Cases in Breast Disease :Cases in Breast Disease M3 Student Lecture Jennifer Griffin, MD Department of Obstetrics and Gynecology


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


Mastalgia :Mastalgia Cyclic: Hormonal changes Fibrocystic changes


Mastalgia :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 :Evaluation of Mastalgia Physical exam. No imaging needed if 35 without masses or discharge, screening mammography. If mass or discharge present, evaluate as appropriate.


Case 1 :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 :Fibrocystic Changes Most common breast condition. Occurs in up to 60% of women. Usually during reproductive years. Fibrocystic disease????


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


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


Case 2 :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 :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 :Evaluation of a Palpable Mass Ultrasound Patient 35 yrs.


Evaluation of a Palpable Mass :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 4-6 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 :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 :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 :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 :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 :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 :Causes of Nipple Discharge Blood malignancy vs papilloma Purulent infection, usually related to lactation Milky after childbearing up to one year hypothyroidism, prolactinomas medications: OCPs, tricyclic antidepressants, dopamine agonists Grey, brown, green, sticky Duct ectasia. Common 5th decade, with nipple tenderness and pain.


Causes of Nipple Discharge :Causes of Nipple Discharge Spontaneous, bloody, unilateral, from one duct = more likely cancer Non-spontaneous, non-bloody, bilateral = less likely cancer


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


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


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


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


Case 5 :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 :Breast Cancer Classic exam characteristics: Single lesion Hard Immovable Irregular border Skin dimpling Size >2 cm 90% are found by the patient!!


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


Demographics :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 :Relative Risk Lower Risk (RR 17 years. Menopause < 45 years. Oophorectomy < 35 years. Term pregnancy < 35 years. Table 32.2 text


Relative Risk :Relative Risk RR 1.1-2.0: Menarche 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 :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 :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 :Modifiable Risk Factors Obesity. Sedentary lifestyle. Excessive alcohol use.


Histologic Risk Factors :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 :Oncogenic Biomarkers Her-2/neu Cyclooxygenase 2 (COX 2)


Gail Model :Gail Model


Evaluation :Evaluation U/S for patients with dense breasts Mammography Digital vs. Conventional MRI, PET scan??? Referral for biopsy for palpable mass.


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


Mammography :Mammography BI-RADS Classification: 0: Needs more imaging 1: Negative 2: Benign findings 3: Probable benign, repeat imaging 4: Suspicious abnormality 5: Highly suspicious


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


Breast Cancer :Breast Cancer Types: Ductal, Lobular, Nipple Paget’s Disease 70-80%-- invasive ductal carcinoma


Breast Cancer :Breast Cancer Breast Conserving Therapy Contraindications: Persistently positive margins Multicentric disease Prior radiation Pregnancy