Disorders of the BreastUNC School of Medicine

Obstetrics and Gynecology ClerkshipCase Based Seminar Series

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

Primarily adipose tissue, glandular tissue, and suspensory ligaments

Composed of 15-25 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

Breast Anatomy

Breast Anatomy

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

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

Evaluation: History

Risk Factors vs. Protective Factors

Evaluation: History

Risk Factors Protective 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

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

Evaluation: Physical Exam

Clinical Breast Exam:

Evaluation: Physical Exam

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

Position the patient in the direction of palpation for the CBE.

Sanslow, D, et. al. Clinical breast examination” practical recommendations for optimizing performance and reporting. CA Cancer J Clin. 2004 Nov-Dec; 54(6): 327-44

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

Benign Nonproliferative

Fibrocystic changes Simple cysts Lactational adenoma Fibroadenoma

Hyperplasia without atypia Epithelial hyperplasia Sclerosing adenosis Intraductal papillomas

Hyperplasia with atypia LCIS DCIS

Breast Disease

Malignant Ductal carcinoma Lobular carcinoma Tubular carcinoma Mucinous carcinoma Micropapillary carcinoma Metaplastic carcinoma Inflammatory carcinoma

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

Mastalgia: Incidence

Differential Diagnosis: 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

Mastalgia: Etiology

History Unilateral vs. bilateral Cyclic vs. noncyclic Systemic or local symptoms (e.g. erythema, fever) History of trauma

Clinical breast exam

Evaluation Ultrasound Mammogram

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

Mastalgia: Evaluation

Fibrocystic disease Premenopausal women Premenstrual breast swelling/tenderness Nodules/masses/lumps related to dense breast tissue or cysts

Mastalgia: Fibrocystic Disease

Fibrous tissue Cystically dilated ducts + Calcifications + Ductal hyperplasia

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

Mastalgia: Management

Presentation 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

Mastalgia: Mastitis

Inflammatory breast cancer

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

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

Breast Mass: Etiology

History How it was discovered Duration Change in size Location Relationship of mass to menstrual cycles

Clinical breast exam

Breast Mass: Evaluation

Fibroadenoma Solitary, firm, rubbery, mobile mass Women < 30 yrs Slow growing (? hormonally mediated)

Breast Mass: Fibroadenoma

Fibroadenoma gross specimen Firm, tan, lobulated Well circumscribed mass Variable size

Intraductal papilloma Unilateral bloody nipple discharge Sub-areolar intraductal mass

Breast Mass: Intraductal Papilloma

Intraductal papillary neoplasm with fibrovascular cores lined by benign ductal and myoepithelial cells

Duct excision

Fat Necrosis Caused by trauma Tender, firm mass with indistinct borders May appear suspicious on physical exam Benign breast calcification seen on mammography

Breast Mass: Fat Necrosis

Fat necrosis manifesting as a spiculated mass

Densely calcified 3-cm area of fat necrosis 2 years after blunt trauma to the breast.

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

Breast Mass: Evaluation

Breast Ultrasound

Fibroadenoma

Breast Cancer

Mammogram

Etiology Lactation Physiologic nipple discharge

Hyperprolactinemia Hypothyroidism Medication related Neurogenic stimulation

Pathologic Intraductal papilloma Ductal ectasia DCIS

Nipple Discharge: Etiology

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

Nipple Discharge: Evaluation

Initial evaluation: Breast ultrasound Mammogram

IF woman > 30 yrs Multiductal discharge

UPT, Prolactin, TSH

Further evaluation: Ductography Ductoscopy MRI

Nipple Discharge: Evaluation

Ductogram

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

Nipple Discharge: Management

Pathologic finding on CNB or excision biopsy DCIS/LCIS Invasive carcinoma

Refer to surgical oncologist

Treatment modalities: Radiation Chemotherapy Lumpectomy Mastectomy Hormonal therapy

Malignant Breast Disease

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.

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 (p283-294).

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 (p326-331).