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Lumps, Bumps, Leaking and PainManagement of Breast Conditions
Rebecca A. Jackson, MDProfessor Department of Obstetrics, Gynecology and Reproductive SciencesUniversity of California, San Francisco
I HAVE NO DISCLOSURES
Plan
oPalpablebreastmassoNon‐PalpablebreastmassoMastalgiao NippleDischarge
oPalpablebreastmassoNon‐PalpablebreastmassoMastalgiao NippleDischarge
Likelihood of Cancer in Dominant Breast Mass by Age
1%
9%
37%
0%
10%
20%
30%
40%
50%
60%
<40 yo 41-55 >55 yo
Of all discrete breast masses, about 10% are cancerous. (In contrast, 8% of abnormal mammos = cancer)
Failure to diagnose breast cancer in a timely manner is a leading
cause of malpractice claims
Common reasons:
o Unimpressive
physical findings
o Failure to f/u with pt
o Palpable mass with
negative mammo
Common reasons:
o Unimpressive
physical findings
o Failure to f/u with pt
o Palpable mass with
negative mammo
“Dominant Mass”?
o Discreteordominantmass=standsoutfromadjoiningbreasttissue,definableborders,ismeasurable,notbilateral.
o Nodularityorthickening=ill‐defined,oftenbilateral,fluctuateswithmenstrualcycle
o Inwomen<40referredformass,only1/3hadconfirmeddominantmass
Breast Mass: Diagnostic Options
o Physicalexam
o Ultrasound
o DiagnosticMammogram
o DigitalBreastTomosynthesis(DBT)
o Cystaspiration
o Fineneedleaspiration
o Coreneedlebiopsy
o Excisionalbiopsy
o Physicalexam
o Ultrasound
o DiagnosticMammogram
o DigitalBreastTomosynthesis(DBT)
o Cystaspiration
o Fineneedleaspiration
o Coreneedlebiopsy
o Excisionalbiopsy
Question 1
A42yroldwomanwithnofamilyorpersonalhistoryofbreastcancerhasfoundabreastlump.Shedoesn’tknowhowlongithasbeenthere.Itisnotpainful.
Onexam,itisadiscretemass,2cm,relativelysmooth,mobileandnon‐tender.Shehasnoaxillarylymphadenopathy.
Whatisyournextstep?
A42yroldwomanwithnofamilyorpersonalhistoryofbreastcancerhasfoundabreastlump.Shedoesn’tknowhowlongithasbeenthere.Itisnotpainful.
Onexam,itisadiscretemass,2cm,relativelysmooth,mobileandnon‐tender.Shehasnoaxillarylymphadenopathy.
Whatisyournextstep?
Q1: Palpable mass in 42 yo Nextstep(pickone)?
A. Nothingnow.Re‐examinein1‐2months
B. Ultrasound
C. DigitalMammography
D. DBT:DigitalBreastTomosythesis
E. Officeaspiration
F. FNAB(fineneedleaspirationbiopsy)
G. Corebiopsy
Nextstep(pickone)?
A. Nothingnow.Re‐examinein1‐2months
B. Ultrasound
C. DigitalMammography
D. DBT:DigitalBreastTomosythesis
E. Officeaspiration
F. FNAB(fineneedleaspirationbiopsy)
G. Corebiopsy
Q1b: Palpable mass in 42 yo
Amammographywaschosenandisnegative.Nextstep(pickone)?
A. Re‐examinein1‐2months
B. F/u1yearforannualexam
C. Ultrasound
D. Officeaspiration
E. FNAB
F. Corebiopsy
Amammographywaschosenandisnegative.Nextstep(pickone)?
A. Re‐examinein1‐2months
B. F/u1yearforannualexam
C. Ultrasound
D. Officeaspiration
E. FNAB
F. Corebiopsy
Q1c: Palpable mass in 42 yoAnultrasoundwaschosenasthefirststep.
Itshowsacysticmass.Nextstep?
A. Re‐examinein1‐2months
B. F/u1yearforannualexam
C. Standarddiagnosticmammogram
D. DBT(digitalbreasttomosynthesis)
E. Officeaspiration
F. FNA
G. Corebiopsy
Anultrasoundwaschosenasthefirststep.Itshowsacysticmass.Nextstep?
