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Pathophysiology Most frequently in women with nipple fissures , prolonged breast engorgement e. Clinical features Tender, firm, swollen, erythematous breast generally unilateral Pain during breastfeeding Reduced milk secretion Flu-like symptoms, malaise , fever , and chills In some cases, reactive lymphadenopathy Diagnosis Clinical diagnosis Breast milk cultures or imaging may be required if there is no response to initial treatment. Treatment In nursing mothers, frequent emptying of the breast : Breastfeeding with alternate breasts is recommended every 2—3 hours.
Analgesics e. Consider an underlying breast abscess , which requires surgical drainage. Fibroadenoma Definition : : benign breast tumor with fibrous and glandular tissue Etiology : unknown, but a hormonal relationship has been established increased estrogen , e. Despite the fact that the lesion is typically benign, a suspected phyllodes tumor should be considered a suspicious mass until proven otherwise.
Shows papillary cells with fibrovascular core Otherwise: ductogram : nonspecific findings such as ectasia and filling defects Treatment : surgical excision of the affected duct Prognosis : generally excellent References:           . Surgical removal of the breast glandular tissue is indicated for pubertal gynecomastia which persists after 17 years of age persistent pubertal gynecomastia. Senile gynecomastia Pathological gynecomastia Due to estrogen excess Malignancies: Leydig cell tumor , Sertoli cell tumor , ectopic hCG -producing tumors e.
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Other specific lesions present as lumps. These include multiple papillomas, sclerosing adenosis, and radial scars. Multiple papillomas may present as breast lumps, nodules on ultrasound, or may be the cause of bloody nipple discharge and can be seen on ductography. Sclerosing adenosis is a lobular lesion with increased fibrous tissue and interspersed glandular cells.
Benign Breast Disease
It can present as a mass or a suspicious finding on mammograms. Radial scars are a pathologic diagnosis, usually diagnosed following mammography or palpation and then biopsy. Radial scars are characterized microscopically by a fibroelastic core with radiating ducts and lobules and impart a minimally increased risk of breast cancer similar to that of proliferative changes without atypia Although particularly distressing to the patient, only 5 percent are found to have serious underlying pathology. Age is an important factor with respect to risk of malignancy A careful history characterizes breast discharge as either spontaneous or expressible.
On examination, one can detect by careful inspection whether the discharge emanates from a single or multiple ducts. Nipple discharge can be divided into physiologic and pathologic types. Characteristics of physiologic discharge include non-spontaneous, multiple duct, bilateral, and non-bloody.
Pathologic discharge is characterized as spontaneous, serous or bloody, usually unilateral and usually single duct. Reassuring characteristics are that it must be expressed; is green yellow, brown or milky; that it is bilateral and involves multiple ducts. Spontaneous discharge, whether serous or bloody, requires careful evaluation. A hemoccult card or urine dipstick can be used to test for occult blood if the discharge is spontaneous, unilateral, and from one duct.
Cytologic examination is not recommended. Milky discharge galactorrhea should be evaluated with measurement of a serum prolactin level. If the discharge is physiologic and the patient is under 35, only reassurance is necessary. Screening mammogram is recommended for patients over 35 with physiologic discharge. Pathologic discharge requires diagnostic mammogram, galactography Figure 12 43 , and referral to a surgeon. Galactogram illustrating space occupying lesion. A catheter is inserted into the duct from which the bloody discharge emerges. Contrast material is then injected through the catheter.
The various branches of the duct are outlined. The approach is to obtain a history of other dermatologic problems, or a history of change in soap or clothing. If absent, a diagnostic mammogram should be obtained if the patient is over In a large recent series of patients with nipple discharge, had unilateral discharge and had no breast lump in association with this symptom. For women with bloody discharge from a single duct, galactography is warranted.
Filling defects can be due to intraductal papilloma, intraductal carcinoma, papillomatosis, debris, or air bubbles. Diagnostic studies may then be ordered. Mammography, often in conjunction with ultrasound examination is required for evaluation of discrete palpable lesions in women over 35 whereas ultrasound provides an optional substitute in younger women Round dense lesions on mammography often represent cysts which require only ultrasonography to distinguish them from solid lesions. Complex cysts containing both fluid and solid matter require biopsy.
For solid lesions, radiographically or ultrasonically directed core biopsy provides highly discriminative information regarding the presence or absence of malignancy. Core biopsy utilizes a large cutting needle deployed with a spring loaded, automated biopsy instrument and obtains tissue suitable for histologic analysis familiar to most pathologists.
