Pathology & Presentation of Benign Breast Disease Zdenek ...
Benign Breast Disease
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Transcript of Benign Breast Disease
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Benign Breast Disease
Elizabeth Peralta, M.D.
Breast Surgeon
Sutter Pacific Medical Group of the Redwoods
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Breast Complaints
• Pain
• Mass
• Skin or Nipple Changes
• Nipple Discharge
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Diagnosis and Treatment of Breast Complaints
• Most important is to rule out malignancy
• Significance of a finding is greatest in a high-risk patient
• Balance between reassurance and exhausting all diagnostic options
• Treatment should not be worse than the disease
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Mammary ductogram demonstrating lobules
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Pre-menarchal ductule
Terminal ductal-lobular unit
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Breast Development
Menarche and Reproductive Cycles:• Pulsed estrogen exposure causes rapid
growth, elongation and branching• Term pregnancy leads to terminal
differentiation and stops growth• End bud epithelial tissue undergoes cyclic
proliferation • Breast feeding is associated with a lower risk
of breast cancer
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Normal breast inpregnancy and after
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Breast Development
• Involution: Changes of involution begin after cessation of lactation and continue through menopause
• Competing involution and proliferative processes are patchy and increased in peri-menopause and with HRT
• Hyperplasia with atypia and DCIS peak in this period
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Involutional and cystic change
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Pre-Cancer Changes
• Intraepithelial neoplasia (IEN): a lesion which is non-invasive but contains genetic abnormalities, loss of cellular control functions, and some microscopic features of cancer cells
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Biopsy results which represent increased breast cancer risk:
• Atypical Ductal Hyperplasia (ADH)
• Atypical Lobular Hyperplasia (ALH)
• Lobular Carcinoma in Situ (LCIS)
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Biopsy results which do not show breast cancer risk:
• Cysts
• Fibrosis
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Breast Cancer Risk
Major Risk Factors (RR > 4)•Previous breast cancer
•Family history (bilateral, premenopausal or mother and sister)
•Atypical hyperplasia
•LCIS or DCIS
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L
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Breast Imaging Reporting and Data System (BI-RADS)
Category Definition Action PPVmalignancy
0 Incomplete, possible finding
Additional imaging
15%
1 Negative Routine screening
<1%
2 Benign findings Routine screening
<1%
3 Probably benign findings
6 mo follow-up 2%
4 Suspicious abnormality
Biopsy 30-45%
5 Highly suggestive of malignancy
Biopsy, action as indicated
93%
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Causes of Breast Pain
• Endocrine: Cyclical, peri-menopausal, and with hormone replacement therapy
• Edema/weight (caffeine, lack of support)
• Mastitis (term usually associated with lactational problems)
• Breast Abscess
• Angina, esophagitis
• Costochondritis, fibromyalgia, anxiety?
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Treatment of Breast Pain• Elastic/compressive bra (sport or minimizer style rather
than underwire or push-up)• NSAIDS (topical?) Omega-3 fatty acids (evening primrose
oil)• Decrease or stop hormone replacement• Danazol, gestrinone, tamoxifen may help but cause hot
flashes and masculinizing effects • 50% spontaneous remission, therefore, vitamin E, b
complex, evening primrose oil, decreasing caffeine seem to help half the time!
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Evaluation of a Breast Mass
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Case 1: Palpable breast mass
• 36 y/o woman with cyclical breast tenderness
• Noticed a new mass 2 days ago
• Very anxious because a cousin had breast cancer at age 36
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Mammogram of palpable breast mass
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Sonogram of simple cyst
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Case 2: Palpable breast mass
• 42 y/o woman, “I always have lumpy breasts” found a new lump
• Onset 3 months ago, not changing
• Moderate cyclical breast pain
• Lump is in upper outer quadrant, firm, but very mobile
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Mammogram of palpable breast mass
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Sonogram of fibroadenoma
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Case 3: Breast Redness and Pain
• 55 y/o woman, heavy smoker
• Onset of breast pain 4 days ago
• Gradually worsening, with accompanying mass and erythema
• Not participating in mammographic screening
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Breast Pain and Erythema
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Sonogram of breast abscess
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Non-lactational breast abscess:
• The median age at presentation was 40yr (range 22-71). Among cases, 17 of 19 (89%) were smokers with a mean exposure of 24.4 pk-yr each.
• In the control group, 9 of 42 (21%) were smokers with a mean exposure of 17.7 pk-yr each (p=0.001, chi-square test of independence).
• Ten of the 19 required surgical drainage and one of these revealed carcinoma associated with the abscess, necessitating mastectomy.
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Conclusions: Smoking and Breast Abscesses
• Subareolar abscess is strongly associated with cigarette smoking, with the average patient presenting at age 40 after smoking more than 20 years.
• Aspiration and antibiotics, the preferred treatment for lactational abscess, had less than a 50% success rate in this population.
• Carcinoma must be ruled out in both surgically and conservatively managed patients.
• Smokers who present with subareolar abscess should be urged to quit for this and other health reasons
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Nipple Discharge
• Spontaneous• Unilateral, single
orifice• Clear or blood-tinged• Progresses over time• DDX: Duct ectasia,
intraductal papilloma, DICS
• 10% malignant
• Elicited, intermittent• Multiple ducts,
bilateral• Green, murky, white• May stop if abstain
from manipulation• Biopsy if abnormal
imaging or progressive• Same DDX
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Evaluation of Nipple Discharge
• History• Prolactin, TSH if suspect galactorrhea• Mammogram, ultrasound• Ductogram optional• Surgical consultation, Mammary duct
excision is diagnostic and stops discharge• Vacuum assisted core needle biopsy may
also stop the discharge
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Hormone Replacement Therapy and
Breast Cancer Risk Years ofHormoneTreatment
20 yr cumulative breastcancer rate /1000 women
None
5
20
45
10
47
51
57
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Cancer Prevention
• Quit smoking: More women die of lung cancer than breast cancer
• Maintain a healthy balance of exercise, recreation, rest, and weight control
• Chemoprevention: for women at increased risk (family history, abnormal biopsy)