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  • Nathan Riley, MD

Obgyno Wino Podcast Episode 91 - Diagnosis and Management of Benign Breast Disorders

I've come to realize that the biggest problem anywhere in the world is that people's perceptions of reality are compulsively filtered through the screening mesh of what they want, and do not want, to be true." - Travis Walton


2018 Bordeaux Rosé from French Blue


PB #164, Published June 2016


Five Pearls

1. Fibroadenomas are the most common breast mass in pre-menopausal women

2. Nipple discharge is most likely benign if: bilateral, only present when expressed, milky or green in color, and multiductal

3. Cyclical breast pain is most likely due to hormonal fluctuations, such as those that come with ovulation, pregnancy, or hormonal contraception use.

4. Skin changes don't necessarily mean cancer, but cancer is more likely if skin is warm, erythematous, and edematous.

5. FNA and core needle biopsy are sufficient for most masses. Excisional biopsy is occasional needed when sample from FNA or core needle are insufficient or in circumstances in which these methods are impractical.


Source: Memorial Sloane Kettering

Benign breast masses

- three general categories: 1) nonproliferative, 2) profliferative without atypia ("fibrocystic changes"), and 3) atypical hyperplasia

- tubular adenomas and phyllodes tumors are also benign


Nonproliferative masses

- benign cysts

- found in 1/3 of women age 35-50

- can be microscopic (found on radiograph) or large enough to palpate

- nearly always benign if no internal septations or mural thickening

- only need to be aspirated/removed if bothersome to the patient

- it's not uncommon to see thickening of ductal epithelial cells that doesn't fill the duct

- you can also see focal thickening of the epithelial lining of an apocrine gland


Proliferative without atypia

- fibroadenomas are most common breast mass in adolescent girls (median age is 25)

- also 12% of all masses in menopausal women

- usually small, firm, well-circumscribed, and mobile

- composed of epithelial and stromal elements

- can be tough to distinguish from cysts on palpation or mammography (US is great, though!)

- fibroadenomas can be massive and progressively enlarging

- sclerosing adenosis: increased numbers or size of glandular components (as opposed to hyperplasia, which is merely an increase in epithelial cells lining the ducts)

- small-to-moderate risk of breast cancer in the future

- radial scars can be found incidentally on biopsy, and they are generally excised if found, as they may harbor some sneaky atypical cells

- intraductal papillomas: found within a lactiferous duct; can be solitary or in multiples and found centrally or peripherally

- central papillomas tend to butt up against ducts and, as such, can present with bloody, serous, or clear nipple discharge

- less frequently a palpable mass

- most commonly seen in women 30-50 years old, usually small (<1 cm), but they can be much larger

- can harbor atypical cells or ductal carcinoma in situ (DCIS), but usually not cancer

- if atypia is found on biopsy, excision is recommended (15-20% of women will have invasive or in situ carcinoma is diagnosed)

- women with multiple papillomas (tend to be peripheral when >1, so no nipple discharge), and coexisting or subsequent cancer is diagnosed in ~1/3 of these women


Atypical hyperplasia

-two main types: atypical ductal hyperplasia and atypical lobular hyperplasia

- usually an incidental finding on biopsy

- histology: ductal or lobular elements with uniform cells and loss of apical-basal cellular orientation

- independent risk factor for invasive cancer in either breast


Tubular adenomas

- histology: benign glandular cells w/ minimal stromal elements

- can be found as a palpable mass or on mammography (solid)

- some may be lactating, esp during pregnancy or postpartum (histologically identical to normal lactating tissue)


Phyllodes tumors

- uncommon fibroepithelial tumors, rare (0.5% of all breast masses)

- generally behave as benign tumors but on occasion can invade locally and only 5% metastasize (sarcoma!)

