Triple assessment in breast carcinoma final.pptx

Breast ca

1. Triple assessment in breast carcinoma Dr. V. T. Arasu , M.S Professor, Dept of General surgery, Chengalpattu Medical College

2. Triple assessment Combination of three diagnostic modalities to aid in the diagnosis of breast lump. Clinical Assessment : History and physical examination Radiological Imaging : Mammogram, Ultrasound and MRI Pathological Diagnosis: FNAC and core needle biopsy

3. Clinical assessment - History Clinical symptoms of breast CA: Early breast carcinoma – asymptomatic Late carcinoma presents with Painless lump Nipple discharge – bloody Nipple retraction Breast pain ( < 5% of the patients )

4. Clinical examination Positions for clinical examination : With arms by her side With arms straight up in the air Bending forward With hands on her hips (with and without pectoral muscle contraction)

5. Inspection findings Asymmetrical breast Visible lump or contour change Puckering or dimpling of skin Retraction of nipple Paeu d’ orange Orange peel like appearance Due to blockade of subcutaneous lymphatics Ulceration Dilated veins

6. Palpation Technique : Use the pads of the middle 3 fingers of one hand. Press downward using a circular motion. Apply steady pressure, pushing down to the level of the chest wall. Direction of breast palpation :

7. Palpatory findings Malignant Hard in consistency Irregular border Moves along with the breast tissue Skin involvement: Skin dimpling Skin tethering Edema or Paeu d orange Ulceration Fixation to underlying muscles Benign Firm Well defined borders Freely mobile Skin - free

8. Loco regional assessment Signs of locally advanced breast carcinoma : Axillary node enlargement – first site of spread clinically fixed or matted axillary lymph nodes Ipsilateral supraclavicular or infraclavicular node enlargement Fixity to chest wall Cancer en cuirasse - skin over the chest wall is studded with cancer nodules like an armour coat with n

9. Examination of axilla Technique : Instruct the patient to drop the shoulder and take a deep breath. Support the patient’s arm and elbow with the non-examining hand. Apply deep pressure using a circular motion with the pads of the three middle fingers in all four aspects of the axilla This pattern resembles a diamond.

10. Palpation of the Supraclavicular & Infraclavicular Nodes Using firm pressure in small circular movements, palpate above and below the clavicle.

11. Findings of nodal examination Palpable enlargement of node Hard in consistency Matting of lymph nodes Non tender

12. Clinical assessment of systemic spread Examination of abdomen Hepatomegaly Splenomegaly Ascites Signs of increased intracranial tension Head ache Vomiting Signs of lung involvement Dyspnea Hemoptysis Signs of bone involvement : Bone pain Pathological fracture

13. Inflammatory breast carcinoma Mainly a clinical diagnosis Signs : Edema Erythema involving more than one-third of the breast Pitting or thickening of the skin – paeu ’ d orange Diffuse swelling Warm and tender on examination

14. Paget’s disease Eczema like lesion Unilateral No response to topical treatment Nipple destruction Pathology : Paget cells

15. Breast Imaging The most common imaging modalities for breast include Mammography Ultrasound MRI

16. Mammography Mammogram is an x-ray imaging of the breast to detect and evaluate any changes in the breast Primary imaging modality for screening breast carcinoma.

17. Technique Breast is compressed between two plates attached to an x-ray machine , Adjustable plastic plate on the top and a fixed plate on the bottom holding x-ray film. The dose of radiation is approximately 0.2 rads with two views of each breast, hence the risk of radiation induced cancers is very less.

18. Radiographic views in mammogram Standard views Mediolateral oblique view(MLO) Craniocaudal view ( CC)

19. Additional views True Lateral View - 90º View  Mediolateral View - ML View Lateromedial View - LM View Lateromedial Oblique View - LMO View Spot Compression View Axillary View - Axillary Tail View Cleavage View - Valley View Tangential Views Bulls eye CC View Rolled CC View Elevated Craniocaudal Projection Caudal Cranial Projection Inferomedial Superolateral oblique projection

20. Types of mammography Screening mammography Diagnostic mammography

21. Screening mammography : Performed on asymptomatic women to identify malignancy at an early, potentially curable stage. Done with MLO and CC views Diagnostic mammography : Performed on a symptomatic patient To work-up an abnormality found on screening mammography, Additional specific views are taken along with the standard views

22. Mammographic findings Benign Macro calcification Cystic mass Malignant Specks of micro calcification Solid mass Asymmetric breast tissue Asymmetric breast density Architectural distortion

23. BIRADS ( Breast Imaging-Reporting and Data System) BIRADS is a risk assessment tool used in breast imaging. Classification The lesions are classified into six categories:  BIRADS 0:  Incomplete imaging Further imaging or information is required. BIRADS I : Negative  Symmetrical breasts and no masses, architectural disturbances or suspicious calcifications present

