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Benign Breast Disease

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Benign Breast Disease Elizabeth Peralta, M.D. Breast Surgeon Sutter Pacific Medical Group of the Redwoods Nipple Discharge Spontaneous Unilateral, single orifice ... – PowerPoint PPT presentation

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Title: Benign Breast Disease


1
Benign Breast Disease
  • Elizabeth Peralta, M.D.
  • Breast Surgeon
  • Sutter Pacific Medical Group of the Redwoods

2
Breast Complaints
  • Pain
  • Mass
  • Skin or Nipple Changes
  • Nipple Discharge

3
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

4
Mammary ductogram demonstrating lobules
5
Pre-menarchal ductule
Terminal ductal-lobular unit
6
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

7
Normal breast in pregnancy and after
8
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

9
Involutional and cystic change
10
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

11
Biopsy results which represent increased breast
cancer risk
  • Atypical Ductal Hyperplasia (ADH)
  • Atypical Lobular Hyperplasia (ALH)
  • Lobular Carcinoma in Situ (LCIS)

12
Biopsy results which do not show breast cancer
risk
  • Cysts
  • Fibrosis

13
Breast Cancer RiskMajor Risk Factors (RR gt 4)
  • Previous breast cancer
  • Family history (bilateral, premenopausal or
    mother and sister)
  • Atypical hyperplasia
  • LCIS or DCIS

14
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15
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16
L
17
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19
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
20
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?

21
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!

22
Evaluation of a Breast Mass
23
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24
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

25
Mammogram of palpable breast mass
26
Sonogram of simple cyst
27
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

28
Mammogram of palpable breast mass
29
Sonogram of fibroadenoma
30
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

31
Breast Pain and Erythema
32
Sonogram of breast abscess
33
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34
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.

35
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

36
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

37
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

38
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
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)
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