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Lumps, Bumps, Leaking and PainManagement of Breast Conditions

Rebecca A. Jackson, MDProfessor Department of Obstetrics, Gynecology

and Reproductive SciencesUniversity of California, San Francisco

I HAVE NO DISCLOSURES

Plan

•Palpablebreastmass•Non‐Palpablebreastmass• Mastalgia• NippleDischarge

• Mastitis

•Palpablebreastmass•Non‐Palpablebreastmass• Mastalgia• NippleDischarge

• Mastitis

Gallup Poll: Leading Causes of Death in Women

Gallup Poll

Perceived

Actual

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Failure to diagnose breast cancer in a timely manner is a leading

cause of malpractice claims

Common reasons:

• Unimpressive 

physical findings

• Failure to f/u with pt

• Palpable mass with 

negative mammo

Common reasons:

• Unimpressive 

physical findings

• Failure to f/u with pt

• Palpable mass with 

negative mammo

Likelihood of Cancer in Dominant Breast Mass by Age

Of all discrete breast masses, about 10% are cancerous. (In contrast, 8% of abnormal mammos = cancer)

“Dominant Mass”?

• Discreteordominantmass=standsoutfromadjoiningbreasttissue,definableborders,ismeasurable,notbilateral.

• Nodularityorthickening=ill‐defined,oftenbilateral,fluctuateswithmenstrualcycle

• Inwomen<40referredformass,only1/3hadconfirmeddominantmass

Breast Mass: Diagnostic Options

• Physicalexam

• Ultrasound

• Mammogram

• Cystaspiration

• Fineneedleaspiration

• Coreneedlebiopsy

• Excisionalbiopsy

• Physicalexam

• Ultrasound

• Mammogram

• Cystaspiration

• Fineneedleaspiration

• Coreneedlebiopsy

• Excisionalbiopsy

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Question 1

A42yroldwomanwithnofamilyorpersonalhistoryofbreastcancerhasfoundabreastlump.Shedoesn’tknowhowlongithasbeenthere.Itisnotpainful.

Onexam,itisadiscretemass,2cm,relativelysmooth,mobileandnon‐tender.Shehasnoaxillarylymphadenopathy.

Whatisyournextstep?

A42yroldwomanwithnofamilyorpersonalhistoryofbreastcancerhasfoundabreastlump.Shedoesn’tknowhowlongithasbeenthere.Itisnotpainful.

Onexam,itisadiscretemass,2cm,relativelysmooth,mobileandnon‐tender.Shehasnoaxillarylymphadenopathy.

Whatisyournextstep?

Q1: Palpable mass in 42 yo

Nextstep(pickone)?

A. Nothingnow.Re‐examinein1‐2months

B. Ultrasound

C. Mammography

D. Officeaspiration

E. FNAB

F. Corebiopsy

Nextstep(pickone)?

A. Nothingnow.Re‐examinein1‐2months

B. Ultrasound

C. Mammography

D. Officeaspiration

E. FNAB

F. Corebiopsy

Q1b: Palpable mass in 42 yo

Amammographywaschosenandisnegative.Nextstep(pickone)?

A. Re‐examinein1‐2months

B. F/u1yearforannualexam

C. Ultrasound

D. Officeaspiration

E. FNAB

F. Corebiopsy

Amammographywaschosenandisnegative.Nextstep(pickone)?

A. Re‐examinein1‐2months

B. F/u1yearforannualexam

C. Ultrasound

D. Officeaspiration

E. FNAB

F. Corebiopsy

Q1c: Palpable mass in 42 yo

Anultrasoundwaschosenasthefirststep.Itshowsacysticmass.Nextstep?

A. Re‐examinein1‐2months

B. F/u1yearforannualexam

C. Officeaspiration

D. FNA

E. Corebiopsy

Anultrasoundwaschosenasthefirststep.Itshowsacysticmass.Nextstep?

