BREAST ISSUES: IF IT IS NOT CANCER, WHAT

IS IT?

Alexandra Easson, Assistant Professor

Department of Surgery, University of Toronto

Mount Sinai Hospital

Saira Rashid, Physician Assistant

Mount Sinai Hospital

OBJECTIVES

1. Explore common benign presenting breast complaints in primary care medicine

2. Develop an approach to investigate and distinguish between benign and malignant breast problems

3. Understand risk factors of breast cancer and provide guidance in whom to refer to a specialized breast clinic

DISCLOSURES

• None

BREAST HEALTH

• Breast cancer is the 2nd leading cause of cancer related death in

women (1st is lung cancer)

• 1/9 women in Canada will be diagnosed with breast cancer in their lifetime

• 1/27 women in Canada will die from breast cancer

• 1/100 women with a new breast lump before 40 will have breast cancer14

BREAST ISSUES: IF IT IS NOT CANCER, WHAT IS IT?

• Breast lumps

• Mastalgia

• Nipple discharge

• Non-palpable lesions on screening

• Other

CASE I

29 year old woman, G1P1 comes to family clinic with a chief complaint of feeling a lump in the Left breast

for last 2 months

R L

BREAST HEALTH HISTORY

• Routine medical history (HPI, PMHx, Meds/all)

• Age

• Lump: location, when first noted, change in size over time,

relationship with menstrual cycle, tenderness

• Pain: OPQRST, Cyclical vs. non-cyclical, associated

factors

• Nipple changes: spontaneous nipple discharge- color,

unilateral vs. bilateral

• Skin changes: eczema, dimpling, ulceration, color change

BREAST HEALTH HISTORY CONT’D

• Relevant gynecological history

• Age of menarche, menopause

• Parity, age of first pregnancy, breast feeding

• Relevant past medical history

• Previous breast disease- benign, malignant

• Recent breast trauma

• Family history

• Breast cancer: age of earliest diagnosis, BRCA status if known

• Social history: caffeine, smoking, stress

BREAST CANCER: RISK FACTORS

•Menarche <12 years

•Menopause >55 years

•Nulliparous OR age >35 at 1st delivery

•OCP or HRT >5 years

•Alcohol

•Prior RT exposure

•Hx of breast biopsy especially if atypical hyperplasia

•Hx for

breast/ovarian CA

•1st degree relative

with breast/ovarian

CA

•BRCA 1 or BRCA 2

mutation

•Age >50 years

•Gender (F)

•Obesity

•Ashkenazi Jews

Demographic

Medical

history

Reproductiv

e history

Medication/other

Risk factors

for breast CA

PHYSICAL EXAM

Breast Exam:

• Inspection: (sitting, leaning forward/raising arms and supine)

• Inspect for asymmetry, shape, skin changes, rash, dimpling, color change

Ideal time to examine-

the week after menses

(least engorgement)

BREAST EXAM CONT’D

Palpate infraclavicular, supra-

clavicular and axillary lymph

nodes

Palpate breast in vertical strip

pattern with middle three

fingers in light, medium, deep

pressure.

DOCUMENT, DOCUMENT , D O CU M E N T

Document easiest with a diagram: - breast side - size of lump (2D) - location on clock face - distance from areola (in cm) - Nodes (if palpable)

R L

+ve nodes

3 cm

2.5 cm x 2 cm

BREAST LUMPS

• Normal breast tissue is nodular in premenopausal

women

• Especially upper outer quadrant, infra-mammary

folds

• Breast tissue is dynamic- changes with menstrual

cycle

• Examine without patient demonstration

• If dominant, needs investigation

BREAST MASS: INVESTIGATIONS

• For all dominant masses, consider clinical context

Triple testing

I. clinical examination (Hx and PE)

II. imaging (Mammogram and US)

• Ultrasound- additional modality for dense

breast and/or for patient<30 years

III. Consider non surgical biopsy if uncertainty (Fine

Needle Aspiration FNA/Core Needle Biopsy CNB)

• (US guided CNB high sensitivity and specificity-

predicts100% of malignancies, comparable to

surgical biopsy)5

5 Brooke et al, American Family Physician. 2012

OBSP SCREENING GUIDELINES

• Women age 50-74, every 2 years

• Women age 30-69, identified as being high-risk, with annual

mammography and MRI screening

Who qualifies as high risk ?

