- 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