1. BREAST DISEASE (Lecture # 80085)‏
Tory Davis, PA-C
Mercy Hospital Physician Extender Program

2. 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)

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. Non-cyclic pain
Incidence: 10% of women 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

10. 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/ F) and chills
Usually unilateral

11. 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

12. 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!

13. 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

14. Nipple Discharge
History to obtain: Onset, duration, color, consistency, odor, amount, associated symptoms, medications
Incidence:
% 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

15. 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

16. 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

17. 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

18. 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?

19. 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

20. 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)‏

21. 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.

22. 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

23. 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.

24. 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

25. 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

26. 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

27. 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

28. 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.

29. 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

30. 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

31. 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

32. 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

33. Comprises 10% of all breast masses

34. 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

35. 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

36. 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.

37. 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

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

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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