Breast Disease

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Breast Disease

• Naomi L. Katz, M.D., M.P.H.

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Anatomy
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Anatomy
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Cases
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Case 1

• 35 y.o. G1P1 presents with complaints of pain in
  breasts.
• Pain is bilateral, diffuse. Feels swollen.
• POBHx- SVD x 1
• PGYNHx- regular menses
• PMHx/PSHx- negative
• MEDS- none
• FHx- noncontributory

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Pain

• Differential diagnosis
• Fibrocystic changes
• Mastalgia/mastodynia
• Cyst
• Duct obstruction
• Inflammation/infection- mastitis
• Trauma

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Fibrocystic change

• Most common of benign breast conditions
• Replaces fibrocystic disease
• Multiple tender breast masses
• May be cyclic in nature
• May be exaggerated response to hormones
• Usually present as cyclic, bilateral pain and
  engorgement
• Pain diffuse, often radiates to shoulders or
  upper arms
• Prominent thickened plaques of breast tissue,
  often in upper outer quadrants

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Fibrocystic change

• Management
• Fine-needle aspiration- diagnostic and
  therapeutic
• Open biopsy if bloody fluid, residual mass, cyst
  recurrence
• Restrict caffeine, foods containing
  methylxanthines
• OCPs
• Pain medications- ibuprofen, salicylates,
  acetaminophen
• Diuretics
• Danazol
• Bromocriptine

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Mastalgia/mastodynia

• Affects up to 2/3 of women at some time in
  reproductive lives
• Cyclic in 70 of cases and noncyclic in 25
• Can be difficult to distinguish between
  premenstrual syndrome or fibrocystic changes
• May be associated with abuse, anxiety, depression

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Mastalgia/mastodynia

• Management
• Imaging to r/o cancer (usually benign)
• Mechanical breast support
• Avoid methylxanthines
• Low fat diet
• Evening primrose oil (prostaglandin effect)
• Topical nonsteriodal antiinflammatories
• Bromocriptine
• Tamoxifen
• Danazol

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Mastalgia/mastodynia

• Noncyclic mastalgia responds poorly to treatment
  but resolves spontaneously in 50 of cases
• Cyclic mastalgia resolves spontaneously in 20-30
  of cases

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Infection/inflammation

• Presents with pain, erythema, fever
• Lactational mastitis-
• Occurs postpartum, Staph aureus colonization
• Management- antibiotics, continue breast feeding
  or pumping, incision and drainage of abscess
• Nonlactational abscess-
• Can be due to fistula, tuberculosis, carcinoma

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Case 2

• 35 y.o. G1P1 presents with complaints of
  spontaneous nipple discharge.
• Right breast, bloody discharge.
• POBHx- SVD x 1
• PGYNHx- benign
• PMHx/PSHx- negative
• MEDS- OCPs
• FHx- noncontributory

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Nipple discharge

• Differential diagnosis
• Breast lesions-
• intraductal papilloma, ductal ectasia,
  fibrocystic changes, breast abscess
• Drug induced-
• phenothiazines, reserpine, methyldopa,
  imipramine, amphetamine, OCPs
• CNS lesions-
• pituitary adenoma, empty sella, hypothalamic
  tumor
• Medical conditions-
• Cushings, hypothyroid, chronic renal failure
• Carcinoma
• Idiopathic

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Nipple discharge

• Workup
• Exam
• Labs- Prolactin, TSH
• Mammogram
• Cytologic evaluation of discharge- not very
  useful
• Consider referral to breast surgeon if
  suspicious, even if no mass present
• Ductography

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Intraductal papilloma

• Epithelial tumors arising in ducts of breast
• Main cause of nipple discharge in nonpregnant or
  nonlactating women
• Usually women age 40-45
• Benign
• Size 2-5 mm, usually not palpable
• Present with spontaneous, bloody, serous or
  cloudy nipple discharge
• Management- excisional biopsy

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Ductal ectasia

• Second most common cause of nipple discharge
• Older patients
• Increase in glandular secretion
• Discharge thick, gray/black color
• Can lead to nipple retraction and breast mass
• Management- medical, icepacks, anti-inflammatory
  agents, broad spectrum antibiotics, surgery if
  abscess or mass present

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Nipple discharge

• Bad signs
• Serous, serosanguinous, or watery discharge
• Associated with mass
• Unilateral
• Single duct
• Positive cytology
• Positive mammography
• Age 50 yrs old

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Case 3

• 45 y.o. G2P2 presents with complaints of mass in
  left breast. Noticed on self exam.

