Medical Archive

Breast Exam

Biopsy

Fine-needle aspiration

• For small cystic or solid lesions
• ???? ?? ???? ??.

Core needle biopsy

• For larger solid masses
• ????? US-guided? ???.
• Image-guided core needle biopsy (stereotactic biopsy; ??????, needle localization biopsy; ????????)
  • Clustered microcalcification ? US? ? ???? ??
  • ???? ? ??? ???? ?? ?? ???? ????? ??
  • Hook wire ?? ? ?? ?? ??
• Vacuum assisted CNB ? Mammotome Bx. calcification detection ?, ????? ??.

Excisional biopsy

• ?? ? ???? ??? ????? ??? ??
  • Cellularity ?? fibroadenoma: phyllodes tumor? ?? ??
  • Papillary neoplasm: papillary carcinoma? ?? ??
  • Atypical ductal/lobular hyperplasia (ADH): DCIS?? ?? ??. 

Detection

History

• Gynecomastia
  • ???, ???, ??? ??. ??? ???? ?????? ?
  • ?, ???? ?? ? mammo (??????)
  • Spironolactone, digoxin ?? ??. ?? ????. 
  • ???? ????? ?? ?? ??? ??

Physical exam

??
Single duct nipple discharge? ????

Breast self-examination

??, ?? ?? ? ??? ?? (MCD 5~10?, follicular phase)
??? hormonal stimulation? ?? ?? ??.

Breast imaging

Mammography

• Screening? ?, ?? ??
• ??? ??? ????? ? but Dense breast ?
• 30? ???? ? ???? ??.
• Mammo?? ???????
  • ?? view? ??? ?? sono ???? BIRADS scoring
  • Calcification ? ????& ????? ????.
• ??? ???? ??
  • Macrocalcification (popcorn ??)
  • Vascular calcification
  • Egg-shell calcification – fat necrosis
• ??? ???? ??
  • Stellate / spiculated / ??? distorsion / linear, brancing / clustered microcalcification
• Mammography?? ???? ????? P/E? ???.
  • ????? ?? mammogram+US? BIRADS??
  • Dominant mass or thickening
  • 30? ??, ? ??? US, ??? mammogram
  • Non-diagnostic ? Bx
• Cystic disease
  • aspiration?? bloody ???, residual mass? ??? mammogram & Bx
  • 4?? ??? ?? ?? fluid? ???, 2? ???? mammogram & Bx
  • ?? ????? routine screening ??. 

Ultrasonography

Dense breast ?, ??? ??? ? ?. 30? ???? ?

MRI

?? ?? Hx ?? ? ?, ???? ?? ????
Sensitivity ?, specificity ? (mammography? ????)

PET scan

Breast tissue evaluation: histology and cytology

Fine-needle aspiration

Core needle biopsy

Open excisional biopsy

Histologic analysis

BI-RADS? Assessment category

Ductal lavage cytology

Benign breast conditions

Breast cyst

• If symptomatic
  • Aspiration
  • 2-4 months for a f/u clinical breast examination
  • If the fluid is bloody and/or the mass persists despite aspiration, patients may be at increased risk for breast cancer and should undergo core needle biopsy.
• If the patient has no further symptoms or signs of recurrence.
  • Annual screening

Fibrocystic change

?? upper outer quadrant, multiple, diffuse nodulocystic masses. ????? ?? ?? (hormone-mediated)
Cyclic premenstrual tenderness
Benign, but some are associated with an increased risk for invasive carcinoma

Fibrocystic-related changes	Increased risk
Fibrosis, cysts, and apocrine metaplasia	None
Ductal hyperplasia and sclerosing adenosis	2x
Atypical hyperplasia	5x

Sclerosing lesion

? ? spiculated mass, calcification?? ??? mimic ?? ??
Sclerosing adenoma
Microcalcification ?? ??? needle Bx?? m/c. ??? ??.

Radial scar
?? 1cm ??, cancer risk ?? ?

Atypical ductal/lobular hyperplasia

RR 4?, ? ???? ???.
Cancer? ??? ??
??? ??
?? ??
Single duct ?? ?? ???
????? ?? ??
Painless mass? m/c Sx
?? ??? ??, ??? aspiration, 3-4? ? evaluation

Mastalgia

• Confirm(r/o) ? Reassurance ? Medication
• NSAID (1st line) Danazol, tamoxifen ?
• Ice packs and a supportive bra
• Clogged lactiferous duct
  • Unilateral breast pain
  • The mass is typically located in the subareolar region.
  • Warm compresses and massage

Fibroepithelial lesions

Fibroadenoma

• ??? 30? ?? ?
• Solitary, well-circumscribed, mobile
• Cyclic premenstrual tenderness
• Non-cyclic mass, but estrogen sensitive.
  • Arise from the breast stroma
  • Grows during pregnancy and maybe painful during the menstrual cycle
• Core needle biopsy to confirm the diagnosis
• Management
  • 2cm ????? ??
  • ????, ?? ??? ??