- median age at presentation is 40 years, usually as a single large mass

- can feel just like a fibroadenoma: firm, circumscribed, and mobile), though may be more rapidly growing

- solid mass on imaging

- excision is required (biopsy techniques generally not sufficient) w/ 1 cm margin to decrease likelihood of local recurrence


Lobular carcinoma in situ (LCIS)

- usually an incidental finding on breast mass biopsy

- unlike DCIS, LCIS is not a precursor lesion for breast cancer

- usually benign but is associated with future risk of breast cancer in either breast (10-20% risk of developing invasive ductal or invasive lobular cancer over the next 15 years)


Nipple discharge

- most likely benign if: bilateral, only present when expressed, milky or green in color, and multiductal

- bilateral milky discharge common in pregnancy and postpartum for up to one year after stopping breastfeeding

- galactorrhea outside of these scenarios is generally not malignant, but instead generally caused by excessive breast stimulation, endocrinopathies (e.g. hypothyroidism), prolactin-secreting adenomas, and anti-dopaminergic meds (e.g. anti-psychotics including metoclopramide)

The dermatomes (source: StatPearls)

Mastalgia

- super common, cause of ~50% of breast-related clinic visits in 40-69 year-olds

- cyclical pain is usually related to hormonal fluctuations (e.g. ovulation, pregnancy, or hormonal contraception)

- non-cyclical pain can be due to mastitis, cancer, thrombophlebitis of the lateral thoracic vein (aka Mondor disease), cysts, tumors, trauma, or medications (e.g. antidepressants, cardiac and anti-hypertensive meds, and anti-microbial agents)

- cancer-related pain is also more commonly: unilateral, intense, and progressive

- many women also report pain in their breast when in reality the pain is referred from an extramammary site: costochondritis (Tietze syndrome), rib fracture, chest wall trauma, fibromyalgia, cervical radiculopathy, herpes zoster (aka shingles), angina, or GERD

- imaging may be warranted for focal mastalgia not otherwise explained


Management of mastalgia

- assuming we've ruled out bad stuff...

- make sure bra fits appropriately

- reduce caffeine, salt, and fat intake

- topical evening primrose oil (or active ingredient gamma-linoleic acid)

- inflammatory meds and acetaminophen are great pharmacologic measures

- continuous COCs may work well for cyclical mastalgia

- postmenopausal women who develop mastalgia with HRT may see a resolution of pain with discontinuation of HRT or decrease in the estrogen dose

- for severe mastalgia, prescription meds may be warranted for 3-6 months

- danazole 100 mg BID has been shown to help with cyclical mastalgia

- downsides of danazole: androgenic effects and it's contraindicated in pregnancy or in women who are actively trying to get pregnant

- tamoxifen 10mg/day can also help with mastalgia

- bromocriptine 2.5 mg BID also helpful, but nausea and dizziness lead to high discontinuation rates


Skin changes

- eczema, psoriasis, and contact dermatitis can all be seen on the breast skin (treat as appropriate)

- skin folds under the breast susceptible to candida

- hydradenitis suppurativa can affect the axilla (treat with metronidazole or clindamycin)

- inflammatory breast cancer, Paget's, and other types of breast cancer can be associated with skin changes

Hydradenitis suppurativa

- more likely to be associated with cancer if the skin is edematous (peau d'orange), erythematous, and warm


Note: often mastitis presents like this, but if the mastitis doesn't respond to therapy, then you should evaluate for malignancy

Paget's disease of the breast

- Paget's: rare, nipple/areola affected, associated with DCIS and other invasive cancers

- often presents as a crusty or scaling ulcerated lesion

- nipple may be retracted or hyperpigmented

- often associated with burning or itching (inflamed!)

