Breast disorders module

Introduction:

Women may present with multiple breast symptoms, including pain, masses, skin or nipple changes, or lumpiness.  Many of these may be from benign causes such as infection, cysts, hyperplasia, or fibroadenoma. 

History:

Important questions to ask about in the history include the nature of the symptom, presence of nipple discharge, and cyclical nature.  You should inquire about any prior pathologic diagnoses, the presence of hormonal therapy, and risk factors for breast cancer (family history, age, early age menarche, late age at first pregnancy, late age at menopause, 20 kg weight gain after menopause.)  A history of fibroadenoma does confer an elevated risk of subsequent cancer. 

Physical Examination:

The physical exam of the breast is best done in the vertical strip pattern with the three middle fingers.  There should be 3 levels of palpation.  Abnormalities noted should be documented by either the quadrant method (upper, lower, outer, inner) or the clock method.  The size, shape, texture, and mobility should be noted.  A mass that sticks out from the background is called a "dominant mass" and deserves further work-up.  Further evaluation of breast symptoms may include repeat exam, mammography, ultrasound, fine needle aspiration, and referral for excisional biopsy, depending on the findings.  The best time to examine a breast, particularly if you are bringing patient back for a repeat exam, is during days 1-10 of menstrual cycle because they have the lowest hormone levels.  While patient is waiting to return for repeat exam, a symptom diary may be conducted. 

Diagnostic Testing of Breast Lumps:

All dominant masses should be referred to a surgeon.  Women older than 35 with dominant masses should undergo diagnostic mammography and frequently ultrasound prior to surgical referral.  When vague nodularity or thickening is present, the examination should be repeated at midcycle after one or two menstrual cycles, and women older than 35 should have a mammogram.  If the abnormality of a vague nodularity or thickening persists on repeat examination, the woman should be referred to a surgeon. 

Remember, if a palpable abnormality is noted, a normal mammogram is not the end of the work-up!!! 

Treatment for breast problems:

Cyclic breast pain usually occurs during the late luteal phase of the menstrual cycle, in association with PMS or independently and resolves at the onset of menses.  In the absence of mass or discharge, mild symptoms warrant reassuring the patient.  Correct bra fitting may provide pain relief for pendulous breasts.  Lowering the dose of estrogens in postmenopausal women on hormone therapy or the addition of an androgen may help.  Mild analgesics such as NSAIDS may help.  Other approaches include tamoxifen 10mg daily for 3-6 months or danazol 200mg daily or only during the luteal phase of the menstrual cycle. 

Nipple discharge:

Nipple discharge is distressing to the patient, but only 5% are found to have serious underlying disease.  It is considered to be pathologic if it is spontaneous, arises from a single duct, is persistent, and contains gross or occult blood.  A workup for galactorrhea includes prolactin and thyrotropin levels.  When galactorrhea is not present and the discharge is from one duct, particularly if it is grossly bloody or testing for occult blood is positive, more workup is needed.  Galactography can be done. 

Breast cancer risk:

The Gail and Claus models are commonly used means of estimating the risk of breast cancer and take into considerations risks such as early menarche, late menopause, and family history, etc. 

Breast density on mammographic screening is a risk factor, with an increase in relative risk by a factor of five for the highest density.  Dense breasts contain a higher proportion of stromal and glandular tissue as well as an increased number of lesions classified as usual ductal hyperplasia and atypical ductal hyperplasia. 

BRCA1 carriers have a 65% probability of developing breast cancer by 70, and BRCA2 carriers have a 45% probability. 

The role of MRI in the evaluation of breast lesions and in screening is being investigated. 

Breast cancer prevention:

Tamoxifen for 5 years can be offered as a preventive strategy in women with a 5 year risk of breast cancer of more than 1.67% and no contraindications to tamoxifen therapy.  More intensive screening with multimodality imaging may be required for high risk patients. 

Reference:

Santen RJ and Mansel R. Benign breast disorders. N Eng J Med 2005;353:275-85.