GW’s CREOG Video Project: Learn about benign breast disease by Dr. Emily Capbarat
The topic of this presentation is benign breast disorders so benign in the sense that they’re not cancerous benign breast disorders encompass a heterogeneous group of conditions this can include masses cysts abnormalities seen on imaging nipple discharge breast pain inflammatory breast disease and different different skin disorders it’s quite a lengthy topic if you
Want to review practice bulletin 164 however the objectives to this presentation are to simplify so our first objectives are to list the categories of benign breast lesions in masses so that we can develop a framework review the clinical presentations of common breast lesions within each of those categories briefly review diagnostic imaging of a palpable breast
Mass and briefly review nostalgic classification and treatment as this is something that i don’t think we commonly address but i had a couple of questions on the classification of most benign breast lesions falls within one of three categories non-proliferative proliferative without atypia in atypical hyperplasia there’s a few other benign breast lesions that
Includes tubular adenomas and floyd’s tumors that we’ll talk about briefly as well non-proliferative breast disorders simple breast cysts are the most common type of non-proliferative breast lesion and can be found in up to one-third of women ages 35 to 50 they can vary in size but are almost always benign fluid filled masses they can be microscopic to clinically
Palpable they’re usually discrete compressible and a blood blottable solitary mass in your question vignette you should also think about galactoceles if the clinical vignette discuss a pregnancy or a postpartum patient this is a milk retention cyst common women who are breastfeeding fat necrosis it’s not something listed under the table in the practice bulletin
But is also a breast benign breast finding it can develop after blunt trauma to the breast or surgery such as breast reconstruction or radiation therapy you’ll notice different different palpable changes in the breast you may also see this with skin echo moses a breast abscess again not necessarily benign in the sense that it can’t cause harm but not cancerous
It’s a localized collection of inflammatory oxidate that can develop alongside mastitis or cellulitis and you’ll usually will have all the other signs of infection as well so thinking about the rep the the warmth the redness tenderness but it may also be a discrete mass diabetic mestopathy was something that i wasn’t familiar with but may be seen in a woman with
Long-standing type 1 diabetes who has suspicious fibrous breast lumps that are usually multiple and this would be something that you need to diagnose or biopsy for diagnosis lastly idiopathic granulomatous mastitis is a rare inflammatory disease of the breast that’s usually presents as painful firm and ill-defined mass that can have erythema and edema of the skin
Again not something listed in the practice bulletin but also something that would be a non-proliferative breast mass the next category is proliferative without atipia the most common i think question stem or even the most common cause of breast mass in adolescent girls and young women that you may see are fibroadenomas these are going to account for half of all of
Breast biopsies they can also present in older women accounting for 12 percent of all masses in menopausal women these are glandular and fibrous tissue they’re presenting as a well-defined mobile mass on exam and again are benign a typical adenomas fiber adenoma is small one to two centimeters but there can also be things such as that are called giant fibroadenomas
That are greater than 10 centimeters but that’s going to be an extraordinarily unusual variant of juvenile or adult up fibro adenomas and only account for about four percent of all sclerosing adenosis is a lobular lesion with increasing fibrous tissue there’s no need to treat this they are considered proliferative lesions without atypia but are only associated
With a very small to moderate increased risk of future develop of breast cancer to be notable a radial scar is a pseudo-proliferative lesion and are usually incidental findings on biopsies they’re complex complex sclerosing lesions excision is recommended for this as there sometimes can be they can sometimes harbor or develop atypical proliferations but no other
Treatment is needed intraductal papillomas this is going to be our typical clinical vignette um with the patient with bloody nipple discharge it’s the most common cause of that it’s a tumor in the lactiferous duct they can be solitary and centrally located or multiple and peripherally located so may not give too much of a clue when you’re reading the question and
Most significantly these most commonly occur in ages women ages 50 or excuse me 30 to 50 years old and are typically small but can present as a palpable mass up to five centimeters in size what’s important is that they can harbor ductal carcinoma in situ they’ve been that has been diagnosed within solitary papillomas but they’re not usually associated with cancer
If bothersome or concern for a typica surgical excision is performed if we were to get a slide of an introductory intraductal papilloma this is what it would look like it’s a monotonous array of papillary cells that grow from the wall of a cyst into the lumen occasionally creog throws one of these at us atypical hyperplasia includes atypical ductal hyperplasia
And atypical lobular hypoplasia atypical ductor hyperplasia is a proliferation of uniform epithelial cells with round nuclei that feel part of the duct standard of care absorb after a biopsy proven diagnosis is surgical excision due to the risk of upgrade to ductal carcinoma and for lobular hyperplasia this is monomorphic evenly spliced dehecive cells that fill
Part of the lobule versus the duct but they can also involve the duct which is somewhat confusing referral to a breast oncologist should incur as management varies based on other clinical risk factors and in the other category are tubular adenomas that i haven’t ever i haven’t seen on a question stem but they are benign glandular cells they have minimal stromal
Elements they may be seen as a breast mass or on routine breast imaging lactating adenomas can be seen during pregnancy or postpartum and they would present as a palpable mass it would need biopsy for diagnosis of the benign lesion floyd’s tumors i think is the most uncommon fibroepithelial tumor that we’ll commonly see not see on questions it’s only 0.3 to 0.5
