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 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? Do not miss cancer, always suspect it

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

Breast History 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 8. Most do not have + fam hx

Mastalgia/Mastodynia Only recently defined as a medical problem Incidence: 60% presented with complaint to breast clinic, but only 3.4% sought medical treatment. So how would the provider know? 2. Need to ask

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: associated with FCBC, PMS Usually begins in 20s and worsens until menopause About 1/5 have spontaneous improvement. 3. From ovulation to menses (2nd half of cycle) 7

Cyclic Breast Pain 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 LNMP – from first day of last period. Won’t be in luteal phase, won’t be tender. Usually described as achy and sore 8

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 carcinoma

Mastitis Definition: Inflammation of the breast tissue usually occurring during lactation Incidence: 7%-10%, usually first-timers Symptoms: Severe breast tenderness, induration, erythema, heat, and swelling of the breast, with fever (38-40C/101-103F) and chills Usually unilateral

Mastitis 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)‏ 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 aspiration

Nipple Discharge 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 Onset = gradual or sudden Nipple retraction, breast lump or pain, skin changes Relationship to menses, other activities, recent injury Contraceptives, phenothiazines (antipsychotics, antiemetics), digitalis, diuretics, steroids

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 Can send to lab for staining to confirm with red dye that shows fat globules 16

Galactorrhea 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 quadrant 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 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 women Etiology: Unclear sequence of events Chicken or egg? Infections leading to metaplasia or metaplasia leading to obstruction and later infection Ectasia : Dilation or distention of a tubular structure.

Duct Ectasia Symptoms: Spontaneous dark green nipple discharge from multiple duct openings with or without mass Findings: Tender dilated ducts may be palpable 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

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 Size character (firm/soft, mobile/fixed), relationship to menses, nipple d/c or retraction, lymph nodes (tender or enlarged)‏ Age of menarche/menopause, age of first full-term pregnancy if any, number of full term deliveries, Personal or FH of breast, endometrial or ovarian ca Meds Esp. hormonal

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. 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 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 4. don’t get a break from estrogen

FCBC 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. Findings: Changes are usually diffusely bilateral but may be unilateral or even isolated in one area. 30

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 Reduction of caffeine – 65% reduction in symptoms (Minton et al)‏ 31

FCBC Surgical Treatments: Malignant transformation: 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

Fibroadenoma 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 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.

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?)‏ 4. lung ca

Breast Cancer Lump: non-tender, firm, with poorly delineated margins. Mammogram: calcifications Most common locations UOQ (45%) and under nipple/areola (25%). 38

Breast Cancer Risks 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 39

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 recently, guidelines changed. Controversial. Recommendations by Am. College of Radiology, American Cancer Society, and the American Medical Women’s Association No recommendation for a “baseline” before 40 Pts with 1st degree relative – 1st mammogram 5 years before age that relative was diagnosed. 40

Genetic testing 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 If have strong 1st degree relatives with breast cancer it might be beneficial. No established guidelines. Not screening tests

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 Nodes: axillary, supraclavicular 42

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

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. FNA or stereotactic needle bx are simplest Most definitive dx by open bx under local anesthesia 30% of lesions thought to be cancerous = benign and 15% of lesions thought to be benign = malignant Negative FNA should be followed by open bx; 10% of negative FNA are false- negatives Immunohistological staining for hormone and growth factor receptors 60-80 % of pts w/hormone receptor + tumors respond favorably to hormonal manipulation At the time of pathological confirmation, pts on HRT should be counseled to d/c tx 44

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 Replaces radical mastectomy. Involves removal of all breast tissue, pectoralis m. fascia (not muscle), and axillary lymph nodes. Better cosmetic and functional result – no difference in survival when compared to radical Lumpectomy, segmental mastectomy, partial mastectomy. No difference in survival for Stage I and II Polychemotherapy (> or = 2 agents) superior to single-agent tx. Tamoxifin x 5 years, ovarian ablation Radiation tx used only palliatively for locally advanced tumors with distant mets 45

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