Post on 15-Jan-2016
Benign Breast Disease
Elizabeth Peralta, M.D.
Breast Surgeon
Sutter Pacific Medical Group of the Redwoods
Breast Complaints
• Pain
• Mass
• Skin or Nipple Changes
• Nipple Discharge
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
Mammary ductogram demonstrating lobules
Pre-menarchal ductule
Terminal ductal-lobular unit
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
Normal breast inpregnancy and after
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
Involutional and cystic change
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
Biopsy results which represent increased breast cancer risk:
• Atypical Ductal Hyperplasia (ADH)
• Atypical Lobular Hyperplasia (ALH)
• Lobular Carcinoma in Situ (LCIS)
Biopsy results which do not show breast cancer risk:
• Cysts
• Fibrosis
Breast Cancer Risk
Major Risk Factors (RR > 4)•Previous breast cancer
•Family history (bilateral, premenopausal or mother and sister)
•Atypical hyperplasia
•LCIS or DCIS
L
Breast Imaging Reporting and Data System (BI-RADS)
Category Definition Action PPVmalignancy
0 Incomplete, possible finding
Additional imaging
15%
1 Negative Routine screening
<1%
2 Benign findings Routine screening
<1%
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%
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?
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!
Evaluation of a Breast Mass
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
Mammogram of palpable breast mass
Sonogram of simple cyst
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
Mammogram of palpable breast mass
Sonogram of fibroadenoma
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
Breast Pain and Erythema
Sonogram of breast abscess
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 (p=0.001, chi-square test of independence).
• Ten of the 19 required surgical drainage and one of these revealed carcinoma associated with the abscess, necessitating mastectomy.
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
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
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
Hormone Replacement Therapy and
Breast Cancer Risk Years ofHormoneTreatment
20 yr cumulative breastcancer rate /1000 women
None
5
20
45
10
47
51
57
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)