Disorders of the Breast

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APGO educational topic number 40
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disorders of the breast breast diseases
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encompass a broad spectrum of pathology
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from benign breast disease to breast
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cancer breast care often involves a
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multidisciplinary approach obstetrician
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gynecologists are often the first person
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that a woman consults for breast related
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signs and symptoms the objectives of
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this video are to list factors that
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place individuals at risk for breast
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disorders to describe symptoms and
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physical exam findings of benign or
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malignant conditions of the breast to
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demonstrate the performance of a
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clinical breast examination discuss the
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steps in the evaluation of common breast
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complaints of nostalgia mass nipple
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discharge and discuss initial management
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options for benign and malignant
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conditions of the breast let’s start
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with a review of breast anatomy here is
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the breast and it is organized into 12
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to 20 lobes with glandular or lobular
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tissues the lobules have clusters with
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secretory cells arranged in alveolar
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pattern and are surrounded by
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myoepithelial cells the glands drain
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into milk ducts with about five to ten
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collecting ducts that lead to or drain
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into the nipple typically breast cancer
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arises in the glandular or lobular unit
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of the breast and there is a
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disproportionate amount of glandular
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tissue in the upper outer quadrant of
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each breast
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this is why breast cancer most commonly
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arises in the upper outer quadrant in
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young women the breast consists
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predominantly of glandular tissue with
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age the glands involute and are replaced
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by fat and this process is accelerated
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by menopause the two most common
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complaints related to breasts are one
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pain and two concern about a mass it is
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important to take a careful history
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let’s review some risk factors for
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breast cancer age is the strongest risk
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factor a personal history of breast
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cancer an inherited genetic mutation
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such as brca1 or brca2 high breast
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tissue density a first-degree relative
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with breast or ovarian cancer diagnosed
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at an early age early menarchy late
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menopause no term pregnancies first
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pregnancy after the age of 30 and never
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having breast fed a complete breast
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examination should evaluate both breasts
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in a systematic fashion
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both axilla and the entire chest wall
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various techniques have been described
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for the palpation of breast tissue
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including circles wedges and line
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patterns of examination the best time to
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perform a breast examination is ideally
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in the follicular phase of the menstrual
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cycle let’s now discuss diagnostic
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testing mammography is an x-ray
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technique that is first line imaging for
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women older than 40 it is able to detect
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lesions approximately two years before
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they become palpable mammography can be
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screening or it can be a diagnostic test
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which involves additional views
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ultrasound is especially helpful for
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women younger than 40 and it is useful
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in evaluating inconclusive mammographic
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findings MRI is useful for women who are
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at extremely high risk of developing
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breast cancer for example BRCA carriers
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we will now discuss some common breast
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complaints starting with nostalgia or
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breast pain nostalgia can be cyclic or
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non cyclic the cyclic pain often
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involves the luteal phase of the
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menstrual cycle and the pain is often in
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the outer quadrants of the breasts
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non-cyclic nostalgia is not associated
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with the menstrual cycle and it can be
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associated with medications including
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antidepressants antihypertensive drugs
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and hormones it can also be associated
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with tumors mastitis cysts history of
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breast surgery or it can be idiopathic
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extra memory pain is pain that does not
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arise from the breast tissues and it can
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arise from chest wall trauma rib
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fractures shingles or fibromyalgia the
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non pharmacologic treatments for mast
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algae include a tight-fitting bra or
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sports bra weight reduction and regular
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exercise the only fda-approved
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medication for nostalgia is Dan Issel
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but this medication has significant side
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effects moving now to nipple discharge
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it is important to ask the patient if
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the discharge is spontaneous or
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expressed if it’s bilateral or
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unilateral Yoona ductile or multi
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ductile and the color whether it’s white
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green yellow clear or bloody and is
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there a mass present or not benign
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processes cause non spontaneous non
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bloody green yellow or brown discharge
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that can be bilateral bloody unilateral
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nipple discharge would be more
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concerning for cancer and the next step
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would be a breast duct ography let’s now
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discuss the breast mass characteristics
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of the mass that suggest malignancy or
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size
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greater than two centimeters in mobility
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having poorly defined margins firmness
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having skin dimpling or color changes
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retraction or changes in the nipple
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bloody nipple discharge and EPSA lateral
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lymph adenopathy if the mass appears
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suspicious then the next step will be a
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biopsy and this is usually a core needle
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biopsy there are three histological
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categories of benign breast masses the
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classifications are based on the degree
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of cellular proliferation and a tibia
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non proliferated masses have a relative
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risk of developing breast cancer of one
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these are fibrocystic changes
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fibroadenomas cysts fibrosis and AD
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enosis the masses that are found to be
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proliferative without atypia have a
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relative risk of developing breast
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cancer of 1.5 to 2 these include
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epithelial hyperplasia sclerosing at
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enosis complex sclerosing lesions and
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papillomas the third category is
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proliferative with atypia
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if the cells have atypical hyperplasia
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the relative risk of developing breast
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cancer is 3.7 to 5.3 there is atypical
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ductal hyperplasia or ADH and atypical
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lobular hyperplasia or a LH lobular
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carcinoma in situ is sometimes
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classified in the proliferative with
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atypia category it is a non invasive
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lesion that carries a risk of breast
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cancer in the ipsilateral or the
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contralateral breast with a relative
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risk of two moving now to management if
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the core needle biopsy demonstrates
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atypical ductal hyperplasia atypical
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lobular hyperplasia or lobular carcinoma
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in situ then a surgical excision is
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needed to avoid underestimation of the
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diagnosis if the diagnoses are confirmed
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the next steps will be close
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surveillance lifestyle and diet changes
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and chemo prevention is an option with a
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selective estrogen receptor modulator we
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will conclude by discussing breast
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cancer it is the second most common
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malignancy and women and is the second
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leading cause of cancer-related death in
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women there are three histological cell
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types of breast cancer ductal lobular
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and nipple and 70 to 80 percent of
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cancers are ductal in origin treatment
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of breast cancer often involves both
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surgical and medical therapies surgical
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therapy options include lumpectomy and
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radiation or mess
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to me and medical therapy options
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include chemotherapy and hormonal
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therapies this concludes the aapko video
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on breast disorders we have discussed
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important risk factors symptoms and
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physical exam findings of benign and
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malignant conditions of the breast