24. BIRADS II : Benign findings Calcified fibro adenomas Multiple secretory calcifications Simple breast cyst BIRADS III : probably benign BIRADS IV:  suspicious for malignancy. Further divided into BIRADS IV A: low level of suspicion for malignancy BIRADS IV B: intermediate suspicion for malignancy BIRADS IV C: moderate suspicion for malignancy BIRADS V : highly suggestive of malignancy BIRADS VI:  known biopsy proven malignancy 

25. Follow up in BIRADS BIRADS 1 : Additional views or alternate imaging modality are required Continue annual screening mammography  BIRADS 2 : same plan of follow-up as level 1. BIRADS 3 : Probably benign finding, probability of less than 2% of being malignant. 6 month follow-up mammogram is needed

26. BIRADS 4 : Suspicious abnormality. Probability of malignancy is 25-50%. Biopsy of lesion is recommended BIRADS 5 : Highly suggestive of malignancy. Classic signs of carcinoma are seen. Percentage of malignancy varies between 70- 99 % Biopsy of the lesion is must BIRADS 6 : known biopsy proven malignancy To assess the response of treatment to malignancy

27. Benefits and harms of mammography Advantages : Early detection of cancer. Reduction of breast cancer mortality by about 15-25 % Disadvantages : Less useful in younger age groups because of dense breasts False positive results: 10 % Leads to unnecessary invasive biopsies. False negative results : 2% Delay diagnosis and provide false reassurance. Interval cancers : Interval cancers are cancers detected after a normal screening mammogram and before the next scheduled mammogram

28. Ultrasonography To aid in the diagnosis of a breast mass identified by palpation or mammography. Particularly useful in young women with dense breast. Helpful in resolving equivocal mammographic findings To distinguish cysts from solid lesions To localize impalpable areas of breast pathology. For axillary nodal staging and guided biopsy of lymph nodes.

29. Disadvantages of USG Highly Operator dependent and time consuming. More false positive results. Not useful as a screening tool. Cannot reliably detect lesions ≤1 cm in diameter.

30. MRI Particularly useful in younger women with dense breast. Useful for identifying the unknown primary breast tumor in axillary lymph node metastases. Used in the screening of high-risk women ( family history of breast CA /known genetic mutations) as mammographic evaluation is limited due to the increased breast density at an early age. To detect additional tumors in the index breast (multifocal or multicentric disease) . Useful to distinguish scar from tumour recurrence . Best imaging modality for the breasts of women with implants.

31. Pathological examination Available modalities for pathological examination of breast lesions include FNAC ( Fine Needle Aspiration Cytology ) Core cut biopsy Excision biopsy FNAC or core biopsy are commonly used as they are more cost-effective and avoids a surgical scar.

32. FNAC FNAC is the most common tool used in the diagnosis of palpable breast masses. Technique : Done using a 21G or 23G needle and 10-mL syringe. Multiple passes through the lump with negative pressure in the syringe. The cellular material is then expressed onto microscope slides. Both air-dried and 95% ethanol–fixed microscopic sections are prepared for analysis. Stained using eosin and heamotoxylin

33. Interpretations from FNAC Cystic lesions : Cyst fluid is usually turbid and dark green or amber and can be discarded if the mass totally disappears and the fluid is not bloody. If the cystic fluid is blood-tinged fluid or the mass fails to resolve completely, image-guided core needle biopsy is required to rule out CA. Solid lesions : FNAC can differentiate benign and malignant lesions. It will not discriminate between noninvasive and invasive breast cancers

34. Core needle biopsy Preferred over FNAC for the diagnosis of palpable breast lesions Method of choice to sample non-palpable, image-detected breast abnormalities. Performed under imaging guidance if the lesion is not palpable.

35. INTERPRETATION CORE NEEDLE BIOPSY Can differentiate benign and malignant lesions. In situ and invasive carcinomas can be differentiated In malignancy histologic subtype, grade, and receptor status can also be determined . False negative rates of core biopsy are less than 1%.

36. Excision biopsy Indications : Failure to sample calcifications Diagnosis of atypical lobular hyperplasia or lobular carcinoma in situ Lack of concordance between imaging findings and histologic diagnosis Radial scar Papillary lesions

37. Interpretation of triple assessment Positive test :  Triple assessment is taken as positive if any of the three components is positive Negative test : Taken as negative only if all of its components are negative for malignancy. The sensitivity of triple assessment test is about 99% to 100 %. Hence , proving to be the most useful tool in the assessment of breast carcinoma.

38. Conclusion

39. THANK YOU…