• Are determined to be > 25% lifetime risk of breast cancer (at genetics

clinic)

• Known carriers of BRCA1 or BRCA2

• Are 1st degree relative of mutation carrier (BRCA1 or BRCA2)

• Have received chest radiation treatment before age 30

TO MAMMOGRAM OR NOT?

Brown 2017: retrospective look at 861 women, 30+ y/o with 935 lumps, that underwent mammogram and U/S6

• 858/935 (91.8%) were benign, 77/957 (8.2%) were malignant

• Of 77 malignant lumps, mammogram added clinical value in 27 (35%) by delineating extent of disease

• 0f 858 benign, mammogram added clinical value in 26 by confirming benignity

• 52/861 patients had incidental findings

• 29/52 picked up by mammogram requiring biopsy

• 23/52 picked up by U/S

• Mammogram identified 7 malignancies in incidental non-palpable lumps

• U/S identified 1.

6 Brown et al, American Journal of Roentgenology. 2017

MAMMOGRAM

• Images of mammogram

• Images of ultrasound

Image adopted from Bedford breast center: <www.bedfordbreastcenter.com>

MAMMOGRAM

3D MAMMO- TOMOSYNTHESIS

- 3D imaging allows

better cancer

detection by 10-30%

- Less overlap of breast

tissue seen

- Reduces call back for

further imaging

- Early detection

- Increased accuracy in

combination with 2D

mammo

ULTRASOUND

• Birads chart

INVESTIGATION

• Palpable mass benign mammogram and benign U/S 5

• Negative predictive value is 97-100%Brooke2010

• Re-examine patient, if still dominant mass, but imaging negative ,

refer

• Palpable mass benign imaging and FNA5

• negative predictive value is 99%

*Reassure patient and consider follow up *

5 Brooke et al, American Family Physician. 2012

QUESTION 1

1. In which age group is a new lump most likely to be

cancerous?

a) 20-30 years

b) 31-40 years

c) 41-50 years

d) 51-60 years

BREAST MASS

Differential diagnosis

Cysts

Fibroadenoma / phyllodes

Prominent fibrocystic change

Fat necrosis

Cancer

BREAST MASS: CYSTS

• More common > 35 years but ONLY in menstruating women (or if on

hormones post menopause)

• Account for 25% of all breast lumps 14

• ~7% of all women will present with breast cyst at some point3

• Ultrasound diagnostic

• Aspirate for diagnosis and symptomatic relief only

• Don’t send off for cytology unless

• Fluid is bloody OR

• Does not disappear completely with repeated aspirations

3 Brennan M, Houssami N, French J. Australian Family Physician. 2005

14 Ruth et al, Canadian Medical Association Journal. 2010

BREAST MASS: CYSTS

• If dominant mass

• Follow-up ultrasound and examination in 4-6 weeks

• Excision rarely necessary: Only if

• Recurs in same spot several times and is bothersome

• Bloody fluid

• Triple test doesn’t make sense

• If non palpable and seen on routine imaging, this is NORMAL, part of their normal breast health and will occur until menopause

• Can reassure patient

CYST ASPIRATION

Aspiration: Therapeutic, Immediately diagnostic, cost efficient

14 Ruth et al, Canadian Medical Association Journal. 2010

BREAST MASS: FIBROADENOMA

• Most common solid lesion in the breast

• Overgrowth of benign breast tissue 3, (Stromal and epithelium) of the lobule

• Accounts for 12% of all asymptomatic breast masses3

• Usually 15-35 years old, (Peak incidence 21-25 years)

• 20% unilateral, but may be multiple or bilateral

• Round/oval, mobile, non-tender, firm, rubbery, 1-2 cm, stable

• Doesn’t change with menstrual cycles, does not grow

• Involute in peri-menopausal period (may calcify)

• No increased risk of breast cancer

• risk of cancer controversial if complex, containing proliferative changes within the stroma