A. Re‐examinein1‐2months

B. F/u1yearforannualexam

C. Officeaspiration

D. FNA

E. Corebiopsy

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Step 1: Palpable Breast Mass

• Determineifmassiscysticorsolid

• Simplecystsarebenignanddon’trequirefurtherevaluation

• 20‐25%ofpalpablemassesaresimplecysts,mostoccurringin40‐49yo’s

• Options?:Ultrasound,officeaspiration,FNA,coreneedlebiopsy

• Determineifmassiscysticorsolid

• Simplecystsarebenignanddon’trequirefurtherevaluation

• 20‐25%ofpalpablemassesaresimplecysts,mostoccurringin40‐49yo’s

• Options?:Ultrasound,officeaspiration,FNA,coreneedlebiopsy

Breast Exam

• Nethersensitive(50‐60%)norspecific(60‐90%)(evenwhendonebyexperts)

• Cannotreliablydistinguishcystfromsolid• Nonetheless,itisimportantfordeterminingifmassisdiscrete(vsnodularityorthickening),isanecessaryadjuncttomammogramandisrequiredforfollow‐upofmasses

• Performin2positions,methodical,spiralsorstrips

• Markmasspriortobiopsysootherscanfindit

• Nethersensitive(50‐60%)norspecific(60‐90%)(evenwhendonebyexperts)

• Cannotreliablydistinguishcystfromsolid• Nonetheless,itisimportantfordeterminingifmassisdiscrete(vsnodularityorthickening),isanecessaryadjuncttomammogramandisrequiredforfollow‐upofmasses

• Performin2positions,methodical,spiralsorstrips

• Markmasspriortobiopsysootherscanfindit

Ultrasound

• PrimaryUse:Classifymassascysticor

solid

• Guidanceforcystaspirationorbiopsy

• Adjuncttoevaluatesymmetricdensitiesdetectedbymammography

• Canbethefirsttestperformed&ifcystisconfirmed—theonlytestrequired

• PrimaryUse:Classifymassascysticor

solid

• Guidanceforcystaspirationorbiopsy

• Adjuncttoevaluatesymmetricdensitiesdetectedbymammography

• Canbethefirsttestperformed&ifcystisconfirmed—theonlytestrequired

Fibroadenoma Cancer

Well-circumscribed, superficial

Irregular, deep

Cyst

Anechoic, well-circumscribed,

Ultrasound is 98-100% accurate for diagnosis of simple cysts. However, for solid masses, it cannot reliably distinguish benign from malignant.

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Cyst Aspiration

• Simpleofficeprocedure:20‐23gaugeneedleandsyringe,ultrasoundguidanceoptional,specializedtrainingnotnecessary

• PrimaryUse:Confirmmassiscystic• Secondaryuse:Relievepain/pressureduetosymptomaticcyst

• Benefits:Ifcysticfluidobtained,establishesimmediatediagnosisandprovidessymptomaticrelief

• Simpleofficeprocedure:20‐23gaugeneedleandsyringe,ultrasoundguidanceoptional,specializedtrainingnotnecessary

• PrimaryUse:Confirmmassiscystic• Secondaryuse:Relievepain/pressureduetosymptomaticcyst

• Benefits:Ifcysticfluidobtained,establishesimmediatediagnosisandprovidessymptomaticrelief

Cyst Aspiration (cont’d)

Adequate/reassuringif:1.Cystfullycollapses(noresidualmass)

2.Fluidisnotbrown/red(cloudyok)

3.Doesnotre‐accumulate(i.e.frequentf/u)

• Ifallaretrue,noneedtosendfluid.

• F/uin1‐3monthstoensurenoreaccumulationorresidualmass

• Ifnofluidorifbloodyfurtherworkup

Adequate/reassuringif:1.Cystfullycollapses(noresidualmass)

2.Fluidisnotbrown/red(cloudyok)

3.Doesnotre‐accumulate(i.e.frequentf/u)

• Ifallaretrue,noneedtosendfluid.

