BREAST DISEASE(Lecture # 80085)

Tory Davis, PA-C

Mercy Hospital Physician Extender Program

Breast Anatomy Breast profile:

A: ducts B: lobules C: dilated section of duct to hold milkD: nipple E: fat F: pectoralis major muscle G: chest wall/rib cage

Enlargement: A: normal duct cells B: basement membrane C: lumen (center of duct)

Benign Breast Disease

Very commonly encountered in primary care practice

Benign breast symptoms and findings occur in approximately 50% of women

15 million office visits/yr>90% visits for breast sx result in benign

findings, but breast cancer can mimic benign disease, so prudent approach is to always exclude cancer

– subtext, anyone?

CYA Protect your patients, protect yourself Always have cancer on your ddx, and

always rule it out If unsure, you must refer Breast disease is an extremely litigious

area

Breast History

Duration of symptomsRelation of sx to menstrual periodPresence/type of painNipple dischargeSkin changesMeds/drugsLast MMGPMHX or FHx breast cancer

Mastalgia/Mastodynia

Only recently defined as a medical problem

Incidence: 60% presented with complaint to breast clinic, but only 3.4% sought medical treatment.– So how would the provider know?

Cyclic Breast Pain

Associated with FCBC, PMSUsually benignWorsens in luteal phase

– When is that?

May be unilateral or bilateralUOQ most common site

– What else is common in UOQ?

Hormonal influence

Cyclic Breast Pain

Evaluation: Thorough history and physical exam. Optimal time - days 7-9 after LNMP (why?) – If no obvious abnormalities noted, obtain 2

month breast pain calendar to verify cyclic nature.

Treatment options: Reassurance and mechanical support (well fitted bras), diuretics, low fat diet, evening primrose oil, oral contraceptives, thyroid hormone, and NSAIDs

Non-cyclic pain

Incidence: 10% of women 30-40 years of age with severe breast pain

Cause: More likely to be non-hormonal; (post- surgical, musculoskeletal, trauma, infection, cancer)

Symptoms: “burning” pain, “aching”, “sore”Physical Exam: 7-10% have underlying

carcinoma

Mastitis

Definition: Inflammation of the breast tissue usually occurring during lactation

Incidence: 7%-10%, usually first-timers

Symptoms: Severe breast tenderness, induration, erythema, heat, and swelling of the breast, with fever (38-40C/101-103F) and chills– Usually unilateral

Mastitis

Causes: – failure to empty breasts completely of

milk at each nursing, – pathogens (usually from the baby’s

mouth) gaining entrance into the milk ducts through a crack or fissure in the nipple

– lowered resistance in the mother due to stress, fatigue, and inadequate nutrition

Mastitis Treatment

Bed rest

Antibiotics that cover resistant S. Aureus (eg. dicloxacilllin)

Pain relievers, increased fluid intake, and ice or moist heat applications

Continue to nurse!

Breast abscess

…If tenderness and erythema of mastitis persist after antibiotic therapy, the presence of an abscess should be suspected

Findings: Usually singular and multilocular abscess seen on ultrasound

Treatment: Incision and drainage or aspiration

Nipple Discharge

History to obtain: Onset, duration, color, consistency, odor, amount, associated symptoms, medications

Incidence:– 10 - 50% of women with benign breast disease– 3% of women with breast cancer– 7% of breast surgeries are for nipple discharge

Galactorrhea

Definition: non-puerperal secretion of milk

Symptoms: 1. Spontaneous or expressible milky

discharge from nipple2. May have headache, menstrual

irregularities, infection, osteoporosis, hirsutism

Galactorrhea

Usually multiple ducts bilaterally. Verify that it is milk microscopically by

identifying multiple fat droplets under low magnification

GalactorrheaIdiopathic: 1/3 of all casesDrug Induced: Important to review all

current medications and then check for possible side effects.

Pituitary Adenoma: galactorrhea, hyperprolactinema, and amenorrhea– Treatment: Bromocriptine

– Measure effectiveness by return of menses and normal prolactin levelSurgical resection if unresponsive to medications

Other Nipple discharge

Incidence: 9% of women with benign breast disease

Types: watery 33%; sanguinous 27%; serosanguinous 13%; serous 6%

Physical findings: source and type of discharge important, as is presence or absence of masses.

One or several ducts?

– If only 1 duct, 4xRR cancer– How do you figure that out?

Nipple Discharge

Physical Findings:– Technique: press index finger around

periphery of areola to locate affected quadrant

Differential diagnosis of palpable mass and nipple discharge: Intraductal papilloma, severe fibrocystic breast changes, mammary duct ectasia, cancer

Intraductal Papilloma

Definition: Benign breast mass varying in size from microscopic to 2-3 mm in diameter

Incidence: Accounts for 75% of all non-puerperal pathological nipple discharge– Usually occurs in later reproductive years

(30-50 years old)

Intraductal Papilloma

Symptoms: Spontaneous nipple discharge from a single duct opening

May be clear, serous, serosanguinous, bloody or turbid

Mass usually < .5 cm and located within 1 cm of areola

Findings: Soft non-tender mass in subareolar area.

Intraductal papilloma

Mammogram: Dilated duct with or without a mass. May have benign micro-calcifications in mass.

