Transcript Benign Breast Disease

Benign Breast Disease
Jennifer L. Ragazzo, M.D.
Department of Obstetrics and Gynecology
Division of Women’s Primary Healthcare
March 31, 2009
Objectives
 Review breast anatomy and
development
 Understand the strategies used to
workup common breast complaints
 Know the most common causes of
benign breast disease
Anatomy of the breast
 Boundaries
 2nd and 6th ribs
 Sternal edge and midaxillary line
 Tail of Spence
 Primarily adipose tissue, glandular tissue,
and suspensory ligaments
 Mammary gland is a modified sweat gland –
15-20 gland lobules drain into 15-20
lactiferous ducts which open onto the nipple
Anatomy of the breast
 Blood supply
 Mainly from internal mammary artery
 Lateral thoracic arteries
 Innervation
 Via intercostal nerves 2-6
 Long thoracic nerve – “winged scapula”
 Lymphatic drainage
 Axillary nodes primarily
 Also parasternal, clavicular, and inguinal nodes
Breast development
 Breast tissue undergoes growth, proliferation
and differentiation during
 Puberty
 Pregnancy
 Lactation
 This is a complex endocrine process
involving estrogen, progesterone, prolactin,
cortisol, insulin, thyroid, growth hormone
Approach to breast complaints
 History: relationship to menstrual cycles,
timing, medications particularly hormones,
risk factors for breast cancer
 Physical: breast masses, nipple discharge,
pain, axillary/supraclavicular lymph nodes,
skin changes, breast texture, breast
symmetry
 Further studies: Mammography, ultrasound,
needle aspiration, biopsy, ductography
Differential Diagnosis:
Based on Symptoms
 Breast Pain
 Nipple Discharge
 Palpable Lump
Breast Pain: Mastalgia
 Normal hormonal changes
 Particularly luteal phase of menstrual cycle
 60% of women
 Fibrocystic disease
 increased fibrous or cystic tissue
 Severe or prolonged pain
 Mastitis
 High fever and body aches post-partum
 Usually with pain, redness, induration
 Pendulous breasts
 Stretching Cooper’s ligaments
Treatment of Fibrocystic Disease
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Supportive Bra
NSAIDs
Avoid caffeine (and chocolate!) and nicotine
Low-fat diet
Vitamin E or Evening primrose oil
Medications
 Tamoxifen, Danazol, GnRH agonists, low dose
OCPs, bromocriptine
Nipple discharge
 Non-spontaneous, non-bloody, bilateral
discharge is likely benign
 Intraductal lesions (unilateral cause)
 Duct ectasia – inflammed clogged duct,
releasing thick green or black discharge
 Intraductal Papilloma – benign growth
projects into a milk duct. Can cause
bloody, sticky discharge.
*need to rule out malignancy*
Nipple Discharge: Galactorrhea
 Chronic breast stimulation
 Anything promoting prolactin release
 Medications (steroids, OCP’s), Hypothyroidism,
Chronic renal disease
 Anything inhibiting dopamine release (recall
dopamine is a prolactin-inhibiting factor)
 Medications (methyldopa, phenothiazines)
 Disease in hypothalamus/pituitary area
Breast lumps
 More than 90% of masses in premenopausal
women are benign
 Mammography is recommended in any
woman age 35 or older
 Ultrasound is preferred in women age 35 and
less
 All solid breast masses require biopsy
Breast lumps
 Fibrocystic changes – most common, not a disease
state, no increased cancer risk, solitary or multiple
cysts
 Fibroadenoma
 Firm, rubbery lump
 Age <30
 Growth probably hormonally mediated
 Intraductal Papilloma – can be evaluated by
ductography
 Fat necrosis
 Caused by trauma
 Tender, firm mass
Mammogram
Breast Cancer
Fibroadenoma
Breast Ultrasound
Ductogram
Papilloma