• F/uin1‐3monthstoensurenoreaccumulationorresidualmass

• Ifnofluidorifbloodyfurtherworkup

Fine Needle Aspiration: QUIZ

• FNABshouldbedonebyanexperiencedcytopathologistorbreastsurgeon?….TRUEORFALSE?

• AdiagnosisofFATTYTISSUEonFNAmeanswhat?

• WhenshouldyouFOLLOW‐UPawomanwithapalpablemassandnegativeFNAandmammogram?

• FNABshouldbedonebyanexperiencedcytopathologistorbreastsurgeon?….TRUEORFALSE?

• AdiagnosisofFATTYTISSUEonFNAmeanswhat?

• WhenshouldyouFOLLOW‐UPawomanwithapalpablemassandnegativeFNAandmammogram?

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Fine Needle Aspiration Biopsy

• PrimaryUse:Diagnosisofsolidmasses• Leastinvasivebiopsymethod• Sensitivityisoperatordependent:

– Forexperiencedpersonnel,92‐98%– Foruntrainedpersonnel,75%Average(aslowas65%).

• Experiencedcytopathologistnecessarytointerpret• CannotdiagnoseDCIS,atypicalhyperplasiaorinfiltratingcarcinoma

• Anon‐diagnosticresultinthesettingofadiscretemassrequiresfurtherwork‐up(possiblesamplingerror)

• PrimaryUse:Diagnosisofsolidmasses• Leastinvasivebiopsymethod• Sensitivityisoperatordependent:

– Forexperiencedpersonnel,92‐98%– Foruntrainedpersonnel,75%Average(aslowas65%).

• Experiencedcytopathologistnecessarytointerpret• CannotdiagnoseDCIS,atypicalhyperplasiaorinfiltratingcarcinoma

• Anon‐diagnosticresultinthesettingofadiscretemassrequiresfurtherwork‐up(possiblesamplingerror)

Palpable mass: Diagnostic Mammography

• Cannotaccuratelydifferentiatebenignfrommalignantmassesorcysticfromsolid

• Poorsensitivityinyoungwomenduetodensity• 15‐20%ofmammosarenormal inwomenwithpalpablemass

• PrimaryUse:Screenoppositebreast(inwomen>40yo)andidentifyothernon‐palpablesuspiciousareas

• Secondaryuse:FurtherclassificationofthepalpablemassEVENIFTHEMAMMOISNORMAL,FURTHER

WORK‐UPISREQUIRED

• Cannotaccuratelydifferentiatebenignfrommalignantmassesorcysticfromsolid

• Poorsensitivityinyoungwomenduetodensity• 15‐20%ofmammosarenormal inwomenwithpalpablemass

• PrimaryUse:Screenoppositebreast(inwomen>40yo)andidentifyothernon‐palpablesuspiciousareas

• Secondaryuse:FurtherclassificationofthepalpablemassEVENIFTHEMAMMOISNORMAL,FURTHER

WORK‐UPISREQUIRED

Breast Cyst

Cyst is anechoic on ultrasound

Can’t distinguish cyst from solid on mammogram

Breast Density

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Spiculated mass

Small Cancer

Core Needle Biopsy• PrimaryUse:Diagnosisofsolidmasses,f/uofnon‐diagnosticFNAB

• UnlikeFNAB,itcandistinguishDCISfrominvasivediseaseandbecauseitisatissuespecimen,interpretationiseasier

• FewdirectcomparisonstoFNABforpalpablelesions:Studiesmixedforsensitivity‐someshowingFNAbetterandsomewithCNBbetter.Similarspecificity.

• PrimaryUse:Diagnosisofsolidmasses,f/uofnon‐diagnosticFNAB

• UnlikeFNAB,itcandistinguishDCISfrominvasivediseaseandbecauseitisatissuespecimen,interpretationiseasier

• FewdirectcomparisonstoFNABforpalpablelesions:Studiesmixedforsensitivity‐someshowingFNAbetterandsomewithCNBbetter.Similarspecificity.

