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Cases in Breast Disease

M3 Student Lecture Jennifer Griffin, MD


Department of Obstetrics and Gynecology

Breast Anatomy
   

Glands (Lobules) Milk Ducts Connective Tissue Fat With age, glands involute and are replaced by fat. Pathology can occur in any of the above structures.

Reasons to Examine the Breasts




Routine screening


Annually, women 18+ years

Patient complaints
  

Breast Pain (Mastalgia) Nipple Discharge Breast Mass

Reasons to Examine the Breasts




Cancer Detection 2nd most common malignancy 2nd leading cause of cancer death US: 1 in 8 lifetime risk (12.5%)

Reasons to Examine the Breasts




16% of women ages 40-69 sought advice from a physician related to a breast complaint 23 visits per 1000 woman years

Reasons to Examine the Breasts




Breast cancer identified in 11% of patients with lump, and 4% of women with any complaint. Failure to diagnose breast cancer is the #1 malpractice claim in the U.S.

How to Examine the Breasts




 

Ideally, after menses in premenopausal female. Visualize breasts for skin changes, symmetry. Palpate chest wall, breasts, and axillae. Assess for nipple discharge. Lying and sitting positions.

Case 1
  

25 year old female, G0 c/o bilateral breast pain, especially during week prior to her menses. Feels that breast swell before menses. Exam: doughy, irregular texture, no discrete masses, no nipple discharge or adenopathy Diagnosis??

Mastalgia


 

45% of women reported breast pain, 21% severe. 2/3 cyclical. 1/3 non-cyclical.

Mastalgia
  

Cyclic: Hormonal changes Fibrocystic changes

Mastalgia
   

Non-cyclic: Mastitis Large pendulous breasts Breast cancer, especially inflammatory.




Patients presenting with breast cancer had mastalgia as only complaint in 8% / 15% of cases.

   

Caffeine, tobacco? HRT Ductal ectasia Chest wall pain

Evaluation of Mastalgia
 

Physical exam. No imaging needed if <35 and no masses or discharge. If >35 without masses or discharge, screening mammography. If mass or discharge present, evaluate as appropriate.

Case 1
  

25 year old female, G0 c/o bilateral breast pain, especially during week prior to her menses. Feels that breast swell before menses. Exam: doughy, irregular texture, no discrete masses, no nipple discharge or adenopathy Diagnosis??

Fibrocystic Changes


Most common breast condition. Occurs in up to 60% of women. Usually during reproductive years. Fibrocystic disease????

Fibrocystic Changes


Stages: Stromal proliferation or hyperplasia Adenosis (increased glands) Cyst formation

Fibrocystic Changes


Management:
    

Breast support. Dietary: reduce caffeine, salt? Intermittent diuretics. Evaluate medsOCPs, HRT. Mastectomy in extreme cases. Ultrasound discrete masses. Aspiration of cysts. Biopsy may be necessary.

  

Case 2
 

32 y/o female, G2P2. Presents for annual exam 2 days prior to her menses. Exam: noted to have a 1.5 cm palpable, mobile mass in UOQ right breast. No nipple discharge, skin changes, adenopathy. No tenderness. What should you do??

Evaluation of a Palpable Mass




Serial examination


If physical exam does not confirm presence of a dominant mass, then repeat exam should be done in 2-3 months. If patient <35 without risk factors, reexamine 3-10 days after onset of menses for resolution.

Evaluation of a Palpable Mass




Ultrasound
 

Patient <35 yrs with breast complaint. Determine solid vs. cystic, simple or complex. Indicated for screening starting at age 40. Diagnostic mammogram if U/S suggests complex or solid lesion, or if exam suspicious for cancer and patient >35 yrs.

Mammogram
 

Evaluation of a Palpable Mass




Fine needle aspiration


 

Performed with a 22-24 gauge needle. If fluid clear and cyst resolves, patient can be reassured and reevaluated in 46 weeks for recurrance. If fluid bloody, send for cytology and consider further workup. If no fluid, further work-up necessary.

Evaluation of a Palpable Mass




Core needle biopsy




 

Performed with a 14-18 gauge needle, generally using U/S or stereotactic mammography. Histologic specimen obtained. Correlates with open biopsy 94% of the time, with less cost.

Evaluation of a Palpable Mass




Triple diagnosis


Using exam, imaging, and FNA:


0.7% with cancer if all three suggest benign disease  99.4% with cancer if all three suggest malignancy.


If there is discordance between the three steps, open biopsy or core needle biopsy should be done.

Case 2
 

32 y/o female, G2P2. Presents for annual exam 2 days prior to her menses. Exam: noted to have a 1.5 cm palpable, mobile mass in UOQ right breast. No nipple discharge, skin changes, adenopathy. No tenderness. What should you do??

Fibroadenomas
   

Occur in 10-20% of women. Often young women. May be multiple. (15-20% of pts.) Slow growing, do not change with menses. May be followed conservatively. (only with appropriate pt selection)

Case 3


43 y/o female presents with c/o unilateral bloody nipple discharge. Exam: No palpable mass, light serosanguinous discharge from right nipple, no adenopathy. Differential??

