APPROACH TO THE PATIENT WITH BREAST DISCOMFORT IN PRIMARY CARE

APPROACH TO THE PATIENT WITH BREAST DISCOMFORT

IN PRIMARY CARE

Assist.Prof. Arzu Akalın M.D.

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• Many patients present to their physician for benign conditions of the breast that they perceive to be abnormal

Common Complaints

• Pain • Breast mass • Nipple discharge• Hypertrophy • Breast infections

You must

• Differentiate benign from malignant disease, • Reassure patients with benign conditions,• Manage common symptoms and conditions, and • Seek consultation when necessary

The provider must recognize the emotional distress common during this process

and provide timely and effective communication.

Breast Anatomy

Breast Anatomy

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The breast is composed of 15-20 lobes

and contains • glandular, • ductal, • fibrous, and • fatty tissue.

More lobes are present in the outer quadrants, especially the upper outer quadrants, Therefore many breast conditions (among them, breast cancer) occur more frequently in these regions

• Each lobe contains several lobules. Lobules contain ducts that join to form one of the 6-10 major ducts that emerge at the areola.

• Six to ten pinhole openings are present on the areola.

Axillary tail of breast tissue

• An axillary tail of breast tissue extends toward the anterior axillary fold.

Breast Development

• Begins with • embrionic development and • continues through postmenopausal and older

years

Newborns may present with;• Athelia : Absence of nipple(s)

• Polythelia: More than two nipples

Ectopic nipple tissue may occur at any point in the embrionic breast line

• Amastia Absence of breast tissue

• Polymastiathe presence of more than twomammary glands or nipples

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ArtemisThe Goddess of Ephesus

• Hypertrophied breast tissue caused by stimulation from maternal estrogen and progesterone.

• In most cases spontaneous regression occurs.

• Prepubertal children may develop unilateral or bilateral soft mobile subareolar nodules of uniform consistency that usually resolve spontaneously within a few months

• Biopsy should be avoided as it may impair pubertal breast development

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• In girls, glandular proliferation within the breast marks the normal onset of puberty.

• The first sign of puberty is breast bud development (= thelarche) (average age 11 years;

range 9 to 13.4 years), • The last sign is full breast development

• Thelarche is considered “premature” if it occurs earlier than age 8.

• Premature thelarche without other signs of pubertal development or accelerated growth is usually benign.

• No treatment is needed • EXCEPT :

• precocious puberty, • estrogen-producing tumors, • ovarian cysts or • exogenous estrogen exposure

In Puberty

• Gynecomastia (= the proliferation of glandular breast tissue in a male), is common in the middle phases of pubertal development.

• This may be attributed to serum estradiol levels rising to adult levels before serum testosterone levels.

• More than 90% of affected boys experience regression within 3 years

• Association with precocious puberty is also a concerning sign.

Adulthood

• The normal adult breast may be soft, but it often feels granular, nodular, or lumpy. This uneven texture is normal and may be termed physiologic nodularity. It is often bilateral.

• The nodularity may increase premenstrually – a time when breasts often enlarge and become tender or even painful.

Normal Breast• Changes in size and texture throughout the

menstrual cycle. • During the premenstrual phase acinar cells

increase in number and size, the ductal lumens widen, and breast size and turgor increase.

• These changes reverse in the postmenstrual phase.

• The left mamma is usually slightly larger than the right

During Pregnancy

• Due to hyperplasia of the glandular tissue and increased vascularity, the breasts enlarge and become nodular by the third month of gestation as the mammary tissue hypertrophies.

• The nipples enlarge, darken, and become more erectile

• The areola darken, and Montgomery’s glands appear prominent around the nipples

During Pregnancy

• The venous pattern over the breasts become increasingly visible as pregnancy progresses.

• From mid- to late pregnancy a normal thick, yellowish discharge called colostrum may be expressed from the nipple

Lactation • Mastitis is a cellulitis of the interlobular

connective tissue within the mammary gland. • The clinical spectrum can range

• from focal inflammation • to systemic flulike symptoms of fever, chills,

and muscle aches. • The affected breast will usually exhibit

a tender, erythematous, wedge-shaped swelling.

Lactation • Most cases occur within the first 2 months

postpartum.• The infection is bacterial, usually

staphylococci; • the breast skin and the infant’s mouth have

been proposed as the source

Lactation

• The key to the management of mastitis is complete emptying of the breast, warm compresses, early antibiotics, and bed rest.

• The patient should be advised to continue breastfeeding; stopping breastfeeding would put her at increased risk of abscess formation.

Aging

• The breasts tend to diminish in size as glandular tissue atrophies and is replaced by fat.

• Although the proportion of fat increases, its total amount may also decrease.

