An approach to… BREAST DISEASE
- History – ask about previous mammograms and biopsies
- Bloody D/C? intraductal papilloma, ductal ectasia, cancer
Differential diagnosis
- Benign
- Fibroadenoma < 30 y.o.
- Fibrocystic change > 30 y.o. (response to cyclical hormone changes; +/- mastodynia; decrease caffeine, NSAIDs, vit E, Danazol)
- Intraductal papilloma (bloody D/C)
- Mastitis
- Abscess (lactating women, S. aureus, FNAB +/- incision and drainage à r/o inflammatory cancer)
- Mondor’s disease – thrombophlebitis of breast veins
- Galactocele
- Lipoma
- Cystosarcoma phyllodes – mesenchymal tumor of lobular tissue
- Fat necrosis
- Capsular contracture (implants)
- Malignant
- DCIS (histologically most aggressive is Comedo), carcinoma develops in same breast– Invasive ductal carcinoma
- LCIS, risk of developing cancer in either breast
- Paget’s – infiltrating ductal carcinoma with nipple involvement
- Inflammatory carcinoma – rapid growth, pain, red, warm, edema, metastasizes early, invades the subdermal lymphatics, need a skin biopsy b/c subdermal, rarely curable (chemoTx)
Screening
- Mammograms at 40 y.o.; especially >50 y.o. à every 1-2 years
- Physical exam yearly (breast exam, LN, hepatosplenomegaly)
|
DCIS |
LCIS |
Age |
Same as breast ca |
Pre menopause |
Risk for invasive ca |
Same place |
Either breast |
Palpable |
Yes |
No |
Mammogram |
Calcifications, mass |
None |
Risk Factors
- Increasing age
- FHx
- Precursor lesions
- Early menarche
- Late menopause
- Nulliparity or late first child
- Radiation
Diagnosis
- Mammography
- FNA
- Ultrasound (cystic)
- Core biopsy
- Excision biopsy
Staging
- Bilateral mammogram
- CXR
- Bone scan, alk phos, calcium
- CT abdomen, LFTs
Treatment options
- Segmental lumpectomy with RT
- MRM with LN dissection
- RT (LN>4, chest wall involvement)
- Chemo (LN, young – taxotere, adriamycin, cyclophosphamide, 5-FU)
- Hormonal (Tamoxifen)
- Herceptin (Her-2nu positive)
Nipple discharge
- Milky - milk
- Serious brown green gray – fibrocystic changes
- Bloody blood-tinged serious – benign intraductal papilloma, cancer
- Treatment: milky, bilateral (check prolactin level, bitemporal hemianopsia, amenorrhea, lactation); bloody (excisional Bx of draining duct)
- 10% of non-bloody discharge is cancer
Gynecomastia
- Idiopathic
- Drugs (THC, TCA, spironolactone)
- Klinefelter’s (XXY)
- Testicular feminization
- Liver failure
Physical Exam
Inspection:
Talk to patient, reassure, warn it will be uncomfortable, but necessary
Undrape
Hands on hips (symmetry, contour, nipple retraction, skin changes)
Hands above head (skin changes, symmetry, contour, nipple retraction)
Palpation:
Sitting – axillary nodes, supra and infraclavicular nodes
Laying down – start with normal breast, axillary tail of Spence, transverse lines across breast, nipple
Hepatosplenomegaly
