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Benign Breast Disease Jennifer L. Ragazzo, M.D.

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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

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