A. Re‐examinein1‐2months
B. F/u1yearforannualexam
C. Standarddiagnosticmammogram
D. DBT(digitalbreasttomosynthesis)
E. Officeaspiration
F. FNA
G. Corebiopsy
Step 1: Palpable Breast Mass
oDetermineifmassiscysticorsolid
o Simplecystsarebenignanddon’trequirefurtherevaluation
o 20‐25%ofpalpablemassesaresimplecysts,mostoccurringin40‐49yo’s
o Options?:Ultrasound,officeaspiration,FNA,coreneedlebiopsy
oDetermineifmassiscysticorsolid
o Simplecystsarebenignanddon’trequirefurtherevaluation
o 20‐25%ofpalpablemassesaresimplecysts,mostoccurringin40‐49yo’s
o Options?:Ultrasound,officeaspiration,FNA,coreneedlebiopsy
Breast Exam
o Nethersensitive(50‐60%)norspecific(60‐90%)(evenwhendonebyexperts)
o Cannotreliablydistinguishcystfromsolid(58%accuracy)
o Notreliablefordeterminingifbiopsyneededo Nonetheless,itisimportantfordeterminingifmassisdiscrete(vsnodularityorthickening)andforfollow‐upofmasseso Performin2positions,methodical,spiralsorstripso Markmasspriortobiopsysootherscanfindit
o Nethersensitive(50‐60%)norspecific(60‐90%)(evenwhendonebyexperts)
o Cannotreliablydistinguishcystfromsolid(58%accuracy)
o Notreliablefordeterminingifbiopsyneededo Nonetheless,itisimportantfordeterminingifmassisdiscrete(vsnodularityorthickening)andforfollow‐upofmasseso Performin2positions,methodical,spiralsorstripso Markmasspriortobiopsysootherscanfindit
Ultrasound
o PrimaryUse:Classifymassascysticorsolido AlsocanhelptofurtherclassifymassviaBi‐Radssystemforsono‐‐ butmuchlessdataonriskofcancerassocwitheachclassification
o Guidanceforcystaspirationorbiopsy
o Adjuncttoevaluatesymmetricdensitiesdetectedbymammography
o Canbethefirsttestperformed&ifcystisconfirmed—theonlytestrequired
o PrimaryUse:Classifymassascysticorsolido AlsocanhelptofurtherclassifymassviaBi‐Radssystemforsono‐‐ butmuchlessdataonriskofcancerassocwitheachclassification
o Guidanceforcystaspirationorbiopsy
o Adjuncttoevaluatesymmetricdensitiesdetectedbymammography
o Canbethefirsttestperformed&ifcystisconfirmed—theonlytestrequired
Fibroadenoma Cancer
Well-circumscribed, superficial
Irregular, deep
Cyst
Anechoic, well-circumscribed,
Ultrasound is 98-100% accurate for diagnosis of simple cysts. However, for solid masses, it cannot reliably distinguish benign from malignant.
Cyst Aspiration
o Simpleofficeprocedure:20‐23gaugeneedleandsyringe,ultrasoundguidanceoptional,specializedtrainingnotnecessary
o PrimaryUse:Confirmmassiscystico Secondaryuse:Relievepain/pressureduetosymptomaticcyst
o Benefits:Ifcysticfluidobtained,establishesimmediatediagnosisandprovidessymptomaticrelief
o Simpleofficeprocedure:20‐23gaugeneedleandsyringe,ultrasoundguidanceoptional,specializedtrainingnotnecessary
o PrimaryUse:Confirmmassiscystico Secondaryuse:Relievepain/pressureduetosymptomaticcyst
o Benefits:Ifcysticfluidobtained,establishesimmediatediagnosisandprovidessymptomaticrelief
Cyst Aspiration (cont’d)
Adequate/reassuringif:1.Cystfullycollapses(noresidualmass)
2.Fluidisnotbrown/red(cloudyok)
3.Doesnotre‐accumulate(i.e.frequentf/u)
o Ifallaretrue,noneedtosendfluid.
o F/uin1‐3monthstoensurenoreaccumulation orresidualmass
o Ifnofluidorifbloodyfurther workup
Adequate/reassuringif:1.Cystfullycollapses(noresidualmass)
2.Fluidisnotbrown/red(cloudyok)
3.Doesnotre‐accumulate(i.e.frequentf/u)
o Ifallaretrue,noneedtosendfluid.
o F/uin1‐3monthstoensurenoreaccumulation orresidualmass
o Ifnofluidorifbloodyfurther workup
Fine Needle Aspiration: QUIZ
o FNABshouldbedonebyanexperiencedcytopathologistorbreastsurgeon?….TRUEORFALSE?
o AdiagnosisofFATTYTISSUEonFNAmeanswhat?
o WhenshouldyouFOLLOW‐UPawomanwithapalpablemassandnegativeFNAandmammogram?
o FNABshouldbedonebyanexperiencedcytopathologistorbreastsurgeon?….TRUEORFALSE?
o AdiagnosisofFATTYTISSUEonFNAmeanswhat?
o WhenshouldyouFOLLOW‐UPawomanwithapalpablemassandnegativeFNAandmammogram?