3 Brennan M, Houssami N, French J. Australian Family Physician. 2005

Breast mass: Fibroadenoma

BREAST MASS: FIBROADENOMA

On triple test

• Typical clinical exam/history

• Typical radiological appearance

• Consider biopsy

• No or minimal change in size over time

FIBROADENOMA: MANAGEMENT

If woman >40 years of age, consider excisional biopsy

If woman <40 years of age and benign on triple testing:

• Surgical excision

OR

• Ongoing clinical and Imaging surveillance

Fibroadenoma >3-4 cm, consider excisional biopsy regardless of

triple testing

BREAST MASS: PHYLLODES TUMOR

• Same clinical and imaging feature as a fibroadenoma

• Cannot be differentiated from fibroadenoma on FNA or CNB

alone: need the entire lesion

• Usually locally aggressive, rarely malignant

• Uncommon: < 1% of all breast tumors

• Remove anything solid > 2.5-3.0 cm or growing

• Negative margins

• Radiation therapy if high grade

BREAST MASS: PHYLLODES

Varghese 2017: Retrospective analysis of 92 patients with

median age 43, premenopausal with PT from 2005-201415

• 50% had giant PT (>10cm)

• All B, BL and M tumors had surgical excision and M PT had

RT

• Median duration for fu- 20months

• Total 3/16 of M PT had local recurrence, total 6/16 had

distant metastasis

• Conclusion: For Benign phyllodes, surgical resection with >1cm

margin, no recurrence

• For borderline and malignant PT, consider adjuvant

radiotherapy

PT- phyllodes

tumor

B- benign

BL- borderline

M- malignant

RT-

Radiotherapy

15 Varghese et al, Journal of Clinical and Diagnostic Research. 2017

FIBROCYSTIC CHANGES

On Triple testing:

• P/E: feels nodular

• Imaging: benign non-specific change

• Biopsy: benign pathological change

BREAST MASS: OTHER

• Lipoma

• Hamartoma

• During pregnancy

• Ectopic breast

• Axilla

• Chest wall

• Vulva

• Lactating adenoma

• Well circumscribed, lobulated, mobile

• Epithelial benign neoplasm of the breast

BREAST MASS: MANAGEMENT

• Dominant mass

• Must evaluate

• Post menopausal woman: usually cancer

• DDx of fat necrosis very rare (calcified fibroadenoma)

• Mammogram, ultrasound, core biopsy

• Premenopausal woman (or on hormones)

• Aspirate: if fluid found and mass goes away, US ± mammogram (>30

yrs of age) and follow-up in 4- 6 weeks

• If solid, send aspirate for cytology, US ± mammo (>30 yrs of age) and

follow-up in 4- 6 weeks (unless find cancer sooner)

CASE II

35 year old nulliparous woman comes to her GP with severe sharp pain in left breast for the last 3 months and it is getting worse. She does not have any family history of breast cancer and also does not have significant risk factors for breast cancer. She works as a barista at Starbucks and maintains an active lifestyle

MASTALGIA: HX P/E

• Comprehensive breast disease history

• Pain: OPQRST, Cyclical vs. non-cyclical

• Associated factors: Stress, caffeine, smoking, trauma, exercise eren10

10Eren et al, Breast care. 2016

MASTALGIA

Cyclical Non-cyclical

Most common breast complaint Rule out breast pathology with imaging

Age 30s Age 40+ years

Luteal phase (14-28) No correlation to menses

Diffuse, Usually in UOQ of breast,

radiating to axilla Focal, Inner part of breast or behind

nipple

Bilateral Usually unilateral and time limited

Increased pain, nodularity, swelling.

Discomfort with sensation of fullness, heaviness

Burning stabbing, throbbing

No direct hormonal cause identified

Pressure from bra, costochondritis, trauma, radiating pain from arthritis

QUESTION 2

2. How often is breast pain the presenting symptom for breast cancer?

a. <2%

b. 3-5%

c. 6-10%

d. 11-15%

MASTALGIA: CANCER RISK

• Is this cancer?

