Sutter Pacific Medical Group of the Redwoods 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 ductal-lobular 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 peri-menopause 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 This is a typical spiculated density representing cancer as seen on mammogram

This is an example of clustered microcalcifications associated with ductal carcinoma in situ (DCIS)

But in young women and any woman with breasts as dense as these, there may be not radiologic finding associated with a complaint.

Breast Imaging Reporting and Data System (BI-RADS) Category Definition Action PPVmalignancy Incomplete, possible finding Additional imaging 15% 1 Negative Routine screening <1% 2 Benign findings 3 Probably benign findings 6 mo follow-up 2% 4 Suspicious abnormality Biopsy 30-45% 5 Highly suggestive of malignancy Biopsy, action as indicated 93%

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 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.

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 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 Twenty years of hormone replacement therapy increases breast cancer risk by 27%, so a woman goes from a lifetime risk of 1/8 to 1/6. This means that although HRT is not out of the question, after 5-10 years the indication for continuing it should be reevaluated and an attempt at weaning off slowly (reduce by 1 pill per week over 1-2 months). 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)