Fine Needle Aspiration Biopsyo PrimaryUse:Diagnosisofsolidmasseso Leastinvasivebiopsymethodo Sensitivityisoperatordependent:
o Forexperiencedpersonnel,92‐98%o Foruntrainedpersonnel,75%Average(aslowas65%).
o Experiencedcytopathologist necessarytointerpreto CannotdiagnoseDCIS,atypicalhyperplasiaorinfiltratingcarcinoma.However,>90%thereissufficientmaterialtoperformprognosticstudies
o Anon‐diagnosticresultinthesettingofadiscretemassrequiresfurtherwork‐up(possiblesamplingerror)
o PrimaryUse:Diagnosisofsolidmasseso Leastinvasivebiopsymethodo Sensitivityisoperatordependent:
o Forexperiencedpersonnel,92‐98%o Foruntrainedpersonnel,75%Average(aslowas65%).
o Experiencedcytopathologist necessarytointerpreto CannotdiagnoseDCIS,atypicalhyperplasiaorinfiltratingcarcinoma.However,>90%thereissufficientmaterialtoperformprognosticstudies
o Anon‐diagnosticresultinthesettingofadiscretemassrequiresfurtherwork‐up(possiblesamplingerror)
Palpable mass: Diagnostic Mammography
o Cannotaccuratelydifferentiatebenignfrommalignantmassesorcysticfromsolid
o Poorsensitivityinyoungwomenduetodensityo 15‐20%ofmammosarenormal inwomenwithpalpablemass
o PrimaryUse:Screenoppositebreast(inwomen>40yo)andidentifyothernon‐palpablesuspiciousareas
o Secondaryuse:FurtherclassificationofthepalpablemassEVENIFTHEMAMMOISNORMAL,FURTHER
WORK‐UPISREQUIRED
o Cannotaccuratelydifferentiatebenignfrommalignantmassesorcysticfromsolid
o Poorsensitivityinyoungwomenduetodensityo 15‐20%ofmammosarenormal inwomenwithpalpablemass
o PrimaryUse:Screenoppositebreast(inwomen>40yo)andidentifyothernon‐palpablesuspiciousareas
o Secondaryuse:FurtherclassificationofthepalpablemassEVENIFTHEMAMMOISNORMAL,FURTHER
WORK‐UPISREQUIRED
Breast Cyst
Cyst is anechoic on ultrasound
Can’t distinguish cyst from solid on mammogram
Breast Density
Spiculated mass
Small Cancer
Merriman’s: WaimeaWhat about DBT?
DigitalBreastTomosynthesis;“3DMammography”o 3‐Ddepictionofbreastusingseriesoflow‐dosedigitalmammogramsatvariousangles
o Betterfordelineatingtruelesionsfromspuriouslesionscausedbyoverlappingstructuresseenonroutinemammography.
o Higherradiationdose:sometimestwiceashighb/cdobothadigitalmammogramandDBTaredoneo Newertechniqueshavelowerradiationdosebutupgradingiscostly
DigitalBreastTomosynthesis;“3DMammography”o 3‐Ddepictionofbreastusingseriesoflow‐dosedigitalmammogramsatvariousangles
o Betterfordelineatingtruelesionsfromspuriouslesionscausedbyoverlappingstructuresseenonroutinemammography.
o Higherradiationdose:sometimestwiceashighb/cdobothadigitalmammogramandDBTaredoneo Newertechniqueshavelowerradiationdosebutupgradingiscostly
Is Breast tomosynthesis (DBT) better than mammography for palpable mass?
o Toosoontosay:Moststudieshavebeendoneinscreeningsetting
o Butpromising—especiallyinthesettingofdensebreasts.
o Afewsmallstudiesshowbettercharacterizationoflesionswhenusedindiagnosticsettingleadingtofewerbiopsies
o Toosoontosay:Moststudieshavebeendoneinscreeningsetting
o Butpromising—especiallyinthesettingofdensebreasts.
o Afewsmallstudiesshowbettercharacterizationoflesionswhenusedindiagnosticsettingleadingtofewerbiopsies
Friedewald 2014 JAMA
PtwithmassmarkedbyBB.Difficulttoseewellonmammo.
