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)


  • Mammograms at 40 y.o.; especially >50 y.o. –> every 1-2 years
  • Physical exam yearly (breast exam, LN, hepatosplenomegaly)





Same as breast ca

Pre menopause

Risk for invasive ca

Same place

Either breast





Calcifications, mass


Risk Factors

  • Increasing age
  • Family history
  • Precursor lesions
  • Early menarche
  • Late menopause
  • Nulliparity or late first child
  • Radiation exposure


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


  • 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


  • Idiopathic
  • Drugs (THC, TCA, spironolactone)
  • Klinefelter’s (XXY)
  • Testicular feminization

Breast Physical Exam


  • 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)


  • 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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