Breast Masses

Erin Snyder=

July 26th, 2007

A 36 year old= Female presents to your office with complaints of a breast mass.

What is your differential diagnosis?

Fibrocystic breast disease, Fibroadenoma, Malignancy, = Benign cyst, Abscess

What are the = classic characteristics of a malignant breast mass?

Physical exam= : Single, firm, immobile lesion; Irregular borders; Size > 2cm;

Associated lymphadenopathy, skin or nipple thickening = or retraction

Mammogram: increased density; Irregular margins; Spiculation; Clustered irregular microcalcifications

She reports t= hat the mass is painless, and she first noticed it 2 months ago. It has not changed in that time. On physical exam, you note a mobil= e, 3 cm mass in the upper outer quadrant of her left breast. There is no axillary lymphadenopat= hy.

What is your differential dx now? Fibroadenoma, cyst, malignancy.

Fibroadenoma is the second most common type of benign = breast disease (after fibrocystic breast disease). Fibroadenomas are typically firm, = small, isolated, and slow growing. T= he size of the mass does not typically change with menstrual cycle. There is no increased risk for bre= ast cancer in patients with simple fibroadenomas. More complex masses, with cysts, calcifications, or glandular changes are associated with increased relative risk of breast cancer.

How will you = evaluate this mass? Mammogram init= ially, followed by ultrasound if mass is difficult to visualize. If mass is solid, FNA or core needle biopsy should be done. If the mass is a simple cyst, it could be aspirated, or followed closely.

How would your evaluation change in a 24 year old woman?

It is more likely to be benign fibroadenoma. If physic= al exam is not concerning, would repeat 3-10 days after next menstrual cycle.<= span style=3D'mso-spacerun:yes'> If mass is persistent, would get ultrasound, and proceed with biopsy as above.

A 25 year old= female presents with bilateral breast pain, worse just prior to her menses. <= /o:p>

What is your diagnosis? Fibrocystic breast disease.= Classic symptoms are cyclic pain, most frequently in the upper outer quadrants. Breasts may have increased engorgement and density. Cysts are palpable, and change throughout the menstrual cycle.

What are her treatment options?

Support: well fitted, tight bra for both day and night=

Diet: Decrease caffeine, tobacco, and fat, increase co= mplex carbohydrates. Most studies on these recommendations have been inconclusive.

Medications: Vitamin E, evening primrose oil. There have been studies on both wi= th mixed results

&nbs= p; OCPs/progesterone- Estrogen can make sx worse, but long term use of progesterone seems to help. Should use low dose OCPs in women with fibrocystic disease who desire oral contraception.

&nbs= p; Danazol: androgenic steroid, blocks the effect of estrogen on the breast. Effective in 50-90% of patients, b= ut side effects include weight gain, acne, hirsutism, amenorrhea Tamoxifen: SERM, anti-estrogen effects on breast tissue. Several studies report 70% of wome= n have decreased mastalgia after 3-6 months. Typical therapy limited to 6 months

Surgery: Mastectomy if pain is intractable after above therapy

A woman comes= to your office with complaints of nipple discharge.

What is the differential diagnosis? G= alactorrhea, intraductal papilloma/carcinoma, fibrocystic disease with intraductal component, mastitis, breast cancer.

Galactorrhea is bilateral, milky, non bloody discharge= . DDX of galactorrhea includes hypothyroidism, prolactinoma or functional hyperprolactinemia, chronic breast stimulation, medications (antipsychotics, methyldopa, OCPs).

The patient i= s a 34 year old with bilateral milky nipple discharge. Her youngest child is 4 years old. She also reports irregul= ar periods. On physical exam, yo= u are able to express the discharge from both breasts, but you do not feel any masses.

What evaluati= on needs to be done?

Check UCG, serum prolactin, TSH. Check discharge for occult b= lood.

If guiac is positive, there is more concern for malignancy. In that instance,= would send a sample of the discharge for cytology, obtain MMG, and get breast sur= gery evaluation. If the discharge = is guiac negative, etiology is more likely to be hormonal.

Sample is gui= ac negative; pt has negative pregnancy test and normal TSH. Prolactin is elevated on two occasions. What is the next s= tep in evaluation?

MRI brain to evaluate the pituitary gland. Can treat with a dopamine agonist (Cabergoline, Bromocriptine) to normalize prolactin levels. Surgery is indicated if hormone le= vels or symptom are not improved with dopamine agonists.

49 year old f= emale presents with unilateral, straw colored discharge from one nipple. She first noticed this 6 months ago. Physical exam is normal = and mammogram is negative.

What is the diagnosis? This is classic presentation for intraductal papilloma. 75% of papillomas are beneath the = areola and difficult to palpate, although they can grow to 2-3mm. Treatment/diagnosis is excisional = biopsy of the duct and surrounding tissue. &= nbsp; Intraductal papillomas are associated with an increase risk of the development of breast cancer.

References

Up to Date

Comprehensive Gynecology

Glass’s Office Gynecology

Nipple Discharge Algorithm

From Up To Date, 15.1