#164 Diagnosis and Management of Benign Breast Disorders Flashcards
What breast lesions are classified as nonproliferative type?
Simple cysts, mild hyperplasia (usual type), papillary apocrine change
What is the aggregate relative risk of future breast cancer with nonproliferative breast lesions?
No increased risk. RR 1.17 (0.94-1.47)
What breast lesions are classified as proliferative without atypia type?
Fibroadenoma, giant fibroadenoma, intraductal papilloma, moderate/florid hyperplasia (usual type), sclerosing adenosis, radial scar
What is the aggregate relative risk of future breast cancer with proliferative without atypia breast lesions?
Small-to-moderate increased risk. RR 1.76 (1.58-1.95)
What breast lesions are classified as atypical hyperplasia type?
Atypical ductal hyperplasia, atypical lobular hyperplasia
What is the aggregate relative risk of future breast cancer with atypical hyperplasia breast lesions?
Increased. RR 3.93 (3.24-4.76)
What is the aggregate relative risk of future breast cancer with lobular carcinoma in situ breast lesions?
Greatly increased. RR 6.9-11
What is the most common type of nonproliferative breast lesion?
Simple breast cysts
What proportion of women between 35-50 have to have a simple breast cyst?
up to 1/3
What is management for simple breast cysts?
Expectant vs aspiration if bothersome to the woman
What is seen on histology for breast mild hyperplasia of the usual type?
Focal thickening of the duct epithelial cell layers (four or fewer) that does not fill the duct
What is seen on histology of breast simple papillary apocrine change?
Focal thickening of the epithelial lining of an apocrine cyst
What is the most common cause of breast mass in adolescent girls and young women?
Fibroadenoma
What is the median age of presentation of women with fibroadenomas?
25yo
What percent of breast masses in menopausal women are fibroadenomas?
12%
What are typical characteristics of fibroadenoma?
Small (1-2cm), firm, well-circumscribed, mobile mass composed of a proliferation of epithelial and stromal elements
How can you distinguish a simple breast cyst from fibroadenoma?
Ultrasound is useful. Often similar on physical exam and mammography
What are giant breast fibroadenomas?
Generally >10cm. Unusual variant of juvenile and adult fibroadenomas. Histologically, benign lesions, composed of same epithelial and stromal elements as adult fibroadenomas, tend to have more florid glandular elements with great stromal cellularity
How do giant fibroadenomas present (breast)?
Enlarging masses that typically distort the breast, typically adolescents and young adults
What percent of fibroadenomas are giant fibroadenomas (breast)?
4%
What is seen on histology for moderate (AKA florid) hyperplasia of the usual type (breast)?
Multiple-duct epithelial cell layers (more than 4) that fill the entire duct, but do not have cytologic atypia.
How is sclerosis adenosis characterized (breast)?
Increased numbers of size of glandular components within lobular units
What are radial scars (breast)?
pseudoproliferative lesion and usually are incidentally found on biopsy
What is the management of radial scars and why (breast)?
Excision. May harbor or facilitate the development of atypical proliferations
What are intraductal papillomas?
Tumors in a lactiferous duct that may be solitary and centrally located near the duct opening or multiple and peripherally located in the breast
How do intraductal papillomas present?
Solitary papillomas can present as nipple discharge (blood, serous, or clear), or, less often, as a palpable mass. Women aged 30-50yo, typically 2-4mm
What is the risk of coexisting or subsequent breast cancer in women with multiple peripheral intraductal papillomas
One third
What are the histologic characteristics of atypical ductal hyperplasia?
Ductal elements with uniform cells and loss of apical-basal cellular orientation
What are the histologic characteristics of atypical lobular hyperplasia?
Lobular elements with uniform cells and loss of apical-basal cellular orientation
How do tubular adenomas present? Histology? (breast)
Can present as a breast mass or may be seen on routine breast imaging. Consists of benign glandular cells with minimal stromal elements.. Tissue bx required for diagnosis
What percentage of breast tumors are phyllodes tumors?
0.3-0.5%
What percent of phyllodes tumor exhibit aggress sarcomatous behavior?
5%
What is the median age at presentation for phyllodes tumor?
40yo
What is the usual presentation for phyllodes tumor?
Single enlarging breast mass
What are physical characteristics of phyllodes tumor?
Larger than other fibroadenomas, but are firm, circumscribed, and mobile. Rapid growth causes stretching of overlying skin
True or false: phyllodes tumor has high risk of local recurrence?
