04-21 PATH: Benign Mammary

Question 1

Risk Factors for Developing Breast Cancer

• Direct Risks
• Vulnerability Factors
• Contributing Factors

Answer 1

Direct Risks

• radiation exposure
• inherited mutations

Vulnerability Factors

• early menses
• late menopause
• no preg or lactation

Contributing Factors

• lack of exercise
• excess EtOH
• obesity
• ?def of Vit D, fiber, melatonin
• harmful xenohormones
• ↑ IGF

The majority of patients will have no significant risk factors for cancer other than gender sex?

Question 2

Pt w/ breast pain

• What board categories does the clinician first distinguish between?

Answer 2

• Cyclic Breast Pain
• Non-Cyclic Breast Pain
• Extra-Mammary Pain

Question 3

Cyclic Breast Pain

• Presentation
• Prevalence/Population affected
• Work-Up?

Answer 3

• Diffuse, bilateral pain (4 out of 10)
  
  • Upper, outer breast, can radiate to axilla
  • usually week leading up to menses
• 10% of pre-meno women
  
  • usually starts age 30s-40s
• Work-Up: check for focality, masses, discharge, dimpling, inversion of nipple, etc.
  
  • If nl P.E. → Rx ibuprofen prn
  • No add’l eval needed
• If focal pain or positive P.E.
  
  • focused P.E.
  • U/S
  • consider diagnostic mammo if > 25-30 y/o
    
    • low yield in younger women b/c of tissue density
    • “snowflake in a blizzard”

Question 4

Non-Cyclic Breast Pain

• Presentation
• Prevalence/Population affected
• DDx

Answer 4

Presentation: unilateral, localized to one quadrant

Population: usu woman in her 40s-50s

Differential

• often idopathic
• trauma
• Mondor’s syndrome (thrombophlebitis of chest wall)
• mastitis (Even when lactating)
• meds
• benign tumor
• cancer

Work-Up: check for focality, masses, discharge, dimpling, inversion of nipple, etc.

• If nl P.E.:
  
  • Rx ibuprofen prn
  • No add’l eval needed
• If focal pain or positive P.E.
  
  • focused P.E.
  • U/S
  • consider diagnostic mammo if > 25-30 y/o
    
    • low yield in younger women b/c of tissue density
    • “snowflake in a blizzard”
  • Bx even if imaging is nl if physical is highly suspicious

Question 5

DDx for Extramammary Breast Pain

Answer 5

• Musculoskeletal
  
  • Costochondritis
  • Chest wall pain
  • Fibromyalgia
  • Cervical radiculopathy
  • Shoulder pain
• Herpes zoster
• Pulmonary embolism
• Pleurisy

Question 6

Relative breakdown of breast biopsy findings

• Rate of progression to cancer

Answer 6

Benign lesions (40%)

• Non-prolif lesions
  
  • FCC no ↑ risk of ca

​

• Prolif lesions w/o atypia
• 1.5-2X ↑ risk of ca
  
  • ​Epithelial hyperplasia (moderate or severe)
  • Sclerosing adenosis
  • Complex sclerosing lesion (radial scar)
  • Papilloma (single or multiple)
• Prolif lesions w/ atypia
• 4-5 ↑ risk of ca
  
  • ADH (Atypical ductal hyperplasia)
  • ALH (Atypical lobular hyperplasia)
  • FEA (Flat epithelial atypia)

Benign tumors (25%)

• Fibroadenoma
• Hamartoma

Malignant tumors (25%)** (99% carcinoma)

• Non-invasive carcinomas [DCIS, LCIS] (25%)
  
  • 8-10X ↑ risk of ca
• Invasive carcinomas (75%)

Other – infection , trauma, inflammatory (10%)

Question 7

If a woman’s biopsy came back positive for a high-risk pre-malignant lesion:

• Remind me which those are
• How would you advise the woman?

Answer 7

High-risk pre-malig are:

• ADH
• ALH
• FEA
• LCIS

Advise

• recommend repeat surgery to make sure you didn’t miss a “chocolate chip” (i.e. full-on malig lesion)
• If that’s neg recommend:
  
  • 2x/yr manual exam
  • annual mammos
  • consider MRI
  • consider tamoxifen
  • consider proph masectomy
    
    • bilat if LCIS b/c risk is equal on contralateral side

Question 8

Fibroadenoma

1. Typical presentation of correct answer?
2. Radiologic Findings?
3. Path Findings?
4. Management?

Answer 8

FIBROADENOMA

Presentation:

• usually present < 30 years
• Classic presentation firm, mobile lump (“breast mouse”)
• Giant forms can occur, especially in younger patients

Radiologic Findings

• U/S: hypoechoic (dark) w/pseudocapsule
• Mammo: soft density w/ popcorn calcs

Path Findings

• Proliferating stroma compressing adjacent acinar epithelial structures

Management

• Bx to r/o phyllodes
• Monitor to ensure stability
• Excise if: huge (>4cm), painful, young ♀ who wants babies
  
  • (gets bigger w/ pg hormones)

Question 9

67 y/o female presents w/ a 3 wk h/o spontaneous, unilateral, bloody nipple discharge from the left breast. The most likely diagnosis is:

• a. Intraductal papilloma
• b. Invasive ductal carcinoma
• c. Phyllodes tumor
• d. Fibroadenoma

Question 10

A 34 y/o female presents with “multiple breast lumps” and right breast pain. Pertinent questions when taking a history include all of the following EXCEPT:

• a. Family history of breast cancer
• b. Age of menarche
• c. Tobacco use
• d. Duration of symptoms

Answer 10

C - tobacco use is not associated w/ breast cancer

Question 11

1. 19 yo female presents with a palpable left breast mass. The most likely diagnosis is:
   
   • a. Intraductal papilloma
   • b. Invasive ductal carcinoma
   • c. Phyllodes tumor
   • d. Fibroadenoma

Answer 11

d. fibroadenoma

Question 12

How would you counsel a patient with LCIS on core biopsy in the clinic?

• a. Recommend right mastectomy
• b. Recommend radiation therapy
• c. Discuss increased lifetime risk for the development of breast cancer
• d. Discuss the need for genetic counseling

Answer 12

• I think*:
  c. Discuss increased lifetime risk for the development of breast cancer

Question 13

Nipple Discharge 101

Answer 13

blood - worrisome
clear - usually benign but w/u
green - physiologic, no w/u req’d

Question 14

Nipple Discharge

• DDx
• Work-Up
• Management

Answer 14

NIPPLE DISCHARGE

DDx

• Intraductal papilloma
• DCIS
• Invasive carcinoma
• Fibrocystic change
• Ductal ectasia
• Pagets disease

Work-Up

• Mammo
• Targeted retro-areolar ultrasound
• ?MRI

Management

If imaging reveals a lesion:

• percutaneous biopsy of mass

If imaging nl w/ persistent bloody, yellow or clear discharge:

• Total duct excision to exclude occult carcinoma

Question 15

Review histology in PPT

Answer 15

ok?