions and spinal tenderness (malignancy). • Help patient get dressed and respect privacy.Breast Examination Triple assessment Physical assessment (Age, History, Examination) Radiological assessment (USS, Mammogram) Histological assessment (Fine needle aspirate, Core biopsy) 1. Normal 2. Benign 3. Indeterminate 4. Suspicious 5. Malignant SBA 1 24-year-old presents with a 18mm mobile lump in the left breast at 5o’clock, 1cm away from the areola – what imaging would be ordered? A. No imaging B. USS C. Mammogram D. USS and Mammogram E. CT SBA 1 24-year-old presents with a 18mm mobile lump in the left breast at 5o’clock, 1cm away from the areola – what imaging would be ordered? A. No imaging B. USS C. Mammogram D. USS and Mammogram E. CT SBA 2 25 year old with intermittent pain and heaviness in the both breasts but more in the right, which is worse before her periods ordered?a normal examination (P1) – what imaging would be A. No imaging B. USS C. Mammogram D. USS and Mammogram E. CT SBA 2 27-year-old with intermittent pain and heaviness in the both breasts but more in the right, which is worse before her periods ordered?a normal examination (P1) – what imaging would be A. No imaging B. USS C. Mammogram D. USS and Mammogram E. CT Benign Breast Disease • Fibroadenoma • Breast cyst/fibrocystic disease • Mastitis/abscess • Fat necrosis • Duct ectasia • Chronic inflammatory condition – granulomatous disease, similar appearance to breast cancer, needs biopsy. Usually self-limiting, consider steroids. Fibroadenoma • Benign, solid lump, often referred to as breast mouse. • Commoner inAsian and Afro-Caribbean women. • No increase in risk of developing breast cancer. • A second biopsy is indicated if there is an increase in size. • Diagnostic excision required if over 4cm in size. Fibrocystic disease • Benign fluid filled lump, often multiple • Can be aspirated if there is a large cyst – straw-coloured/green fluid • No increase in risk of developing breast cancer Mastitis/Abscess • Mastitis is infection of the soft tissue without an underlying collection. • Can be lactational or non-lactational. • More common in smokers, post-partum, AI disease, granulomatous disease, skin disease. • Lactational mastitis: caused by skin commensals, advise to express/feed milk, give Abx (usually flucloxacillin unless pen allergic). • If abscess (underlying collection) or no response to Tx, needs referral to breast clinic. • Abscesses may require incision and drainage. • If septic, need to attend A&E. Fat necrosis • A non-suppurative inflammation of adipose tissue caused by the disruption of oxygen supply to fat cells --> cell death. • It is commonly present in female patients who undergo breast procedures or after injury/trauma to breast tissue. • Can be associated with malignancy. • May get associated erythema or bruising around lump/thickened soft tissue. Duct ectasia • Occurs when a milk duct in the breast widens and its walls thicken. • This can cause the duct to become blocked and lead to fluid build-up. • Can get green/brown discharge. • Exact cause is unknown. • Most common in breast feeding mothers and smokers. • Encourage breast-feeding to help with stagnancy of milk in the ducts. SBA 3 28-year-old woman 4 weeks post-partum with a painful, swollen right breast that is hot to touch and red, temperature 38.5 and pulse 120. A. Admit for septic screen and IV Antibiotics B. Discharge with oral antibiotics and breast clinic follow-up C. Urgent referral to breast clinic D. Discharge with lactational advice E. Discharge with GP follow-up SBA 3 28-year-old woman 4 weeks post-partum with a painful, swollen right breast that is hot to touch and red, temperature 38.5 and pulse 120. A. Admit for septic screen and IV Antibiotics B. Discharge with oral antibiotics and breast clinic follow-up C. Urgent referral to breast clinic D. Discharge with lactational advice E. Discharge with GP follow-up SBA 4 Imaging is performed on the 38-year-old and shows an irregular 43mm taken which show lymphocytes, granulomas and fibrosis – how would thisies are be managed? A. Wide local excision and axillary clearance B. Chemotherapy C. Referral to appropriate medical team for consideration of steroids D. Surgery and chemotherapy E. No further action SBA 4 Imaging is performed on the 38-year-old and shows an irregular 43mm taken which show lymphocytes, granulomas and fibrosis – how would thisies are be managed? A. Wide local excision and axillary clearance B. Chemotherapy C. Referral to appropriate medical team for consideration of steroids D. Surgery and chemotherapy E. No further action Breast Cancer Findings • Fixed irregular-shaped mass • New asymmetry when comparing the two breasts (shape or size) • Fixity to chest wall/skin dimpling - Peau d'orange – tethering to the skin by Cooper ligaments • Paget's disease of the nipple/breast -Eczema-like changes to the skin of the nipple and the area of darker skin surrounding the nipple • Fungating mass with ulceration and underlying oedema • Nipple inversion/nipple crusting/nipple discharge • Axillary lymphadenopathy (rarely presents this late) • Symptoms/signs related to metastases if late Breast Cancer • Local treatments: o Surgery (Lumpectomy/Wide local excision/Mastectomy, +/- axillary clearance, +/- reconstruction (e.g. autologous free-flap DIEP/TUG or pedicled flap LD, implant) o Radiotherapy • Systemic treatments: o Chemotherapy o Endocrine therapy (e.g. Anti-oestrogen – tamoxifen) o Immunotherapy (e.g. anti-HER2 – herceptin (trastuzumab)) Targeted to the biology of the cancerBreast Cancer SBA 5 59-year-old with a 26mm G3 IDC ER positive and HER2 positive with involved nodes. What is her likely treatment plan? A. Wide local excision with sentinel node biopsy, chemotherapy, radiotherapy and endocrine B. Chemotherapy and immunotherapy C. Wide local excision with axillary dissection, chemotherapy, immunotherapy, radiotherapy and endocrine D. Endocrine, immunotherapy and surgery E. Chemotherapy, surgery, radiotherapy and endocrine SBA 5 59-year-old with a 26mm G3 IDC ER positive and HER2 positive with involved nodes. What are her available treatment options? A. Wide local excision with sentinel node biopsy, chemotherapy, radiotherapy and endocrine B. Chemotherapy and immunotherapy C. Wide local excision with axillary dissection, chemotherapy, immunotherapy, radiotherapy and endocrine D. Endocrine, immunotherapy and surgery E. Chemotherapy, surgery, radiotherapy and endocrine SBA 6 41-year-old woman with a small breast has 45mm grade 2 invasive ductal likely treatment plan? and HER2 negative, with normal nodes. What is her A. Mastectomy and axillary dissection B. Mastectomy with sentinel node biopsy followed by endocrine treatment C. Radiotherapy D. Wide local excision, radiotherapy and immunotherapy E. Chemotherapy followed by surgery SBA 6 41-year-old woman with a small breast has 45mm grade 2 invasive ductal likely treatment plan? and HER2 negative, with normal nodes. What is her A. Mastectomy and axillary dissection B. Mastectomy with sentinel node biopsy followed by endocrine treatment C. Radiotherapy D. Wide local excision, radiotherapy and immunotherapy E. Chemotherapy followed by surgeryTHANK YOU FOR COMING! PLEASE FILL IN THE FEEDBACK FORM!