Pocket ObGyn – Benign Breast Disease

Pocket ObGyn – Benign Breast Disease
See Abbreviations

Workup of a Breast Mass
  • Palpable breast mass ® mammogram/US ® needle bx after imaging or 2 w prior (to avoid artifact) w/ FNA or core needle bx ® excision if concerning or rpt exam in 6 w Likely benign mass: Mobile, soft, smooth, <2 cm

Concerning mass: Hard, fixed, single, irreg margins, >2 cm, adenopathy, bloody nipple discharge, overlying skin changes, nonsymmetric breast appearance

  • Triple test = clinical exam + imaging + breast bx ® >99% NPV for concordant negative triple If all negative, monit q6mo by clinical exam alone. If any of these assessments sugg malig ® excision.

 

Mammography, BIRADS (Breast Imaging Reporting and Data System) scoring
Score Description Risk of cancer F/u
0 Incomplete NA Need to rpt mammogram or breast US
1 Negative Minimal Continue routine screening
2 Benign finding Minimal Continue routine screening
3 Probably benign findings 2% F/u mammogram in 6 mo to reassess

 

Score Description Risk of cancer F/u
4 Suspicious abnormality 25–30% May need bx
5 Highly suggestive of malig 95% Core or excisional bx of mass
6 Biopsy-confirmed breast cancer known 100% (known) Excision, chemo, or radiation
Abnormal Radiology Findings
  • Poorly defined soft tissue density, irreg borders – sometimes in a “star” appearance
  • Clustered microcalcifications in 1 area
  • Calcification w/i a soft tissue mass/density
  • Asym w/i the breast, or skewing of breast tissue
  • New abnormality not previously seen
  • Worrisome findings: Soft tissue mass, clustered microcalcifications
  • Most common breast mass in <25 yo, gradual growth, “lumpy” on exam, low risk for cancer ® if increasing in size, consider bx

 

Benign breast disease
Mastalgia Definition: Breast pain, can be cyclic or noncyclic.

Cyclic: Usually most painful before menses, relieved w/ menses, unilateral or bilateral. May be due to edema & inflammation & can form cysts that are relieved w/ aspiration.

Noncyclic: May be due to hormonal fluctuations, muscle soreness, & mostly w/o an identifiable cause.

Tx: Most resolve spontaneously, can be helped w/ NSAIDs, supportive bras, OCPs, recommend decreasing caffeine & chocolate intake, magnesium therapy is controversial.

Mastitis Definition: Acute cellulitis that can progress to an abscess, typically seen in breast-feeding women; presents often in a wedge distribution of ducts w/ warmth, erythema, tenderness, fevers, & malaise made by clinical dx.

Tx: Dicloxacillin 500 mg QID ´10 d, or cephalexin 500 mg QID ´10 d, warm compresses, pt must continue breast-feeding to help provide an outlet for drainage. Infants are safe to breast-feed as bacteria originated from infant’s mouth flora.

(Nipple discharge: 95% of time from benign causes)

Breast cysts Definition: Fluid-filled cyst is usually simple from terminal duct, common in 35–50 yo, causes localized breast pain, usually resolves.

W/u: Expectant mgmt for 6 w or aspiration or breast US ® if sanguineous aspirate recurs, or concerning on radiology, refer for breast bx/excision.

Fat necrosis Definition: Hard or indurated areas usually after trauma (seat belt, bx, radiation, infxn). Common in subareolar region.

W/u: Can asses w/ mammography or breast US.

Fibroadenoma Definition: Most common breast mass in <25 yo, gradual growth, “lumpy” & mobile on exam, low risk for cancer.

W/u: If increasing in size, consider bx.

Nipple Discharge
  • Very common complaint, usually benign
  • Nml discharge: Common on stimulation, bilateral, serous
  • Galactorrhea: Milky discharge unrelated to Preg, Causes: Unknown, endocrine abnormalities a/w amenorrhea or hypothalamic dysfxn from endocrine abnormalities or pituitary mass, many psychiatric meds (Dopamine inhibitors).

W/u: HPI asking about visual changes, HAs, menses, thyroid sx, current meds; PE looking at visual field defects (tunnel vision).

Labs: Prolactin, TSH, free T4, CT head looking for a pituitary adenoma if elevated prolactin.

  • Nonbenign discharge: Unilateral, bloody (can guaiac test if not visible), serous, or colored discharge can be a/w breast mass or overlying skin Caused by carcinoma, intraductal papilloma, duct ectasia, fibrocystic changes.

W/u: Send discharge for cytology, mammogram if >35 yo or breast US if <35 yo. Cytology is of little value & has a low sens.

See Abbreviations