DistinctedgesonDBT.
U/Sconfirmedacyst.
PtwithmassmarkedbyBB.Difficulttoseewellonmammo.
DistinctedgesonDBT.
U/Sconfirmedacyst.
Conventional DBTRadiol Clin North Am. 2010 Sep; 48(5): 917–929.
Traditional Mammo DBT
Invasive ductal carcinoma: Subtle on mammoSpiculated edges well seen on DBT
Radiol Clin North Am. 2010 Sep; 48(5): 917–929.
Breast Tomosynthesis: patient experience
Breast tomosynthesis: Radiology experience
Core Needle Biopsyo PrimaryUse:Diagnosisofsolidmasses,f/uofnon‐diagnosticFNAB
o CandistinguishDCISfrominvasivediseaseandbecauseitisatissuespecimen,interpretationiseasier(unlikeFNA)
o FewdirectcomparisonstoFNABforpalpablelesions:Studiesmixedforsensitivity‐ someshowingFNAbetterandsomewithCNBbetter.Similarspecificity.
o PrimaryUse:Diagnosisofsolidmasses,f/uofnon‐diagnosticFNAB
o CandistinguishDCISfrominvasivediseaseandbecauseitisatissuespecimen,interpretationiseasier(unlikeFNA)
o FewdirectcomparisonstoFNABforpalpablelesions:Studiesmixedforsensitivity‐ someshowingFNAbetterandsomewithCNBbetter.Similarspecificity.
o Preferred for biopsy non-palpable lesions
Question 1
A42yearoldwomanwithnofamilyorpersonalhistoryofbreastcancer hasfoundabreastlump.Shedoesn’tknowhowlongithasbeenthere.Itisnotpainful.
Onexam,itisadiscretemass,about2cm,relativelysmooth,mobileandnon‐tender.Shehasnoaxillarylymphadenopathy.
Whatisyournextstep?
A42yearoldwomanwithnofamilyorpersonalhistoryofbreastcancer hasfoundabreastlump.Shedoesn’tknowhowlongithasbeenthere.Itisnotpainful.
Onexam,itisadiscretemass,about2cm,relativelysmooth,mobileandnon‐tender.Shehasnoaxillarylymphadenopathy.
Whatisyournextstep?
So, what is the best first step?o Firststep=determineifcysticorsolid.
o Howdependsonyourinstitution(availabilityandexpertiseofvariousservices)andwhetherpatientissymptomatic
o FNAB:Therapeutic,diagnosticandcost‐efficient
o U/S:SimilarincosttoFNAB,butFNABmorecosteffectiveb/c80%ofmassesareNOTcysticonU/SandwillrequireFNABtofurtherevaluate
o IfFNABnotavailable:U/Sfirstwilleliminateneedforcorebiopsyin20%thatdohavecysts
o Firststep=determineifcysticorsolid.
o Howdependsonyourinstitution(availabilityandexpertiseofvariousservices)andwhetherpatientissymptomatic
o FNAB:Therapeutic,diagnosticandcost‐efficient
o U/S:SimilarincosttoFNAB,butFNABmorecosteffectiveb/c80%ofmassesareNOTcysticonU/SandwillrequireFNABtofurtherevaluate
o IfFNABnotavailable:U/Sfirstwilleliminateneedforcorebiopsyin20%thatdohavecysts
So, what is the best first step?o Officeaspiration:Reasonable1st stepespifsymptomatic.Ifnotcystic,willrequirebiopsy
o Mammography: notbest1st stepb/ccan’treliablydistinguishbenignfrommalignantorcysticfromsolid(butisusuallypartofacompleteevaluation)
o F/U1‐2mos:Couldbeokinyoungwoman(<40)whowillreliablyfollow‐up.Discussoptions,getagreement,documentwell.Ifmasspersists,gotoU/SorFNA.
o Officeaspiration:Reasonable1st stepespifsymptomatic.Ifnotcystic,willrequirebiopsy
o Mammography: notbest1st stepb/ccan’treliablydistinguishbenignfrommalignantorcysticfromsolid(butisusuallypartofacompleteevaluation)
o F/U1‐2mos:Couldbeokinyoungwoman(<40)whowillreliablyfollow‐up.Discussoptions,getagreement,documentwell.Ifmasspersists,gotoU/SorFNA.
