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1、BREAST DISEASE(Lecture#80085),Tory Davis,PA-CMercy Hospital Physician Extender Program,Breast Anatomy,Breast profile:A:ducts B:lobules C:dilated section of duct to hold milkD:nipple E:fat F:pectoralis major muscle G:chest wall/rib cage Enlargement:A:normal duct cells B:basement membrane C:lumen(cent
2、er of duct),Benign Breast Disease,Very commonly encountered in primary care practiceBenign breast symptoms and findings occur in approximately 50%of women15 million office visits/yr90%visits for breast sx result in benign findings,but breast cancer can mimic benign disease,so prudent approach is to
3、always exclude cancersubtext,anyone?,CYA,Protect your patients,protect yourselfAlways have cancer on your ddx,and always rule it outIf unsure,you must referBreast disease is an extremely litigious area,Breast History,Duration of symptomsRelation of sx to menstrual periodPresence/type of painNipple d
4、ischargeSkin changesMeds/drugsLast MMGPMHX or FHx breast cancer,Mastalgia/Mastodynia,Only recently defined as a medical problemIncidence:60%presented with complaint to breast clinic,but only 3.4%sought medical treatment.So how would the provider know?,Cyclic Breast Pain,Associated with FCBC,PMSUsual
5、ly benignWorsens in luteal phaseWhen is that?May be unilateral or bilateralUOQ most common siteWhat else is common in UOQ?Hormonal influence,Cyclic Breast Pain,Evaluation:Thorough history and physical exam.Optimal time-days 7-9 after LNMP(why?)If no obvious abnormalities noted,obtain 2 month breast
6、pain calendar to verify cyclic nature.Treatment options:Reassurance and mechanical support(well fitted bras),diuretics,low fat diet,evening primrose oil,oral contraceptives,thyroid hormone,and NSAIDs,Non-cyclic pain,Incidence:10%of women 30-40 years of age with severe breast painCause:More likely to
7、 be non-hormonal;(post-surgical,musculoskeletal,trauma,infection,cancer)Symptoms:“burning”pain,“aching”,“sore”Physical Exam:7-10%have underlying carcinoma,Mastitis,Definition:Inflammation of the breast tissue usually occurring during lactationIncidence:7%-10%,usually first-timersSymptoms:Severe brea
8、st tenderness,induration,erythema,heat,and swelling of the breast,with fever(38-40C/101-103F)and chillsUsually unilateral,Mastitis,Causes:failure to empty breasts completely of milk at each nursing,pathogens(usually from the babys mouth)gaining entrance into the milk ducts through a crack or fissure
9、 in the nipple lowered resistance in the mother due to stress,fatigue,and inadequate nutrition,Mastitis Treatment,Bed restAntibiotics that cover resistant S.Aureus(eg.dicloxacilllin)Pain relievers,increased fluid intake,and ice or moist heat applicationsContinue to nurse!,Breast abscess,If tendernes
10、s and erythema of mastitis persist after antibiotic therapy,the presence of an abscess should be suspectedFindings:Usually singular and multilocular abscess seen on ultrasoundTreatment:Incision and drainage or aspiration,Nipple Discharge,History to obtain:Onset,duration,color,consistency,odor,amount
11、,associated symptoms,medicationsIncidence:10-50%of women with benign breast disease3%of women with breast cancer7%of breast surgeries are for nipple discharge,Galactorrhea,Definition:non-puerperal secretion of milkSymptoms:1.Spontaneous or expressible milky discharge from nipple2.May have headache,m
12、enstrual irregularities,infection,osteoporosis,hirsutism,Galactorrhea,Usually multiple ducts bilaterally.Verify that it is milk microscopically by identifying multiple fat droplets under low magnification,Galactorrhea,Idiopathic:1/3 of all casesDrug Induced:Important to review all current medication
13、s and then check for possible side effects.Pituitary Adenoma:galactorrhea,hyperprolactinema,and amenorrhea Treatment:Bromocriptine Measure effectiveness by return of menses and normal prolactin levelSurgical resection if unresponsive to medications,Other Nipple discharge,Incidence:9%of women with be
14、nign breast diseaseTypes:watery 33%;sanguinous 27%;serosanguinous 13%;serous 6%Physical findings:source and type of discharge important,as is presence or absence of masses.One or several ducts?If only 1 duct,4xRR cancerHow do you figure that out?,Nipple Discharge,Physical Findings:Technique:press in
15、dex finger around periphery of areola to locate affected quadrant Differential diagnosis of palpable mass and nipple discharge:Intraductal papilloma,severe fibrocystic breast changes,mammary duct ectasia,cancer,Intraductal Papilloma,Definition:Benign breast mass varying in size from microscopic to 2
16、-3 mm in diameterIncidence:Accounts for 75%of all non-puerperal pathological nipple dischargeUsually occurs in later reproductive years(30-50 years old),Intraductal Papilloma,Symptoms:Spontaneous nipple discharge from a single duct opening May be clear,serous,serosanguinous,bloody or turbidMass usua
17、lly.5 cm and located within 1 cm of areolaFindings:Soft non-tender mass in subareolar area.,Intraductal papilloma,Mammogram:Dilated duct with or without a mass.May have benign micro-calcifications in mass.Treatment:Surgical excision needed for definitive diagnosis and treatment,Duct Ectasia,Definiti
18、on:Dilation of duct system in areolar terminal ducts,often with surrounding inflammationIncidence:20-25%perimenopausal womenEtiology:Unclear sequence of eventsChicken or egg?Infections leading to metaplasia or metaplasia leading to obstruction and later infection,Duct Ectasia,Symptoms:Spontaneous da
