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Done by Mohammad Binhussein & Mohammad Mini. A 34year-old woman has been having bloody nipple discharge from the right nipple, on and off for several months. There are no palpable masses. . What is the diagnosis?. Intraductal papllioma . INTRADUCTAL PAPILLOMA

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Done by mohammad binhussein mohammad mini

Done by

Mohammad Binhussein

&

Mohammad Mini


Done by mohammad binhussein mohammad mini

A 34year-old woman has been having bloody nipple discharge from the right nipple, on and off for several months. There are no palpable masses.

What is the diagnosis?

Intraductal papllioma


Done by mohammad binhussein mohammad mini

INTRADUCTAL PAPILLOMA from the right nipple, on and off for several months. There are no palpable masses.

  • It is a benign, solitary polypoid lesion involving epithelium-lined major subareolar ducts.

    Presents as

  • bloody nipple discharge in premenopausal women..

  • Major differential diagnosis is between intraductal papilloma and invasive papillary carcinoma

    Management:

  • Cancer should be ruled out , Ductogram can help

  • Excision of involved duct (microdochectomy) after localization by physical examination


Done by mohammad binhussein mohammad mini

A 43 -year- old women presents with blood tinged discharge from her right nipples. She indicates that this problem has been occurring intermittently over the past several weeks. Her past medical history is significant for hypothyroidism . Her medication consist of OCP and levothyroxine.

On examination , she is found to have fibrocystic changes in both breast . there is evidence of thickening in the right retroareolar region . there is no evidence of nipple discharge or adominant mass in the left breast .


Done by mohammad binhussein mohammad mini

A from her right nipples. She indicates that this problem has been occurring intermittently over the past several weeks. Her past medical history is significant for hypothyroidism . Her medication consist of OCP and levothyroxine.43 -year- old women presents with blood tinged discharge from her right nipples. She indicates that this problem has been occurring intermittently over the past several weeks. Her past medical history is significant for hypothyroidism . Her medication consist of OCP and levothyroxine.

On examination , she is found to have fibrocystic changes in both breast . there is evidence of thickening in the right retroareolar region . there is no evidence of nipple discharge or adominant mass in the left breast .


Done by mohammad binhussein mohammad mini

What should be your next step ? from her right nipples. She indicates that this problem has been occurring intermittently over the past several weeks. Her past medical history is significant for hypothyroidism . Her medication consist of OCP and levothyroxine.

Cytology

Mammograghy

Us

Ductogram

Biopsy


Done by mohammad binhussein mohammad mini

History: from her right nipples. She indicates that this problem has been occurring intermittently over the past several weeks. Her past medical history is significant for hypothyroidism . Her medication consist of OCP and levothyroxine.

spontaneous

characteristic (bloody, milky , purulent , green to yellow )

uni or bilateral

lactation ( duration and time of weaning)

pain


Types of discharge
Types of Discharge from her right nipples. She indicates that this problem has been occurring intermittently over the past several weeks. Her past medical history is significant for hypothyroidism . Her medication consist of OCP and levothyroxine.

Milky white discharge

galactorrhe (bilateral)

Pregnancy common after

Lactation (as long as two

years)

Straw-colored, transparent discharge

due to a papilloma. The resulting increase in vascular pressure causes a transudate to form in the duct.


Types of discharge1
Types of Discharge from her right nipples. She indicates that this problem has been occurring intermittently over the past several weeks. Her past medical history is significant for hypothyroidism . Her medication consist of OCP and levothyroxine.

Grossly bloody discharge

1/3 due to an intraductal carcinoma, 1/3 due to bleeding papillomata, and 1/3 from fibrocystic changes with an active intraductal component.

Guaiac positive discharge

Nipple secretion that is not grossly bloody, but is guaiac positive.

causes: intraductal pathologies or plasma cell mastitis with duct ectasia.