Plate lunch, loco moco, and malasadas
Honokaa, past Waimea on the way to Hilo or Waipio Valley
Step 2: for a cystic mass…
o Ifsymptomatic,aspirateo Ifdiagnosedbyultrasoundandnoaspirationisdone,f/u1year.
o Ifaspiratedandfluidisnotbloody,f/u1‐3monthstoensurenoresidualmassorre‐accumulation
o Foranypatient>40,alsogetmammoforscreening(>50recommend,>40shareddecision)
o Ifsymptomatic,aspirateo Ifdiagnosedbyultrasoundandnoaspirationisdone,f/u1year.
o Ifaspiratedandfluidisnotbloody,f/u1‐3monthstoensurenoresidualmassorre‐accumulation
o Foranypatient>40,alsogetmammoforscreening(>50recommend,>40shareddecision)
Step 2: for a solid mass
Biopsy (FNAorcoreneedlebiopsy)
PLUS
Mammogram (tofurthercharacterizemassandtoscreenrestofbreasts)
o Ifbotharenegative,f/u3‐6months
o Ifeitherisequivocalorresultsarenotconcordant,refertobreastsurgeonforfurtherevaluation
Biopsy (FNAorcoreneedlebiopsy)
PLUS
Mammogram (tofurthercharacterizemassandtoscreenrestofbreasts)
o Ifbotharenegative,f/u3‐6months
o Ifeitherisequivocalorresultsarenotconcordant,refertobreastsurgeonforfurtherevaluation
Ultrasound F/u instead of biopsy for solid mass?
o 2smallretrospectivecohortstudies—largestn=312withpalpablemass&U/S=“probablybenign”
o Mostlyyoungwomensolowpretestprobabilityofcancer(avgage34yo)
o Strictcriteriaforcallinglesion“probablybenign”
o 2of312werecancer.NPV=0.6%.
o Concludeoktonotbiopsyandfollowwithq6mou/sfor2yrs(simtof/uofbirads3mammo)
o Caution:retrospective
o 2smallretrospectivecohortstudies—largestn=312withpalpablemass&U/S=“probablybenign”
o Mostlyyoungwomensolowpretestprobabilityofcancer(avgage34yo)
o Strictcriteriaforcallinglesion“probablybenign”
o 2of312werecancer.NPV=0.6%.
o Concludeoktonotbiopsyandfollowwithq6mou/sfor2yrs(simtof/uofbirads3mammo)
o Caution:retrospectivePark, Acta Radiologica, 2008
Surveillance instead of biopsy for solid mass?
o Retrospectivecohortstudyof441patientswithbenignsolidlesionsbysono(Birads3and4A)
o Excludedthosewithimmediatebiopsy(300)leaving141 whohadsurveillance.
o 3of141hadcancerinf/ubiopsy
o Unacceptablyhighrate(butsmallretrospectivestudywithincompletef/u)
o Retrospectivecohortstudyof441patientswithbenignsolidlesionsbysono(Birads3and4A)
o Excludedthosewithimmediatebiopsy(300)leaving141 whohadsurveillance.
o 3of141hadcancerinf/ubiopsy
o Unacceptablyhighrate(butsmallretrospectivestudywithincompletef/u)
Giess, Ultrasound Med, 2012
How are we doing?
o Inastudyofwomenwithapalpablemassandnegativemammo,only57%receivedany subsequentevaluation.o Latinas,obeseanduninsuredlesslikelytohaveanysubsequentevaluation
o Onestudyofdelayindiagnosisfoundthemostcommonreasonwasinappropriatereassuranceofwomenwithalumpandnormalmammogram
o Inastudyofwomenwithapalpablemassandnegativemammo,only57%receivedany subsequentevaluation.o Latinas,obeseanduninsuredlesslikelytohaveanysubsequentevaluation
o Onestudyofdelayindiagnosisfoundthemostcommonreasonwasinappropriatereassuranceofwomenwithalumpandnormalmammogram
Haas, JGIM, 2005; Goodson, Arch Int Med 2002
Summary: Palpable Breast Masso Choiceofwork‐upoftendependsonavailabilityandexpertiseofFNA,U/Sandcoreneedlebiopsy
o Noneofthesetestsis100%accurate,maintainahighindexofsuspicion
o Ifanyoftestisdiscordant continuework‐up
o Frequentf/uevenformassesthoughttobebenigntodetectfalsenegatives
o Choiceofwork‐upoftendependsonavailabilityandexpertiseofFNA,U/Sandcoreneedlebiopsy
o Noneofthesetestsis100%accurate,maintainahighindexofsuspicion
o Ifanyoftestisdiscordant continuework‐up
o Frequentf/uevenformassesthoughttobebenigntodetectfalsenegatives
Recommended Review: Kerlikowske, Annals Int Med, 2003
Dominant Breast Mass
U/S or Aspirate*
Solid or complex cystDo FNA or core bx
Simple cyst
If aspirate and no residual lump, fluid not bloody then do CBE 4-6 wks. If u/s, no further w/u.
