BREAST DISEASE (Lecture # 80085) ‏

1. BREAST DISEASE(Lecture # 80085)‏ Tory Davis, PA-C Mercy Hospital Physician Extender Program

2. 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)

3. 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?

4. 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

5. Breast History • Duration of symptoms • Relation of sx to menstrual period • Presence/type of pain • Nipple discharge • Skin changes • Meds/drugs • Last MMG • PMHX or FHx breast cancer

6. 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?

7. Cyclic Breast Pain • Associated with FCBC, PMS • Usually benign • Worsens in luteal phase • When is that? • May be unilateral or bilateral • UOQ most common site • What else is common in UOQ? • Hormonal influence

8. 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

9. 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

10. 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

11. 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

12. 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!

13. 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

14. 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

15. Galactorrhea Definition: non-puerperal secretion of milk Symptoms: • 1. Spontaneous or expressible milky discharge from nipple • 2. May have headache, menstrual irregularities, infection, osteoporosis, hirsutism

16. Galactorrhea • Usually multiple ducts bilaterally. • Verify that it is milk microscopically by identifying multiple fat droplets under low magnification

17. Galactorrhea • Idiopathic: 1/3 of all cases • Drug 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 level • Surgical resection if unresponsive to medications

18. 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?

19. 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

20. 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)‏

21. 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.

22. 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

23. 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

24. 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

25. 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

26. If pt presents with a breast LUMP, you should ask… • Length of time present, come and go, relationship to menses • Tenderness or pain (characterize), dimpling, change in contour • Changes in lump • Associated symptoms • Medications

27. 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

28. 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.

29. 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

30. 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.

31. FCBC Tx Reassurance about benign nature Supportive bra Mild diuretics: 2-3 days/cycle Dietary modifications: Decrease caffeine (including chocolate)‏ Meds: oral contraceptives, danazol, tamoxifen, bromocriptine

32. 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

33. Comprises 10% of all breast masses

34. 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

35. 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

36. Lipoma • Definition: you tell me!  • Incidence: Mean age: 45 • Symptoms: Soft, painless mass • Findings: Soft, nontender dominant mass with moderate mobility usually in or near skin around areola. May feel more fibrous than lipoma in other body sites.

37. 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?)‏

38. Breast Cancer • Lump: non-tender, firm, with poorly delineated margins. • Mammogram: calcifications • Most common locations UOQ (45%) and under nipple/areola (25%).

39. 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 menopause • Previous breast or endometrial ca

40. 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 40-50 • recently, guidelines changed. Controversial.

41. Genetic testing • BRCA1 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

42. S/Sx of Advanced Cancer • Palpable nodes (where?)‏ • Nipple retraction • Dimpling of the skin (peau d’orange)‏ • Ulceration or redness of skin • Fixation to the chest wall • Edema of the ipsilateral arm • Signs of distant mets: weight loss, jaundice, bone pain, cough

43. 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

44. 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

45. Treatment • Multidisciplinary team approach and individualized treatment • Modified radical mastectomy vs. breast conservation therapy • Chemotherapy and hormonal therapy • Radiation usually only palliative • Attention to the REST of your patient

46. 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