Guaiac test
Guaiac Test from her right nipples. She indicates that this problem has been occurring intermittently over the past several weeks. Her past medical history is significant for hypothyroidism . Her medication consist of OCP and levothyroxine.

Positive guaiac test shown on right

Negative on left


Nipple discharge
Nipple Discharge from her right nipples. She indicates that this problem has been occurring intermittently over the past several weeks. Her past medical history is significant for hypothyroidism . Her medication consist of OCP and levothyroxine.

  • Causes (in order of frequency)

  • Physiological

  • Duct papilloma

  • Duct ectasia

  • Periductal mastitis

  • Cancer

  • Galactorrhoea


Expressing of discharge
Expressing of discharge from her right nipples. She indicates that this problem has been occurring intermittently over the past several weeks. Her past medical history is significant for hypothyroidism . Her medication consist of OCP and levothyroxine.


Bilateral multiductal secretion
Bilateral multiductal secretion from her right nipples. She indicates that this problem has been occurring intermittently over the past several weeks. Her past medical history is significant for hypothyroidism . Her medication consist of OCP and levothyroxine.

is usually normal and tests negative on the guaiac card

(i.e. Not bloody) regardless of color

treatment is reassurance and endocrinological follow-up if abnormal

However, prolactin and

TSH concentration should

be measured.


Unilateral discharge
UNILATERAL DISCHARGE from her right nipples. She indicates that this problem has been occurring intermittently over the past several weeks. Her past medical history is significant for hypothyroidism . Her medication consist of OCP and levothyroxine.

-multiductal unilateral discharge is unlikely to represint significant disease and should be investigated similarly to bilateral discharge .

Uniductal discharge

is more likely to

represent underlying

pathology .


Investigation
Investigation from her right nipples. She indicates that this problem has been occurring intermittently over the past several weeks. Her past medical history is significant for hypothyroidism . Her medication consist of OCP and levothyroxine.

Cytologic examination

recommended for guaiac positive or bloody discharge.

useful for differentiating between proliferative lesions and inflammatory lesions .

Mammography and ultrasound


Done by mohammad binhussein mohammad mini

Ductography from her right nipples. She indicates that this problem has been occurring intermittently over the past several weeks. Her past medical history is significant for hypothyroidism . Her medication consist of OCP and levothyroxine.

It can often identify intraluminal lesions, Cytology can also be

obtained at the

time of the

ductogram.


Done by mohammad binhussein mohammad mini

Ductoscopy from her right nipples. She indicates that this problem has been occurring intermittently over the past several weeks. Her past medical history is significant for hypothyroidism . Her medication consist of OCP and levothyroxine.

Ductoscopy is increasingly employed as a minimally invasive method for evaluation and treatment of nipple discharge.

(It involves placing a small (outer diameter 0.625 cm) fiberoptic cannula in the offending duct; the procedure can be done in the office or in the operating room. Ductoscopic biopsy is also possible in some cases and obviates the need to excise the surgical duct.)


Done by mohammad binhussein mohammad mini

TREATMENT from her right nipples. She indicates that this problem has been occurring intermittently over the past several weeks. Her past medical history is significant for hypothyroidism . Her medication consist of OCP and levothyroxine.

An isolated papilloma is benign, but diffuse papillomatosis is associated with an increased risk of breast cancer. In both cases, surgery is necessary to treat the nipple discharge and confirm the diagnosis.

All guaiac positive and/or bloody nipple discharge without imaging correlate should be resected by a terminal duct excision.


Nipple discharge1
Nipple discharge from her right nipples. She indicates that this problem has been occurring intermittently over the past several weeks. Her past medical history is significant for hypothyroidism . Her medication consist of OCP and levothyroxine.


Done by mohammad binhussein mohammad mini

KEY POINTS from her right nipples. She indicates that this problem has been occurring intermittently over the past several weeks. Her past medical history is significant for hypothyroidism . Her medication consist of OCP and levothyroxine.