Core Needle Biopsy (cont’d)

• Like FNAB, requires training to prevent false negatives due to sampling error

• Used instead of FNAB by consultant preference or where cytopathology service not skilled in interpretation

• Also preferred for evaluation of non‐palpable lesions

• Like FNAB, requires training to prevent false negatives due to sampling error

• Used instead of FNAB by consultant preference or where cytopathology service not skilled in interpretation

• Also preferred for evaluation of non‐palpable lesions

Question 1

A42yearoldwomanwithnofamilyorpersonalhistoryofbreastcancer hasfoundabreastlump.Shedoesn’tknowhowlongithasbeenthere.Itisnotpainful.

Onexam,itisadiscretemass,about2cm,relativelysmooth,mobileandnon‐tender.Shehasnoaxillarylymphadenopathy.

Whatisyournextstep?

A42yearoldwomanwithnofamilyorpersonalhistoryofbreastcancer hasfoundabreastlump.Shedoesn’tknowhowlongithasbeenthere.Itisnotpainful.

Onexam,itisadiscretemass,about2cm,relativelysmooth,mobileandnon‐tender.Shehasnoaxillarylymphadenopathy.

Whatisyournextstep?

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So, what is the best first step?• Firststep=determineifcysticorsolid.

• Howdependsonyourinstitution(availabilityandexpertiseofvariousservices)andwhetherpatientissymptomatic

• FNAB:Therapeutic,diagnosticandcost‐efficient

• U/S:SimilarincosttoFNAB,butFNABmorecosteffectiveb/c80%ofmassesareNOTcysticonU/SandwillrequireFNABtofurtherevaluate

• IfFNABnotavailable:U/Sfirstwilleliminateneedforcorebiopsyin20%thatdohavecysts

• Firststep=determineifcysticorsolid.

• Howdependsonyourinstitution(availabilityandexpertiseofvariousservices)andwhetherpatientissymptomatic

• FNAB:Therapeutic,diagnosticandcost‐efficient

• U/S:SimilarincosttoFNAB,butFNABmorecosteffectiveb/c80%ofmassesareNOTcysticonU/SandwillrequireFNABtofurtherevaluate

• IfFNABnotavailable:U/Sfirstwilleliminateneedforcorebiopsyin20%thatdohavecysts

So, what is the best first step?• Officeaspiration:Reasonable1st stepespifsymptomatic.Ifnotcystic,willrequirebiopsy

• Mammography: notbest1st stepb/ccan’treliablydistinguishbenignfrommalignantorcysticfromsolid(butisusuallypartofacompleteevaluation)

• F/U1‐2mos:Couldbeokinyoungwoman(<40)whowillreliablyfollow‐up.Discussoptions,getagreement,documentwell.Ifmasspersists,gotoU/SorFNA.

• Officeaspiration:Reasonable1st stepespifsymptomatic.Ifnotcystic,willrequirebiopsy

• Mammography: notbest1st stepb/ccan’treliablydistinguishbenignfrommalignantorcysticfromsolid(butisusuallypartofacompleteevaluation)

• F/U1‐2mos:Couldbeokinyoungwoman(<40)whowillreliablyfollow‐up.Discussoptions,getagreement,documentwell.Ifmasspersists,gotoU/SorFNA.

Triple test

• Improvedaccuracybycombining:

1.FNABorcorebiopsy2.Mammography(orultrasound)3.Physicalexam

• Whenall3resultsconcordant,99%accuracy

• However,PEaddslittleb/cnotspecific.Itsroleissimplytodocumentdominantpalpablemass

• Ifanyoneissuspicious,coreorexcisionalbiopsy

• Improvedaccuracybycombining:

1.FNABorcorebiopsy2.Mammography(orultrasound)3.Physicalexam

• Whenall3resultsconcordant,99%accuracy

• However,PEaddslittleb/cnotspecific.Itsroleissimplytodocumentdominantpalpablemass

• Ifanyoneissuspicious,coreorexcisionalbiopsy

Accuracy of triple test

Mass “benign “on Palpation

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Step 2: for a cystic mass…

• Ifsymptomatic,aspirate• Ifdiagnosedbyultrasoundandnoaspirationisdone,f/u1year.

