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

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Presentation on theme: "Benign Breast Disease Jennifer L. Ragazzo, M.D. Department of Obstetrics and Gynecology Division of Women’s Primary Healthcare March 31, 2009."— Presentation transcript:

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  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  2 nd and 6 th 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  Boundaries  2 nd and 6 th 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  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  Blood supply  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  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  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  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  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  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*  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  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  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  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 Fibroadenoma Breast Cancer

15 Breast Ultrasound

16 Ductogram Papilloma


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