- Nipple discharge is common and usually of benign origin.

- Bilateral and multiductal nipple discharge are almost always due to benign processes.

- Discharge characteristics associated with a higher risk of underlying malignancy are spontaneous, persistent, unilateral discharge; discharge limited to one duct; presence of a breast mass; and bloody fluid.


Done by mohammad binhussein mohammad mini

- A straw-colored, transparent, sticky discharge is characteristic of an intraductal papilloma.

- Cytology should be performed only when nipple discharge is grossly bloody or guaiac positive. Surgical excision is warranted after imaging for grossly bloody or guaiac positive discharge.

  • - Cytology may be useful for differentiating between proliferative lesions and inflammatory lesions in women with guaiac positive discharge. Both processes require excision.


Breast screening
Breast Screening characteristic of an intraductal papilloma.

Aim Of Screening:

-The early detection of cancer

-Any mass < 2 cm is not palpable


Clinical presentation of breast lesion
Clinical presentation of breast lesion characteristic of an intraductal papilloma.


When should done
When should Done ? characteristic of an intraductal papilloma.


When should done1
When should Done ? characteristic of an intraductal papilloma.

No controversy:all women aged 50 and older should have a mammogram(CDC recommendation) , (Grade 1A), every 1-2 year(Grade 2A)

Also clinical breast examination(Grade 1B)

Women aged 40 to 49(Grade 2B)

In high risk group The decision depends on individual risk .


Screening introduction outcome
Screening Introduction OutCome characteristic of an intraductal papilloma.

Incidence for women > 50 yrs (rate per 100.000)


Screening introduction outcome1
Screening Introduction OutCome characteristic of an intraductal papilloma.


Number of women needing to be screened to detect one new breast cancer
Number of women needing to be screened to detect one new breast cancer

Age Group no. needed

  • 20 to 24 67,000

  • 30 to 34 4,000

  • 40 to 44 850

  • 50 to 54 375

  • 60 to 64 275

  • 70 to 74 210

  • 80 to 84 210


Radiological sign
Radiological Sign breast cancer

  • irregular border , 90% of such lesion is invasive carcinoma


Done by mohammad binhussein mohammad mini

Well Circumscribed Mass D.D breast cancer

( Fibroadenoma Fibrocystic Changes )


Done by mohammad binhussein mohammad mini

Multiple Clusters Of Small , Irregular Calcifications In A Segmental Distribution

The suspicious Calcification Should Be Biopsied

20% to 30% is DCIS


Reading the mammogram
Reading the Mammogram Segmental Distribution

Where is the

suspecious lesion???


Medically proven malignancy
Medically proven Segmental Distributionmalignancy.


A benign microcacification
A benign microcacification Segmental Distribution


Done by mohammad binhussein mohammad mini

Reading the Mammogram Segmental Distribution

Best if read by radiologist

specializing in mammography.

Using Category of American College Of Radiology.



Limitation of mammogram
Limitation of Mammogram Segmental Distribution

Mammogram is best method of detecting breast cancer at an early stage, but is it perfect ??

There is No perfect test , screening mammogram lead to over-diagnosis and subsequent problem of false positive


Case presentation
CASE PRESENTATION Segmental Distribution

A 59-year-old Woman Comes into your office for health maintenance examination.

Her PMH is remarkable for mild hypertension controlled on thiazide. Her PSH is unremarkable.

On exam. her vitals within normal range thyroid is norm. to palpation. The breasts are nontender and without masses. Pelvic exam. Is unremarkable.


Case presentation1
CASE PRESENTATION Segmental Distribution

A 59-year-old Woman Comes into your office for health maintenance examination.

Her PMH is remarkable for mild hypertension controlled on thiazide. Her PSH is unremarkable.

On exam. her vitals within normal range thyroid is norm. to palpation. The breasts are nontender and without masses. Pelvic exam. Is unremarkable.



