BREAST DISEASE (Lecture # 80085) Tory Davis, PA-C Mercy Hospital Physician Extender Program
Dec 22, 2015
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