- skin with this appearance apart from nipple/areola should be concerning for other types of breast cancer

Inflammatory breast disorders

- infectious and non-infectious causes

- mastitis is the most common infectious cause

- nonpuerperal infections are managed differently based on location: periareolar ("periductal") or peripheral

- periductal infection is the common variety in younger women

- smoking is a major risk factor, and abscesses may form

- peripheral abscesses can occur spontaneously in immunocompromised women or after trauma (often difficult to identify cause)

- mammary duct ectasia : more common in smokers and older women; usually asymptomatic but notable as calcifications on mammography

- can also present as nipple discharge, nipple inversion, palpable subareolar mass, noncyclic mastalgia (managed conservatively)


Clinical examination

- check for skin changes, tenderness, breast symmetry, puckering, bulging, or palpable masses

- if she's complaining of nipple discharge try to express discharge systematically, squeezing the breast and pressing around the areola to compress individual ducts

- think of the breast as a clockface so that you can accurately describe location of mass, skin changes, or area that elicited discharge

- any suspicious findings should prompt imaging, biopsy, or both


Imaging

- US, mammography, or digital tomosynthesis (depends on patient's age, BI-RADS category, and degree of clinical suspicion)

- tissue diagnosis may also be warranted based on imaging findings

- simple cysts can generally be left alone (if not bothersome to patient)

- non-simple cyst features: internal septations or mural thickening

- non-simple features should prompt counseling around either close surveillance or aspiration

- if aspiration fluid is not bloody and the cyst doesn't recur, then no sweat...toss the fluid; commence routine surveillance

- if it's bloody or cyst doesn't resolve, then image-guided aspiration, core needle biopsy, or excision is recommended



Tissue diagnosis

- three techniques: fine-needle aspiration (FNA), core needle biopsy, or excisional biopsy

- FNA: 21-25 gauge needle used to extract cells for analysis; inexpensive and minimallyinvasive

- core needle biopsy: more tissue obtain but still minimally invasive (12-16 gauge needle); histologic analysis possible; guided by palpation or mammography ("stereotactic"), US, or MRI; another advantage is that you can leave a clip in place to mark the biopsy site!

- excisional biopsy: reserved for the rare instance in which location or imaging characteristics (or in the case of implants, perhaps) make it difficult to do FNA or core needle biopsy

- excisional biopsy may also be warranted if more tissue is needed after core need biopsy (e.g. atypical hyperplasia, flat epithelial atypia, LCIS, mucinous tumors, possible phyllodes tumors, and radial scars (esp if atypia present)






Note: If patient presents with complaint of a mass, but it's not palpable in the exam room, close clinical follow-up is recommended.


What if atypical hyperplasia is found on tissue biopsy?

- excision because DCIS or invasive cancer is found in up to 20% of cases

- surveillance then includes annual mammography, clinical breast exam every 6-12 mos, and breast self-awareness

- for women ≥ 30 years, annual MRI is reasonable

- risk reduction strategies also include: limiting alcohol intake, increasing physical activity, and medications such as tamoxifen (pre-menopausal), raloxifene (post-menopausal), or aromatase inhibitors (post-menopausal)


What if lobular carcinoma in-situ is found on tissue biopsy?

- surgical excision is recommended to rule out DCIS or invasive cancer if >4 ductal lobular units are involved

- surveillance includes annual screening mammography q6-12 mos starting at age 30

- breast awareness education is important along with lifestyle changes (same lifestyle changes as atypical hyperplasia should be adopted)

- reasonable to consider annual MRI

- prophylactic mastectomy reasonable


Nipple discharge workup:


How are inflammatory breast disorders managed?

- do a thorough exam

- treat mastitis if suspected to avoid abscess formation

- Staph aureus is most common in puerperal infections (but also Streptococcus, Staph epidermidis, Enterococcus, and anaerobes)

- Non-puerperal breast infections can be treated empirically with amoxicillin-clavulanic acid (Augmentin) or erythromycin and metronidazole if PCN-allergic

- if symptoms don't resolve from adequate antibiotic therapy, imaging should be performed to rule-out abscess or other pathology

- in the case of abscess, incision and drainage should be performed (antibiotics guided by culture)

- refer to breast specialist if any concerning signs for malignancy

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