Breast Disease

  • History – ask about previous mammograms and biopsies
  • Bloody discharge? 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, vitamin E, Danazol)
    • Intraductal papilloma (bloody discharge)
    • Mastitis
    • Abscess (lactating women, S. aureus, FNAB +/- incision and drainage –> rule out  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 because subdermal, rarely curable (chemotherapy)

Screening

  • Mammograms at 40 y.o.; especially >50 y.o. –> 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
  • Family history
  • Precursor lesions
  • Early menarche
  • Late menopause
  • Nulliparity or late first child
  • Radiation exposure

Diagnosis

  • Mammography
  • Fine needle aspiration 
  • Ultrasound (cystic)
  • Core biopsy
  • Excision biopsy

Staging

  • Bilateral mammogram
  • Chest x-ray
  • Bone scan, alk phos, calcium
  • CT or ultrasound of the abdomen, LFTs

Treatment options

  • Segmental lumpectomy with RT
  • Modified radical mastectomy with lymph node dissection
  • RT (LN>4, chest wall involvement)
  • Chemo (LN, young – taxotere, adriamycin, cyclophosphamide, 5-FU)
  • Hormonal — If ER/PR positive (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

Breast 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

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