APPROACH TO THE PATIENT WITH BREAST DISCOMFORT IN PRIMARY CARE

1. APPROACH TO THE PATIENT WITH BREAST DISCOMFORT IN PRIMARY CARE Assist.Prof. Arzu Akalın M.D.

3. Many patients present to their physician for benign conditions of the breast that they perceive to be abnormal

4. Common Complaints • Pain • Breast mass • Nipple discharge • Hypertrophy • Breast infections

5. Youmust • Differentiate benign from malignant disease, • Reassure patients with benign conditions, • Manage common symptoms and conditions, and • Seek consultation when necessary The provider must recognize the emotional distress common during this process and provide timely and effective communication.

6. Breast Anatomy

7. Breast Anatomy The breast is composed of 15-20 lobes and contains glandular, ductal, fibrous, and fatty tissue.

8. More lobes are present in the outer quadrants, especially the upper outer quadrants, Therefore many breast conditions (among them, breast cancer) occur more frequently in these regions

9. Each lobe contains several lobules. Lobules contain ducts that join to form one of the 6-10 major ducts that emerge at the areola. • Six to ten pinhole openings are present on the areola.

10. Axillarytail of breast tissue • An axillary tail of breast tissue extends toward the anterior axillary fold.

11. Breast Development • Beginswith • embrionicdevelopmentand • continuesthroughpostmenopausalandolderyears

12. Newbornsmaypresentwith; • Athelia: Absence of nipple(s) • Polythelia: Morethantwonipples Ectopicnippletissuemayoccur at anypoint in theembrionicbreastline

13. Amastia Absence of breasttissue • Polymastia the presence of morethan two mammary glands or nipples

14. Artemis The Goddess of Ephesus

15. Hypertrophied breast tissue caused by stimulation from maternal estrogen and progesterone. • In most cases spontaneous regression occurs.

16. Prepubertal children may develop unilateral or bilateral soft mobile subareolar nodules of uniform consistency that usually resolve spontaneously within a few months • Biopsy should be avoided as it may impair pubertal breast development

18. In girls, glandular proliferation within the breastmarks the normal onset ofpuberty. • The first sign of puberty isbreast bud development (= thelarche) (average age 11 years; range 9 to 13.4 years), • The last sign is full breast development • Thelarche is considered “premature” if it occurs earlier than age 8.

19. Premature thelarche without other signs of pubertal development or accelerated growth is usually benign. • No treatment is needed • EXCEPT : • precociouspuberty, • estrogen-producingtumors, • ovariancystsor • exogenousestrogenexposure

20. InPuberty • Gynecomastia (= the proliferation of glandular breast tissue in a male), is common in the middle phases of pubertal development. • This may be attributed to serum estradiol levels rising to adult levels before serum testosterone levels. • More than 90% of affected boys experience regression within 3 years • Association with precocious puberty is also a concerning sign.

21. Adulthood • The normal adult breast may be soft, but it often feels granular, nodular, or lumpy. This uneven texture is normal and may be termed physiologic nodularity. It is often bilateral. • The nodularity may increase premenstrually – a time when breasts often enlarge and become tender or even painful.

22. Normal Breast • Changes in size and texture throughout the menstrual cycle. • During the premenstrual phase acinar cells increase in number and size, the ductal lumens widen, and breast size and turgor increase. • These changes reverse in the postmenstrual phase. • The left mamma is usually slightly larger than the right

23. During Pregnancy • Due to hyperplasia of the glandular tissue and increased vascularity, the breasts enlarge and become nodular by the third month of gestation as the mammary tissue hypertrophies. • The nipples enlarge, darken, and become more erectile • The areola darken, and Montgomery’s glands appear prominent around the nipples

24. During Pregnancy • The venous pattern over the breasts become increasingly visible as pregnancy progresses. • From mid- to late pregnancy a normal thick, yellowish discharge called colostrum may be expressed from the nipple

25. Lactation • Mastitis is a cellulitis of the interlobular connective tissuewithin the mammary gland. • The clinical spectrum can range • from focal inflammation • to systemic flulike symptoms of fever,chills, and muscle aches. • The affected breast will usuallyexhibit a tender, erythematous, wedge-shaped swelling.