• The breasts often become flaccid and pendulous

Gynecomastia • It is common for men in their 50s

and 60s to experience breast enlargement. • Gynecomastia associated with

• pain, • asymmetry, • rapid onset or progression galactorrhea, • and/or erectile dysfunction

requires further workup • Can also occur due to some drugs and some

diseases

ASSESSMENT OF AN INDIVIDUAL WITH BREAST COMPLAINTS

Keypoints

• History• Examination of the Breast• Laboratory Evaluation• Diagnostic Tests• Pathologic Findings

History Taking

DESCRIBE • when and in what setting symptoms first

occurred, • any change over time, and • past history of similar symptoms.• relation of symptoms to the menstrual cycle. • include the menstrual and reproductive history

(age of menarche and menopause)

History Taking

• parity (age of the first-term pregnancy); • whether currently pregnant;• lactation; • use of hormonal therapy or contraceptives; • rapidity and amount of weight gain after menopause; • whether breast self-examination is performed • any past breast surgery • The patient should also be queried for any family

history of breast and ovarian cancers.

Examination of the Breast(Inspection & Palpation)

The exam should be performed in a well-lit room and privacy is facilitated by draping parts of the body not being examined.

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Examination of the Breast

Inspection • Occurs with the patient seated,

– Arms at side; – With hands on hips; and – With arms above the head.

• Changes in size, shape, symmetry, or texture are noted.

Examination of the Breast

Palpation • Is performed with the

patient supine, arms flexed at a 90-degree angle at the sides.

• Palpation includes supraclavicular, infraclavicular, and axillary nodes.

• Compression may identify a mass and/or elicit a discharge.

• Nipples should be examined for deviation, retraction, skin changes, or discharge.

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Laboratory Evaluation

• Genetic screening is not part of the routine evaluation

Diagnostic Tests

1. Imaging a. Mammography b. Ultrasonography

2. Magnetic resonance imaging is utilized in some settings.3. Aspiration4. Fine-needle aspiration (FNA)5. Fine-needle aspiration and biopsy (FNAB)6. Triple test: combines physical examination,

mammography, and FNAB7. Open biopsy

Common Complaints

1. Pain2. Mass3. Nipple discharge

Pain (Mastalgia)

• Pain without an associated mass is unlikely to be the presenting symptom of breast cancer,

• Mastalgia may be classified as 1. Cyclical (2/3) 2. Noncyclical (1/3)

• May be acute or chronic.

Pain History

Must include • Palliative or provocative factors • Quality (dull, sharp, burning, heavy,...)• Radiation (arm, axilla,....)• Severity (mild, severe to limit activities)• Location • Laterality (bilateral / unilateral) of pain

Pain History

• Timing with regard to menstrual cycle• Association with oral contraceptive pills, other

hormonal contraceptives or hormone replacement use, • RECENT

• Birth • Pregnancy • Loss of pregnancy or termination

• History of trauma, heavy muscular exertion, should be sought.

Pain - Physical Exam

• Should be used to evaluate for • Mass • Nipple discharge

• To localize areas of tenderness • To assess for

• Lymphadenopathy • Changes in symmetry, • Contour, and overlying skin

Benign Breast Masses General Considerations

• Benign breast masses will often change with the menstrual cycle, while worrisome masses are persistent throughout.

• Greater than 90% of palpable breast masses in women between 20 and 55 are benign.

• Masses may be discrete or poorly defined, but differ from the surrounding breast tissue and the corresponding area in the contralateral breast.

• Cancer should be excluded in a woman who presents with a solid mass.

Benign Breast Masses

• Breast cysts• Fibrocystic breast changes• Fibroadenoma• Ductal papilloma

1. Benign2. May be aspirated if

large

Breast Cyst

Fibroadenoma

Most common benign breast tumor

1) 20%+ of premenopausal women

2) Discomfort, cysts3) Treatment rarely required

Fibrocystic Breast Changes

may produce “chocolate” or bloody discharge from nipple

Intraductal Papilloma

Algorithm for palpablebreast mass.

CBE clinical breast examination;FNA fine-needle aspiration

Nipple Discharge • Nipple discharge: Secretions from the breast(s)

of a woman who is not lactating

• Nipple discharge is an extremely common concern in young women

• Most isolated complaints of discharge are benign

Nipple Discharge

• Categorized as 1. Physiologic2. Pathologic (nonphysiologic).

Physiologic Pathologic

Nonspontaneous Spontaneous

Bilateral Unilateral

Arising from multiple ducts

Arise from a single duct

Carcinoma of the breast

• Most common malignant tumor among women• 1/8 of women will develop breast cancer

Progression to Breast Cancer

a. Slowly growing, painless mass

b. May demonstrate retracted nipple

c. May be bleeding from nipple

d. May be distorted areola, or breast contour

e. Skin dimpling* in more advanced stages with

retraction of Cooper’s ligaments

Physical Signs

Note skin dimpling in the 6 o'clock radius

*Dimple=Gamze

f. Attachment of mass

g. Edema of skin 1)with “orange skin” appearance

(peau d’orange) due to blocked lymphatics

h. Enlarged axillary or deep cervical lymph nodes

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Common sites for metastasisa. Lungs & pleurab. Skeleton system (skull, vertebral column,

pelvis)c. Liver

Atypical carcinomasa. Inflammatory carcinoma (hormonal,

chemotherapy) b. Paget’s disease of the breast

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Breast Cancer Screening Guidelines of ACS* 2012

BSE ages ≥20 monthly or irregularCBE ages 20-30 part of periodic

examination at least every 3 year ages ≥40 annually

Mammography begin anuual mammography at age 40

* American Cancer Society

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End of Lecture Class dismissed!