Presentation on theme: "Sutter Pacific Medical Group of the Redwoods"— Presentation transcript:
1Sutter Pacific Medical Group of the Redwoods Benign Breast DiseaseElizabeth Peralta, M.D.Breast SurgeonSutter Pacific Medical Group of the Redwoods
2Breast ComplaintsPainMassSkin or Nipple ChangesNipple Discharge
3Diagnosis and Treatment of Breast Complaints Most important is to rule out malignancySignificance of a finding is greatest in a high-risk patientBalance between reassurance and exhausting all diagnostic optionsTreatment should not be worse than the disease
5Pre-menarchal ductule Terminal ductal-lobular unit
6Breast Development Menarche and Reproductive Cycles: Pulsed estrogen exposure causes rapid growth, elongation and branchingTerm pregnancy leads to terminal differentiation and stops growthEnd bud epithelial tissue undergoes cyclic proliferationBreast feeding is associated with a lower risk of breast cancer
8Breast DevelopmentInvolution: Changes of involution begin after cessation of lactation and continue through menopauseCompeting involution and proliferative processes are patchy and increased in peri-menopause and with HRTHyperplasia with atypia and DCIS peak in this period
10Pre-Cancer ChangesIntraepithelial neoplasia (IEN): a lesion which is non-invasive but contains genetic abnormalities, loss of cellular control functions, and some microscopic features of cancer cells
11Biopsy results which represent increased breast cancer risk: Atypical Ductal Hyperplasia (ADH)Atypical Lobular Hyperplasia (ALH)Lobular Carcinoma in Situ (LCIS)
12Biopsy results which do not show breast cancer risk: CystsFibrosis
13Breast Cancer Risk Major Risk Factors (RR > 4) Previous breast cancerFamily history (bilateral, premenopausal or mother and sister)Atypical hyperplasiaLCIS or DCIS
16LThis is a typical spiculated density representing cancer as seen on mammogram
17This is an example of clustered microcalcifications associated with ductal carcinoma in situ (DCIS)
18But in young women and any woman with breasts as dense as these, there may be not radiologic finding associated with a complaint.
19Breast Imaging Reporting and Data System (BI-RADS) CategoryDefinitionActionPPVmalignancyIncomplete, possible findingAdditional imaging15%1NegativeRoutine screening<1%2Benign findings3Probably benign findings6 mo follow-up2%4Suspicious abnormalityBiopsy30-45%5Highly suggestive of malignancyBiopsy, action as indicated93%
20Causes of Breast PainEndocrine: Cyclical, peri-menopausal, and with hormone replacement therapyEdema/weight (caffeine, lack of support)Mastitis (term usually associated with lactational problems)Breast AbscessAngina, esophagitisCostochondritis, fibromyalgia, anxiety?
21Treatment of Breast Pain Elastic/compressive bra (sport or minimizer style rather than underwire or push-up)NSAIDS (topical?) Omega-3 fatty acids (evening primrose oil)Decrease or stop hormone replacementDanazol, gestrinone, tamoxifen may help but cause hot flashes and masculinizing effects50% spontaneous remission, therefore, vitamin E, b complex, evening primrose oil, decreasing caffeine seem to help half the time!
27Case 2: Palpable breast mass 42 y/o woman, “I always have lumpy breasts” found a new lumpOnset 3 months ago, not changingModerate cyclical breast painLump is in upper outer quadrant, firm, but very mobile
34Non-lactational breast abscess: The median age at presentation was 40yr (range 22-71). Among cases, 17 of 19 (89%) were smokers with a mean exposure of 24.4 pk-yr each.In the control group, 9 of 42 (21%) were smokers with a mean exposure of 17.7 pk-yr each (p=0.001, chi-square test of independence).Ten of the 19 required surgical drainage and one of these revealed carcinoma associated with the abscess, necessitating mastectomy.
35Conclusions: Smoking and Breast Abscesses Subareolar abscess is strongly associated with cigarette smoking, with the average patient presenting at age 40 after smoking more than 20 years.Aspiration and antibiotics, the preferred treatment for lactational abscess, had less than a 50% success rate in this population.Carcinoma must be ruled out in both surgically and conservatively managed patients.Smokers who present with subareolar abscess should be urged to quit for this and other health reasons
36Nipple Discharge Spontaneous Unilateral, single orifice Clear or blood-tingedProgresses over timeDDX: Duct ectasia, intraductal papilloma, DICS10% malignantElicited, intermittentMultiple ducts, bilateralGreen, murky, whiteMay stop if abstain from manipulationBiopsy if abnormal imaging or progressiveSame DDX
37Evaluation of Nipple Discharge HistoryProlactin, TSH if suspect galactorrheaMammogram, ultrasoundDuctogram optionalSurgical consultation, Mammary duct excision is diagnostic and stops dischargeVacuum assisted core needle biopsy may also stop the discharge
38Hormone Replacement Therapy and Breast Cancer Risk Years ofHormoneTreatment20 yr cumulative breastcancer rate /1000 womenNone45547Twenty years of hormone replacement therapy increases breast cancer risk by 27%, so a woman goes from a lifetime risk of 1/8 to 1/6. This means that although HRT is not out of the question, after 5-10 years the indication for continuing it should be reevaluated and an attempt at weaning off slowly (reduce by 1 pill per week over 1-2 months).10512057
39Cancer PreventionQuit smoking: More women die of lung cancer than breast cancerMaintain a healthy balance of exercise, recreation, rest, and weight controlChemoprevention: for women at increased risk (family history, abnormal biopsy)