Cases in Breast Disease

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Cases in Breast Disease

• M3 Student Lecture
• Jennifer Griffin, MD
• Department of Obstetrics and Gynecology

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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.

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Reasons to Examine the Breasts

• Routine screening
• Annually, women 18 years
• Patient complaints
• Breast Pain (Mastalgia)
• Nipple Discharge
• Breast Mass

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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)

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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

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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.

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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.

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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??

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Mastalgia

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

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Mastalgia

• Cyclic
• Hormonal changes
• Fibrocystic changes

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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

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Evaluation of Mastalgia

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

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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??

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Fibrocystic Changes

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

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Fibrocystic Changes

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

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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.

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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??

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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 3-10 days after onset of menses for resolution.

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Evaluation of a Palpable Mass

• Ultrasound
• Patient
• Determine solid vs. cystic, simple or complex.
• Mammogram
• 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.

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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.

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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.

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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.

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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??

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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)

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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??

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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.

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Causes of Nipple Discharge

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

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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??

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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

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Case 4

• 27 y/o G1P1, POD3 following c-section, complains
  of tender mass in her armpit.
• Exam soft, tender 4 cm mass in axillae on left,
  patient is afebrile.
• Diagnosis??

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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

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Mastitis

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

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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!

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Breast Abcess

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

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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.

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Breast Cancer

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

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Demographics

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

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Demographics

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

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Relative Risk

• Lower Risk (RR
• Menarche 17 years.
• Menopause
• Oophorectomy
• Term pregnancy
• Table 32.2 text

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Relative Risk

• RR 1.1-2.0
• Menarche
• 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.

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Relative Risk

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

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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.

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Modifiable Risk Factors

• Obesity.
• Sedentary lifestyle.
• Excessive alcohol use.

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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.
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Oncogenic Biomarkers

• Her-2/neu
• Cyclooxygenase 2 (COX 2)

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Gail Model
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Evaluation

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

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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.

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Mammography

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

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Mammography

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

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Biopsy Techniques

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

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Breast Cancer

• Types
• Ductal, Lobular, Nipple
• Pagets Disease
• 70-80-- invasive ductal carcinoma

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Breast Cancer

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