BenignAtypical, suspicious
Cancer Non-diagnostic
Treat
Core or excisional biopsy
Repeat FNA, core or excision biopsy
Positive Mammo
Negative Mammo
CBE 3-6 mos
More imaging, core
or excision bx
U/S or Aspirate*
* Aspirate=office aspiration or FNAB Adapted from Kerlikowske, Ann Int Med, 2003
Q1b: Palpable mass in 42 yo
Amammographywaschosenandisnegative.Nextstep(pickone)?
A. Re‐examinein1‐2months
B. F/u1yearforannualexam
C. Ultrasound
D. Officeaspiration
E. FNA
F. Corebiopsy
Amammographywaschosenandisnegative.Nextstep(pickone)?
A. Re‐examinein1‐2months
B. F/u1yearforannualexam
C. Ultrasound
D. Officeaspiration
E. FNA
F. Corebiopsy
Mammo cannot distinguish cyst from solid and is negative in 15% with palpable mass so need to proceed with work-up from Step 1 ie cyst vs solid
Q1c: Palpable mass in 42 yo
Anultrasoundwaschosenasthefirststep.Itshowsacysticmass.Nextstep?
A. Re‐examinein1‐2months
B. F/u1yearforannualexam
C. Officeaspiration
D. FNA
E. Corebiopsy
Anultrasoundwaschosenasthefirststep.Itshowsacysticmass.Nextstep?
A. Re‐examinein1‐2months
B. F/u1yearforannualexam
C. Officeaspiration
D. FNA
E. Corebiopsy
Simple cysts are benign and no further work-up is required. If the cyst is symptomatic, may aspirate in office.
Great Road Trip: Akaka Falls and/or Hawaii Tropical Botanical Gardens
A few miles outside Hilo. Incredibly lush. Quintessential Hawaii
Work-up of non-palpable lesions
BI-RADS: Breast Imaging Reporting and Data System
Pre/Post Test Probability of cancer based on mammo results and age
Kerlikowske, Annals Int Med, 2003
Follow-up of abnormal screening mammogram
Kerlikowske, K. et. al. Ann Intern Med 2003;139:274-284
If normal, repeat screen 6 mos then q 1-2 yrs
Consider breast exam to see if lesion is palpable & biopsiable
Breast Pain
o 2/3 -3/4 report it
o > 1/2 of breast visits
o Etiology unknown: not associated with prolactin,
estrogen or progesterone levels
o 2 types: cyclic & non-cyclic
o Both types chronic, relapsing especially if severe or early onset
o Severe breast pain interferes with sex (46%), activity (36%), social (13%), work (6%)
o 2/3 -3/4 report it
o > 1/2 of breast visits
o Etiology unknown: not associated with prolactin,
estrogen or progesterone levels
o 2 types: cyclic & non-cyclic
o Both types chronic, relapsing especially if severe or early onset
o Severe breast pain interferes with sex (46%), activity (36%), social (13%), work (6%)
Kalopa State Park
Short nature hike or up to 5 miles
Near Honoka’a, 15 miles past Waimea
Mastalgia: Treatment
o Work‐up:goalistoreassurethemitsnot
cancer;exam,mammoif>40years
o DetermineeffectonQOL
o 60‐80%resolvespontaneously.
o Reassuranceoftensufficient
o Work‐up:goalistoreassurethemitsnot
cancer;exam,mammoif>40years
o DetermineeffectonQOL
o 60‐80%resolvespontaneously.
