Breast Disease : Common Problems

1. Breast Disease: Common Problems Jennifer Griffin, MD, MPH Associate Professor Residency Program Director Department of Obstetrics and Gynecology

2. Why do women seek care for breast problems? • Rarely they have symptoms that are too bothersome and want treatment. • Frequently they are concerned they have a sign/symptom of breast cancer.

3. Their concern is justified • Breast cancer is diagnosed in 1 in 8 women in the U.S. • Over 200,000 cases in the U.S annually. • Over half of cases are symptom detected. • Breast cancer is diagnosed in 11% of women presenting with a breast mass, and 4% with any complaint.

4. Steps of a Breast Evaluation • HPI • Risk Assessment • Physical Exam • Imaging • Diagnostic Steps • Follow up plan

5. HPI • Complaint • Associated Symptoms • Timing • Duration

6. Risk Assessment • AGE • 1 in 2000 in 20s, 1 in 25 in their 70s • Family History • Reproductive History • Breast History

7. Risk Assessment • AGE • Family History • Look for pattern suggesting genetic predisposition • Early age of diagnosis • Multiple relatives, same side of family, 1st, 2nd, 3rd degree relatives • Reproductive History • Breast History

8. Risk Assessment • AGE • Family History • Reproductive History • Menarche age <12, menopause >55 • Age of first birth >30 • Nulliparity • No breastfeeding • Hormone therapy E+P after menopause • Breast History

9. Risk Assessment • AGE • Family History • Reproductive History • Breast History • Prior breast biopsies • Proliferative lesions—slight increase risk • ADH, ALH, FEA, LCIS ~20% LR

10. Physical Exam • Think about symmetry • Visualization • Seated / Supine • Take adequate time

11. Imaging • Mammography/Tomosynthesis • Ultrasound • MRI

12. Mammo/Tomo • First imaging step in women >=30 • Detects differences in density • Sensitivity is limited by density • Safe in pregnancy, but limited by density

13. Breast Density

14. Ultrasound • Initial imaging for women <30. • Adjuvant imaging for women 30+. • Lack of anatomic landmarks limits utility for screening.

15. MRI • Used to screen high risk women. • Used for cancer treatment planning. • Not helpful in evaluation of breast complaints.

16. BI-RADS Classification • 0: Incomplete; needs more imaging • 1: Negative • 2: Benign findings • 3: Probably benign (<2% likelihood) • Repeat imaging in 6 months • 4: Suspicious (3-94% likelihood) • Consider biopsy • 5: Highly Suspicious (>=95% likelihood) • Biopsy indicated • 6: Biopsy Proven Malignancy

17. Diagnostic Steps • Core needle biopsy • Preferred in most situations • Correlates with open biopsy ~95% of the time • Excisional biopsy • When core biopsy isn’t feasible • When core biopsy is non diagnostic or requires additional sampling • Fine Needle Aspiration • Cytology specimen • Part of “triple test” • Quick turn around of results.

18. Breast Mass • Distressing for providers and patients • Systematic approach includes imaging in almost all cases

19. Workup—Key Elements • Physical Exam • Is there symmetry? • Is this a 3D mass? • Imaging • When can we trust our radiologists? • Follow up • Have a plan in place

20. Common Masses • Cysts • Simple, complicated, complex • Fibrocystic change • Fibroadenomas • Phylloides tumors • Skin problems • Fat necrosis • Diabetic mastopathy • Pseudoangiomatous stromal hyperplasia (PASH) • Malignancies

21. Cysts

22. Fibrocystic Breast Change

23. Fibroadenomas

24. Breast Cancer

25. Management • Does imaging correlate with exam? • If yes, follow BI-RADS guidelines. • If no, follow up.

26. Nipple Discharge • Is it a breast or endocrine problem? • Key Questions: • Spontaneous or expressed? • Bilateral or unilateral? • Color? • Multiductal or uniductal?

27. Galactorrhea • Bilateral, spontaneous, milky • Check prolactin, TSH • Meds: • H2 receptor antagonists (cimetidine) • Dopamine receptor antagonists (risperidone) • OCPs, SSRIs • Stimulation • If prolactin>40, should have imaging to look for pituitary adenoma

28. Benign Breast Causes • Multiductal, any color is benign • Inspect nipple for skin change • Duct ectasia • Women 50-60s with grey, green sticky discharge • May have nipple inversion • Mammary duct inflammatory sequence • Ecsema

29. More Concerning Discharge • Serous or bloody, single duct • Requires imaging • Requires biopsy • Majority of cases will be due to benign papillomas. • Can be associated with fibrocystic change or malignancy (DCIS)

30. Discharge • Paget’s Disease Ductogram with Intraductal Lesion (Papilloma?)

31. Inflammation • Lactational mastitis • Non-lactational mastitis • Periductal mastitis/Mammary duct inflammatory sequence • Granulomatous mastitis • Inflammatory cancer

32. Lactational Mastitis • 1st Line • Dicloxicillin 500 mg tid x 10 d • Keflex • Think MRSA • Recent hospitalization • Abscess • Start with Bactrim 100 mg bid x 10 d • Drain abscess (aspiration when feasible)

33. Lactational Mastitis

34. PeriductalMastits • Seen in classic duct ectasia or MDAIS • Can result in fistulas

35. Granulomatous Mastitis • Idiopathic, infectious • TB, Mycoplasma

36. HidradenitisSuppurativa

37. Inflammatory Cancer • Stage 4 by definition with skin involvement • Punch biopsy of skin