FNA frequently yields sufficient cellular material to allow adequate cytologic evaluation but requires an experienced cytopathologist. The exact role of MRI in evaluating breast lesions is currently being determined Galactography ductography is useful for detection of focal lesions in a single duct. Cytology of nipple discharge is of limited value with the sensitivity of detecting malignancy only 35 to 47 percent Ideally a team including a radiologist experienced in mammography, ultrasound, MRI and core needle biopsy as well as an internist, gynecologist, or surgeon with expertise in breast diseases should be involved in the evaluation of patients with breast disorders.
MRI mammography, ductography, or ultrasound may be utilized Figures 12 and Information to be obtained by a focused history and physical examination are outlined on Table 3. The method of documenting whether breast pain is chest wall related is illustrated on Figure 11 A-D. Imaging has become an integral part of the management of benign breast disorders. Mammography is useful for evaluation of palpable lesions, particularly in those over Digital mammography is preferred because of its ability to penetrate through dense breast tissue which is commonly found in younger women.
Ultrasound is often used as initial evaluation of a palpable mass in women under age If a simple cyst is present, no further evaluation is necessary Figure If not, mammography may also be necessary to fully evaluate the lump. If the mass has findings suggestive of a fibroadenoma by ultrasound and mammography, short term follow-up and re-imaging can be considered usually performed in 6 months. Experts are divided as to the necessity to biopsy all fibroadenomas. MRI is more sensitive than digital mammography but false positives are more common Upper panel illustrates by ultrasound a non-dense black area representing cyst fluid.
The lower panel is the corresponding area on mammogram showing a dense area. With the combination of mammogram and ultrasound, the lesion can be shown to be a cyst. Fibrocystic change typically presents on mammogram as round or oval, well defined masses that can be subsequently shown to represent cysts on ultrasound Figure Diffusely scattered dystrophic calcifications may also be found on the mammogram.
Definition of benign breast disease - NCI Dictionary of Cancer Terms - National Cancer Institute
Consequently, the goal of mammographic evaluation is to provide reassurance to the patient and physician that the risk of neoplasm is low. Aspiration of cysts is usually necessary only in a those cases where the mass does not fulfill all criteria for a simple cyst or if the cyst is painful. Biopsy may be necessary to confirm the benign nature of calcifications, particularly if clustered, linear or variously shaped. If the risk is believed to be greater, core biopsy is recommended. Stereotactically directed core biopsy is ideal for evaluation of calcifications and provides highly discriminative information regarding the presence or absence of malignancy.
If this technique is not available, insertion of a wire into the lesion radiographically followed by surgical excision or mere removal of a palpable lesion is warranted. Careful examination distinguishes solitary, discrete, dominant, persistent masses from vague nodularity and thickening. Practice Guidelines of the Society of Surgical Oncology 51 recommend the following evaluation: In women less than age 35, all dominant discrete palpable lesions require referral to a surgeon.
If vague nodularity, thickening or asymmetrical nodularity is present, the examination is repeated at midcycle after one or two menstrual cycles. If the abnormality resolves, the patient is reassured and if not, referred to a surgeon. Breast imaging may be appropriate. With vague nodularity or thickening, one obtains a mammogram with repeat physical exam at mid-cyle 1 to 2 months later and refers to surgeon if the abnormality persists.
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Post-menopausal women are referred for surgical consultation after a mammogram. For gross cysts i. If the aspirated fluid does not contain blood, the fluid is discarded without further histologic analysis unless the cyst contains solid components i. If the fluid contains blood or if the cyst is complex, the, fluid is sent for cytology and consultation from a surgeon requested. With persistent refilling of the same cyst after aspiration, surgical consultation is warranted. When mammography is negative but a dominant mass is present, biopsy is required to rule out malignancy since lobular carcinoma may not be seen on mammograms.
In those younger, mammography may be omitted if ultrasound and biopsy yield definitive information. Many experts omit biopsy in younger women with lesions characteristic of fibroadenoma on ultrasound and elect to follow carefully with serial ultrasounds at six monthly intervals for two years and yearly thereafter.
However, other experienced surgeons disagree and believe that all fibroadenomas require diagnostic core biopsy or FNA and especially in BRCA mutation carriers in whom medullary cancer may be found. Biopsy confirmation of a fibroadenoma eliminates the need for serial ultrasounds.
Breast discharge is evaluated according to the algorithm illustrated below on Figure Careful attention to several factors are necessary including determination whether the discharge arises from one duct or multiple ducts, is bloody, or is milky. The initial step in evaluating pain is to distinguish true breast pain from chest wall pain Figure Several well designed, randomized, controlled, double blind, cross over trials have validated the efficacy of medical therapy for cyclic mastalgia.
Based upon these studies, we categorize therapies as definitely effective, definitely ineffective , possibly effective , and insufficiently studied. For classification as definitely effective, two or more randomized trials are required. For the category, possibly effective, one randomized trial must be positive in some respect but others may be negative.