o Reassuranceoftensufficient
Mastalgia: TreatmentProven in RCT’s:o NSAID’s (topical and oral) o Evening Primrose Oil o Iodineo Vitex agnus castus extract-
containing solution (VACS) o Gestrinone (N/A in US)o Progesterone vaginal creamo Bromocryptineo Danazolo Tamoxifen
Proven in RCT’s:o NSAID’s (topical and oral) o Evening Primrose Oil o Iodineo Vitex agnus castus extract-
containing solution (VACS) o Gestrinone (N/A in US)o Progesterone vaginal creamo Bromocryptineo Danazolo Tamoxifen
No benefit (per RCT’s, though many are small and likely underpowered)
o Caffeine restrictiono Vitamin Eo Vitamin B6o Diureticso Provera o Soya proteino Isoflavones
No benefit (per RCT’s, though many are small and likely underpowered)
o Caffeine restrictiono Vitamin Eo Vitamin B6o Diureticso Provera o Soya proteino Isoflavones
Other: Supportive, well fitting bra, bra at night, trigger point injections for localized pain OCP’s—help some, make worse in others. If on OCP, try lower dose of Estradiol
Most effective but poorly tolerated
Possibly effective, 1000 mg bid-tid for 2-3 months
Topical diclofenac very effective
Topical NSAID for mastalgiaDiclofenac topical (Voltaren) q 8hr vs placebo cream. Randomized, double-blinded
Colac, Journal of the American College of Surgeons, April 2003
Very large decrease in pain score
Mastalgia: Prescribing GuideProven in RCT’s:
o **NSAID’s (topical diclofenac q 8hr very effective in 3 RCTs; oral NSAIDs—moderately effective in some but not all RCTS )
o Evening Primrose Oil: 1000mg tid for at least 1 mo trial, >$2/day, mild nausea. Recent meta-analysis showed no benefit
o Bromocriptine: increase dose gradually to decrease side effects (nausea, dizziness, orthostatic hypotension, headache). 1.25 mg qhs, increase by 1.25 mg every week until 5 mg/day.
o Danazol: best of the endocrine agents but virulizing side effects make it less desirable, teratogenic, expensive. Start at 200mg qd. Taper down as tolerated to 100mg every other day or qd during luteal phase.
Proven in RCT’s:
o **NSAID’s (topical diclofenac q 8hr very effective in 3 RCTs; oral NSAIDs—moderately effective in some but not all RCTS )
o Evening Primrose Oil: 1000mg tid for at least 1 mo trial, >$2/day, mild nausea. Recent meta-analysis showed no benefit
o Bromocriptine: increase dose gradually to decrease side effects (nausea, dizziness, orthostatic hypotension, headache). 1.25 mg qhs, increase by 1.25 mg every week until 5 mg/day.
o Danazol: best of the endocrine agents but virulizing side effects make it less desirable, teratogenic, expensive. Start at 200mg qd. Taper down as tolerated to 100mg every other day or qd during luteal phase.
Mastalgia: Prescribing Guide
Proven in RCT’s (continued):
o Tamoxifen: 10 mg qd, hot flashes, expensive
o Torimefin: 30 mg qd, vag d/c, irreg menses
o GnRH agonists: very expensive, menopausal side effects, can only use for 6 months due to bone loss.
o Local Injections: trigger point injection of 1% lidocaine (1cc) and methyl prednisone (40mg). Half require second injection in 2-3 months.
Proven in RCT’s (continued):
o Tamoxifen: 10 mg qd, hot flashes, expensive
o Torimefin: 30 mg qd, vag d/c, irreg menses
o GnRH agonists: very expensive, menopausal side effects, can only use for 6 months due to bone loss.
o Local Injections: trigger point injection of 1% lidocaine (1cc) and methyl prednisone (40mg). Half require second injection in 2-3 months.
Nipple Discharge
o Usually benign or malignant?
o Most common cause of unilateral discharge?
o Other causes: duct ectasia, nipple eczema, Paget disease, breast cancer/DCIS
o If associated with mass, more likely to be cancer (but cancer uncommonly presents with nipple d/c)
o Usually benign or malignant?
o Most common cause of unilateral discharge?