• Ifaspiratedandfluidisnotbloody,f/u1‐3monthstoensurenoresidualmassorre‐accumulation

• Foranypatient>40,alsogetmammoforscreening(>50recommend,>40shareddecision)

• Ifsymptomatic,aspirate• Ifdiagnosedbyultrasoundandnoaspirationisdone,f/u1year.

• Ifaspiratedandfluidisnotbloody,f/u1‐3monthstoensurenoresidualmassorre‐accumulation

• Foranypatient>40,alsogetmammoforscreening(>50recommend,>40shareddecision)

Step 2: for a solid mass

Biopsy (FNAorcoreneedlebiopsy)

PLUS

Mammogram (tofurthercharacterizemassandtoscreenrestofbreasts)

• Ifbotharenegative,f/u3‐6months

• Ifeitherisequivocalorresultsarenotconcordant,refertobreastsurgeonforfurtherevaluation

Biopsy (FNAorcoreneedlebiopsy)

PLUS

Mammogram (tofurthercharacterizemassandtoscreenrestofbreasts)

• Ifbotharenegative,f/u3‐6months

• Ifeitherisequivocalorresultsarenotconcordant,refertobreastsurgeonforfurtherevaluation

Ultrasound F/u instead of biopsy for solid mass?

• 2smallretrospectivecohortstudies—largestn=312withpalpablemass&U/S=“probablybenign”

• Mostlyyoungwomensolowpretestprobabilityofcancer(avgage34yo)

• Strictcriteriaforcallinglesion“probablybenign”

• 2of312werecancer.NPV=0.6%.

• Concludeoktonotbiopsyandfollowwithq6mou/sfor2yrs(simtof/uofbirads3mammo)

• Caution:retrospective

• 2smallretrospectivecohortstudies—largestn=312withpalpablemass&U/S=“probablybenign”

• Mostlyyoungwomensolowpretestprobabilityofcancer(avgage34yo)

• Strictcriteriaforcallinglesion“probablybenign”

• 2of312werecancer.NPV=0.6%.

• Concludeoktonotbiopsyandfollowwithq6mou/sfor2yrs(simtof/uofbirads3mammo)

• Caution:retrospectivePark, Acta Radiologica, 2008

How are we doing?

• Inastudyofwomenwithapalpablemassandnegativemammo,only57%receivedany subsequentevaluation.– Latinas,obeseanduninsuredlesslikelytohaveanysubsequentevaluation

• Arecentstudyofdelayindiagnosisfoundthemostcommonreasonwasinappropriatereassuranceofwomenwithalumpandnormalmammogram

• Inastudyofwomenwithapalpablemassandnegativemammo,only57%receivedany subsequentevaluation.– Latinas,obeseanduninsuredlesslikelytohaveanysubsequentevaluation

• Arecentstudyofdelayindiagnosisfoundthemostcommonreasonwasinappropriatereassuranceofwomenwithalumpandnormalmammogram

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Summary: Palpable Breast Mass• Choiceofwork‐upoftendependsonavailabilityandexpertiseofFNA,U/Sandcoreneedlebiopsy

• Noneofthesetestsis100%accurate,maintainahighindexofsuspicion

• Tripletestisgoldstandard.Ifanyofthe3testsisdiscordant continuework‐up

• Frequentf/uevenformassesthoughttobebenigntodetectfalsenegatives

• Choiceofwork‐upoftendependsonavailabilityandexpertiseofFNA,U/Sandcoreneedlebiopsy

• Noneofthesetestsis100%accurate,maintainahighindexofsuspicion

• Tripletestisgoldstandard.Ifanyofthe3testsisdiscordant continuework‐up

• Frequentf/uevenformassesthoughttobebenigntodetectfalsenegatives

Recommended Review: Kerlikowske, Annals Int Med, 2003

Dominant Breast Mass

U/S or Aspirate*

Solid or complex cystDo FNA or core bx

Simple cyst

If aspirate and no residual lump, fluid not bloody then do CBE 4-6 wks. If u/s, no further w/u.

