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.