1. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 1 Breast Problems CAPT Mike Hughey, MC, USNR

2. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 2 Breast Development Contains mainly fat tissue, connective tissue and glands 15-25 ducts Breast tissue extends into axilla (“tail”) Smallest, day 4-7

3. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 3 Quadrants Breast is divided into quadrants Upper-Outer quadrant has the greatest mass UOQ is the site of about half of all breast cancers

4. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 4 Supernumerary Breasts Relatively common Found along “milk line” Most identified during pregnancy/lactation Most common in axilla Not dangerous

5. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 5 Supernumerary Nipples More common than supernumerary breasts Found along milk line May darken during pregnancy Not dangerous

6. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 6 Inverted Nipples Often will evert with stimulation Mostly a cosmetic issue Successful breastfeeding is usually possible.

7. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 7 Adolescent Breast Problems Assymetric growth is the rule rather than the exception. Mammary hypertrophy: Postpone surgical intervention until all growth has occurred Breast masses are ~100% benign and surgery or FNA is almost never warranted (disturbs breast architecture and may be disfiguring

8. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 8 Pregnancy Changes 1st TM: Tender breasts and nipples 2nd TM: Non-tender breasts enlarge 2nd-3rd TM: Steady darkening of nipples and prominent Montgomery’s glands

9. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 9 Puerperal Mastitis Rapid onset of red, hot, swollen, tender breast High fever Prompt treatment (Amox, Diclox, Erythromycin, Azithromycin Abscess needs drainage Keep breast-feeding

10. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 10 Nipple Laceration Keep clean and dry. Stop breastfeeding that side and allow to heal Antibiotics usually not necessary

11. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 11 Cyclic Breast Pain Worst just before menses Thick, tender, nodular breasts Not dangerous but annoying Rx: OCPs (cyclic or continuous) Rx: Danazol (extreme cases) Reduce caffeine? Vitamin E?

12. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 12 Non-Cyclic Breast Pain Often due to trauma (breast or chest wall) May be due to muscle strain May be due to increased levels of estrogen Usually not due to cancer Examine and refer if cause is not obvious.

13. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 13 Nipple Discharge Normal nipple discharge is clear, milky or green- tinged. If bloody, needs surgical evaluation If it stains the inside of the bra each day, that is galactorrhea and will need thyroid and pituitary evaluation.

14. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 14 Fat Necrosis Tender, thickened, bruised area of breast Follows trauma Benign Resolves spontaneously over weeks to months Atypical cases should have FNA

15. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 15 Breast Cyst Smooth, unilateral mass Feels like a cyst Infrequently associated with malignancy Aspirate Watch for reforming of cyst Recurring cysts are more worrisome

16. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 16 Paget’s Disease Crusty, flaking lesion Gradual onset over months or years Associated with underlying breast malignancy Diagnosis confirmed by needle biopsy

17. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 17 Breast Mass Dominant mass Unilateral Persists through the menstrual cycle Usually biopsied (FNA or excisional) Can wait weeks but not months

18. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 18 Fibroadenoma Common Benign Solid, rubbery, non-tender Round or oval Rarely grow > 2-3 cm FNA or excisional Bx Observe in adolescents

19. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 19 Breast Cancer 30% of all cancers in women Treatment is successful in 3/4 Rare before age 25 Steadily increasing frequency with increasing age Affects 1/9 women reaching age 90.

20. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 20 Breast Cancer Risk Factors Strong family history Menopause after age 55 No term pregnancy prior to age 35 Most (80%) of breast cancer occurs in women not at increased risk.

21. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 21 Breast Examination

22. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 22