For the category definitely ineffective, prospective trials must be uniformly negative. For the category, insufficiently studied, only one randomized trial, either negative or positive is available. Danazol, bromocriptine, and tamoxifen have been proven to be effective Figure Linoleic acid in the form of evening primrose oil has been shown effective in two randomized trials but not in the third, the largest trial.
Its role in treatment therefore remains uncertain Vitamin E is considered definitely ineffective and iodine and vaginal progesterone possibly effective. Medroxyprogesterone acetate, caffeine avoidance, and progesterone have not been sufficiently studied. Several other therapies have not been examined in randomized controlled trials but are likely to be beneficial since they are based upon physiologic principles. For example, precise fitting of a bra to provide support for pendulous breasts has been reported to relieve pain in observational studies. Onset of menopause is known to reduce the frequency of breast pain.
This therapy is reserved for patients in whom all other measures fail and the pain is considered severe. Reduction of the dosage of estrogens in post-menopausal women or addition of an androgen to estrogen replacement therapy e. Relative efficacy of agents to treat breast pain. These data are from the Breast Clinic in Cardiff, Wales and represent observational studies and not randomized, controlled efficacy trails. No large randomized, controlled studies have compared the relative efficacy of danazol, bromocriptine, evening primrose oil and tamoxifen.
Figure 15 rank orders them according to efficacy based upon data from individual reports from the same clinic. Minimal data are available from clinical trials which involve direct head to head comparisons. It should be noted that overall responses to danazol, bromocriptine and evening primrose oil are lower in those with non-cyclic pain than those with cyclic pain. However, not all studies have carefully excluded patients with non-breast pain and therefore conclusions regarding non-cyclic pain should be considered tentative.
The approach to non-breast pain is outlined in Figure A major consideration for women who present with breast problems is whether they have a higher than normal risk of developing breast cancer. Certain breast lesions such as fibrocystic changes are associated with no increased risk of subsequent breast cancer Table I. A recent report also suggested that radial scars increase relative risk by 1. It should be noted that the Gail model for assessing breast cancer risk, which is based predominantly on reproductive factors, underestimates the long term risk of breast cancer in women with benign breast disease.
On the other hand, the five year prediction is more accurate The presence of dense breast tissue on mammography has also been reported to be a predictor of increased incidence of breast cancer Figure Two components of this finding must be considered : one , the presence of high breast density makes it more difficult to read mammograms and masks the sensitivity of finding a breast cancer initially but identifies it later and two , there is an increased risk of breast cancer associated with increased breast density. With long tem follow-up studies, masking is not the explanation for the increased breast cancer risk Breast cancer risk is also increased in association with high plasma estradiol and testosterone levels in postmenopausal women 62;65 and 20 kg or more weight gain 66 in the pre-menopausal years.
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Another risk factor is use of hormone replacement therapy. This risk is probably increased further in women starting this therapy shortly after the menopause i. Starting this therapy a long time after experiencing menopause long gap is associated with a lesser relative risk The use of estrogen alone in the WHI was associated with a trend toward reduction of risk of breast cancer at five years and a statistically significant reduction in those adhering to therapy Available data suggest that the effects of menopausal hormone therapy in the WHI is a class effect and not related to the specific type of estrogen or progestin.
One study, however, suggests that use of crystalline progesterone as the progestogen is associated with a lesser risk than use of medroxyprogesterone acetate To aid in assessing breast cancer risk, a questionnaire developed by Gail, utilizes answers to 7 questions to calculate the 5 year and lifetime risk of developing breast cancer This model has recognized deficiencies in that it does not consider second degree relatives with breast cancer, proliferative lesions of breast other than ADH, alcohol intake, obesity, or birth control pill and menopausal hormone therapy MHT use.
Nonetheless, the Gail model has been prospectively validated in over women followed for an average of 4. Patients with benign breast lesions imparting an increased risk of breast cancer can be offered tamoxifen or raloxifene as a prevention strategy. The risk of breast cancer is determined using the Gail or Tyrer-Cuzick model and the benefits versus risks of tamoxifen evaluated.
Risk factors not included in the Gail or Claus models include degree of breast density, plasma free estradiol levels, bone density, weight gain after menopause, and waist-hip ratio 25;65;66; Current recommendations suggest that women with a five year risk of breast cancer of over 1.
A recent overview has shown a 38 percent reduction of the relative risk of breast cancer with tamoxifen but benefits may be offset by increased risks of thromboembolic phenomena, endometrial cancer, and maturation of cataracts The Star trial addressed whether raloxifene might be preferable to tamoxifen and 79 demonstrated relative equivalence. However, of interest was the fact that tamoxifen prevented more non-invasive breast cancers than did raloxifene More intensive and frequent screening with multi-modality imaging i.
Standardized measures of lobular involution and subsequent breast cancer risk among women with benign breast disease: a nested case-control study. Hormonal control of breast development.