1. Disorders of the Breast
UNC School of Medicine
Obstetrics and Gynecology Clerkship
Case Based Seminar Series

2. Objectives for Disorders of the Breast
Describe the symptoms and physical examination findings of benign or malignant conditions of the breast
Demonstrate the performance of a clinical breast examination
Discuss the steps in evaluation of common breast complaints: mastalgia, mass, nipple discharge
Discuss the initial management options for benign and malignant conditions of the breast

3. Breast Anatomy
Primarily adipose tissue, glandular tissue, and suspensory ligaments
Composed of radially arranged lobes of parenchyma, each associated with a major lactiferous duct
Each major duct extends from the nipple to terminate in a “terminal duct-lobular unit” via branching ducts of diminishing caliber

4. Breast Anatomy
Ruan, W, Kleinberg, DL. Endocrinology 1999; 140:5075. Copyright © 1999 The Endocrine Society.

5. Evaluation: History History:
Change in general appearance of breast (size, symmetry)
New or persistent skin changes
New nipple inversion
Breast pain (cyclic vs. noncyclic, duration, location in breast)
Breast mass (how it was discovered, duration, change in size, location)
Relationship of mass to menstrual cycles
Nipple discharge (unilateral vs. bilateral, color)
Medications (e.g. hormones)
Risk factors for breast cancer

6. Evaluation: History Risk Factors vs. Protective Factors Risk Factors
BRCA1 and BRCA2
Breastfeeding
1˚ relative with breast or ovarian cancer
Parity
Personal history of breast disease
Recreational exercise
Age > 70 yrs
Postmenopause BMI < 23
Age at menarche < 12 yrs
Oophorectomy at < 35 yrs
Nulliparous or age at first birth > 30 yrs
Aspirin
Never breastfed
Age at menopause > 55 yrs
Use of OCP’s
HRT (estrogen + progestin)
Radiation exposure to chest
EtOH

7. Evaluation: Physical Exam
Clinical Breast Exam:
Inspect (relaxed, arms raised, hands on hips)
Breast symmetry
Skin changes (dimpling, retraction, edema, ulceration)
Nipples (symmetry, inversion/retraction, discharge)
Palapation (breasts, axillae, entire chest wall)
Pain
Masses
Regional lymph nodes (Axillary and Supraclavicular)
Documentation
“Clock” system
Location of concern and abnormality
Distance from areola
Size of mass

8. Evaluation: Physical Exam
Clinical Breast Exam:
Position the patient in the direction of palpation for the CBE.
Use pads of the index, third, and fourth fingers (inset) make small circular motions
Make three circles with the finger pads, increasing the level of pressure (subcutaneous, mid-level, and down to the chest wall) with each circle
Sanslow, D, et. al. Clinical breast examination” practical recommendations for optimizing performance and reporting. CA Cancer J Clin Nov-Dec; 54(6):

9. Benign Characteristics Malignant Characteristics
Benign vs. Malignant
Chief Complaint
Benign Characteristics
Malignant Characteristics
Breast mass
Multiple lesions
Single lesion
“Rubbery”
Hard
Mobile
Immovable
Well circumscribed border
Irregular borders
Nipple discharge
Bilateral
Unilateral
Multiductal
Uniductal
Milky
Bloody, Clear, or Colored
Spontaneous
Persistent
Skin changes
Retraction
Dimpling
Thickening

10. Breast Disease Benign Malignant Nonproliferative
Fibrocystic changes
Simple cysts
Lactational adenoma
Fibroadenoma
Hyperplasia without atypia
Epithelial hyperplasia
Sclerosing adenosis
Intraductal papillomas
Hyperplasia with atypia
LCIS
DCIS
Malignant
Ductal carcinoma
Lobular carcinoma
Tubular carcinoma
Mucinous carcinoma
Micropapillary carcinoma
Metaplastic carcinoma
Inflammatory carcinoma

11. Mastalgia: Incidence
Approximately 45% of women have mild breast pain, and 21% have severe breast pain in their lifetime
Breast cancer is found in 1.2 – 6.7% of women presenting with breast pain

12. Mastalgia: Etiology Differential Diagnosis: Cyclic Non-cyclic
Cyclic mastalgia
Fibrocystic disease
Non-cyclic
Large pendulous breasts
Diet, lifestyle
Mastitis
Hormone replacement therapy
Ductal ectasia
Inflammatory breast cancer
Extramammary (non-breast) pain

13. Mastalgia: Evaluation
History
Unilateral vs. bilateral
Cyclic vs. noncyclic
Systemic or local symptoms (e.g. erythema, fever)
History of trauma
Clinical breast exam
Evaluation
Ultrasound
Mammogram

14. Mastalgia: Evaluation
Cyclic mastalgia
Normal hormonal changes
Particularly luteal phase of menstrual cycle
Fibrocystic disease
Increased fibrous or cystic tissue
Pendulous breasts
Stretching of Cooper’s ligaments

15. Mastalgia: Fibrocystic Disease
Premenopausal women
Premenstrual breast swelling/tenderness
Nodules/masses/lumps related to dense breast tissue or cysts
Fibrous tissue
Cystically dilated ducts
+ Calcifications
+ Ductal hyperplasia