BenignAtypical, suspicious

Cancer Non-diagnostic

Treat

Core or excisional biopsy

Repeat FNA, core or excision biopsy

Positive Mammo

Negative Mammo

CBE 3-6 mos

More imaging, core

or excision bx

U/S or Aspirate*

* Aspirate=office aspiration or FNAB Adapted from Kerlikowske, Ann Int Med, 2003

Q1b: Palpable mass in 42 yo

Amammographywaschosenandisnegative.Nextstep(pickone)?

A. Re‐examinein1‐2months

B. F/u1yearforannualexam

C. Ultrasound

D. Officeaspiration

E. FNA

F. Corebiopsy

Amammographywaschosenandisnegative.Nextstep(pickone)?

A. Re‐examinein1‐2months

B. F/u1yearforannualexam

C. Ultrasound

D. Officeaspiration

E. FNA

F. Corebiopsy

Mammo cannot distinguish cyst from solid and is negative in 15% with palpable mass so need to proceed with work-up from Step 1 ie cyst vs solid

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Q1c: Palpable mass in 42 yo

Anultrasoundwaschosenasthefirststep.Itshowsacysticmass.Nextstep?

A. Re‐examinein1‐2months

B. F/u1yearforannualexam

C. Officeaspiration

D. FNA

E. Corebiopsy

Anultrasoundwaschosenasthefirststep.Itshowsacysticmass.Nextstep?

A. Re‐examinein1‐2months

B. F/u1yearforannualexam

C. Officeaspiration

D. FNA

E. Corebiopsy

Simple cysts are benign and no further work-up is required. If the cyst is symptomatic, may aspirate in office.

Work-up of non-palpable lesions

BI-RADS: Breast Imaging Reporting and Data System

Pre/Post Test Probability of cancer based on mammo results and age

Kerlikowske, Annals Int Med, 2003

Follow-up of abnormal screening mammogram

Kerlikowske, K. et. al. Ann Intern Med 2003;139:274-284

If normal, repeat screen 6 mos then q 1-2 yrs

Consider breast exam to see if lesion is palpable & biopsiable

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Breast Pain

• 2/3 -3/4 report it

• > 1/2 of breast visits

• Etiology unknown: not associated with prolactin,

estrogen or progesterone levels

• 2 types: cyclic & non-cyclic

• Both types chronic, relapsing especially if severe or early onset

• Severe breast pain interferes with sex (46%), activity (36%), social (13%), work (6%)

• 2/3 -3/4 report it

• > 1/2 of breast visits

• Etiology unknown: not associated with prolactin,

estrogen or progesterone levels

• 2 types: cyclic & non-cyclic

• Both types chronic, relapsing especially if severe or early onset

• Severe breast pain interferes with sex (46%), activity (36%), social (13%), work (6%)

Mastalgia: Treatment

• Work‐up:riskfactorevaluation,exam,

mammoif>40years

• DetermineeffectonQOL

• 60‐80%resolvespontaneously.

• Reassuranceoftensufficient

• Work‐up:riskfactorevaluation,exam,

mammoif>40years

• DetermineeffectonQOL

• 60‐80%resolvespontaneously.

