Breast Disorders

Mastitis/Abscess

  • Staph aureus (MC) enters through nipple fissures, milk stasis ➔ favorable conditions for bx ➔ inflammation of breast

  • SSX

    • Tender, firm, erythematous breast ➔ pain with feeds

    • ± flu like sx, LN

  • DX is clinical but culture milk if ABX not resolving

    • DX breast abscess with US if needed

  • TX

    • NSAIDs, cold compress, continue breastfeeding to prevent stasis

    • PO dicloxacillin (clinda or TMP-SMX for MRSA)

Abscess (complication of mastitis)

  • SSX

    • Purulent nipple discharge, fluctuant mass

    • ± overlying necrotic skin

  • TX

    • Needle aspiration or I&D and PO dicloxacillin

Galactorrhea

  • Milk production ➔ discharge in men or nonbreastfeeding women

  • Pituitary adenoma ➔ hyperprolactinemia

  • DA antagonists, TCA's, methyldopa ➔ ↓ or ⊣ DA ➔ ↑ prolactin

  • 1° hypothyroid ➔ ↑ TRH ➔ ↑ prolactin

  • DX

    • Elevated prolactin and

      • ↑ TSH ➔ 1° hypothyroid

      • ↑HCG ➔ pregnancy

      • ↑ Cr ➔ renal failure (↓ prolactin clearance)

    • Elevated prolactin with above negative ➔ MRI of pituitary

Benign Breast Conditions

Breast Cyst

  • Well circumscribed collection of fluid influenced by hormonal changes

  • MC 35-50yo

  • Simple (solitary or clustered microcysts)

    • US: Posterior acoustic enhancement, internally anechoic

      • No vascular flow, no solid components

      • Typically BI-RADS 2

      • Simple cyst on US ➔ FNA ➔ collapse of cyst and confirms dx

  • Complicated

    • US: Homogenous low-level internal echoes (echogenic debris)

      • No vascular flow, no solid components

      • Typically BI-RADS 2, can be BI-RADS 3

      • F/u imaging q6mo

        • Core needle biopsy if ∆ size/imaging

  • Complex

    • US: Cystic and solid components ➔ anechoic and echogenic features

      • Thick walls (> 0.5mm), ± septa

      • Posterior wall enhancement if mostly cystic

      • Should be BI-RADS 4 or 5 ➔ core needle biopsy or excision

Benign Breast Neoplasm

Fibroadenoma

  • MC 15-35yo

  • Benign breast neoplasm of fibrous, glandular tissue

  • ↑ estrogen ➔ ↑ growth and regresses after menopause

  • MC tumor <35yo

  • SSX

    • Usually a single, rubbery, non-tender, mobile mass with well defined borders

  • DX

    • US shows well defined mass

    • Mammogram shows well defined mass ± popcorn calcifications

    • FNA or core needle biopsy confirms glandular tissue

  • TX

    • Regular follow-ups

Phyllodes tumor

  • Fibroepithelial tumor, 25% chance of malignancy

  • 40-50yo

  • SSX

    • Mulinodular breast lump

    • Larger (>4cm) with rapid growth

  • DX

    • Looks like fibroadenoma on US and mammogram (well defined mass)

    • Core needle biopsy shows leaf-like architecture

  • TX

    • Excision because typically recurs and has ↑ risk of malignancy

Intraductal papilloma

  • Epithelium of lactiferous ducts ➔ MCC of bloody nipple discharge

  • MC 40-50yo

  • SSX

    • Central papilloma: Solitary lesion near nipple ➔ serous/bloody discharge

    • Peripheral papilloma: Multiple smaller lesions

  • DX

    • Palpable lesion ➔ core needle biopsy

      • Shows papillary cells covered with epithelial/myoepithelial cells

      • Atypical hyperplasia ➔ ↑ risk of breast cancer

    • Non-palpable ➔ ductogram (mammogram with contrast to visualize ducts)

  • TX

    • Excision of affected lactiferous duct

Fibrocystic Changes

  • MC 20-50yo

  • Common benign breast changes of fibrotic and/or cystic tissue

  • Cysts rupture and inflammation ➔ stromal fibroblasts ➔ fibrosis over time

  • SSX

    • Premenstrual breast (tissue) pain/tenderness (usually bilateral)

    • Lumps in fibrous tissue ➔ cobblestone texture

    • Multiple breast nodules ± tenderness

  • DX

    • US and diagnostic mammogram if >30yo

  • TX

    • Dual oral contraceptives

    • Fine needle aspiration of cystic nodule if severe pain/disfiguration

Breast Cancer

Breast Cancer Risk

  • ↑ exposure of estrogen/progesterone (early menarche, late menopause)

  • Linked to BRCA1, BRCA2 (MC in men) mutations

Screening

  • Self-exam not recommended (↑ unnecessary biopsies)

    • If self exam done, should be 1wk after menstruation ends

  • Clinical breast exam only if complaint

Mammography for average risk women

  • ACOG: Start at 40yo, yearly until 75yo

  • ACS: Start at 45yo, yearly until 54yo

    • Every 2yrs starting at 55yo

  • USPSTF: Start at 50yo, every 2yrs until 74

Screening for high risk women

  • MRI or US AND mammogram every year

    • Staggered so imaging is every 6mo

  • Breast cancer DX

    • Diagnostic mammography and core/excisional biopsy

  • Breast cancer TX

    • Breast-conserving therapy (lumpectomy then radiation)

    • Mastectomy (with or without radiation therapy)

    • Sentinel lymph node biopsy

    • Hormone receptor positive breast cancer

      • Tamoxifen OR

      • Letrozole or anastrozole (aromatase inhibitors) s/p lumpectomy and radiation

        • Aromatase inhibitors ➔ osteoporosis (get bone scan)

    • First mammogram s/p tx: no earlier than 6mo after completing radiation

Inflammatory Breast Cancer

  • Invasive carcinoma affecting dermal lymphatic system

  • SSX

    • Erythematous, warm, edematous plaques and prominent hair follicles ➔ Peau d'orange

  • DX

    • Core needle biopsy and 2 skin punch biopsies (MRI no sensitive enough)

  • TX

    • Chemo and radiation and mastectomy

Paget disease of breast

  • SSX

    • Scaly, raw, vesicular/ulcerated lesions; begins on nipple, spreads to areola

    • Pain, burning, pruritus

    • ± breast mass

  • DX

    • Full-thickness punch/wedge nipple biopsy or nipple scrape cytology

  • TX

    • Mastectomy

    • Can try nipple-areolar resection with wide excision if negative margins can be obtained (needs radiation afterward)

Breast Imaging-Reporting and Data System (BI-RADS)

Classification system for mammography/ultrasound/MRI of breast

  • BI-RADS 0: Needs repeat imaging

  • BI-RADS 1: Negative, continue routine screening

  • BI-RADS 2: Benign findings (fibroadenoma), continue routine screening

  • BI-RADS 3: Probably benign but repeat US and/or diagnostic mammogram q6mo

  • BI-RADS 4: Suspicious, needs biopsy

    • 4A: 2-9% chance of malignancy

    • 4B: 10-49% chance of malignancy

    • 4C: 50-94% chance of malignancy

  • BI-RADS 5: Highly suspicious, needs biopsy

  • BI-RADS 6: Biopsy already proved malignancy

    • Hasn't been excised but getting more imaging/second opinion