Benign Breast Disease
Elizabeth Peralta, M.D.
Breast Surgeon
Sutter Pacific Medical Group of the
Redwoods
Breast Complaints
•
•
•
•
Pain
Mass
Skin or Nipple Changes
Nipple Discharge
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
Mammary ductogram demonstrating lobules
Pre-menarchal ductule
Terminal ductallobular unit
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
Normal breast in
pregnancy and
after
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 perimenopause and with HRT
• Hyperplasia with atypia and DCIS peak in
this period
Involutional and
cystic change
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
Biopsy results which represent
increased breast cancer risk:
• Atypical Ductal Hyperplasia (ADH)
• Atypical Lobular Hyperplasia (ALH)
• Lobular Carcinoma in Situ (LCIS)
Biopsy results which do not show
breast cancer risk:
• Cysts
• Fibrosis
Breast Cancer Risk
Major Risk Factors (RR > 4)
•Previous breast cancer
•Family history (bilateral, premenopausal or
mother and sister)
•Atypical hyperplasia
•LCIS or DCIS
L
Breast Imaging Reporting and Data System (BI-RADS)
Category
Definition
Action
PPVmalignancy
2
Benign findings
3
Probably benign
findings
Suspicious
abnormality
Highly suggestive of
malignancy
Additional
imaging
Routine
screening
Routine
screening
6 mo follow-up
15%
1
Incomplete, possible
finding
Negative
Biopsy
30-45%
Biopsy, action
as indicated
93%
0
4
5
<1%
<1%
2%
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?
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!
Evaluation of a Breast Mass
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
Mammogram of palpable breast mass
Sonogram of simple cyst
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
Mammogram of palpable breast mass
Sonogram of fibroadenoma
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
Breast Pain and Erythema
Sonogram of breast abscess
Non-lactational breast abscess:
• The median age at presentation was 40yr (range 2271). 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, chisquare test of independence).
• Ten of the 19 required surgical drainage and one of
these revealed carcinoma associated with the
abscess, necessitating mastectomy.
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
Nipple Discharge
• 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
Evaluation of Nipple Discharge
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•
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•
•
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
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
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)