1. Sutter Pacific Medical Group of the Redwoods
Benign Breast Disease
Elizabeth Peralta, M.D.
Breast Surgeon
Sutter Pacific Medical Group of the Redwoods

2. Breast Complaints
Pain
Mass
Skin or Nipple Changes
Nipple Discharge

3. 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

4. Mammary ductogram demonstrating lobules

5. Pre-menarchal ductule
Terminal ductal-lobular unit

6. 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

7. Normal breast in
pregnancy and
after

8. 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

9. Involutional and
cystic change

10. 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

11. Biopsy results which represent increased breast cancer risk:
Atypical Ductal Hyperplasia (ADH)
Atypical Lobular Hyperplasia (ALH)
Lobular Carcinoma in Situ (LCIS)

12. Biopsy results which do not show breast cancer risk:
Cysts
Fibrosis

13. Breast Cancer Risk Major Risk Factors (RR > 4)
Previous breast cancer
Family history (bilateral, premenopausal or mother and sister)
Atypical hyperplasia
LCIS or DCIS

16. L
This is a typical spiculated density representing cancer as seen on mammogram

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

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

19. 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%

20. 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?

21. 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!

22. Evaluation of a Breast Mass

24. 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

25. Mammogram of palpable breast mass

26. Sonogram of simple cyst

27. 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

28. Mammogram of palpable breast mass

29. Sonogram of fibroadenoma

30. 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

31. Breast Pain and Erythema

32. Sonogram of breast abscess

34. 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.

35. 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

36. 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

37. 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

38. 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

39. 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)