Percent of all cases of breast tumors the median age at presentation is 40 years old with the usual presentation of a single enlarging breast mass they have the same characteristics of fibroadenoma so on palpation they’re firm circumscribed and mobile but they have rapid growth which i think is going to be the key in the clinical vignette only about five percent
Of all cases of floyd’s tumors will develop a propensity for local record recurrence to a sarcoma capable producing distance mets which is why they are more important to characterize whether it’s benign or abnormal for lobular carcinoma in situ it’s a histologic finding that does not usually present as a mass but is usually diagnosed as an incidental finding on a
Breast biopsy for some other lesion and unlike dcis lcis is not considered a precursor lesion for breast cancer but rather it’s a risk marker for future development of breast cancer women who are diagnosed with lcis have an estimated 10 to 20 percent risk of developing invasive ductal or invasive lobular cancer in the following 15 years for diagnostic imaging this
Is quite a lengthy topic in itself um just to review briefly bi-rads is the breast imaging reporting and data system and it goes from category zero up to category six category zero is incomplete category one is negative category two benign three is probably benign four is suspicious five is highly suggestive of malignancy and six is known biopsy proven malignancy
There are two useful tables figure one and figure two within the practice bulletin goes under goes over the management of a palpable mass in women younger than 30 years old but in over 30 years old and for younger than 30 years old it depends on your clinical suspicion if you have a very low clinical suspicion for a cancerous mass you can actually observe for one
To two menstrual cycles if the mass resolves you do reaching follow-up screening but if the mass persists you go to ultrasound and again for a palpable mass less than 30 years old ultrasonography is the primary means and after ultrasonography it depends on the bi-rads so if it’s solid it whether it’s classified as bi-rads three four or five depends on what type of
Tissue biopsy or further examination but i think that’s too much information to go in through this presentation for a papal breast mass for someone greater than 30 years old diagnostic mammography is the gold standard and you don’t observe and then after getting the diagnostic memo based on the bi-rads classification if it’s one to three you go to ultrasonography
Versus four to five you go immediately to tissue biopsy in clinical practice ultrasonography happens most of the time alongside the diagnostic mammal which is something to consider when writing prescriptions for a diagnostic mammal when you have a suspicion for a clinical mass a question a 45 year old woman presents for her annual well-wound visit she is concerned
Because she has a large quarter-sized lump in her left breast that she reports has grown significantly over the past six months on clinical exam the mass is firm circumscribed and immobile there’s also noticeable stretching of the overlying skin breast imaging shows a solid mass what is the next best step and i hope you chose excisional biopsy this question is
Characteristic of a phalloides tumor again they typically behave in benign manners like fibroadenomas so the firm circumscribed mobile mass but what is significant here is that it’s grown significantly over six months and there’s no noticeable stretching of the overlying skin so an excisional biopsy as compared to a core needle biopsy which may be helped diagnose a
Fibroadenoma is important this was a question that i got on true learn that actually i believe has the incorrect answer that i should submit to true learn so this is in regards to what how can you best treat nostalgia using danizol which is an androgen for severe nostalgia the correct the incorrect correct answer that truly enlisted was that dietary changes like
Low-fat high complex carbohydrate diet may be effective when on page 10 of the practice bulletin it specifically says and also relates to number three that elimination of caffeine or these low-fat low or high complex carbohydrate diets are not conclusively demonstrated to reduce nostalgia number four tamoxifen is considered a first-line treatment of nostalgia
That’s not correct it can be utilized for severe refractory cases of nostalgia and then vitamin e i didn’t come across anything so that one is null but just briefly about nostalgia it can be classified into three different categories cyclical or related to hormonal changes cyclical nostalgia with a normal physical exam generally doesn’t require any other workup
And reassurance can be appropriate in this management non-cyclical may indicate a breast etiology of course not varied by the menstrual cycle so less like mastitis cysts tumors cancer very rarely presents with nostalgia with no other clinical findings so doing a breast exam and then you can look at up to date about when to refer someone with nostalgia for what
Type of diagnostic imaging and extra mammary problems may present with breast pain but not our breast and etiology so how is nostalgia manage again reassurance may be most appropriate with cyclic nostalgia and a normal exam non-pharmacologic treatment is generally first line so well fitted and supportive braziers using pharmacologic treatment with nsaids or
Acetaminophen initiation of ocps is not a proven treatment for nostalgia but if somebody is getting nostalgia and is taking ocps they can use a more continuous dosage to improve their symptoms and then and back to related to the question about dianazole it is an androgen it is the only medication that is actually approved by the fda but it’s no longer approved
Since 2018 for fibrocystic disease so i think the question is a little bit confusing tamoxifen is a selective estrogen receptor modulator and has been demonstrated to reduce breast pain in people with cyclic pain but given the adverse effects of dianazole and tamoxifen their use is really limited and are pretty much limited to severe and refractory cases i hope
That helps in your creog review of benign breast disorders
Transcribed from video
Benign Breast Lesions By EDU Chief GW