• Reassuranceoftensufficient

Mastalgia: TreatmentProven in RCT’s:• NSAID’s (topical and oral) • Evening Primrose Oil • Iodine• Vitex agnus castus extract-

containing solution (VACS) • Gestrinone (N/A in US)• Progesterone vaginal cream• Bromocryptine• Danazol• Tamoxifen

Proven in RCT’s:• NSAID’s (topical and oral) • Evening Primrose Oil • Iodine• Vitex agnus castus extract-

containing solution (VACS) • Gestrinone (N/A in US)• Progesterone vaginal cream• Bromocryptine• Danazol• Tamoxifen

No benefit (per RCT’s, though many are small and likely underpowered)

• Caffeine restriction• Vitamin E• Vitamin B6• Diuretics• Provera • Soya protein• Isoflavones

No benefit (per RCT’s, though many are small and likely underpowered)

• Caffeine restriction• Vitamin E• Vitamin B6• Diuretics• Provera • Soya protein• Isoflavones

Other: Supportive, well fitting bra, bra at night, trigger point injections for localized pain, OCP’s—help some, make worse in others. If on OCP, try lower dose of Estradiol

Most effective but poorly tolerated

Possibly effective, 1000 mg bid-tid for 2-3 months

Topical diclofenac very effective

Topical NSAID for mastalgiaDiclofenac topical (Voltaren) q 8hr vs placebo cream. Randomized, double-blinded

Colac, Journal of the American College of Surgeons, April 2003

Very large decrease in pain score

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Mastalgia: Prescribing GuideProven in RCT’s:

• **NSAID’s (topical diclofenac q 8hr very effective in 3 RCTs; oral NSAIDs—moderately effective in some but not all RCTS )

• Evening Primrose Oil: 1000mg tid for at least 1 mo trial, >$2/day, mild nausea. Recent meta-analysis showed no benefit

• Bromocriptine: increase dose gradually to decrease side effects (nausea, dizziness, orthostatic hypotension, headache). 1.25 mg qhs, increase by 1.25 mg every week until 5 mg/day.

• Danazol: best of the endocrine agents but virulizing side effects make it less desirable, teratogenic, expensive. Start at 200mg qd. Taper down as tolerated to 100mg every other day or qd during luteal phase.

Proven in RCT’s:

• **NSAID’s (topical diclofenac q 8hr very effective in 3 RCTs; oral NSAIDs—moderately effective in some but not all RCTS )

• Evening Primrose Oil: 1000mg tid for at least 1 mo trial, >$2/day, mild nausea. Recent meta-analysis showed no benefit

• Bromocriptine: increase dose gradually to decrease side effects (nausea, dizziness, orthostatic hypotension, headache). 1.25 mg qhs, increase by 1.25 mg every week until 5 mg/day.

• Danazol: best of the endocrine agents but virulizing side effects make it less desirable, teratogenic, expensive. Start at 200mg qd. Taper down as tolerated to 100mg every other day or qd during luteal phase.

Mastalgia: Prescribing Guide

Proven in RCT’s (continued):

• Tamoxifen: 10 mg qd, hot flashes, expensive

• Torimefin: 30 mg qd, vag d/c, irreg menses

• GnRH agonists: very expensive, menopausal side effects, can only use for 6 months due to bone loss.

• Local Injections: trigger point injection of 1% lidocaine (1cc) and methyl prednisone (40mg). Half require second injection in 2-3 months.

Proven in RCT’s (continued):

• Tamoxifen: 10 mg qd, hot flashes, expensive

• Torimefin: 30 mg qd, vag d/c, irreg menses

• GnRH agonists: very expensive, menopausal side effects, can only use for 6 months due to bone loss.

• Local Injections: trigger point injection of 1% lidocaine (1cc) and methyl prednisone (40mg). Half require second injection in 2-3 months.

Nipple Discharge

• Usually benign or malignant?

• Most common cause of unilateral discharge?

• Other causes: duct ectasia, nipple eczema,

Paget disease

• If associated with mass, more likely to be

cancer (but cancer rarely presents with nipple d/c)

• Usually benign or malignant?

• Most common cause of unilateral discharge?

