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Benign Breast Disorders Valerie Swiatkowski, MD Medical Student Lecture Introduction 16% of women ages 40-69 will seek advice from their physician regarding breast complaints over 10 years. Failure to diagnose breast cancer is a leading cause of malpractice claims. 90% of patients will have benign disease Objectives At the end of this lecture, you will know: Clinical breast exam Evaluation of a breast mass Major causes of benign breast disease Evaluation of nipple discharge Management of abnormal mammography Scenario 1 NM is a 31 y/o G1P1001 who presents annual w/o Her friendfor was just exam diagnosed complaints. with breast cancer. She wants to know if you will order a mammogram for her… What are the screening guidelines? Screening Guidelines by Age Age 20 - 35 Age 35 - 40 Baseline mammography Age 40 - 50 Breast self-exam once a month Physical Exam Yearly Mammography every one to two years Age 50 + Mammography yearly Breast Self Exam Timing Premenopausal: one week after onset of menstruation Postmenopausal: the same day each month Breast Self Exam NM is grateful for your time and teaching. You counsel her that you will see her in a year… Scenario 2 Your next patient, FC, is a 22 y/o Go comes in with a new right breast mass… What do you do? Tell FC that cancer is rare in young women and she shouldn’t worry about it… Order mammogram now Refer to a breast specialist Talk to FC and get more history What do you do? Tell FC that cancer is rare in young women and she shouldn’t worry about it… Order mammogram now Refer to a breast specialist Talk to FC and get more history What information do you want to know? Key Points in her History The precise location of the lump How it was first noted (accidentally, by breast self-examination, or during a screening clinical breast examination or mammogram) How long has she noted its presence? Any accompanying nipple discharge? Has the lump has changed in size? Does the lump wax and wane in size? Any risk factors for breast cancer? Risk Factors for Breast Cancer Age Age at Menarche Age at first birth Age at Menopause Parity/ breastfeeding history History of breast biopsy History of Atypical Hyperplasia Family history of Breast Cancer BRCA1/2 positive Scenario 2 (cont) FC tells you she has noticed this mass for the last three months, it has increase in size over that time. She has no tenderness or nipple discharge. Now what do you do? Order mammogram now Examine the patient Recommend surgical excision Now what do you do? Order mammogram now Examine the patient Recommend surgical excision What do you need to know from physical exam? Physical Exam Delineate and document breast masses Elicit discharge from the nipple Identify localized areas of tenderness Detect enlarged lymph nodes Detect skin changes: Asymmetry Skin retraction Dimpling Edema Erythema Ulceration Scenario 2 (cont) During your clinical breast exam you palpate a mass in the right upper outer quadrant 1 cm, firm, mobile, nontender, no LAD Scenario 2 (cont) FC is really worried… What could the mass be? What do you do next? So what is the differential diagnosis? General Categories of Breast Disease Physiologic Nodularity Mastalgia Dominant Lumps Nipple Discharge Infections and Inflammation General Categories of Breast Disease Physiologic Nodularity Mastalgia Dominant Lumps Nipple Discharge Infections and Inflammation Differential Diagnosis of Breast Masses Macrocysts Fibrocystic Changes Fibroadenoma Galactocele Lipoma Mongor’s disease Granuloma Hamartoma Neurofibroma Mastitis Fat Necrosis Ductal hyperplasia Lobular hyperplasia Sclerosing adenosis Diffuse papillomatosis Complex fibroadenoma Radial scars Cancer Differential Diagnosis of Breast Masses Macrocysts Fibrocystic Changes/Cyst Fibroadenoma Galactocele Lipoma Mongor’s disease Granuloma Hamartoma Neurofibroma Mastitis Fat Necrosis Ductal hyperplasia Lobular hyperplasia Sclerosing adenosis Diffuse papillomatosis Complex fibroadenoma Radial