breast tumors

1. Disorders of the Breast
UNC School of Medicine
Obstetrics and Gynecology Clerkship
Case Based Seminar Series

2. Objectives for Disorders of the Breast
 Describe the symptoms and physical examination
findings of benign or malignant conditions of the breast
 Demonstrate the performance of a clinical breast
examination
 Discuss the steps in evaluation of common breast
complaints: mastalgia, mass, nipple discharge
 Discuss the initial management options for benign and
malignant conditions of the breast

3.  Primarily adipose tissue, glandular tissue, and
suspensory ligaments
 Composed of 15-25 radially arranged lobes of
parenchyma, each associated with a major lactiferous
duct
 Each major duct extends from the nipple to terminate
in a “terminal duct-lobular unit” via branching ducts of
diminishing caliber
Breast Anatomy

4. Breast Anatomy
Ruan, W, Kleinberg, DL. Endocrinology 1999; 140:5075. Copyright © 1999 The Endocrine Society.

5.  History:
 Change in general appearance of breast (size, symmetry)
 New or persistent skin changes
 New nipple inversion
 Breast pain (cyclic vs. noncyclic, duration, location in breast)
 Breast mass (how it was discovered, duration, change in size, location)
 Relationship of mass to menstrual cycles
 Nipple discharge (unilateral vs. bilateral, color)
 Medications (e.g. hormones)
 Risk factors for breast cancer
Evaluation: History

6.  Risk Factors vs. Protective Factors
Evaluation: History
Risk Factors Protective factors
BRCA1 and BRCA2 Breastfeeding
1˚ relative with breast or ovarian cancer Parity
Personal history of breast disease Recreational exercise
Age > 70 yrs Postmenopause BMI < 23
Age at menarche < 12 yrs Oophorectomy at < 35 yrs
Nulliparous or age at first birth > 30 yrs Aspirin
Never breastfed
Age at menopause > 55 yrs
Use of OCP’s
HRT (estrogen + progestin)
Radiation exposure to chest
EtOH

7.  Clinical Breast Exam:
 Inspect (relaxed, arms raised, hands on hips)
 Breast symmetry
 Skin changes (dimpling, retraction, edema, ulceration)
 Nipples (symmetry, inversion/retraction, discharge)
 Palapation (breasts, axillae, entire chest wall)
 Pain
 Masses
 Regional lymph nodes (Axillary and Supraclavicular)
 Documentation
 “Clock” system
 Location of concern and abnormality
 Distance from areola
 Size of mass
Evaluation: Physical Exam

8.  Clinical Breast Exam:
Evaluation: Physical Exam
Use pads of the index, third,
and fourth fingers (inset)
make small circular motions
Make three circles with the finger
pads, increasing the level of
pressure (subcutaneous, mid-level,
and down to the chest wall) with
each circle
Position the patient in the
direction of palpation for the
CBE.
Sanslow, D, et. al. Clinical breast examination” practical recommendations for optimizing performance and reporting. CA Cancer J Clin.
2004 Nov-Dec; 54(6): 327-44

9. Benign vs. Malignant
Chief Complaint Benign Characteristics Malignant Characteristics
Breast mass Multiple lesions Single lesion
“Rubbery” Hard
Mobile Immovable
Well circumscribed border Irregular borders
Nipple discharge Bilateral Unilateral
Multiductal Uniductal
Milky Bloody, Clear, or Colored
Spontaneous
Persistent
Skin changes Retraction
Dimpling
Thickening

10.  Benign
 Nonproliferative
 Fibrocystic changes
 Simple cysts
 Lactational adenoma
 Fibroadenoma
 Hyperplasia without atypia
 Epithelial hyperplasia
 Sclerosing adenosis
 Intraductal papillomas
 Hyperplasia with atypia
 LCIS
 DCIS
Breast Disease
 Malignant
 Ductal carcinoma
 Lobular carcinoma
 Tubular carcinoma
 Mucinous carcinoma
 Micropapillary carcinoma
 Metaplastic carcinoma
 Inflammatory carcinoma

11.  Approximately 45% of women have mild breast pain,
and 21% have severe breast pain in their lifetime
 Breast cancer is found in 1.2 – 6.7% of women
presenting with breast pain
Mastalgia: Incidence

12.  Differential Diagnosis:
 Cyclic
 Cyclic mastalgia
 Fibrocystic disease
 Non-cyclic
 Large pendulous breasts
 Diet, lifestyle
 Mastitis
 Hormone replacement therapy
 Ductal ectasia
 Inflammatory breast cancer
 Extramammary (non-breast) pain
Mastalgia: Etiology

13.  History
 Unilateral vs. bilateral
 Cyclic vs. noncyclic
 Systemic or local symptoms (e.g. erythema, fever)
 History of trauma
 Clinical breast exam
 Evaluation
 Ultrasound
 Mammogram
Mastalgia: Evaluation

14.  Cyclic mastalgia
 Normal hormonal changes
 Particularly luteal phase of menstrual cycle
 Fibrocystic disease
 Increased fibrous or cystic tissue
 Pendulous breasts
 Stretching of Cooper’s ligaments
Mastalgia: Evaluation

15.  Fibrocystic disease
 Premenopausal women
 Premenstrual breast swelling/tenderness
 Nodules/masses/lumps related to dense breast tissue or cysts
Mastalgia: Fibrocystic Disease
 Fibrous tissue  Cystically dilated ducts
 + Calcifications
 + Ductal hyperplasia

16.  Treatment:
 Lifestyle
 Eliminate caffeine
 Low fat diet
 Symptomatic
 Support garments (well-fitting, supportive bra, sports bra)
 Compresses
 Medication
 NSAID’s
 OCP’s, Progestogens
 Danazol
 Bromocriptine
 GnRH agonists
 Tamoxifen - IF severe mastalgia
Mastalgia: Management