True
True or false: lobular carcinoma in situ is a precursor lesion for breast cancer?
False, it is a risk marker for future development of breast cancer
What is the 15 year risk of developing invasive ductal or invasive lobular breast cancer after LCIS diagnosis?
10-20%
True or false: nipple discharge is most often associated with malignancy?
False
What are the characteristics of benign nipple discharge?
More likely to be bilateral, only present when expressed, milky or green in color, multiductal
What characteristics of nipple discharge are more concerning for malignancy?
Unilateral, uniductal, and spontaneous
What are causes of non-cyclic mastalgia?
Mastitis, trauma, thrombophlebitis (Mondor disease), cysts, tumors, and cancer
What are extramammary causes of mastitis?
Costochondritis, chest wall trauma, rib fractures, fibromyalgia, cervical radiculopathy, herpes zoster, angina, GERD, pregnancy
How are nonpuerperal breast infections separated?
Periareolar and peripheral infections
What are most cases of mastitis related to?
Lactation (puerperal mastitis)
What is a risk factor for periareolar infection?
Smoking
How is periareolar infection characterized?
Inflammation around nondilated subareolar ducts. Periareolar inflammation and can have an abscess.
What are peripheral infections associated with (breast)?
Trauma and conditions that impair immunity (eg diabetes, steroid use, RA, granulomatous lobular mastitis)
How does mammary duct ectasia present clinically?
Nipple discharge, nipple inversion, palpable subareolar mass, noncyclic mastalgia, or infection
How is mammary duct ectasia managed?
Conservatively, does not require surgery
At what age does mammary duct ectasia occur?
Middle-aged and elderly women
How does mammary duct ectasia present on mammogram?
Microcalcifications
How does Paget disease of nipple clinically present?
Ulcerated, crusted, or scaling lesion on the nipple that can extend to the areola. Nipple can be retracted or hyperpigmented. Patient may have pain, burning, itching.
What does BI-RADS 0 mean?
Incomplete. Need additional imaging evaluation
What is BI-RADS 1? Likelihood of malignancy?
Negative. Essentially 0% likelihood of malignancy
What is BI-RADS 2? Likelihood of malignancy?
Benign. Essentially 0% likelihood of malignancy.
What is BI-RADS 3? Likelihood of malignancy?
Probably benign. >0% but less than or equal to 2% likelihood of malignancy
What is the recommended follow up for BI-RADS 3? (for mammo, ultrasound, MRI)
Short-interval (6 month) follow-up or continued surveillance
What is the recommended follow up for BI-RADS 0?
Recall for additional imaging
What is BI-RADS 4? Likelihood of malignancy?
Suspicious. >2% but <95% likelihood of malignancy
What is recommended follow up for BI-RADS 4?
Tissue diagnosis
What is BI-RADS 4A? Likelihood of malignancy?
Low suspicion for malignancy. >2% to less than or equal 10% likelihood of malignancy
What is BI-RADS 4B? Likelihood of malignancy?
Moderate suspicion for malignancy. >10% to less than or equal to 50%
What is BI-RADS 4C? Likelihood of malignancy?
High suspicion for malignancy. >50% to <95% likelihood of malignancy
What is BI-RADS 5? Likelihood of malignancy?
Highly suggestive of malignancy. Greater than or equal to 95% malignancy.
What is recommended follow up for BI-RADS 5?
Tissue diagnosis
What is BI-RADS 6?
Known biopsy-proved malignancy
What does BI-RADS stand for?
Breast Imaging Reporting and Data System category
Next step in management for palpable mass in woman younger than 30, with clinical suspicion for malignancy?
Ultrasound
Next step in management for palpable mass in woman younger than 30, with low clinical suspicion for malignancy?
Observe for 1-2 menstrual cycles, if mass persists > ultrasound
Next step in management for palpable mass in woman 30 years or older?
Diagnostic mammography
What are options for histologic evaluation (techniques to get specimen) of abnormal findings on diagnostic breast imaging?
- Fine needle aspiration
- Core needle biopsy
- Excisional biopsy
What patients need excisional breast biopsy?
