Benign Breast Disease

1. Benign Breast Disease Elizabeth Peralta, M.D. Breast Surgeon Sutter Pacific Medical Group of the Redwoods

2. Breast Complaints • Pain • Mass • Skin or Nipple Changes • Nipple Discharge

3. Diagnosis and Treatment of Breast Complaints • Most important is to rule out malignancy • Significance of a finding is greatest in a high-risk patient • Balance between reassurance and exhausting all diagnostic options • Treatment should not be worse than the disease

4. Mammary ductogram demonstrating lobules

5. Pre-menarchal ductule Terminal ductal-lobular unit

6. Breast Development Menarche and Reproductive Cycles: • Pulsed estrogen exposure causes rapid growth, elongation and branching • Term pregnancy leads to terminal differentiation and stops growth • End bud epithelial tissue undergoes cyclic proliferation • Breast feeding is associated with a lower risk of breast cancer

7. Normal breast in pregnancy and after

8. Breast Development • Involution: Changes of involution begin after cessation of lactation and continue through menopause • Competing involution and proliferative processes are patchy and increased in peri-menopause and with HRT • Hyperplasia with atypia and DCIS peak in this period

9. Involutional and cystic change

10. Pre-Cancer Changes • Intraepithelial neoplasia (IEN): a lesion which is non-invasive but contains genetic abnormalities, loss of cellular control functions, and some microscopic features of cancer cells

11. Biopsy results which represent increased breast cancer risk: • Atypical Ductal Hyperplasia (ADH) • Atypical Lobular Hyperplasia (ALH) • Lobular Carcinoma in Situ (LCIS)

12. Biopsy results which do not show breast cancer risk: • Cysts • Fibrosis

13. Breast Cancer RiskMajor Risk Factors (RR > 4) Previous breast cancer Family history (bilateral, premenopausal or mother and sister) Atypical hyperplasia LCIS or DCIS

16. L

19. Breast Imaging Reporting and Data System (BI-RADS)

20. Causes of Breast Pain • Endocrine: Cyclical, peri-menopausal, and with hormone replacement therapy • Edema/weight (caffeine, lack of support) • Mastitis (term usually associated with lactational problems) • Breast Abscess • Angina, esophagitis • Costochondritis, fibromyalgia, anxiety?

21. Treatment of Breast Pain • Elastic/compressive bra (sport or minimizer style rather than underwire or push-up) • NSAIDS (topical?) Omega-3 fatty acids (evening primrose oil) • Decrease or stop hormone replacement • Danazol, gestrinone, tamoxifen may help but cause hot flashes and masculinizing effects • 50% spontaneous remission, therefore, vitamin E, b complex, evening primrose oil, decreasing caffeine seem to help half the time!

22. Evaluation of a Breast Mass

24. Case 1: Palpable breast mass • 36 y/o woman with cyclical breast tenderness • Noticed a new mass 2 days ago • Very anxious because a cousin had breast cancer at age 36

25. Mammogram of palpable breast mass

26. Sonogram of simple cyst

27. Case 2: Palpable breast mass • 42 y/o woman, “I always have lumpy breasts” found a new lump • Onset 3 months ago, not changing • Moderate cyclical breast pain • Lump is in upper outer quadrant, firm, but very mobile

28. Mammogram of palpable breast mass

29. Sonogram of fibroadenoma

30. Case 3: Breast Redness and Pain • 55 y/o woman, heavy smoker • Onset of breast pain 4 days ago • Gradually worsening, with accompanying mass and erythema • Not participating in mammographic screening

31. Breast Pain and Erythema

32. Sonogram of breast abscess

34. Non-lactational breast abscess: • The median age at presentation was 40yr (range 22-71). Among cases, 17 of 19 (89%) were smokers with a mean exposure of 24.4 pk-yr each. • In the control group, 9 of 42 (21%) were smokers with a mean exposure of 17.7 pk-yr each (p=0.001, chi-square test of independence). • Ten of the 19 required surgical drainage and one of these revealed carcinoma associated with the abscess, necessitating mastectomy.

35. Conclusions: Smoking and Breast Abscesses • Subareolar abscess is strongly associated with cigarette smoking, with the average patient presenting at age 40 after smoking more than 20 years. • Aspiration and antibiotics, the preferred treatment for lactational abscess, had less than a 50% success rate in this population. • Carcinoma must be ruled out in both surgically and conservatively managed patients. • Smokers who present with subareolar abscess should be urged to quit for this and other health reasons

36. Spontaneous Unilateral, single orifice Clear or blood-tinged Progresses over time DDX: Duct ectasia, intraductal papilloma, DICS 10% malignant Elicited, intermittent Multiple ducts, bilateral Green, murky, white May stop if abstain from manipulation Biopsy if abnormal imaging or progressive Same DDX Nipple Discharge

37. Evaluation of Nipple Discharge • History • Prolactin, TSH if suspect galactorrhea • Mammogram, ultrasound • Ductogram optional • Surgical consultation, Mammary duct excision is diagnostic and stops discharge • Vacuum assisted core needle biopsy may also stop the discharge

38. Hormone Replacement Therapy and Breast Cancer Risk Years of HormoneTreatment 20 yr cumulative breast cancer rate /1000 women None 45 5 47 10 51 20 57

39. Cancer Prevention • Quit smoking: More women die of lung cancer than breast cancer • Maintain a healthy balance of exercise, recreation, rest, and weight control • Chemoprevention: for women at increased risk (family history, abnormal biopsy)