Title: Benign Breast Disease
1Benign Breast Disease
- Elizabeth Peralta, M.D.
- Breast Surgeon
- Sutter Pacific Medical Group of the Redwoods
2Breast Complaints
- Pain
- Mass
- Skin or Nipple Changes
- Nipple Discharge
3Diagnosis and Treatment of Breast Complaints
- Most important is to rule out malignancy
- Significance of a finding is greatest in a
high-risk patient - Balance between reassurance and exhausting all
diagnostic options - Treatment should not be worse than the disease
4Mammary ductogram demonstrating lobules
5Pre-menarchal ductule
Terminal ductal-lobular unit
6Breast Development
- Menarche and Reproductive Cycles
- Pulsed estrogen exposure causes rapid growth,
elongation and branching - Term pregnancy leads to terminal differentiation
and stops growth - End bud epithelial tissue undergoes cyclic
proliferation - Breast feeding is associated with a lower risk of
breast cancer
7Normal breast in pregnancy and after
8Breast Development
- Involution Changes of involution begin after
cessation of lactation and continue through
menopause - Competing involution and proliferative processes
are patchy and increased in peri-menopause and
with HRT - Hyperplasia with atypia and DCIS peak in this
period
9Involutional and cystic change
10Pre-Cancer Changes
- Intraepithelial neoplasia (IEN) a lesion which
is non-invasive but contains genetic
abnormalities, loss of cellular control
functions, and some microscopic features of
cancer cells
11Biopsy results which represent increased breast
cancer risk
- Atypical Ductal Hyperplasia (ADH)
- Atypical Lobular Hyperplasia (ALH)
- Lobular Carcinoma in Situ (LCIS)
12Biopsy results which do not show breast cancer
risk
13Breast Cancer RiskMajor Risk Factors (RR gt 4)
- Previous breast cancer
- Family history (bilateral, premenopausal or
mother and sister) - Atypical hyperplasia
- LCIS or DCIS
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19Breast Imaging Reporting and Data System (BI-RADS)
Category Definition Action PPVmalignancy
0 Incomplete, possible finding Additional imaging 15
1 Negative Routine screening lt1
2 Benign findings Routine screening lt1
3 Probably benign findings 6 mo follow-up 2
4 Suspicious abnormality Biopsy 30-45
5 Highly suggestive of malignancy Biopsy, action as indicated 93
20Causes of Breast Pain
- Endocrine Cyclical, peri-menopausal, and with
hormone replacement therapy - Edema/weight (caffeine, lack of support)
- Mastitis (term usually associated with
lactational problems) - Breast Abscess
- Angina, esophagitis
- Costochondritis, fibromyalgia, anxiety?
21Treatment of Breast Pain
- Elastic/compressive bra (sport or minimizer style
rather than underwire or push-up) - NSAIDS (topical?) Omega-3 fatty acids (evening
primrose oil) - Decrease or stop hormone replacement
- Danazol, gestrinone, tamoxifen may help but cause
hot flashes and masculinizing effects - 50 spontaneous remission, therefore, vitamin E,
b complex, evening primrose oil, decreasing
caffeine seem to help half the time!
22Evaluation of a Breast Mass
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24Case 1 Palpable breast mass
- 36 y/o woman with cyclical breast tenderness
- Noticed a new mass 2 days ago
- Very anxious because a cousin had breast cancer
at age 36
25Mammogram of palpable breast mass
26Sonogram of simple cyst
27Case 2 Palpable breast mass
- 42 y/o woman, I always have lumpy breasts found
a new lump - Onset 3 months ago, not changing
- Moderate cyclical breast pain
- Lump is in upper outer quadrant, firm, but very
mobile
28Mammogram of palpable breast mass
29Sonogram of fibroadenoma
30Case 3 Breast Redness and Pain
- 55 y/o woman, heavy smoker
- Onset of breast pain 4 days ago
- Gradually worsening, with accompanying mass and
erythema - Not participating in mammographic screening
31Breast Pain and Erythema
32Sonogram of breast abscess
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34Non-lactational breast abscess
- The median age at presentation was 40yr (range
22-71). Among cases, 17 of 19 (89) were smokers
with a mean exposure of 24.4 pk-yr each. - In the control group, 9 of 42 (21) were smokers
with a mean exposure of 17.7 pk-yr each (p0.001,
chi-square test of independence). - Ten of the 19 required surgical drainage and one
of these revealed carcinoma associated with the
abscess, necessitating mastectomy.
35Conclusions Smoking and Breast Abscesses
- Subareolar abscess is strongly associated with
cigarette smoking, with the average patient
presenting at age 40 after smoking more than 20
years. - Aspiration and antibiotics, the preferred
treatment for lactational abscess, had less than
a 50 success rate in this population. - Carcinoma must be ruled out in both surgically
and conservatively managed patients. - Smokers who present with subareolar abscess
should be urged to quit for this and other health
reasons
36Nipple Discharge
- Spontaneous
- Unilateral, single orifice
- Clear or blood-tinged
- Progresses over time
- DDX Duct ectasia, intraductal papilloma, DICS
- 10 malignant
- Elicited, intermittent
- Multiple ducts, bilateral
- Green, murky, white
- May stop if abstain from manipulation
- Biopsy if abnormal imaging or progressive
- Same DDX
37Evaluation of Nipple Discharge
- History
- Prolactin, TSH if suspect galactorrhea
- Mammogram, ultrasound
- Ductogram optional
- Surgical consultation, Mammary duct excision is
diagnostic and stops discharge - Vacuum assisted core needle biopsy may also stop
the discharge
38Hormone Replacement Therapy and Breast Cancer
Risk
Years of HormoneTreatment
20 yr cumulative breast cancer rate /1000 women
None
45
5
47
10
51
20
57
39 Cancer Prevention
- Quit smoking More women die of lung cancer than
breast cancer - Maintain a healthy balance of exercise,
recreation, rest, and weight control - Chemoprevention for women at increased risk
(family history, abnormal biopsy)