Phyllodes tumor

• Fibroadenoma? ?? variant.
• ?? 2cm ??, ??? ??. 30? ?? ?
• FNAB? ?? ??? ?? CNB to confirm the diagnosis
• Management
  • Wide excision, 2cm margin.
  • Axillary LND? ?? ??? ?? ??.
  • 5cm??, ??? ??? CTx ???(Doxorubicin, ifosfosfamide)

Breast conditions requiring evaluation

Nipple discharge

?? nipple discharge? 95%? benign, intraductal papilloma? ? ????
???? ?? Cytology. Ductography (? ?? 2-3? ?? ????? ?? ?? ? ??)

Physiologic nipple discharge

Reassurance and recommend avoidance of nipple stimulation

Galactocele (????)

• ?? ?? ? 6-10?? ? ??.
• ??? ??, mobile
• needle aspiration?? thick, creamy

Mammary duct ectasia

• Inflammation with dilation (ectasia) of the subareolar ducts
• Rare; classically arises in multiparous postmenopausal women
• Presents as a periareolar mass with green-brown nipple discharge (inflammatory debris)
• Chronic inflammation with plasma cells is seen on biopsy.

Intraductal papilloma

• Fibrovascular projections lined by epithelial(luminal). And myoepithelial cells.
• Classically presents as bloody nipple discharge in a premenopausal woman.
• Diagnosis
  • If small, mammography is often normal
  • Ultrasound is indicated for evaluation of ductal pathology and may demonstrate a dilated duct
• Must be distinguished from papillary carcinoma, which also presents as bloody nipple discharge.
  • Papillary carcinoma is characterized by fibrovascular projections lined by epithelial cells without underlying myoepithelial cells.
  • Risk of papillary carcinoma increases with age; thus, it is more commonly seen in postmenopausal women.

Fat necrosis

• Post trauma/surgery
• Firm, irregular mass. Possible ecchymosis of the overlying skin.
• Spiculated calcification on mammography (d/t saponification)
• Biopsy: necrotic fat with associated calcifications and giant cells.

Breast abscess

Lactational abscess (acute mastitis)

• Bacterial(S.aureus-m/c), Mycoses, etc.
• ??? ??? ?. Nipple? fissure? ?? ??? ?.
• ??: ???, ?? ??? ??? ??? ??.
• Diagnosis
  • ???; Heterogenous hypoechoic collection
• Treatment
  • In nursing mothers, frequent emptying of the breast: Breastfeeding with alternate breasts is recommended every 2–3 hours. 
  • Analgesics (e.g., ibuprofen)
  • Cold compresses
  • Antibiotic treatment
    • Oral penicillinase-resistant penicillin or cephalosporin (e.g., dicloxacillin or cephalexin)
    • In the case of methicillin-resistant Staphylococcus aureus (MRSA): clindamycin or trimethoprim-sulfamethoxazole (TMP-SMX) 
  • In the case of inadequate response to initial treatment: 
    • Initiate treatment according to breast milk culture results.
    • Consider an underlying breast abscess, which requires surgical drainage.
  • Confirmed abscess
    • Drainage with either needle aspiration or incision & drainage.
    • Empiric antibiotics against MSSA for the surrounding mastitis.
    • Continued breast feeding is recommended for continued milk drainage.
    • ??? ????

Nonlactational abscess

Subareolar abscess and lactiferous duct fistula (periductal mastitis)

• Usually seen in smokers. Relative vitamin A deficiency results in squamous metaplasia of lactiferous ducts, producing duct blockage and inflammation.
• Subareolar mass with nipple retraction.

Differential diagnosis	Clinical features
Engorgement	Bilateral, symmetric fullness, tenderness & warmth
Nipple injury	Abrasion, bruising, cracking &/or blistering from poor latch
Plugged duct	Focal tenderness & firmness &/or erythema; no fever
Galactocele	Subareolar, mobile, well-circumscribed, nontender mass; no fever
Mastitis	Tenderness/erythema + fever
Abscess	Symptoms of mastitis + fluctuant mass

# Mondor’s disease

• ??? ??? ?? ?? ? thrombophlebitis
• Etiology
  • Unknown
  • Surgical procedure of breast
  • Infectious processes, stress-related exercise ?? ?????.
• Management
  • Benign and self-limited disease.
  • Salicylate, ??, ????? ?? ??, ?? 2-6? ? ?? ?.

Breast cancer

C75 Breast Cancer