Causes of Nipple Discharge


  

Blood


malignancy vs papilloma infection, usually related to lactation after childbearing up to one year hypothyroidism, prolactinomas medications: OCPs, tricyclic antidepressants, dopamine agonists Duct ectasia. Common 5th decade, with nipple tenderness and pain.

Purulent


Milky
  

Grey, brown, green, sticky




Causes of Nipple Discharge




Spontaneous, bloody, unilateral, from one duct = more likely cancer Non-spontaneous, non-bloody, bilateral = less likely cancer

Case 3


43 y/o female presents with c/o unilateral bloody nipple discharge. Exam: No palpable mass, light serosanguinous discharge from right nipple, no adenopathy. Differential??

Case 3
     

Classic finding of intraductal papilloma. Malignancy must be excluded. Usually 2-5 mm, non-palpable. May perform cytology on discharge. Ductography may diagnose. Biopsy may be necessary. May increase risk of breast cancer, even if singular without hyperplasia

Case 4


27 y/o G1P1, POD#3 following csection, complains of tender mass in her armpit. Exam: soft, tender 4 cm mass in axillae on left, patient is afebrile. Diagnosis??

Galactocele


Lactating patients may develop soft, cystic masses from dilated ducts or glands that are not draining. Treatment: Decompressionvia breastfeeding or pumping, may require needle aspiration to prevent infection

Mastitis


Occurs in 1-3% of breastfeeding mothers. Fevers, tender area of breast, myalgias. Exam: erythematous wedgeshaped tender area of breast. Treatment??

Mastitis
 

Dicloxicillin 500 mg qid x 10 days. Alternatives:


 

Cephalexin (Keflex) Augmentin

 

Perform culture and sensitivity if persistent >24-48 hrs or recurrent. Anti-inflammatories. Continue nursing!

Breast Abcess
   

Mastitis + fluctuant mass. Complication of 5-10% of mastitis. Requires incision and drainage. Continue to nurse and pump.

Case 5


58 y/o female presents with complaint of breast mass she felt on self-exam. Exam: Rubbery, 3 cm, non-discrete lesion. Some dimpling of skin over area. No nipple discharge.

Breast Cancer
      

Classic exam characteristics: Single lesion Hard Immovable Irregular border Skin dimpling Size >2 cm 90% are found by the patient!!

Demographics


1 in 8 lifetime risk. 1 in 2000 for woman in her 20s. 1 in 25 for woman in her 70s.

 

Demographics


BRCA mutations: Less than 1% of women are carriers. Account for 3-10% of breast CA. BRCA carrier 85-90% lifetime risk.

  

Relative Risk


Lower Risk (RR<1.0): Menarche > 17 years. Menopause < 45 years. Oophorectomy < 35 years. Term pregnancy < 35 years.
Table 32.2 text

   

Relative Risk


RR 1.1-2.0: Menarche < 12 years. Menopause > 55 years. First term pregnancy > 35 years. No term pregnancies. Personal hx of endometrial, ovary, or colon CA. Never breast fed. Recent OCPs/ HRT.

    

 

Relative Risk


RR 2.1-4.0: One first degree relative with breast cancer. Atypical hyperplasia on biopsy. Personal hx of salivary gland CA.

 

Relative Risk
    

RR> 4.0: Personal hx of breast cancer. 2+ 1st degree relatives with breast CA. Age > 65. Inherited genetic mutations. RR> 8.0: Premenopausal 1st degree relative with bilateral breast cancer.

 

Modifiable Risk Factors


  

Obesity. Sedentary lifestyle. Excessive alcohol use.

Histologic Risk Factors


Relative Risk of Breast Cancer with Different Breast Lesions

Breast cancer will often occur many years later and in a different location than the original lesion.

Oncogenic Biomarkers
 

Her-2/neu Cyclooxygenase 2 (COX 2)

Gail Model

Evaluation
 

U/S for patients with dense breasts Mammography




Digital vs. Conventional

 

MRI, PET scan??? Referral for biopsy for palpable mass.

Mammography


 

Able to detect lesions down to 1mm, ~2 years prior to palpated mass. Diagnostic: for palpable masses. Screening: age 40 q 1-2 years, age 50+ every year.

Mammography


Features suggestive of cancer: Increased density. Irregular border. Spiculation. Clustered irregular microcalcifications.

   

Mammography


BI-RADS Classification:
     

0: 1: 2: 3: 4: 5:

Needs more imaging Negative Benign findings Probable benign, repeat imaging Suspicious abnormality Highly suspicious

Biopsy Techniques
   

Cyst aspiration (cytology FN 20%) Fine needle aspiration (FN 20%) Stereotactic core biopsy Open biopsy

Breast Cancer


Types:
 

Ductal, Lobular, Nipple Pagets Disease

70-80%-- invasive ductal carcinoma

Breast Cancer
 

Breast Conserving Therapy Contraindications:


   

Persistently positive margins Multicentric disease Prior radiation Pregnancy