• May get worse as peri-menopausal

• May be unilateral

• “Most women with pain don’t have breast cancer and most women with breast cancer don’t have pain”

• Joyce 2014: Prospective study of 3,331 of 5,841 as mastalgia the only symptom undergoing triple testing:

• 39 patients (1.2%) had breast cancer, all over age 35 years12

• Arsalan 2016: Retrospective analysis of 798 of 2798 women with mastalgia alone underwent triple testing

• 0.2% presenting with mastalgia alone had breast cancer 1

• Smith 2004: 2-7% presenting with pain had breast cancer 17

17 Smith et al, Mayo Clinic Proc 2004:79:363 12Joyce et al. Ir J Med Sci. 2014 1 Arsalan et al, J Breast Health., 2016

INVESTIGATIONS

• For Mastalgia as the only breast complain for patient under age 35 years, Reassurance, no need for investigation

• Chetlan 2017: Of 236 pts with mastalgia undergoing mammogram

• 10 with cyclical pain- no image correlate

• 116 with noncyclical, non-focal pain- no image correlate

• 110 with cyclical, focal pain- 7 image correlate (3%), 1 cancer (0.4%)

• For significant Mastalgia and another breast issue (lump, ND etc.)

• Screening mammogram: age 30-50 years

• Ultrasound < age 30

MASTALGIA: MANAGEMENT

• If Investigation normal

• REASSURANCE and patient education: 78-85% successful

• pain chart

• Proper bra support

• Diet

• Low fat diet (< 20% total intake)

• Caffeine: equivocal

• Oil of evening primrose

• Medications- NSAIDs

• Relaxation therapy, acupuncture, applied kinesiology

18 Millett et al Obstet Gynecol surv 2002:57:451.

PAIN CHART

9 Gautam et al, Indian J Surg. 2016

MASTALGIA: DRUGS

• Analgesics

• no investigations to compare: ?NSAIDS better

• Topical NSAIDS maybe relief?

• For severe mastalgia, Hormone therapy

• Oral contraceptive

• Danazol: derivative of testosterone

• side effects in 30%

• Bromocriptine: bad side effects

• Tamoxifen

• Not useful: iodine, diuretics, antibiotics, thyroxine, vitamins

CASE II I

57 year old woman, G2P1 comes to see her family physician, complaining of seeing discharge on her night gown from right breast for last 2 weeks. She lives at home with her 19 year old daughter, works as an accountant. She does not have any personal or family history of breast disease

NIPPLE DISCHARGE: HX AND P/E

Is Nipple discharge:

• Spontaneous vs. expressive

• Unilateral vs. bilateral

• Color (clear, yellow, milky, green, brown, worry if bloody)

• Frequency

• Duration of discharge

Complete breast exam

• May ask patient to express discharge to characterize

• Inspect for nipple ulceration, skin changes, any

associated masses

NIPPLE DISCHARGE

• Explore if Physiologic or pathologic

Physiologic ND Pathologic ND 5

On expression Spontaneous

From multiple ducts Single duct

Bilateral Unilateral

Milky, yellow, green Bloody, clear

No other breast abnormality Associated palpable lump

Not concerning Requires investigation

Cause: galactorrhea, endocrinopathy

Cause: rule out CA

Ix: BHCG, serum prolactin, TSH Ix: diagnostic mammogram, U/S

5 Brooke et al, American Family Physician. 2012

PATHOLOGIC NIPPLE DISCHARGE- DDX

• Spontaneous nipple discharge, single duct

• Intraductal Papilloma (clear or bloodstained)- Unilateral

• Duct ectasia- bilateral

• Atypical papilloma

• DCIS in atypical papilloma

• Infection

• Recommend duct excision

NIPPLE DISCHARGE: INVESTIGATION

• Mammogram and targeted subareaoloar ultrasound (may miss intra-

ductal lesions)

• ductogram, ductoscopy and MRI (highly sensitive in identifying ductal and intra-ductal lesions)

• Cytology: highly specific if malignant cells found, but poor sensitivity

• Yilmaz 2017: 26 out of 50 patients with pathologic Nipple discharge and intraductal masses underwent U/S, MRI and Ductoscopy pre-op.

