Breast Disease

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BREAST DISEASE
(Lecture # 80085)
Tory Davis, PA-C
Mercy Hospital Physician
Extender Program
Breast Anatomy

Breast profile:
A: ducts
B: lobules
C: dilated section of
duct to hold milk
D: nipple
E: fat
F: pectoralis major
muscle
G: chest wall/rib cage
Enlargement:
A: normal duct cells
B: basement
membrane
C: lumen (center of
duct)
Benign Breast Disease
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Very commonly encountered in primary care
practice
Benign breast symptoms and findings occur
in approximately 50% of women
15 million office visits/yr
>90% visits for breast sx result in benign
findings, but breast cancer can mimic
benign disease, so prudent approach is to
always exclude cancer
– subtext, anyone?
CYA
Protect your patients, protect yourself
 Always have cancer on your ddx, and
always rule it out
 If unsure, you must refer
 Breast disease is an extremely litigious
area
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Breast History
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Duration of symptoms
Relation of sx to menstrual period
Presence/type of pain
Nipple discharge
Skin changes
Meds/drugs
Last MMG
PMHX or FHx breast cancer
Mastalgia/Mastodynia

Only recently defined as a medical
problem
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Incidence: 60% presented with
complaint to breast clinic, but only
3.4% sought medical treatment.
– So how would the provider know?
Cyclic Breast Pain
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Associated with FCBC, PMS
Usually benign
Worsens in luteal phase
– When is that?
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May be unilateral or bilateral
UOQ most common site
– What else is common in UOQ?
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Hormonal influence
Cyclic Breast Pain
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Evaluation: Thorough history and physical
exam. Optimal time - days 7-9 after LNMP
(why?)
– If no obvious abnormalities noted, obtain 2
month breast pain calendar to verify cyclic
nature.

Treatment options: Reassurance and
mechanical support (well fitted bras),
diuretics, low fat diet, evening primrose oil,
oral contraceptives, thyroid hormone, and
NSAIDs
Non-cyclic pain
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Incidence: 10% of women 30-40 years of
age with severe breast pain
Cause: More likely to be non-hormonal;
(post- surgical, musculoskeletal, trauma,
infection, cancer)
Symptoms: “burning” pain, “aching”, “sore”
Physical Exam: 7-10% have underlying
carcinoma
Mastitis
Definition: Inflammation of the breast
tissue usually occurring during
lactation
 Incidence: 7%-10%, usually firsttimers
 Symptoms: Severe breast
tenderness, induration, erythema,
heat, and swelling of the breast, with
fever (38-40C/101-103F) and chills

– Usually unilateral
Mastitis
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Causes:
– failure to empty breasts completely of
milk at each nursing,
– pathogens (usually from the baby’s
mouth) gaining entrance into the milk
ducts through a crack or fissure in the
nipple
– lowered resistance in the mother due to
stress, fatigue, and inadequate nutrition
Mastitis Treatment
Bed rest