17.  Presentation
 Usually seen in breastfeeding mothers
 Unilateral, swollen, wedge-shaped area of breast
 Pain, redness, induration (hardening)
 Systemic symptoms (high fever, malaise, chills)
 Treatment
 Rest, fluids
 Dicloxicllin 500mg QID x 10-14d
 Continue frequent breast feeding
Mastalgia: Mastitis

18.  Inflammatory breast cancer
Mastalgia: Inflammatory Breast Cancer
 Peau d’orange-dimpling of involved skin due to
retraction caused by lymphatic involvement and
obstruction
 Associated erythema
 Cellulitis may mimic inflammatory carcinoma

19.  More than 90% of palpable breast masses in women
in their 20’s to early 50’s are benign
 Differential Diagnosis:
 Fibrocystic changes
 Fibroadenoma
 Fat necrosis
 Phyllodes tumor
 Intraductal papilloma
 Breast cancer
Breast Mass: Etiology

20.  History
 How it was discovered
 Duration
 Change in size
 Location
 Relationship of mass to menstrual cycles
 Clinical breast exam
Breast Mass: Evaluation

21.  Fibroadenoma
 Solitary, firm, rubbery, mobile mass
 Women < 30 yrs
 Slow growing (? hormonally mediated)
Breast Mass: Fibroadenoma
Fibroadenoma gross specimen
 Firm, tan, lobulated
 Well circumscribed mass
 Variable size

22.  Intraductal papilloma
 Unilateral bloody nipple discharge
 Sub-areolar intraductal mass
Breast Mass: Intraductal Papilloma
Intraductal papillary neoplasm
with fibrovascular cores lined
by benign ductal and
myoepithelial cells
Duct
excision

23.  Fat Necrosis
 Caused by trauma
 Tender, firm mass with indistinct borders
 May appear suspicious on physical exam
 Benign breast calcification seen on mammography
Breast Mass: Fat Necrosis
Fat necrosis manifesting as a
spiculated mass
Densely calcified 3-cm area of fat
necrosis 2 years after blunt
trauma to the breast.

24.  Initial evaluation
 < 30 yr – Diagnostic ultrasound + Diagnostic mammogram
 > 30 yr – Diagnostic mammogram
 Further evaluation
 Simple cyst
 Symptomatic – Aspirate
 Asymptomatic – Observe for 2-4 months
 Complicated cyst – Ultrasound-guided aspiration
 Solid mass – Core needle biopsy (CNB) or Excision
 No specific findings – Re-examine after two cycles
Breast Mass: Evaluation

25. Breast Ultrasound

26. Fibroadenoma
Breast Cancer
Mammogram

27.  Etiology
 Lactation
 Physiologic nipple discharge
 Hyperprolactinemia
 Hypothyroidism
 Medication related
 Neurogenic stimulation
 Pathologic
 Intraductal papilloma
 Ductal ectasia
 DCIS
Nipple Discharge: Etiology

28.  History
 Unilateral vs. bilateral
 Spontaneous vs. provoked discharge
 Appearance of discharge
 Medications (e.g. antipsychotics, antidepressants)
 History of trauma
 History of amenorrhea
 History of hypogonadism (e.g. hot flashes, vaginal dryness)
 Clinical breast exam
 Attempt to elicit discharge, identify involved duct(s)
 Evaluate discharge for gross blood or guaiac positivity
Nipple Discharge: Evaluation

29.  Initial evaluation:
 Breast ultrasound
 Mammogram
 IF woman > 30 yrs
 Multiductal discharge
 UPT, Prolactin, TSH
 Further evaluation:
 Ductography
 Ductoscopy
 MRI
Nipple Discharge: Evaluation
Ductogram

30.  Management
 Physiologic nipple discharge
 Directed at underlying cause
 Pathologic nipple discharge
 Refer to surgeon
 Terminal duct excision
 Central (total) terminal duct excision
 Resection of intraductal papilloma
Nipple Discharge: Management

31.  Pathologic finding on CNB or excision biopsy
 DCIS/LCIS
 Invasive carcinoma
 Refer to surgical oncologist
 Treatment modalities:
 Radiation
 Chemotherapy
 Lumpectomy
 Mastectomy
 Hormonal therapy
Malignant Breast Disease

32. Bottom Line Concepts
 It is important to evaluate breast complaints thoroughly to ensure that breast
cancers, as well as benign breast lesions, are diagnosed and treated promptly.
 Evaluation of a woman presenting with a breast complaints requires careful
assessment of symptoms and risk factors for developing breast cancer.
 The clinical breast exam include inspection and palpation of the breast tissue,
chest wall, and regional lymph nodes. Documentation should included both
positive and negative findings.
 Women with breast problems can present with any combination of symptoms
including breast mass or thickening, breast pain, nipple discharge, or skin
changes.
 Typically, women presenting with a suspicious breast mass who are > 30 yrs
should receive a diagnostic mammogram, whereas women younger than 30
should receive a diagnostic ultrasound.
 Negative imaging should not stop further investigation is a suspicious lump is
felt on clinical exam.
 Masses that are solid on ultrasound imaging require biopsy to exclude cancer
and provide a histological diagnosis.

33. References and Resources
 APGO Medical Student Educational Objectives, 9th
edition, (2009),
Educational Topic 40 (p84-85).
 Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010),
Charles RB Beckmann, Frank W Ling, Barabara M Barzansky, William
NP Herbert, Douglas W Laube, Roger P Smith. Chapter 31 (p283-294).
 Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and
Gynecology, 5th edition (2009), Neville F Hacker, Joseph C Gambone,
Calvin J Hobel. Chapter 29 (p326-331).