Following surgical excision, the pathology results determined the accuracy of diagnosis predicted by various imaging modality16

• MRI and ductoscopy had 90%-95% sensitivity respectively in

determining accurate diagnosis, whereas US had 67%

• MRI and U/S had similar specificity 66.7% and ductoscopy had 40%

MRI highly sensitive and non-invasive modality in diagnosing intraductal masses for pathologic nipple discharge

16 Yilmaz et al, Balkan Med J. 2017

NIPPLE DISCHARGE: CANCER RISK?

• Jin 2017: a retrospective analysis of 334 patient, median

age 45, with nipple discharge11

• 60/334 (18%) had breast cancer

• Blood discharge alone, was not associated with

malignancy

• Major predictors of malignancy with suspicious nipple

discharge:

• Advanced age

• Suspicious lump

11 Jin et al, Anticancer Research 2017

DUCTOGRAM

A non-invasive approach to diagnosing pathologic ND

CASE IV

50 year old woman had a lesion identified on her first screening mammogram. This lesions was not palpable by her or her GP. Being anxious about her first mammogram result being abnormal, she underwent a core needle biopsy. The biopsy report reads:

Columnar cell hyperplasia without atypia

Now what?

• Usually the radiologist will make a recommendation

NON-PALPABLE BENIGN LESIONS

• Increased screening results in:

• Increase in benign findings on imaging

• Increased numbers of biopsies

• Changes within the breast are a spectrum of histological changes

• Standard classification of benign lesions

• Plethora of terms

• New pathological classifications and reclassifications

NON-PALPABLE LESIONS

• 3 pathologic categories

• Non-proliferative lesions

• Proliferative lesions (hyperplasia) without atypia

• Proliferative lesions with atypia

PATHOLOGIC DEFINITIONS:

BENIGN BREAST CHANGES

NO increased risk SLIGHLTY INCREASED RISK (RR=1.5-

2)

MODERATELY INCREASED

RISK (RR=4-5)

•Non-proliferative

lesions

•Adenosis

•Cysts

•Apocrine

metaplasia

•Duct ectasia

•Fibroadenoma

•Squamous cell

metaplasia

•Fibrosis

Proliferative lesions without atypia

• Moderate or florid hyperplasia

• Duct papilloma with fibro-vascular core

• Multiple papillomatosis

• Sclerosing Adenosis • Pseudoangiomatous

stromal hyperplasia (PASH)

• Columnar hyperplasia without atypia

• Atypical lesions

• Atypical ductal

hyperplasia

(ADH)

• Lobular

neoplasms

• Atypical

lobular

hyperplasia

(ALH)

• Lobular

carcinoma in

situ (LCIS)

PSEUDOANGIOMATOUS STROMAL HYPERPLASIA (PASH)

• often an incidental finding but may be palpable (23% in 200 cases)

• younger patients

• Non specific imaging findings

• PATHOLOGY

• Keloid-like fibrosis, slit-like pseudovascular spaces (acellular or lined with fibroblasts)

• DDX angiosarcoma

• excisional biopsy for diagnosis

Columnar Cell Change, NOT ATYPICAL:

Histologic Features

• Uniform ovoid/elongated

nuclei

• Nucleoli absent or

inconspicuous

• Cells oriented

perpendicular to bm

• Apical snouts and

calcifications may be

present

NON-PALPABLE LESIONS: MANAGEMENT

• Core biopsy diagnoses for 3 pathologic categories

• Non-proliferative lesions: usually diagnostic

• Proliferative lesions (hyperplasia) without atypia: usually

diagnostic

• Atypical lesions: will usually recommend excisional biopsy

CASE V

31 year old female, G2P2 4 weeks post-partum, comes to family clinic with excruciating pain in her right breast for 4 days. She does not have any personal or family history of breast disease. Her pregnancy and delivery was unremarkable and she is breastfeeding a healthy infant.

MASTITIS

• Most commonly lactation mastitis:

• In first few weeks of lactation, presents as

pain, swelling, lumps

• Staphylococcus aureus infection

• Due to poor latch + milk stasis

MASTITIS: MANAGEMENT

• 1st line: Cephalexin 500mg PO QID x 5-7 days

• 2nd line: Levofloxacin 500mg PO daily x 5-7 days

• If purulent drainage:

• 1st line: TMP-SMX (septra) DS 1tab PO BID x 5-7 days **avoid

if breastfeeding, especially if baby is premature, ill or

jaundiced**

If evidence of systemic infection and/or significant cellulitis

send to ER

If evidence of breast abscess send to ER

- need ultrasound guided aspiration +/- surgical drainage.

