390 likes | 610 Views
Breast Disease : Common Problems. Jennifer Griffin, MD, MPH Associate Professor Residency Program Director Department of Obstetrics and Gynecology. Why do women seek care for breast problems?. Rarely they have symptoms that are too bothersome and want treatment.
E N D
Breast Disease: Common Problems Jennifer Griffin, MD, MPH Associate Professor Residency Program Director Department of Obstetrics and Gynecology
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.
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.
Steps of a Breast Evaluation • HPI • Risk Assessment • Physical Exam • Imaging • Diagnostic Steps • Follow up plan
HPI • Complaint • Associated Symptoms • Timing • Duration
Risk Assessment • AGE • 1 in 2000 in 20s, 1 in 25 in their 70s • Family History • Reproductive History • Breast History
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
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
Risk Assessment • AGE • Family History • Reproductive History • Breast History • Prior breast biopsies • Proliferative lesions—slight increase risk • ADH, ALH, FEA, LCIS ~20% LR
Physical Exam • Think about symmetry • Visualization • Seated / Supine • Take adequate time
Imaging • Mammography/Tomosynthesis • Ultrasound • MRI
Mammo/Tomo • First imaging step in women >=30 • Detects differences in density • Sensitivity is limited by density • Safe in pregnancy, but limited by density
Ultrasound • Initial imaging for women <30. • Adjuvant imaging for women 30+. • Lack of anatomic landmarks limits utility for screening.
MRI • Used to screen high risk women. • Used for cancer treatment planning. • Not helpful in evaluation of breast complaints.
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
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.
Breast Mass • Distressing for providers and patients • Systematic approach includes imaging in almost all cases
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
Common Masses • Cysts • Simple, complicated, complex • Fibrocystic change • Fibroadenomas • Phylloides tumors • Skin problems • Fat necrosis • Diabetic mastopathy • Pseudoangiomatous stromal hyperplasia (PASH) • Malignancies
Management • Does imaging correlate with exam? • If yes, follow BI-RADS guidelines. • If no, follow up.
Nipple Discharge • Is it a breast or endocrine problem? • Key Questions: • Spontaneous or expressed? • Bilateral or unilateral? • Color? • Multiductal or uniductal?
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
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
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)
Discharge • Paget’s Disease Ductogram with Intraductal Lesion (Papilloma?)
Inflammation • Lactational mastitis • Non-lactational mastitis • Periductal mastitis/Mammary duct inflammatory sequence • Granulomatous mastitis • Inflammatory cancer
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)
PeriductalMastits • Seen in classic duct ectasia or MDAIS • Can result in fistulas
Granulomatous Mastitis • Idiopathic, infectious • TB, Mycoplasma
Inflammatory Cancer • Stage 4 by definition with skin involvement • Punch biopsy of skin