Treatment: Surgical excision needed for definitive diagnosis and treatment

Duct Ectasia

Definition: Dilation of duct system in areolar terminal ducts, often with surrounding inflammation

Incidence: 20-25% perimenopausal women

Etiology: Unclear sequence of events– Chicken or egg? Infections leading to

metaplasia or metaplasia leading to obstruction and later infection

Duct Ectasia

Symptoms: Spontaneous dark green nipple discharge from multiple duct openings with or without mass

Findings: Tender dilated ducts may be palpable– In more advanced cases, may find

palpable tumor which is firm, rounded, relatively fixed with skin retractions

Duct Ectasia Dx/Tx

Mammogram and ultrasound appropriate

Fine Needle Aspiration (FNA) for definitive diagnosis

Conservative treatment may improve symptoms, but recurrent disease usually requires excision.

Antibiotic use is not helpful

If pt presents with a breast LUMP, you should

ask…Length of time present, come and go,

relationship to mensesTenderness or pain (characterize),

dimpling, change in contourChanges in lumpAssociated symptomsMedications

Breast Lumps

More than 90% of all breast lumps are discovered by women themselves.

The majority of all breast lumps are benign.

BUT…about one women in eight (12%) will develop breast cancer sometime in her life.– You need to make sure you don’t miss it

Fibrocystic Breast Changes (FCBC)

FCBC: catch-all term for benign mastalgia, lumps, cysts

Definition: Enhanced reaction of breast tissue to cyclic production of ovarian hormones

Breasts are nodular, dense, and tender to palpation– 50% of women have irregular breasts on

palpation.

FCBC stats 10% of <22 y/o 25% of reproductive aged adults 50% of perimenopausal women Most common in women with early

menarche, 1st live birth after age 30, or nulliparous women

FCBC

Symptoms: Bilateral pain and tenderness, possible lump which worsens premenstrually. Occasional nipple discharge. Symptoms may be localized or even non-painful and be unrelated to menstrual cycle.

Findings: Poorly defined thickness or palpable lumpiness. May have dominant cystic mass.

FCBC Tx

Reassurance about benign natureSupportive braMild diuretics: 2-3 days/cycleDietary modifications: Decrease

caffeine (including chocolate)Meds: oral contraceptives, danazol,

tamoxifen, bromocriptine

FCBC

Surgical Treatments: – Cyst aspiration – Biopsy of suspicious lesions – NB: Even in a breast with FCBC, not all masses

are benign…

Malignant transformation: – no evidence of progression or increased risk

Comprises 10% of all breast masses

Fibroadenoma

Definition: Benign, firm, fully mobile solid breast mass averaging 2.5 cm in diameter.

Incidence: Most common benign breast mass. Most <30 y/o

Juvenile form very common in black women

Fibroadenoma

Symptoms: Painless mass which might increase in size with menses

Findings: Firm, mobile, smooth or lobulated non tender dominant mass

Mammogram and Ultrasound appropriate– FNA: Benign findings– Treatment: Conservative management

for asymptomatic lesions. Excisional biopsy for large or enlarging lesions

Lipoma

Definition: you tell me! Incidence: Mean age: 45Symptoms: Soft, painless massFindings: Soft, nontender dominant

mass with moderate mobility usually in or near skin around areola. May feel more fibrous than lipoma in other body sites.

Breast Cancer 1 in 8 women Usually involves glandular cells in

ducts or lobules MC pres: asymptomatic lump found

by BSE, CBE or MMG 2nd leading cause of cancer death in

women (#1 is what?)

Breast Cancer

Lump: non-tender, firm, with poorly delineated margins.

Mammogram: calcificationsMost common locations UOQ (45%)

and under nipple/areola (25%).

Breast Cancer Risks

Breast cancer in first-degree relative (what is that?) doubles to triples the risk– 2 first degree relatives 6xRR– BUT…90% of women with breast cancer

have no family history

Nulliparity or first full-term pregnancy >35

Early menarche and late menopausePrevious breast or endometrial ca

Patients with Increased Risk

Need to identify and screen these patients carefully

Routine PE and mammography of asymptomatic patients– Breast self-exam monthly over age 20

Some groups not recommending

– Clinical breast exam every 3 years between 20 and 39 years, annually over 40 years

– Mammogram annually starts at age 40-50recently, guidelines changed. Controversial.

Genetic testingBRCA1 AND BRCA 2 genetic

mutations– Increased risk for breast, ovarian, colon,

prostate, and pancreatic cancers– 5-10% of women with breast cancer may

have these mutations.– If a pt has these mutations, risk of

developing breast cancer between 40 and 85%

– No established guidelines for testing or tx

S/Sx of Advanced CancerPalpable nodes (where?)Nipple retractionDimpling of the skin (peau d’orange)Ulceration or redness of skinFixation to the chest wallEdema of the ipsilateral arm Signs of distant mets: weight loss,

jaundice, bone pain, cough

Other Types of Breast Cancer

Paget’s disease: 1% of all breast cancers, first symptoms often itching or burning of nipple with superficial erosion or ulceration; eczematous changes of nipple and areola; palpable mass in 60% of cases

Inflammatory carcinoma: less than 5% of all cases; diffuse, brawny induration of the skin, no mass; most aggressive form; often confused w/mastitis

If You Suspect Breast Cancer

Refer to surgeon or breast specialist for work-up

Mammography is never a substitute for biopsy. Must have tissue dx.– FNA or stereotactic needle bx are

simplest

Most definitive dx by open bx under local anesthesia

TreatmentMultidisciplinary team approach

and individualized treatment Modified radical mastectomy vs.

breast conservation therapyChemotherapy and hormonal

therapyRadiation usually only palliativeAttention to the REST of your

patient

FACTS WORTH REPEATING:

More than 90% of all breast lumps are discovered by women themselves.

The majority of all breast lumps are benign.

About one women in eight (12%) will develop breast cancer sometime in her life.

90% of women with breast cancer have no family history