What is your next step
What Is Your Next Step? around a small mass.

U.S guided FNAC vs. U.S guided core biopsy ,

Unfortunately the lesion not seen by ultra sound

Then what is your next step?


Done by mohammad binhussein mohammad mini

Stereotactic Biopsy around a small mass.

or

needle-localization excisional biopsy

Depends on the site of the lesion and/or patient preference


Case discussion
Case Discussion around a small mass.

What are stereotactic core biopsy and needle localization core biopsy?


Done by mohammad binhussein mohammad mini

Stereotactic core biopsy: biopsies are taken as directed with computer-assisted techniques. (For non palpable mass) and has 2% to 4% “miss rates”


Case discussion1
Case Discussion with computer-assisted techniques. (For non palpable mass) and has 2% to 4% “miss rates”

  • If FNA cytology detecting benign cells, so either continue routine screening, (or close follow-up in non-certain cytological analysis) .


Case discussion2
Case Discussion with computer-assisted techniques. (For non palpable mass) and has 2% to 4% “miss rates”

If FNA cytology detecting malignant cells, so Needle localization core-biopsy should be obtained as many as 50% of such a case will reveal a (DCIS). ACS surgery principle and practice 2006

(Nowadays they use iodine-125 seed localizing biopsy in some center to avoid needle placement) a called emerging technique


Case discussion3
Case Discussion with computer-assisted techniques. (For non palpable mass) and has 2% to 4% “miss rates”

  • The tissue biopsy come back and diagnosed as

DCIS.


Case discussion4
Case Discussion with computer-assisted techniques. (For non palpable mass) and has 2% to 4% “miss rates”

What is the management ?

  • 1- wide excision→→ assess the margins once negative →→+/-irradiate breastand follow up.

  • 2 – If margins are positive, patient worried of recurrence and/or lesion > 5 cm →→ simple mastectomy +/- reconstruction


Lobular carcinoma in situ lcis
Lobular Carcinoma in Situ with computer-assisted techniques. (For non palpable mass) and has 2% to 4% “miss rates”LCIS

  • Rare , occurs in young women

  • Always almost incidental finding in biopsy for other reason.

  • found bilaterally in 25% of cases

  • Marker of increased risk for invasive carcinoma

  • Treatment either close follow up or prophylactic simple mastectomy.


Miscellaneous
Miscellaneous with computer-assisted techniques. (For non palpable mass) and has 2% to 4% “miss rates”


Studies evaluating breast self examination
Studies evaluating Breast Self Examination with computer-assisted techniques. (For non palpable mass) and has 2% to 4% “miss rates”

  • No difference in breast cancer mortality

  • No difference in stage of cancer at diagnosis

  • More provider visits: 8% vs. 4%

  • More benign biopsies


Nipple laceration
Nipple Laceration with computer-assisted techniques. (For non palpable mass) and has 2% to 4% “miss rates”

  • Keep clean and dry.

  • Stop breastfeeding that side and allow to heal

  • Antibiotics usually not necessary


Supernumerary breasts
Supernumerary Breasts with computer-assisted techniques. (For non palpable mass) and has 2% to 4% “miss rates”

Relatively common

Found along “milk line”

Most identified during pregnancy/lactation

Most common in axilla

Not dangerous


Supernumerary nipples
Supernumerary Nipples with computer-assisted techniques. (For non palpable mass) and has 2% to 4% “miss rates”

More common than supernumerary breasts

Found along milk line

May darken during pregnancy

Not dangerous


Mondor s disease
Mondor’s disease with computer-assisted techniques. (For non palpable mass) and has 2% to 4% “miss rates”

thrombophlebitis of lateral thoracic vein.


Male breast carcinoma
Male breast Carcinoma with computer-assisted techniques. (For non palpable mass) and has 2% to 4% “miss rates”

  • Risk factor are:

    1- gynecomastia

    2- BRCA 2