19、rk green nipple discharge from multiple duct openings with or without massFindings:Tender dilated ducts may be palpableIn more advanced cases,may find palpable tumor which is firm,rounded,relatively fixed with skin retractions,Duct Ectasia Dx/Tx,Mammogram and ultrasound appropriateFine Needle Aspira
20、tion(FNA)for definitive diagnosisConservative treatment may improve symptoms,but recurrent disease usually requires excision.Antibiotic use is not helpful,If pt presents with a breast LUMP,you should ask,Length of time present,come and go,relationship to mensesTenderness or pain(characterize),dimpli
21、ng,change in contourChanges in lumpAssociated symptomsMedications,Breast Lumps,More than 90%of all breast lumps are discovered by women themselves.The majority of all breast lumps are benign.BUTabout one women in eight(12%)will develop breast cancer sometime in her life.You need to make sure you don
22、t miss it,Fibrocystic Breast Changes(FCBC),FCBC:catch-all term for benign mastalgia,lumps,cystsDefinition:Enhanced reaction of breast tissue to cyclic production of ovarian hormonesBreasts are nodular,dense,and tender to palpation50%of women have irregular breasts on palpation.,FCBC stats,10%of 22 y
23、/o 25%of reproductive aged adults50%of perimenopausal womenMost common in women with early menarche,1st live birth after age 30,or nulliparous women,FCBC,Symptoms:Bilateral pain and tenderness,possible lump which worsens premenstrually.Occasional nipple discharge.Symptoms may be localized or even no
24、n-painful and be unrelated to menstrual cycle.Findings:Poorly defined thickness or palpable lumpiness.May have dominant cystic mass.,FCBC Tx,Reassurance about benign natureSupportive braMild diuretics:2-3 days/cycleDietary modifications:Decrease caffeine(including chocolate)Meds:oral contraceptives,
25、danazol,tamoxifen,bromocriptine,FCBC,Surgical Treatments:Cyst aspiration Biopsy of suspicious lesions NB:Even in a breast with FCBC,not all masses are benignMalignant transformation:no evidence of progression or increased risk,Comprises 10%of all breast masses,Fibroadenoma,Definition:Benign,firm,ful
26、ly mobile solid breast mass averaging 2.5 cm in diameter.Incidence:Most common benign breast mass.Most 30 y/o Juvenile form very common in black women,Fibroadenoma,Symptoms:Painless mass which might increase in size with mensesFindings:Firm,mobile,smooth or lobulated non tender dominant massMammogra
27、m and Ultrasound appropriateFNA:Benign findingsTreatment:Conservative management for asymptomatic lesions.Excisional biopsy for large or enlarging lesions,Lipoma,Definition:you tell me!Incidence:Mean age:45Symptoms:Soft,painless massFindings:Soft,nontender dominant mass with moderate mobility usuall
28、y in or near skin around areola.May feel more fibrous than lipoma in other body sites.,Breast Cancer,1 in 8 womenUsually involves glandular cells in ducts or lobulesMC pres:asymptomatic lump found by BSE,CBE or MMG2nd leading cause of cancer death in women(#1 is what?),Breast Cancer,Lump:non-tender,
29、firm,with poorly delineated margins.Mammogram:calcificationsMost common locations UOQ(45%)and under nipple/areola(25%).,Breast Cancer Risks,Breast cancer in first-degree relative(what is that?)doubles to triples the risk2 first degree relatives 6xRRBUT90%of women with breast cancer have no family hi
30、storyNulliparity or first full-term pregnancy 35Early menarche and late menopausePrevious breast or endometrial ca,Patients with Increased Risk,Need to identify and screen these patients carefullyRoutine PE and mammography of asymptomatic patientsBreast self-exam monthly over age 20Some groups not r
31、ecommendingClinical breast exam every 3 years between 20 and 39 years,annually over 40 yearsMammogram annually starts at age 40-50recently,guidelines changed.Controversial.,Genetic testing,BRCA1 AND BRCA 2 genetic mutationsIncreased risk for breast,ovarian,colon,prostate,and pancreatic cancers5-10%o
32、f women with breast cancer may have these mutations.If a pt has these mutations,risk of developing breast cancer between 40 and 85%No established guidelines for testing or tx,S/Sx of Advanced Cancer,Palpable nodes(where?)Nipple retractionDimpling of the skin(peau dorange)Ulceration or redness of ski
33、nFixation to the chest wallEdema of the ipsilateral arm Signs of distant mets:weight loss,jaundice,bone pain,cough,Other Types of Breast Cancer,Pagets disease:1%of all breast cancers,first symptoms often itching or burning of nipple with superficial erosion or ulceration;eczematous changes of nipple
34、 and areola;palpable mass in 60%of casesInflammatory carcinoma:less than 5%of all cases;diffuse,brawny induration of the skin,no mass;most aggressive form;often confused w/mastitis,If You Suspect Breast Cancer,Refer to surgeon or breast specialist for work-upMammography is never a substitute for bio
35、psy.Must have tissue dx.FNA or stereotactic needle bx are simplestMost definitive dx by open bx under local anesthesia,Treatment,Multidisciplinary team approach and individualized treatment Modified radical mastectomy vs.breast conservation therapyChemotherapy and hormonal therapyRadiation usually o
36、nly palliativeAttention to the REST of your patient,FACTS WORTH REPEATING:,More than 90%of all breast lumps are discovered by women themselves.The majority of all breast lumps are benign.About one women in eight(12%)will develop breast cancer sometime in her life.90%of women with breast cancer have no family history,