- Lesion not amenable to stereotactic or US-guided bx (location, imaging characteristics, impants)
- Certain histologic findings on core needle bx (atypical hyperplasia, flat epithelial atypia, LCIS, mucinous tumors, possible phyllodes tumors, and radial scars)
- If core needle bx nondiagnostic or discordant with clinical examination or imaging findings
What is the next step in management if woman presents because of a breast mass, but patient and physician unable to identify the mass?
Clinical follow-up examination is recommended
When can you discard the cyst fluid aspirated from a BI-RADS 3 cyst? What if does not meet criteria for discard?
When fluid is not bloody and the mass resolves with aspiration. If doesn’t meet criteria then image-guided aspiration, core needle biopsy, or excision of mass is indicated.
Can you aspirate BI-RADS 4-5 cysts?
No, require biopsy
How is mastalgia associated with cancer typically described?
Unilateral, intense, noncyclic, progressive
What is Mondor disease?
Superficial thrombophlebitis of lateral thoracic vein, a rare condition that causes noncyclic breast pain and tenderness.
What are the typical physical findings in Mondor disease?
Palpable cord, initially red and tender and subsequently is accompanied by linear skin dimpling. [Mondor disease = superficial thrombophlebitis of lateral thoracic vein]
What work up should be done for Mondor disease?
Age-appropriate breast imaging. Association with breast cancer. [Mondor disease = superficial thrombophlebitis of lateral thoracic vien]
What is the only medication with FDA approval for treatment of mastitis?
Danazol
What pharmacologic agents can be considered to treat mastalgia?
NSAIDs, tylenol, Danazol, continuous OCPs (if cyclic pain), tamoxifen, bromobriptine
How is breast atypical hyperplasia managed? Why?
Surgical excision. Either DCIS or invasive cancer is detected at the time of surgical excision in 10-20% of cases. Risk-reduction therapy strongly recommended: include tamoxifen, raloxifene, aromatase inhibitors
What are screening recommendations for women with breast atypical hyperplasia?
Annual mammography, clinical breast exam q6-12mo, breast self-awareness. Annual MRI can be considered for 30yrs or older.
How is lobular carcinoma in situ managed? Initial, further screening, role for further medical management?
Excision to rule out adjacent more serious lesions such as DCIS or invasive carcinoma. Screening: annual screening mammography and clinical breast exam every 6-12mo, but not before age 30; consider annual MRI. Recommend risk-reduction therapy: tamoxifen, raloxifene, aromatase inhib. Prophylactic mastectomy is an option.
Would you offer prophylactic mastectomy to patient with LCIS?
Is a possible option.
What medications are associated with galactorrhea?
Phenothiazines and other antipsychotics, metoclopramide, domperidone, methyldopa, reserpine, verapamil, and combined oral contraceptives
True or false, a small amount of expressible clear discharge from the female nipple is physiologically normal?
True
True or false, all women presenting with spontaneous, unilateral, uniductal nipple discharge (clear, serous, or bloody) should be worked up with ultrasound?
True. Women over 30 should also get diagnostic mammography
For women with BI-RADS 1-3 imaging with work up for persistent, spontaneous, unilateral, single duct nipple discharge (serous, sanguineous, or serosanguineous) what is the next step?
Duct excision
What organism is most common in puerperal infectious mastitis?
Staphylococcus aureus
What organisms cause infectious mastitis?
Staph aureus, streptococcus, staph epidermidis, enterococcus, and anaerobes
How do you treat skin-associated breast infections in nonlactating women?
Treat empirically with amoxicillin and clavulanic acid or for PCN allergic patients, erythromycin and metronidazole
How should you treat a breast abscess?
Aspiration or incision and drainage, with culture to guide antibiotic therapy
What is the typical presentation of a patient with inflammatory breast cancer?
Pain, progressive breast tenderness, and skin discoloration (erythema, “bruising”) and often have a firm and enlarged breast
What is the work up for suspected inflammatory breast cancer?
Diagnostic mammography and ultrasound are appropriate first steps, and a punch biopsy of breast skin when findings suggestive of malignancy and not responsive to antibiotic therapy
How does periductal mastitis present?
Focal inflammation of the periareolar area and may be accompanied by abscess formation or even mammary duct fistula. Usually seen in young smokers, may be recurrent
What is the treatment for periductal mastitis?
Empiric antibiotics including anaerobic coverage, and supported by culture results if available. Ultrasonography should be performed and abscesses should be aspirated or I+D’d
What percentage of cases of Paget disease are associated with an underlying invasive breast carcinoma or DCIS?
85%
