Breast disorders2 8-11

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Information about Breast disorders2 8-11

Published on September 16, 2015

Author: Ajode

Source: slideshare.net

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.  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

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

5.  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

6.  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

7.  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

8.  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

9. 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.  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

11.  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

12.  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

13.  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

14.  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

15.  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

16.  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

17.  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

18.  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

19.  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

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

21.  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

22.  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

23.  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.

24.  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

25. Breast Ultrasound

26. Fibroadenoma Breast Cancer Mammogram

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

28.  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

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

30.  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

31.  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

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 (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).

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