Benign Breast Disorders Valerie Swiatkowski, MD Medical Student Lecture Introduction ‡ 16% of women ages 40-69 will seek advice from their physician regarding breast complaints over 10 years ‡ Failure to diagnose breast cancer is a leading cause of malpractice claims ‡ 90% of patients will have benign disease Objectives ‡ At the end of this lecture, you will know: „ „ „ „ „ Clinical breast exam Evaluation of a breast mass Major causes of benign breast disease Evaluation of nipple discharge Management of abnormal mammography Scenario NM is a 31 y/o G1P1001 who presents annual w/o Her friendfor was just exam diagnosed complaints with breast cancer She wants to know if you will order a mammogram for her… What are the screening guidelines? Screening Guidelines by Age ‡ Age 20 - 35 „ „ ‡ Age 35 - 40 „ ‡ Baseline mammography Age 40 - 50 „ ‡ Breast self-exam once a month Physical Exam Yearly Mammography every one to two years Age 50 + „ Mammography yearly Breast Self Exam Timing Premenopausal: one week after onset of menstruation Postmenopausal: the same day each month Breast Self Exam NM is grateful for your time and teaching You counsel her that you will see her in a year… Scenario Your next patient, FC, is a 22 y/o Go comes in with a new right breast mass… What you do? ‡ Tell FC that cancer is rare in young women and she shouldn’t worry about it… ‡ Order mammogram now ‡ Refer to a breast specialist ‡ Talk to FC and get more history How you start the evaluation? History and Physical What you ask? Remember the OPQRSTAA History Specifics Spontaneous or Provoked ‡ Unilateral or Bilateral ‡ Quality of discharge ‡ PMH ‡ Meds ‡ LMP ‡ Pregnancy History/Breastfeeding History ‡ Physical Activity ‡ Physical Exam will usually confirm your working dx DE tells you she has noticed that has bilateral white discharge that is spontaneous Her LMP was months ago She has no medical problems and is not taking any meds Further Workup? ‡ Physical Exam always is first „ „ „ ‡ What you next? „ ‡ Evaluate discharge on white background Microscopy of discharge Hemoccult Depends on the type of discharge What you think she has? Galactorrhea Spontaneous Milky Discharge ‡ Causes ‡ „ „ „ „ ‡ Hypothyroidism Hyperprolactinemia Physiologic Medication Effect Workup for Galactorrhea „ „ PRL TSH What if the discharge has color? ‡ Duct Ectasia „ „ „ „ ‡ Spontaneous Green/Black Discharge Bilateral Self Limited Median age 43 Fibrocystic Changes „ „ Greenish Benign What if the discharge has color? ‡ Bloody Discharge „ „ „ ‡ May appear green or black Hemoccult all discharge Usually unilateral Requires additional evaluation „ „ „ (Refer to a breast specialist) Ductogram Possible Surgical exploration Intraductal Papilloma ‡ ‡ ‡ ‡ Most common cause of bloody nipple discharge Monotonous array of papillary cells Often diagnosed by ductography Referral to breast specialist nec You explain to DE that she needs to start a workup for galactorrhea… She will return to the office for her lab results Scenario BR is a 51 y/o G5P3023 who presented for annual exam w/o complaints Screening mammography came back BIRADS What is BIRADS? Breast Imaging Reporting and Data System ‡ Classification from BIRADS to ‡ Mammography 10% of palpable tumors are not seen by mammography ‡ Stereotactic FNA is possible for nonpalpable lesions ‡ Ultrasound can be used in conjunction to determine cystic vs solid ‡ Conclusions Most patients presenting with breast related complaints will have benign conditions ‡ Primary care physicians should be equipt with the knowledge to perform the appropriate workup with referral as necessary ‡ History and physical exam is essential for proper evaluation of breast complaints ‡ Any Questions? Thank you!! Differential Diagnosis of Breast ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Fibrocystic Changes/Cyst Fibroadenoma Galactocele Ductal Ectasia Intraductal Papilloma Lipoma Mongor’s disease Granuloma Hamartoma Neurofibroma ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Mastitis Fat Necrosis Ductal hyperplasia Lobular hyperplasia Sclerosing adenosis Diffuse papillomatosis Complex fibroadenoma Radial scars Cancer [...]... the lump has changed in size? ‡ Does the lump wax and wane in size? ‡ Any risk factors for breast cancer? ‡ Risk Factors for Breast Cancer Age ‡ Age at Menarche ‡ Age at first birth ‡ Age at Menopause ‡ Parity/ breastfeeding history ‡ History of breast biopsy ‡ History of Atypical Hyperplasia ‡ Family history of Breast Cancer ‡ BRCA1/2 positive ‡ Scenario 2 (cont) FC tells you she has noticed this mass... women and she shouldn’t worry about it… ‡ Order mammogram now ‡ Refer to a breast specialist ‡ ‡ Talk to FC and get more history What information do you want to know? Key Points in her History The precise location of the lump ‡ How it was first noted (accidentally, by breast ‡ self-examination, or during a screening clinical breast examination or mammogram) How long has she noted its presence? ‡ Any... what is the differential diagnosis? General Categories of Breast Disease Physiologic ‡ Nodularity ‡ Mastalgia ‡ Dominant Lumps ‡ Nipple Discharge ‡ Infections and Inflammation ‡ General Categories of Breast Disease Physiologic ‡ Nodularity ‡ Mastalgia ‡ ‡Dominant Lumps Nipple Discharge ‡ Infections and Inflammation ‡ Differential Diagnosis of Breast Masses ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Macrocysts Fibrocystic Changes... Differential Diagnosis of Breast Masses ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Macrocysts Fibrocystic Changes/Cyst Fibroadenoma Galactocele Lipoma Mongor’s disease Granuloma Hamartoma Neurofibroma ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Mastitis Fat Necrosis Ductal hyperplasia Lobular hyperplasia Sclerosing adenosis Diffuse papillomatosis Complex fibroadenoma Radial scars Cancer Fibroadenoma ‡ ‡ ‡ Most common benign solid tumor of the breast Present in... need to know from physical exam? Physical Exam ‡ ‡ ‡ ‡ ‡ Delineate and document breast masses Elicit discharge from the nipple Identify localized areas of tenderness Detect enlarged lymph nodes Detect skin changes: „ „ „ „ „ „ Asymmetry Skin retraction Dimpling Edema Erythema Ulceration Scenario 2 (cont) During your clinical breast exam you palpate a mass in the right upper outer quadrant 1 cm, firm,... discharge? ‡ Normal Breast Secretions „ „ ‡ Lactation Galactorrhea Abnormal Discharge „ „ „ „ „ Intraductal Papilloma Fibrocystic Changes Ductal Ectasia DCIS Paget’s Disease How do you start the evaluation? History and Physical What do you ask? Remember the OPQRSTAA History Specifics Spontaneous or Provoked ‡ Unilateral or Bilateral ‡ Quality of discharge ‡ PMH ‡ Meds ‡ LMP ‡ Pregnancy History/Breastfeeding ... ‡ At the end of this lecture, you will know: „ „ „ „ „ Clinical breast exam Evaluation of a breast mass Major causes of benign breast disease Evaluation of nipple discharge Management of abnormal... Any risk factors for breast cancer? ‡ Risk Factors for Breast Cancer Age ‡ Age at Menarche ‡ Age at first birth ‡ Age at Menopause ‡ Parity/ breastfeeding history ‡ History of breast biopsy ‡ History... from their physician regarding breast complaints over 10 years ‡ Failure to diagnose breast cancer is a leading cause of malpractice claims ‡ 90% of patients will have benign disease Objectives ‡