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A mass

• History
• Length of time present
• Presence of pain
• Change in size or texture
• Relationship to menstrual cycle
• Nipple discharge
• Family history of breast or ovarian cancer and
  ages
• Age at first live birth, menarche, menopause

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A mass

• Differential diagnosis
• Fibroadenoma
• Macrocysts
• Galactoceles
• Lipoma
• Abscess
• Rare causes- sclerosing adenosis, cystosarcoma
  phyllodes
• Malignancy

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A mass

• Work up
• Exam
• Imaging-
• Diagnostic mammogram- less sensitive in younger
  women due to breast density
• Ultrasound- can distinguish cystic lesions from
  solid masses (require further evaluation)
• Consider referral to breast surgeon
• Biopsy-
• Fine needle aspiration, Core needle biopsy, Open
  biopsy

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Mammography
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Ultrasound
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Fibroadenoma

• Second most common benign breast disease, most
  common benign solid tumor
• Firm, painless, mobile breast mass, 2-3 cm,
  commonly in upper outer quadrants
• Usually women aged 20-40
• Multiple in 15-20 of patients
• Slow growing, do not regress spontaneously
• Can be stimulated by exogenous estrogen,
  progesterone, lactation, pregnancy
• Management- biopsy or excision

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Macrocysts

• Most often women age 35-50
• Fluid-filled sac
• Often solitary but can be multiple
• Can have associated nipple discharge
• Aspiration for diagnosis and therapy

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Galactocele

• Milk-filled cyst
• Usually follows lactation
• Firm, tender mass
• Usually in upper quadrants
• Diagnostic aspiration often curative

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Lipoma

• Nontender
• No associated skin or nipple changes
• Usually postmenopausal women
• Management- biopsy or excision

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Breast cancer

• 211,000 new cases per year (estimated from 2005)
• 40,000 deaths per year (estimated from 2005)
• Second leading cause of cancer-related death in
  women
• Lifetime risk of breast cancer 12
• One in eight women will develop breast cancer
• 80 in women 50 yrs old, 20 in women

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Breast cancer

• Increasing incidence but decreasing mortality
• Incidence rates increased rapidly in 1980s due to
  increased use of mammo
• Gradual increase since that time
• Increase since 1990 mainly in women 50
• Decreased mortality due to increased awareness,
  earlier detection through screening, and improved
  treatments

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U.S. Cancer PrevalenceNCI, 2003
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Cancer Incidence
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Cancer death rates
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Cancer-related death rates
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Breast cancer

• Risk factors (21 of cases)
• Factor Relative Risk
• FHx 1.2-3.0
• Menstrual Hx (menarche 40 yrs
  total) 1.3-2.0
• OCP use No effect
• Estrogen replacement
• Pregnancy (1st 35 y.o., nulliparous) 2.0-3.0
• Contralateral breast cancer 5.0
• Ovarian/uterine cancer 2.0

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Breast cancer

• Classification
• Ductal adenocarcinoma
• In situ- intracystic, Pagets disease
• Infiltrative- medullary, colloid, tubular,
  papillary, inflammatory, Pagets disease,
  apocrine duct
• Lobular adenocarcinoma
• Noninvasive- intraductal, in situ
• Infiltrative- signet-ring cell variant
• Rare variants
• Juvenile, epidermoid, carcinoid, squamous cell,
  spindle cell
• Sarcoma and carcinosarcoma
• Cystosarcoma phyllodes, angiosarcoma, malignant
  lymphoma

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Breast cancer

• Symptoms
• Early- mammo abnormality, painless, mobile tumor
• 80 present with mass
• Pain is not usually early symptom, more likely
  benign
• Later- borders less distinct, fixed to supporting
  ligaments or underlying fascia, nipple discharge,
  skin changes (peau dorange), retraction of nipple

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Breast cancer

• Screening
• Breast self-exam- 90 of breast cancers found by
  patient, benefit not proven for early detection
  of cancer
• Clinical breast exam- yearly for women age 30,
  PPV 73, NPV 87, optimal exam is 1 week after
  onset of menses, screening benefit not proven

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Breast cancer

• Screening cont
• Mammogram-
• AMA and ACS- Annually every year age 40, before
  age 40 in selected high-risk patients
• ACOG- Every 1-2 years age 40, every year age 50
• USPSTF- Every 1-2 years age 40
• Start 5-10 yrs before age of affected family
  member
• Decreases mortality by up to 30 (not proven in
  women age 40-49)

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Breast cancer

• Screening controversies-
• Is self breast exam better than no screening?
• Is clinical exam effective?
• Optimal screening interval 1-2 years?
• When to stop screening?

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Hereditary breast cancers

• Hereditary breast cancers 5-15 of breast cancers
• BRCA1 mutation-
• chromosome 17q21, thought to be tumor suppressor
  gene
• lifetime risk of breast cancer 82, lifetime risk
  of ovarian cancer 44
• BRCA2 mutation-
• chromosome 13q12, early age of onset, male breast
  cancer
• lifetime risk of breast cancer is 70, lifetime
  risk of ovarian cancer 17

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BRCA Mutations

• Prophylactic measures-
• OCPs (for ovarian cancer prevention)
• Imaging- Mammography, ?TV U/S
• Chemoprevention- tamoxifen, raloxifene, aromatase
  inhibitors
• Surgery- bilateral prophylactic mastectomy,
  oophorectomy
• Multidisciplinary approach

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Hereditary breast cancers