1. Benign Breast Disease Jennifer L. Ragazzo, M.D.
Department of Obstetrics and Gynecology
Division of Women’s Primary Healthcare
March 31, 2009

2. Objectives Review breast anatomy and development
Understand the strategies used to workup common breast complaints
Know the most common causes of benign breast disease

3. Anatomy of the breast Boundaries
2nd and 6th ribs
Sternal edge and midaxillary line
Tail of Spence
Primarily adipose tissue, glandular tissue, and suspensory ligaments
Mammary gland is a modified sweat gland – gland lobules drain into lactiferous ducts which open onto the nipple

4. Anatomy of the breast Blood supply Innervation Lymphatic drainage
Mainly from internal mammary artery
Lateral thoracic arteries
Innervation
Via intercostal nerves 2-6
Long thoracic nerve – “winged scapula”
Lymphatic drainage
Axillary nodes primarily
Also parasternal, clavicular, and inguinal nodes

5. Breast development
Breast tissue undergoes growth, proliferation and differentiation during
Puberty
Pregnancy
Lactation
This is a complex endocrine process involving estrogen, progesterone, prolactin, cortisol, insulin, thyroid, growth hormone

6. Approach to breast complaints
History: relationship to menstrual cycles, timing, medications particularly hormones, risk factors for breast cancer
Physical: breast masses, nipple discharge, pain, axillary/supraclavicular lymph nodes, skin changes, breast texture, breast symmetry
Further studies: Mammography, ultrasound, needle aspiration, biopsy, ductography

7. Differential Diagnosis: Based on Symptoms
Breast Pain
Nipple Discharge
Palpable Lump

8. Breast Pain: Mastalgia
Normal hormonal changes
Particularly luteal phase of menstrual cycle
60% of women
Fibrocystic disease
increased fibrous or cystic tissue
Severe or prolonged pain
Mastitis
High fever and body aches post-partum
Usually with pain, redness, induration
Pendulous breasts
Stretching Cooper’s ligaments

9. Treatment of Fibrocystic Disease
Supportive Bra
NSAIDs
Avoid caffeine (and chocolate!) and nicotine
Low-fat diet
Vitamin E or Evening primrose oil
Medications
Tamoxifen, Danazol, GnRH agonists, low dose OCPs, bromocriptine

10. Nipple discharge
Non-spontaneous, non-bloody, bilateral discharge is likely benign
Intraductal lesions (unilateral cause)
Duct ectasia – inflammed clogged duct, releasing thick green or black discharge
Intraductal Papilloma – benign growth projects into a milk duct. Can cause bloody, sticky discharge.
*need to rule out malignancy*

11. Nipple Discharge: Galactorrhea
Chronic breast stimulation
Anything promoting prolactin release
Medications (steroids, OCP’s), Hypothyroidism, Chronic renal disease
Anything inhibiting dopamine release (recall dopamine is a prolactin-inhibiting factor)
Medications (methyldopa, phenothiazines)
Disease in hypothalamus/pituitary area

12. Breast lumps More than 90% of masses in premenopausal women are benign
Mammography is recommended in any woman age 35 or older
Ultrasound is preferred in women age 35 and less
All solid breast masses require biopsy

13. Breast lumps
Fibrocystic changes – most common, not a disease state, no increased cancer risk, solitary or multiple cysts
Fibroadenoma
Firm, rubbery lump
Age <30
Growth probably hormonally mediated
Intraductal Papilloma – can be evaluated by ductography
Fat necrosis
Caused by trauma
Tender, firm mass

14. Mammogram
Breast Cancer
Fibroadenoma

15. Breast Ultrasound

16. Ductogram
Papilloma