26. Lactation • Most cases occur within the first 2 months postpartum. • The infection is bacterial, usually staphylococci; • the breastskin and the infant’s mouth have been proposed as the source

27. Lactation • The key to the management of mastitis is complete emptying of the breast, warm compresses, early antibiotics, and bed rest. • The patient should be advised to continue breastfeeding;stopping breastfeeding would put her at increased risk of abscessformation.

28. Aging • The breasts tend to diminish in size as glandular tissue atrophies and is replaced by fat. • Although the proportion of fat increases, its total amount may also decrease. • The breasts often become flaccid and pendulous

29. Gynecomastia • It is common for men in their 50s and 60s to experience breast enlargement. • Gynecomastia associated with • pain, • asymmetry, • rapid onset or progression galactorrhea, • and/or erectile dysfunction requires further workup • Can alsooccurduetosomedrugsandsomediseases

30. ASSESSMENT OF AN INDIVIDUAL WITH BREAST COMPLAINTS

31. Keypoints • History • Examination of the Breast • Laboratory Evaluation • Diagnostic Tests • Pathologic Findings

32. HistoryTaking DESCRIBE • when and in what setting symptoms first occurred, • any change over time, and • past history of similar symptoms. • relation of symptoms to the menstrual cycle. • include the menstrual and reproductive history (age of menarche and menopause)

33. HistoryTaking • parity (age of the first-term pregnancy); • whether currently pregnant; • lactation; • use of hormonal therapy or contraceptives; • rapidity and amount of weight gain after menopause; • whether breast self-examination is performed • any past breast surgery • The patient should also be queried for any family history of breast and ovarian cancers.

34. Examination of the Breast(Inspection& Palpation) The exam should be performed in a well-lit room and privacy is facilitated by draping parts of the body not being examined.

35. Examination of the Breast Inspection • Occurswith the patient seated, • Arms at side; • With hands on hips; and • With arms above the head. • Changes in size, shape, symmetry, or texture are noted.

36. Examination of the Breast Palpation • Is performed with the • patient supine, • arms flexed at a 90-degree angle at the sides. • Palpation includes supraclavicular, infraclavicular, and axillary nodes. • Compression may identify a mass and/or elicit a discharge. • Nipples should be examined for deviation, retraction, skin changes, or discharge.

39. Laboratory Evaluation • Genetic screening is not part of the routine evaluation

40. Diagnostic Tests • Imaging • Mammography • Ultrasonography • Magnetic resonance imaging is utilized in some settings. • Aspiration • Fine-needle aspiration (FNA) • Fine-needle aspiration and biopsy (FNAB) • Triple test: combines physical examination, mammography, and FNAB • Open biopsy

41. Common Complaints • Pain • Mass • Nippledischarge

42. Pain (Mastalgia) • Pain without an associated mass is unlikely to be the presenting symptom of breast cancer, • Mastalgia may be classified as • Cyclical (2/3) • Noncyclical (1/3) • Maybe acute or chronic.

43. PainHistory Mustinclude • Palliative or provocative factors • Quality (dull, sharp, burning, heavy,...) • Radiation (arm, axilla,....) • Severity (mild, severe to limit activities) • Location • Laterality (bilateral / unilateral) of pain

44. PainHistory • Timing with regard to menstrual cycle • Association with oral contraceptive pills, other hormonal contraceptives or hormone replacement use, • RECENT • Birth • Pregnancy • Loss of pregnancy or termination • History of trauma, heavy muscular exertion, should be sought.

45. Pain - Physical Exam • Should be used to evaluate for • Mass • Nipple discharge • To localize areas of tenderness • To assess for • Lymphadenopathy • Changes in symmetry, • Contour, and overlying skin

46. Benign BreastMasses General Considerations • Benign breast masses will often change with the menstrual cycle, while worrisome masses are persistent throughout. • Greater than 90% of palpable breast masses in women between 20 and 55 are benign. • Masses may be discrete or poorly defined, but differ from the surrounding breast tissue and the corresponding area in the contralateral breast. • Cancer should be excluded in a woman who presents with a solid mass.

47. Benign BreastMasses • Breast cysts • Fibrocystic breast changes • Fibroadenoma • Ductalpapilloma

48. Breast Cyst 1. Benign 2. May be aspirated if large

49. Fibroadenoma Mostcommon benign breast tumor

50. Fibrocystic BreastChanges 1) 20%+ ofpremenopausal women 2) Discomfort, cysts 3) Treatmentrarely required