16. Mastalgia: Management
Treatment:
Lifestyle
Eliminate caffeine
Low fat diet
Symptomatic
Support garments (well-fitting, supportive bra, sports bra)
Compresses
Medication
NSAID’s
OCP’s, Progestogens
Danazol
Bromocriptine
GnRH agonists
Tamoxifen - IF severe mastalgia

17. Mastalgia: Mastitis Presentation Treatment
Usually seen in breastfeeding mothers
Unilateral, swollen, wedge-shaped area of breast
Pain, redness, induration (hardening)
Systemic symptoms (high fever, malaise, chills)
Treatment
Rest, fluids
Dicloxicllin 500mg QID x 10-14d
Continue frequent breast feeding

18. Mastalgia: Inflammatory Breast Cancer
Peau d’orange-dimpling of involved skin due to retraction caused by lymphatic involvement and obstruction
Associated erythema
Cellulitis may mimic inflammatory carcinoma

19. Breast Mass: Etiology
More than 90% of palpable breast masses in women in their 20’s to early 50’s are benign
Differential Diagnosis:
Fibrocystic changes
Fibroadenoma
Fat necrosis
Phyllodes tumor
Intraductal papilloma
Breast cancer

20. Breast Mass: Evaluation
History
How it was discovered
Duration
Change in size
Location
Relationship of mass to menstrual cycles
Clinical breast exam

21. Breast Mass: Fibroadenoma
Solitary, firm, rubbery, mobile mass
Women < 30 yrs
Slow growing (? hormonally mediated)
Fibroadenoma gross specimen
Firm, tan, lobulated
Well circumscribed mass
Variable size

22. Breast Mass: Intraductal Papilloma
Unilateral bloody nipple discharge
Sub-areolar intraductal mass
Duct excision
Intraductal papillary neoplasm with fibrovascular cores lined by benign ductal and myoepithelial cells

23. Breast Mass: Fat Necrosis
Caused by trauma
Tender, firm mass with indistinct borders
May appear suspicious on physical exam
Benign breast calcification seen on mammography
Fat necrosis manifesting as a spiculated mass
Densely calcified 3-cm area of fat necrosis 2 years after blunt trauma to the breast.

24. Breast Mass: Evaluation
Initial evaluation
< 30 yr – Diagnostic ultrasound + Diagnostic mammogram
> 30 yr – Diagnostic mammogram
Further evaluation
Simple cyst
Symptomatic – Aspirate
Asymptomatic – Observe for 2-4 months
Complicated cyst – Ultrasound-guided aspiration
Solid mass – Core needle biopsy (CNB) or Excision
No specific findings – Re-examine after two cycles

25. Breast Ultrasound

26. Mammogram
Breast Cancer
Fibroadenoma

27. Nipple Discharge: Etiology
Lactation
Physiologic nipple discharge
Hyperprolactinemia
Hypothyroidism
Medication related
Neurogenic stimulation
Pathologic
Intraductal papilloma
Ductal ectasia
DCIS

28. Nipple Discharge: Evaluation
History
Unilateral vs. bilateral
Spontaneous vs. provoked discharge
Appearance of discharge
Medications (e.g. antipsychotics, antidepressants)
History of trauma
History of amenorrhea
History of hypogonadism (e.g. hot flashes, vaginal dryness)
Clinical breast exam
Attempt to elicit discharge, identify involved duct(s)
Evaluate discharge for gross blood or guaiac positivity

29. Nipple Discharge: Evaluation
Initial evaluation:
Breast ultrasound
Mammogram
IF woman > 30 yrs
Multiductal discharge
UPT, Prolactin, TSH
Further evaluation:
Ductography
Ductoscopy
MRI
Ductogram

30. Nipple Discharge: Management
Physiologic nipple discharge
Directed at underlying cause
Pathologic nipple discharge
Refer to surgeon
Terminal duct excision
Central (total) terminal duct excision
Resection of intraductal papilloma

31. Malignant Breast Disease
Pathologic finding on CNB or excision biopsy
DCIS/LCIS
Invasive carcinoma
Refer to surgical oncologist
Treatment modalities:
Radiation
Chemotherapy
Lumpectomy
Mastectomy
Hormonal therapy

32. Bottom Line Concepts
It is important to evaluate breast complaints thoroughly to ensure that breast cancers, as well as benign breast lesions, are diagnosed and treated promptly.
Evaluation of a woman presenting with a breast complaints requires careful assessment of symptoms and risk factors for developing breast cancer.
The clinical breast exam include inspection and palpation of the breast tissue, chest wall, and regional lymph nodes. Documentation should included both positive and negative findings.
Women with breast problems can present with any combination of symptoms including breast mass or thickening, breast pain, nipple discharge, or skin changes.
Typically, women presenting with a suspicious breast mass who are > 30 yrs should receive a diagnostic mammogram, whereas women younger than 30 should receive a diagnostic ultrasound.
Negative imaging should not stop further investigation is a suspicious lump is felt on clinical exam.
Masses that are solid on ultrasound imaging require biopsy to exclude cancer and provide a histological diagnosis.

33. References and Resources
APGO Medical Student Educational Objectives, 9th edition, (2009), Educational Topic 40 (p84-85).
Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010), Charles RB Beckmann, Frank W Ling, Barabara M Barzansky, William NP Herbert, Douglas W Laube, Roger P Smith. Chapter 31 (p ).
Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and Gynecology, 5th edition (2009), Neville F Hacker, Joseph C Gambone, Calvin J Hobel. Chapter 29 (p ).