CASE VI

17 year old girl comes to see her GP with marked asymmetry of breasts

congenital asymmetry

CONCLUSION

• Benign breast problems are common

• More common than malignancy

• Key Points:

• Rule out malignancy

• Avoid unnecessary imaging

• Appropriate patient reassurance and education

SUMMARY SLIDE: BREAST MASS

5 Brooke et al, Common Breast Problems. American Family Physician. 2012 Aug 15;86(4):343-349

SUMMARY SLIDE : MASTALGIA

5 Brooke et al, Common Breast Problems. American Family Physician. 2012 Aug 15;86(4):343-349

SUMMARY SLIDE: NIPPLE DISCHARGE

5 Brooke et al, Common Breast Problems. American Family Physician. 2012 Aug 15;86(4):343-349

WHEN TO ORDER MAMMO

• Routine screening every 1-2 years for woman >50 years

• Screening every year for woman with strong family history of

breast cancer (10 years before the earliest diagnosis)

• Annual screening for woman with dense breast tissue

• For significant issue: lump, pain, discharge

WHEN TO ORDER AN US

To differentiate between cystic and solid lesion

May be diagnostic:

• U/S guided Needle aspiration for cystic lesions

• U/S guided CNB, FNA

Thank you!

Questions

?

References

1. Arsalan et al, Retrospective Analysis of Women with Only Mastalgia. J Breast Health. 2016 Oct 1;12(4):151-154

2. Brennan M, Houssami N, French J. Management of Benign Breast Conditions Part 1- Painful Breast. Australian Family Physician. 2005 Mar; 34 (3); 143-14

3. Brennan M, Houssami N, French J. Management of Benign Breast Conditions Part 2- Breast lump and lesion. Australian Family Physician. 2005 Apr; 34 (4); 253-255

4. Brennan M, Houssami N, French J. Management of Benign Breast Conditions Part 3-Other Breast Issues. Australian Family Physician. 2005 May; 34 (5); 353-355

5. Brooke et al, Common Breast Problems. American Family Physician. 2012 Aug 15;86(4):343-349

6. Brown et al, Clinical Value of Mammography in the Evaluation of Palpable Breast Lumps in Women 30 Years Old and Older. American Journal of Roentgenology. 2017 Aug; 209(4):935-942

7. Cheetlan et al, Mastalgia: Imaging Work-up Appropriateness. Academic Radiology. 2017 Mar;24(3):345-349

8. Donnelly J. Breast lump detection: who is more accurate, patients or their GPs?. The International Journal of Clinical Practice. 2010 Mar; 64 (4); 439-441

9. Gautam et al, New Breast Pain Chart for Objective Record of Mastalgia. Indian J Surg. 2016 Jun;78(3):245-8

10. Eren et al, Factors Effecting Mastalgia. Breast care. 2016 Jun;11(3):188-93

11. Jin et al, Predictors of Malignancy for Female Patients with Suspicious Nipple Discharge: A Retrospective Study. Anticancer Research 2017 Aug;37(8):4655-4658

12. Joyce et al. Breast clinic referrals: can mastalgia be managed in primary care? Ir J Med Sci. 2014 Dec;183(4):639-42

13. Morrow M. The Evaluation of Common Breast Problems. American Family Physician. 2000 Apr 15;61(8):2371-2378

14. Ruth et al, Office management of a palpable breast lump with aspiration. Canadian Medical Association Journal. 2010 Apr 20; 182(7): 693–696

15. Varghese et al, Radiotherapy in Phyllodes Tumour. Journal of Clinical and Diagnostic Research. 2017 Jan;11(1):XC01-XC03

16. Yilmaz et al, Diagnosis of Nipple Discharge: Value of Magnetic Resonance Imaging and Ultrasonography in Comparison with Ductoscopy. Balkan Med J. 2017 Apr 5;34(2):119-126