Benign breast disorders

Benign Breast Disorders
Valerie Swiatkowski, MD
Medical Student Lecture


Introduction
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16% of women ages 40-69 will seek
advice from their physician regarding
breast complaints over 10 years.

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Failure to diagnose breast cancer is a
leading cause of malpractice claims.

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90% of patients will have benign disease


Objectives
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At the end of this lecture, you will know:
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Clinical breast exam
Evaluation of a breast mass
Major causes of benign breast disease
Evaluation of nipple discharge
Management of abnormal mammography


Scenario 1
NM is a 31 y/o G1P1001 who
presents
annual
w/o
Her
friendfor
was
just exam
diagnosed
complaints.
with breast
cancer.

She wants to know if you will
order a mammogram for her…

What are the screening guidelines?


Screening Guidelines by Age
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Age 20 - 35
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Age 35 - 40
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Baseline mammography

Age 40 - 50
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Breast self-exam once a month
Physical Exam Yearly

Mammography every one to two years

Age 50 +
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Mammography yearly

Breast Self Exam Timing
Premenopausal:
one week after onset of menstruation

Postmenopausal:
the same day each month


Breast Self Exam


NM is grateful for your time and
teaching. You counsel her that
you will see her in a year…


Scenario 2
Your next patient, FC,
is a 22 y/o Go comes in with a
new right breast mass…


What do you do?
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Tell FC that cancer is rare in young women
and she shouldn’t worry about it…

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Order mammogram now

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Refer to a breast specialist

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Talk to FC and get more history


What do you do?
Tell FC that cancer is rare in young women
and she shouldn’t worry about it…
‡ Order mammogram now
‡ Refer to a breast specialist
‡

‡ Talk

to FC and get more history

What information do you want to know?


Key Points in her History
The precise location of the lump
‡ How it was first noted (accidentally, by breast
‡

self-examination, or during a screening clinical
breast examination or mammogram)

How long has she noted its presence?
‡ Any accompanying nipple discharge?
‡ Has the lump has changed in size?
‡ Does the lump wax and wane in size?
‡ Any risk factors for breast cancer?
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Risk Factors for Breast Cancer
Age
‡ Age at Menarche
‡ Age at first birth
‡ Age at Menopause
‡ Parity/ breastfeeding history
‡ History of breast biopsy
‡ History of Atypical Hyperplasia
‡ Family history of Breast Cancer
‡ BRCA1/2 positive
‡


Scenario 2 (cont)
FC tells you she has noticed this
mass for the last three months,
it has increase in size over that
time. She has no tenderness or
nipple discharge.

Now what do you do?
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Order mammogram now

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Examine the patient

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Recommend surgical excision


Now what do you do?
‡

Order mammogram now

‡Examine
‡

the patient

Recommend surgical excision

What do you need to know from physical exam?

Physical Exam
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Delineate and document breast masses
Elicit discharge from the nipple
Identify localized areas of tenderness
Detect enlarged lymph nodes
Detect skin changes:
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Asymmetry
Skin retraction
Dimpling
Edema
Erythema
Ulceration


Scenario 2 (cont)
During your clinical breast exam

you palpate a mass in the right
upper outer quadrant
1 cm, firm, mobile, nontender, no LAD


Scenario 2 (cont)
FC is really worried…
What could the mass be?
What do you do next?
So what is the differential diagnosis?


General Categories of Breast Disease
Physiologic
‡ Nodularity
‡ Mastalgia
‡ Dominant Lumps
‡ Nipple Discharge
‡ Infections and Inflammation
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General Categories of Breast Disease
Physiologic
‡ Nodularity
‡ Mastalgia
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‡Dominant

Lumps

Nipple Discharge
‡ Infections and Inflammation
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Differential Diagnosis of Breast Masses
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Macrocysts
Fibrocystic Changes
Fibroadenoma
Galactocele
Lipoma
Mongor’s disease
Granuloma
Hamartoma
Neurofibroma

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Mastitis
Fat Necrosis
Ductal hyperplasia
Lobular hyperplasia
Sclerosing adenosis
Diffuse papillomatosis
Complex
fibroadenoma
Radial scars
Cancer


Differential Diagnosis of Breast Masses
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Macrocysts
Fibrocystic
Changes/Cyst
Fibroadenoma
Galactocele
Lipoma
Mongor’s disease
Granuloma
Hamartoma
Neurofibroma

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Mastitis
Fat Necrosis
Ductal hyperplasia
Lobular hyperplasia
Sclerosing adenosis
Diffuse papillomatosis
Complex

fibroadenoma
Radial scars
Cancer


Fibroadenoma
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‡
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Most common benign
solid tumor of the
breast
Present in third
decade of life
Painless, well
circumscribed, mobile