scars Cancer Fibroadenoma Most common benign solid tumor of the breast Present in third decade of life Painless, well circumscribed, mobile Fibrocystic Changes Present with pain, mass or nipple discharge Fibrocystic Changes: Proliferation of stroma, adenosis and cyst formation with marked proliferation, and later, large cysts Gross Cysts Most common age 3550 Palpable fluid filled sac Presenting symptom: PAIN! Workup: Aspiration: both diagnostic and therapeutic Send bloody aspirate for cytology Ultrasound What is a galactocele? What tests do you order? Mammogram Ultrasound Fine Needle Aspiration Excisional Biopsy What tests do you order? Mammogram Ultrasound Fine Needle Aspiration Excisional Biopsy Why FNA? What if she was 55 years old? Mammogram Ultrasound Fine Needle Aspiration Excisional Biopsy What if she was 55 years old? Diagnostic Mammogram Ultrasound Fine Needle Aspiration Who Excisional would Biopsy you order a mammogram for? Women over 35 years of age The Diagnostic Triad Possible Outcomes Any one suggesting Malignancy Combination of: physical exam Mammography skilled FNAB Excisional Biopsy All Three Negative Follow with Exam q 3-6 mo x 1 yr All Three suggest Cancer Refer for Definitive Therapy Scenario 3 DE is a 36 y/o G3P1021 who presents with new onset of nipple discharge What can cause nipple discharge? Normal Breast Secretions Lactation Galactorrhea Abnormal Discharge Intraductal Papilloma Fibrocystic Changes Ductal Ectasia DCIS Paget’s Disease How do you start the evaluation? History and Physical What do you ask? Remember the OPQRSTAA History Specifics Spontaneous or Provoked Unilateral or Bilateral Quality of discharge PMH Meds LMP Pregnancy History/Breastfeeding History Physical Activity Physical Exam will usually confirm your working dx DE tells you she has noticed that has bilateral white discharge that is spontaneous. Her LMP was 6 months ago. She has no medical problems and is not taking any meds. Further Workup? Physical Exam always is first What do you do next? Evaluate discharge on white background Microscopy of discharge Hemoccult Depends on the type of discharge What do you think she has? Galactorrhea Spontaneous Milky Discharge Causes Hypothyroidism Hyperprolactinemia Physiologic Medication Effect Workup for Galactorrhea PRL TSH What if the discharge has color? Duct Ectasia Spontaneous Green/Black Discharge Bilateral Self Limited Median age 43 Fibrocystic Changes Greenish Benign What if the discharge has color? Bloody Discharge May appear green or black Hemoccult all discharge Usually unilateral Requires additional evaluation (Refer to a breast specialist) Ductogram Possible Surgical exploration Intraductal Papilloma Most common cause of bloody nipple discharge Monotonous array of papillary cells Often diagnosed by ductography Referral to breast specialist nec. You explain to DE that she needs to start a workup for galactorrhea… She will return to the office for her lab results. Scenario 4 BR is a 51 y/o G5P3023 who presented for annual exam w/o complaints. Screening mammography came back BIRADS 3. What is BIRADS? Breast Imaging Reporting and Data System Classification from BIRADS 1 to 5 Mammography 10% of palpable tumors are not seen by mammography Stereotactic FNA is possible for nonpalpable lesions Ultrasound can be used in conjunction to determine cystic vs. solid Conclusions Most patients presenting with breast related complaints will have benign conditions Primary care physicians should be equipt with the knowledge to perform the appropriate workup with referral as necessary History and physical exam is essential for proper evaluation of breast complaints Any Questions? Thank you!! Differential Diagnosis of Breast Fibrocystic Changes/Cyst Fibroadenoma Galactocele Ductal Ectasia Intraductal Papilloma Lipoma Mongor’s disease Granuloma Hamartoma Neurofibroma Mastitis Fat Necrosis Ductal hyperplasia Lobular hyperplasia Sclerosing adenosis Diffuse papillomatosis Complex fibroadenoma Radial scars Cancer