Antibiotics that cover resistant S.
Aureus (eg. dicloxacilllin)
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Pain relievers, increased fluid intake,
and ice or moist heat applications
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Continue to nurse!
Breast abscess
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…If tenderness and erythema of mastitis
persist after antibiotic therapy, the presence
of an abscess should be suspected
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Findings: Usually singular and multilocular
abscess seen on ultrasound
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Treatment: Incision and drainage or
aspiration
Nipple Discharge
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History to obtain: Onset, duration, color,
consistency, odor, amount, associated
symptoms, medications
Incidence:
– 10 - 50% of women with benign breast disease
– 3% of women with breast cancer
– 7% of breast surgeries are for nipple discharge
Galactorrhea
Definition: non-puerperal secretion of
milk
Symptoms:
 1.
Spontaneous or expressible milky
discharge from nipple
 2. May have headache, menstrual
irregularities, infection, osteoporosis,
hirsutism
Galactorrhea
Usually multiple ducts bilaterally.
 Verify that it is milk microscopically by
identifying multiple fat droplets under
low magnification
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Galactorrhea
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Idiopathic: 1/3 of all cases
Drug Induced: Important to review all
current medications and then check for
possible side effects.
Pituitary Adenoma: galactorrhea,
hyperprolactinema, and amenorrhea
– Treatment: Bromocriptine
– Measure effectiveness by return of
menses and normal prolactin level
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Surgical resection if unresponsive to medications
Other Nipple discharge
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Incidence: 9% of women with benign
breast disease
Types: watery 33%; sanguinous 27%;
serosanguinous 13%; serous 6%
Physical findings: source and type of
discharge important, as is presence or
absence of masses.
One or several ducts?
– If only 1 duct, 4xRR cancer
– How do you figure that out?
Nipple Discharge
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Physical Findings:
– Technique: press index finger around
periphery of areola to locate affected
quadrant
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Differential diagnosis of palpable
mass and nipple discharge:
Intraductal papilloma, severe
fibrocystic breast changes, mammary
duct ectasia, cancer
Intraductal Papilloma
Definition: Benign breast mass
varying in size from microscopic to 2-3
mm in diameter
 Incidence: Accounts for 75% of all
non-puerperal pathological nipple
discharge
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– Usually occurs in later reproductive years
(30-50 years old)
Intraductal Papilloma
Symptoms: Spontaneous nipple
discharge from a single duct opening
 May be clear, serous, serosanguinous,
bloody or turbid
 Mass usually < .5 cm and located
within 1 cm of areola
 Findings: Soft non-tender mass in
subareolar area.
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Intraductal papilloma
Mammogram: Dilated duct with or
without a mass. May have benign
micro-calcifications in mass.
 Treatment: Surgical excision needed
for definitive diagnosis and treatment
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Duct Ectasia
Definition: Dilation of duct system in
areolar terminal ducts, often with
surrounding inflammation
 Incidence: 20-25% perimenopausal
women
 Etiology: Unclear sequence of events

