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
G: chest wall/rib cage
A: normal duct cells
B: basement
C: lumen (center of
Benign Breast Disease
Very commonly encountered in primary care
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?
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
Breast History
Duration of symptoms
Relation of sx to menstrual period
Presence/type of pain
Nipple discharge
Skin changes
Last MMG
PMHX or FHx breast cancer
Only recently defined as a medical
Incidence: 60% presented with
complaint to breast clinic, but only
3.4% sought medical treatment.
– So how would the provider know?
Cyclic Breast Pain
Associated with FCBC, PMS
Usually benign
Worsens in luteal phase
– When is that?
May be unilateral or bilateral
UOQ most common site
– What else is common in UOQ?
Hormonal influence
Cyclic Breast Pain
Evaluation: Thorough history and physical
exam. Optimal time - days 7-9 after LNMP
– If no obvious abnormalities noted, obtain 2
month breast pain calendar to verify cyclic
Treatment options: Reassurance and
mechanical support (well fitted bras),
diuretics, low fat diet, evening primrose oil,
oral contraceptives, thyroid hormone, and
Non-cyclic pain
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
Definition: Inflammation of the breast
tissue usually occurring during
 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
– 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
– lowered resistance in the mother due to
stress, fatigue, and inadequate nutrition
Mastitis Treatment
Bed rest
Antibiotics that cover resistant S.
Aureus (eg. dicloxacilllin)
Pain relievers, increased fluid intake,
and ice or moist heat applications
Continue to nurse!
Breast abscess
…If tenderness and erythema of mastitis
persist after antibiotic therapy, the presence
of an abscess should be suspected
Findings: Usually singular and multilocular
abscess seen on ultrasound
Treatment: Incision and drainage or
Nipple Discharge
History to obtain: Onset, duration, color,
consistency, odor, amount, associated
symptoms, medications
– 10 - 50% of women with benign breast disease
– 3% of women with breast cancer
– 7% of breast surgeries are for nipple discharge
Definition: non-puerperal secretion of
 1.
Spontaneous or expressible milky
discharge from nipple
 2. May have headache, menstrual
irregularities, infection, osteoporosis,
Usually multiple ducts bilaterally.
 Verify that it is milk microscopically by
identifying multiple fat droplets under
low magnification
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
Surgical resection if unresponsive to medications
Other Nipple discharge
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
Physical Findings:
– Technique: press index finger around
periphery of areola to locate affected
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
– 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.
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
Duct Ectasia
Definition: Dilation of duct system in
areolar terminal ducts, often with
surrounding inflammation
 Incidence: 20-25% perimenopausal
 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
– In more advanced cases, may find
palpable tumor which is firm, rounded,
relatively fixed with skin retractions
Duct Ectasia Dx/Tx
Mammogram and ultrasound
 Fine Needle Aspiration (FNA) for
definitive diagnosis
 Conservative treatment may improve
symptoms, but recurrent disease
usually requires excision.
 Antibiotic use is not helpful
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
Breast Lumps
More than 90% of all breast lumps are
discovered by women themselves.
 The majority of all breast lumps are
 BUT…about one women in eight
(12%) will develop breast cancer
sometime in her life.
– You need to make sure you don’t miss it
Fibrocystic Breast
Changes (FCBC)
FCBC: catch-all term for benign mastalgia,
lumps, cysts
Definition: Enhanced reaction of breast
tissue to cyclic production of ovarian
Breasts are nodular, dense, and tender to
– 50% of women have irregular breasts on
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
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.
Findings: Poorly defined thickness or
palpable lumpiness. May have dominant
cystic mass.
Reassurance about benign nature
Supportive bra
Mild diuretics: 2-3 days/cycle
Dietary modifications: Decrease
caffeine (including chocolate)
Meds: oral contraceptives, danazol,
tamoxifen, bromocriptine
Surgical Treatments:
– Cyst aspiration
– Biopsy of suspicious lesions
– NB: Even in a breast with FCBC, not all masses
are benign…
Malignant transformation:
– no evidence of progression or increased risk
Comprises 10% of all breast masses
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
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
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
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?)
Breast Cancer
Lump: non-tender, firm, with poorly
delineated margins.
 Mammogram: calcifications
 Most common locations UOQ (45%)
and under nipple/areola (25%).
Breast Cancer Risks
Breast cancer in first-degree relative
(what is that?) doubles to triples the
– 2 first degree relatives  6xRR
– BUT…90% of women with breast cancer
have no family history
Nulliparity or first full-term pregnancy
 Early menarche and late menopause
 Previous breast or endometrial ca
Patients with
Increased Risk
Need to identify and screen these
patients carefully
 Routine PE and mammography of
asymptomatic patients
– 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
BRCA1 AND BRCA 2 genetic
– 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
Other Types of Breast
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
If You Suspect Breast
Refer to surgeon or breast specialist
for work-up
 Mammography is never a substitute for
biopsy. Must have tissue dx.
– FNA or stereotactic needle bx are
Most definitive dx by open bx under
local anesthesia
 Multidisciplinary
team approach
and individualized treatment
 Modified radical mastectomy vs.
breast conservation therapy
 Chemotherapy and hormonal
 Radiation usually only palliative
 Attention to the REST of your
More than 90% of all breast lumps
are discovered by women
 The majority of all breast lumps are
 About one women in eight (12%) will
develop breast cancer sometime in her
 90% of women with breast cancer have
no family history

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