o Other causes: duct ectasia, nipple eczema, Paget disease, breast cancer/DCIS
o If associated with mass, more likely to be cancer (but cancer uncommonly presents with nipple d/c)
Nice review: Bhavika, Am J Med 2015
benignintraductal papilloma
Paget’s Dz
Nipple Discharge
Physiologic:
o Due to galactorrhea (ie
increased prolactin) or
nipple stimulation
o With compression
o Multiple ducts
o Clear, yellow, white
o No mass
Physiologic:
o Due to galactorrhea (ie
increased prolactin) or
nipple stimulation
o With compression
o Multiple ducts
o Clear, yellow, white
o No mass
Pathologic:
o Papilloma, cancer
o Spontaneous
o Single duct
o Bloody
o Mass present
Pathologic:
o Papilloma, cancer
o Spontaneous
o Single duct
o Bloody
o Mass present
Nipple Discharge: Diagnosis
Physiologic:
o History: running,
breast stimulation
o Prolactin, TSH
o Meds:
Psychotropics
Physiologic:
o History: running,
breast stimulation
o Prolactin, TSH
o Meds:
Psychotropics
Pathologic (Spont, unilat):
o Isolate involved duct
o Hemoccult to confirm blood, cytology not useful
o Mammography with retro-alveolar views
o Galactography vs MRI
o Surgery referral
Pathologic (Spont, unilat):
o Isolate involved duct
o Hemoccult to confirm blood, cytology not useful
o Mammography with retro-alveolar views
o Galactography vs MRI
o Surgery referral
Questions? Mastitis
o 2types:lactatingvsnon‐lactating
o Primaryvssecondary(cellulitis,folliculitis,hydradinitis,sebaceouscyst)
o 2types:lactatingvsnon‐lactating
o Primaryvssecondary(cellulitis,folliculitis,hydradinitis,sebaceouscyst)
Cellulitis
Lactational Mastitis
o Suspect in any breast-feeding woman with a fever and malaise
o Often wedge shaped redness over involved duct
o Staph, Strept—(community acquired MRSA becoming more common so do culture of milk)
o Suspect in any breast-feeding woman with a fever and malaise
o Often wedge shaped redness over involved duct
o Staph, Strept—(community acquired MRSA becoming more common so do culture of milk)
Non-Lactational Mastitis
o Difficult to treat
o Often chronic, recurrent
o Peri-areolar: young (avg 32), 90% are smokers, central pain, nipple retraction and discharge, often assoc with abscess
o Difficult to treat
o Often chronic, recurrent
o Peri-areolar: young (avg 32), 90% are smokers, central pain, nipple retraction and discharge, often assoc with abscess
o Peripheral: elderly, usually associated with underlying disease (diabetes) or trauma
o Gram negatives, staph, strept, anaerobes
o Peripheral: elderly, usually associated with underlying disease (diabetes) or trauma
o Gram negatives, staph, strept, anaerobes
Mastitis Treatment
Lactational
o Increase feeding, warm compresses
o Keflex, Dicloxicillin
o IV if not better quickly
o Septra or Clinda for community acquired MRSA
Lactational
o Increase feeding, warm compresses
o Keflex, Dicloxicillin
o IV if not better quickly
o Septra or Clinda for community acquired MRSA
Non-Lacatational
o Include anaerobic coverage
o Clindamycin or Flagyl + Ancef or Nafcillin
Non-Lacatational
o Include anaerobic coverage
o Clindamycin or Flagyl + Ancef or Nafcillin
** Biopsy if recurrent or doesn’t resolve
Cancer can mimic mastitis
Inflammatory Cancer
Breast Abscesso Suspectif“lump”onexamorifmastitisnotrespondingtoabx
o Ultrasoundtoconfirmo Getcultureo AspirationnowpreferredoverI&D
o Sometimesneedrepeatedaspirationsordrain
o I&Doftenassocwithpoorcosmeticresultorfistula
o Suspectif“lump”onexamorifmastitisnotrespondingtoabx
o Ultrasoundtoconfirmo Getcultureo AspirationnowpreferredoverI&D
o Sometimesneedrepeatedaspirationsordrain
o I&Doftenassocwithpoorcosmeticresultorfistula
Core Needle Biopsy (cont’d)
o Like FNAB, requires training to prevent false negatives due to sampling error
o Used instead of FNAB by consultant preference or where cytopathology service not skilled in interpretation
o Also preferred for evaluation of non‐palpable lesions
o Like FNAB, requires training to prevent false negatives due to sampling error
o Used instead of FNAB by consultant preference or where cytopathology service not skilled in interpretation
o Also preferred for evaluation of non‐palpable lesions
![PRIMARY NON-HODGKIN LYMPHOMA OF THE ORBIT ......the patients, presentation is with orbital mass [2]. Common signs at presentation are: palpable mass, pain, exophtalmia, ptosis, dyplopia,](https://img.pdfslide.us/doc/110x75/614396f46b2ee0265c0224b6/primary-non-hodgkin-lymphoma-of-the-orbit-the-patients-presentation-is.jpg)
