Benign Breast Disease

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Benign Breast Disease

• Elizabeth Peralta, M.D.
• Breast Surgeon
• Sutter Pacific Medical Group of the Redwoods

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Breast Complaints

• Pain
• Mass
• Skin or Nipple Changes
• Nipple Discharge

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Diagnosis 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

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Mammary ductogram demonstrating lobules
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Pre-menarchal ductule
Terminal ductal-lobular unit
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Breast 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

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Normal breast in pregnancy and after
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Breast 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

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Involutional and cystic change
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Pre-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

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Biopsy results which represent increased breast
cancer risk

• Atypical Ductal Hyperplasia (ADH)
• Atypical Lobular Hyperplasia (ALH)
• Lobular Carcinoma in Situ (LCIS)

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Biopsy results which do not show breast cancer
risk

• Cysts
• Fibrosis

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Breast 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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Breast 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
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Causes 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?

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Treatment 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!

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Evaluation of a Breast Mass
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Case 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

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Mammogram of palpable breast mass
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Sonogram of simple cyst
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Case 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

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Mammogram of palpable breast mass
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Sonogram of fibroadenoma
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Case 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

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Breast Pain and Erythema
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Sonogram of breast abscess
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Non-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.

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Conclusions 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

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Nipple 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

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Evaluation 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

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Hormone 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
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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)