Benign Breast Disease

Elizabeth Peralta, M.D.

Breast Surgeon

Sutter Pacific Medical Group of the Redwoods

Breast Complaints

• Pain

• Mass

• Skin or Nipple Changes

• Nipple Discharge

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

Mammary ductogram demonstrating lobules

Pre-menarchal ductule

Terminal ductal-lobular unit

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

Normal breast inpregnancy and after

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

Involutional and cystic change

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

Biopsy results which represent increased breast cancer risk:

• Atypical Ductal Hyperplasia (ADH)

• Atypical Lobular Hyperplasia (ALH)

• Lobular Carcinoma in Situ (LCIS)

Biopsy results which do not show breast cancer risk:

• Cysts

• Fibrosis

Breast Cancer Risk

Major Risk Factors (RR > 4)•Previous breast cancer

•Family history (bilateral, premenopausal or mother and sister)

•Atypical hyperplasia

•LCIS or DCIS

L

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%

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?

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!

Evaluation of a Breast Mass

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

Mammogram of palpable breast mass

Sonogram of simple cyst

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

Mammogram of palpable breast mass

Sonogram of fibroadenoma

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

Breast Pain and Erythema

Sonogram of breast abscess

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.

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

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

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

Hormone Replacement Therapy and

Breast Cancer Risk Years ofHormoneTreatment

20 yr cumulative breastcancer rate /1000 women

None

5

20

45

10

47

51

57

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)