– Chicken or egg? Infections leading to
metaplasia or metaplasia leading to
obstruction and later infection
Duct Ectasia
Symptoms: Spontaneous dark green
nipple discharge from multiple duct
openings with or without mass
 Findings: Tender dilated ducts may be
palpable
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– In more advanced cases, may find
palpable tumor which is firm, rounded,
relatively fixed with skin retractions
Duct Ectasia Dx/Tx
Mammogram and ultrasound
appropriate
 Fine Needle Aspiration (FNA) for
definitive diagnosis
 Conservative treatment may improve
symptoms, but recurrent disease
usually requires excision.
 Antibiotic use is not helpful
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If pt presents with a
breast LUMP, you
should ask…
Length of time present, come and go,
relationship to menses
 Tenderness or pain (characterize),
dimpling, change in contour
 Changes in lump
 Associated symptoms
 Medications
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Breast Lumps
More than 90% of all breast lumps are
discovered by women themselves.
 The majority of all breast lumps are
benign.
 BUT…about one women in eight
(12%) will develop breast cancer
sometime in her life.
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– You need to make sure you don’t miss it
Fibrocystic Breast
Changes (FCBC)
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FCBC: catch-all term for benign mastalgia,
lumps, cysts
Definition: Enhanced reaction of breast
tissue to cyclic production of ovarian
hormones
Breasts are nodular, dense, and tender to
palpation
– 50% of women have irregular breasts on
palpation.
FCBC stats
10% of <22 y/o
 25% of reproductive aged adults
 50% of perimenopausal women
 Most common in women with early
menarche, 1st live birth after age 30, or
nulliparous women
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FCBC
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Symptoms: Bilateral pain and tenderness,
possible lump which worsens
premenstrually. Occasional nipple
discharge. Symptoms may be localized or
even non-painful and be unrelated to
menstrual cycle.
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Findings: Poorly defined thickness or
palpable lumpiness. May have dominant
cystic mass.
FCBC Tx
Reassurance about benign nature
Supportive bra
Mild diuretics: 2-3 days/cycle
Dietary modifications: Decrease
caffeine (including chocolate)
Meds: oral contraceptives, danazol,
tamoxifen, bromocriptine
FCBC
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Surgical Treatments:
– Cyst aspiration
– Biopsy of suspicious lesions
– NB: Even in a breast with FCBC, not all masses
are benign…
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Malignant transformation:
– no evidence of progression or increased risk
Comprises 10% of all breast masses
Fibroadenoma
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Definition: Benign, firm, fully mobile solid
breast mass averaging 2.5 cm in diameter.
Incidence: Most common benign
breast mass. Most <30 y/o
Juvenile form very common in black
women
Fibroadenoma
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Symptoms: Painless mass which might
increase in size with menses
Findings: Firm, mobile, smooth or lobulated
non tender dominant mass
Mammogram and Ultrasound appropriate
– FNA: Benign findings
– Treatment: Conservative management
for asymptomatic lesions. Excisional
biopsy for large or enlarging lesions
Lipoma
Definition: you tell me! 
 Incidence: Mean age: 45
 Symptoms: Soft, painless mass
 Findings: Soft, nontender dominant
mass with moderate mobility usually in
or near skin around areola. May feel
more fibrous than lipoma in other body
sites.
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Breast Cancer
1 in 8 women
 Usually involves glandular cells in
ducts or lobules
 MC pres: asymptomatic lump found
by BSE, CBE or MMG
 2nd leading cause of cancer death in
women (#1 is what?)
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Breast Cancer
Lump: non-tender, firm, with poorly
delineated margins.
 Mammogram: calcifications
 Most common locations UOQ (45%)
and under nipple/areola (25%).
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Breast Cancer Risks
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Breast cancer in first-degree relative
(what is that?) doubles to triples the
risk
– 2 first degree relatives  6xRR
– BUT…90% of women with breast cancer
have no family history
Nulliparity or first full-term pregnancy
>35
 Early menarche and late menopause
 Previous breast or endometrial ca
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Patients with
Increased Risk
Need to identify and screen these
patients carefully
 Routine PE and mammography of
asymptomatic patients
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– Breast self-exam monthly over age 20
 Some
groups not recommending
– Clinical breast exam every 3 years
between 20 and 39 years, annually over
40 years
– Mammogram annually starts at age 40-50
Genetic testing
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BRCA1 AND BRCA 2 genetic
mutations
– Increased risk for breast, ovarian, colon,
prostate, and pancreatic cancers
– 5-10% of women with breast cancer may
have these mutations.
– If a pt has these mutations, risk of
developing breast cancer between 40
and 85%
– No established guidelines for testing or tx
S/Sx of Advanced Cancer
Palpable nodes (where?)
 Nipple retraction
 Dimpling of the skin (peau d’orange)
 Ulceration or redness of skin
 Fixation to the chest wall
 Edema of the ipsilateral arm
 Signs of distant mets: weight loss,
jaundice, bone pain, cough
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Other Types of Breast
Cancer
Paget’s disease: 1% of all breast
cancers, first symptoms often itching or
burning of nipple with superficial erosion
or ulceration; eczematous changes of
nipple and areola; palpable mass in
60% of cases
 Inflammatory carcinoma: less than 5%
of all cases; diffuse, brawny induration
of the skin, no mass; most aggressive
form; often confused w/mastitis
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If You Suspect Breast
Cancer
Refer to surgeon or breast specialist
for work-up
 Mammography is never a substitute for
biopsy. Must have tissue dx.
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– FNA or stereotactic needle bx are
simplest
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Most definitive dx by open bx under
local anesthesia
Treatment
 Multidisciplinary
team approach
and individualized treatment
 Modified radical mastectomy vs.
breast conservation therapy
 Chemotherapy and hormonal
therapy
 Radiation usually only palliative
 Attention to the REST of your
patient
FACTS WORTH
REPEATING:
More than 90% of all breast lumps
are discovered by women
themselves.
 The majority of all breast lumps are
benign.
 About one women in eight (12%) will
develop breast cancer sometime in her
life.
 90% of women with breast cancer have
no family history
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