• Other causes: duct ectasia, nipple eczema,

Paget disease

• If associated with mass, more likely to be

cancer (but cancer rarely presents with nipple d/c)

benignintraductal papilloma

Paget’s

Nipple Discharge

Physiologic:

• Due to galactorrhea (ie

increased prolactin) or

nipple stimulation

• With compression

• Multiple ducts

• Clear, yellow, white

• No mass

Physiologic:

• Due to galactorrhea (ie

increased prolactin) or

nipple stimulation

• With compression

• Multiple ducts

• Clear, yellow, white

• No mass

Pathologic:

• Papilloma, cancer

• Spontaneous

• Single duct

• Bloody

• Mass present

Pathologic:

• Papilloma, cancer

• Spontaneous

• Single duct

• Bloody

• Mass present

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Nipple Discharge: Diagnosis

Physiologic:

• History: running,

breast stimulation

• Prolactin, TSH

• Meds:

Psychotropics

Physiologic:

• History: running,

breast stimulation

• Prolactin, TSH

• Meds:

Psychotropics

Pathologic (Spont, unilat):

• Isolate involved duct

• Hemoccult to confirm blood, cytology not useful

• Mammography with retro-alveolar views

• Galactography controversial

• Surgery referral

Pathologic (Spont, unilat):

• Isolate involved duct

• Hemoccult to confirm blood, cytology not useful

• Mammography with retro-alveolar views

• Galactography controversial

• Surgery referral

Mastitis

• 2types:lactatingvsnon‐lactating

• Primaryvssecondary(cellulitis,folliculitis,hydradinitis,sebaceouscyst)

• 2types:lactatingvsnon‐lactating

• Primaryvssecondary(cellulitis,folliculitis,hydradinitis,sebaceouscyst)

Cellulitis

Lactational Mastitis

• Suspect in any breast-feeding woman with a fever and malaise

• Often wedge shaped redness over involved duct

• Staph, Strept—(community acquired MRSA becoming more common so do culture of milk)

• Suspect in any breast-feeding woman with a fever and malaise

• Often wedge shaped redness over involved duct

• Staph, Strept—(community acquired MRSA becoming more common so do culture of milk)

Non-Lactational Mastitis

• Difficult to treat

• Often chronic, recurrent

• Peri-areolar: young (avg 32), 90% are smokers, central pain, nipple retraction and discharge, often assoc with abscess

• Difficult to treat

• Often chronic, recurrent

• Peri-areolar: young (avg 32), 90% are smokers, central pain, nipple retraction and discharge, often assoc with abscess

• Peripheral: elderly, usually associated with underlying disease (diabetes) or trauma

• Gram negatives, staph, strept, anaerobes

• Peripheral: elderly, usually associated with underlying disease (diabetes) or trauma

• Gram negatives, staph, strept, anaerobes

6/21/2013

15

Mastitis Treatment

Lactational

• Increase feeding, warm compresses

• Keflex, Dicloxicillin

• IV if not better quickly

• Septra or Clinda for community acquired MRSA

Lactational

• Increase feeding, warm compresses

• Keflex, Dicloxicillin

• IV if not better quickly

• Septra or Clinda for community acquired MRSA

Non-Lacatational

• Include anaerobic coverage

• Clindamycin or Flagyl + Ancef or Nafcillin

Non-Lacatational

• Include anaerobic coverage

• Clindamycin or Flagyl + Ancef or Nafcillin

** Biopsy if recurrent or doesn’t resolve

Cancer can mimic mastitis

Inflammatory Cancer

Breast Abscess• Suspectif“lump”onexamorifmastitisnotrespondingtoabx

• Ultrasoundtoconfirm• Getculture• AspirationnowpreferredoverI&D

• Sometimesneedrepeatedaspirations

• I&Doftenassocwithpoorcosmeticresultorfistula

• Suspectif“lump”onexamorifmastitisnotrespondingtoabx

• Ultrasoundtoconfirm• Getculture• AspirationnowpreferredoverI&D

• Sometimesneedrepeatedaspirations

• I&Doftenassocwithpoorcosmeticresultorfistula