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ApproachtoBreastDiseaseDRCABENNINTRODUCTION•Ultimategoalasdoctors•Surgicalevolutionversus“revolution”BACKROUND•INCIDENCEBENIGN•INCIDENCEMALIGNANTDISEASE•AFRICANAMERICANEXPERIENCE•OLDSERVICESOFFERED•ANEWBEGINNINGScreeninginBreastCancer-anupdateBreastcancerscreeninginEurope-currentstatusBadpress????Poortechnology????Wrongtest???Overlyaggressiveclinicians???Faultisbreastcancer????Howpatientspresent……..•Mass•Pain•Discharge•BasicmanagementINTRODUCTION•INCREASINGAWARENESSOFCANCER•POSSIBILITYTHATMASTALGIAISINDICATIVEOFDISEASE•PHYSICIANSAREINADEQUATELYTRAINEDFORTREATINGTHISCONDITION…..•HELP!ACADEMICS•CYCLICMASTALGIA(67%)•NONCYCLICMASTALGIA(26%)•CHESTWALLPAIN(7%)FACT…...•90%OFPATIENTSWITHCYCLICMASTALGIAAND64%OFPATIENTSWITHNONCYCLICMASTALGIAOBTAINRELIEFFROMACOMBINATIONOFNONPRESCRIPTIONANDPRESCRIPTIONDRUGSHISTORY•ISTHISBREASTPAIN?EXCLUDE..•Cardiac•Respiratory•Gastrointestinal•Dermatological•Musculoskeletal•Endocrine•Gynaecological•Haematological•HabitsTHOROUGHEXAMINATIONSPECIFICALLYTHEBREASTSFINDINGS•NORMALSMALL,MEDIUMORLARGEBREASTS•BREASTSWITHAMASS,NIPPLEDISCHARGEORTHICKENINGASSESSMENT….•Normalbreastpain•Extenttowhichitdisruptsthepatient’slife[work,sleep,sex,….]*•Providethepatientwithabreastpainchartandasymptomchart*CheckdietanddrugsINVESTIGATIONS..GENERAL•Bloodtests(HIV,Prolactin)andothertestsdependingonclinicalsuspicionSPECIFICALLY•Sonarandmammogramdependingontheageofthepatient•FIBROCYSTICCHANGEISNOTDISEASE•ANDICLASSIFICATIONTHEORIESOFCAUSATIONMANAGEMENTOFMASTALGIAThereisalonglistofsuggestedmodalitiesforthetreatmentofanentitythatisubiquitous;hasanunknownaetiology,andapoorlyunderstoodrelationshiptofibrocysticdiseaseandcancer.MASTALGIAMANAGEMENTSUMMARY•THOROUGHHISTORY•PHYSICALEXAMINATION•MAMMOGRAPHYAND/ORSONAR•ABNORMALITIES…….BIOPSY•CLASSIFY•REASSURANCEMASTALGIAMANAGEMENTSUMMARY•ABSTENTIONFROMCERTAINMEDICATIONSANDFOOD•EVENINGPRIMROSEOIL•DRUGSNIPPLEDISCHARGE•HISTORY&EXAMINATIONoneduct,multipleducts,onebreastorbothclear,bloodstained,green,yellowblacketcINVESTIGATIONS•pusswabmc&s•mammogram,sonar•ductogram•bloods:BHCG,prolactinNippleDischarge•Introduction•Clinicalfeatures•Investigations•TreatmentPlan•GeneralCommentsClinicalfeaturesofMDAIDS•NippleDischarge•BreastPainandtenderness•NippleRetractionandSubareolarmass•Subareolarbreastabscessandrecurrentabscess•PeriareolarMammaryductFistulaCONCLUSION•Antibiotics:•SurgeryforcomplicateddiseaseIntractablepainRecurrentdischargenotrespondingtoantibioticsAbscessFistulaMANAGEMENT•DUCTECTASIA•medicalantibiotics•surgeryforcomplicationsfistula,abscess,intractablepainandrecurrentdischargenonresponsivewithantibioticsDUCTPAPILLOMAsurgicalexcisionPhysiologicaldischargeMedicationandConservativemanagementAPPROACHTOABREASTMASS•HISTORYRELATEDTOMASSposition,duration,noticedwhenassocfeaturesFAMILYHISTORYanycancerhistorybreastotherGYNAE/ENDOCRINEHISTORYmenarche,menopausechildren,breastfeedingOCP,HRTHISTORYAPPROACHTOBREASTMASSEXAMINATIONGENERALpale,jaundicedwastedVITALSBREASTEXAMinspectionpalpatioinbothbreastsTHEBODYhead&neckthoraxabdomenEXAMINATIONBREASTMASSESREQUIREATISSUEDIAGNOSISREGARDLESSOFTHEAGEOFTHEPATIENT•ALLBREASTMASSESTOGETATISSUEDIAGNOSIS•WHY?•CANCERINYOUNGWOMEN•UNUSUALDIAGNOSIS•LYMPHOMA•TUBERCULOSIS•HOW?•FINENEEDLEASPIRATE•CORE/TRUCUTBIOPSY•SONARGUIDEDFNAORCORE•MAMMOGRAMGUIDED•HOOKWIRE•LASTRESORTEXCISIONALDIAGNOSIS95%ofallpatientsshouldhavethediagnosismadepriortosurgeryFrombenigntomalignant….•Largevarietyofbenignlesions•Broadtermsused(FCD;BBD)usedforconvenience•Transitiontheory:benign,hyperplasia,cellularatypia,carcinomainsitu.•Whatisthebreastcancerriskandatwhatstageshouldalesionbeconsideredmalignant?TheEvolutionofBreastCancerFloridhyperplasiaLobularcarcinomainsitu•NormalbreastProliferativeChangesAtypicalepithelium(mildtomoderateductallobularorductalorlobularhyperplasia)hyperplasiaDCISNonproliferativechanges(fibroadenoma,ductectasia,cystsPapillomatosisfibrosis,apocrinemetaplasia,stromalsclerosis)InvasivecancerLobularCarcinomaInSituEpidemiology•youngwomen(44-47yrs)Pathology•“BusyBosom”•ipsilateralmulticentricity/contralateral/bilateral/……inalmosteverycase•homogenous,slowgrowth,lownucleargradePrognosisandManagementofLCIS•Riskappliesequallytobothbreasts•Incidencevariable[1%peryear,lifetime5%(4-13%),37%ofcases]•Malignanciesarising(50-65%)areductal•FrombilateralmastectomytoipsilateralmastectomyandblindcontralateralbiopsytononoperativecloseobservationDCIS:MoreOminousEpidemiology•FemalesandMales•OccursbetweentheageofpresentationofLCISandCaPathology•Historically4histologicaltypes:Papillaryandmicropapillary,cribriformandsolid.•ComedoversusNonComedoApplyingarelativeriskreductiontotreatmentdecisions•IndividualtreatmentalgorythmFamilyhistoryofBreast/othercancerAgeatdiagnosisTumournecrosisandNuclearGradeResectionmarginsSTAGING•TNMCLASSIFICATION•MANCHESTER•ABIOLOGICALCLASSIFICATIONBreastCancermanagement•MultimodalApproach•Surgical•Radiationtherapy•ChemotherapySurgery1.Breastconservationormastectomywithimmediate/delayedreconstruction•Sizeofthebreast•Sizeofthetumour•Patientswishes1.Axilla•Clearance(7l