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1. How is the breast examination performed? In general, be methodical and consistent. Palpation should be systematic and with variable pressure.

Examine the patient while she is in the sitting and supine positions. Have the patient flex the pectora-lis muscle to look for any skin retraction or dimpling. The areola should be compressed to identify any discharge as well as to evaluate for nipple retraction. To evaluate for lymph nodes, ask the patient to open the axilla by placing the ipsilateral hand behind her head.

2. What physiologic changes occur in the breast during the luteal phase of the menstrual cycle?

Cyclic symptoms of increased sensitivity, pain, or even nipple discharge result from an increase in size, nodularity, and density. Breast volume increases an average of 25 to 30 mL. Breast examination is therefore best performed shortly after menses.

3. How common is breast pain (mastalgia)? Breast pain occurs in more than two thirds of menstruating women. Cyclic pain tends to be diffuse,

bilateral, and associated with benign fibrocystic changes. Noncyclic breast pain is localized and may be associated with an identifiable cyst or mass. Pain alone is rarely a presenting symptom of malignant disease. Various treatments have been used for mastalgia and include analgesics, low-dose diuretics, danazol, and reduced caffeine intake.

4. What is mastitis? Mastitis refers to the inflammation of breast tissue. It can be categorized as infectious or noninfec-

tious. Noninfectious mastitis may warrant workup for possible malignancy. Lactational mastitis occurs in 2% to 10% of breastfeeding women and manifests with fever and a tender, red, engorged breast. Treatment is directed against Staphylococcus aureus (including methicillin-resistant S. aureus [MRSA]), and women are encouraged to continue breastfeeding.

5. What is galactorrhea, and what are common causes? Galactorrhea refers to spontaneous milky, nonbloody discharge from the nipple. It results from

increased prolactin levels. Dopamine exerts negative feedback on prolactin release, and thyrotropin-releasing hormone (TRH) promotes prolactin release. Therefore, medications that have dopamine antagonist activity (e.g., antipsychotics or other phenothiazine drugs) or conditions in which the patient would have high levels of TRH (hypothyroidism) can cause galactorrhea. Pregnancy, oral contraceptives, and prolactinomas can also cause galactorrhea.

6. What is the most common cause of bloody nipple discharge? Bloody discharge is most commonly the result of a breast neoplasm, and the most frequent neoplasm

is a benign intraductal papilloma.

7. What are fibrocystic changes of the breast? Fibrocystic changes are the most common benign breast conditions. They are characterized by fibro-

sis of breast stroma and the formation of cysts, and they typically affect women of reproductive age. Some women can palpate changes in the breast, but most women with fibrocystic change experience cyclic breast pain. Fibrocystic changes are not associated with an increased risk of breast cancer.

8. How should a mass be described? Size, contour, consistency, and mobility should be noted, along with any attachment to skin or

underlying fascia. Careful examination of the axillary and supraclavicular lymph nodes should also be performed, and any nipple discharge or rashes should be noted.

9. What is the differential diagnosis of a breast mass? Breast cancer, fibrocystic disease, fibroadenoma, and trauma (fat necrosis); the frequency varies with

age. Fibrocystic change is the most common cause of a breast mass.

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BREAST DISEASE 85

10. What important information should be obtained from a patient being evaluated for a breast mass?

Most newly discovered breast masses are found by the patient herself. It is important to ask when the mass was first found, how it has changed, whether it changes with the menstrual cycle, and whether it is painful.

11. What characteristics of a breast mass suggest malignancy? Palpable breast cancers usually have irregular or indistinct borders and may be attached to the skin,

dermal attachments, or underlying fascia. More advanced local disease produces skin changes that result in retraction, dimpling, induration, edema (“peau d’orange”), ulceration, or inflammation. How-ever, no physical characteristics can reliably distinguish between benign and malignant lesions—any breast mass should be examined by biopsy.

12. What are the risk factors for breast cancer? Carcinoma of the breast, the most common malignant disease in women, occurs in 12% (1 in 8) of

women during their lifetime. Risk factors include age, family history of breast cancer, history of breast cancer in the opposite breast, combined estrogen and progesterone hormone therapy (HT), early menarche or late menopause, nulliparity, radiation exposure, and a history of colon or uterine cancer. The Gail model is a computer model that combines various risk factors to produce an individualized risk assessment. It does not, however, include whether a woman has been tested for BRCA genes or used HT.

13. What are the BRCA genes, and why are they important? The breast and ovarian cancer genes BRCA1 and BRCA2 are found on two separate chromosomes.

The lifetime risk of breast cancer in women with these mutations may be as high as 85%, and the lifetime risk for ovarian cancer is 20% to 40%. Women with a strong family history of breast or ovarian cancer may choose to be screened. Women who test positive require increased surveillance for cancer and are offered prophylactic mastectomy or oophorectomy after childbearing has been completed.

14. Does the use of HT increase a woman’s risk of breast cancer? According to the Women’s Health Initiative (WHI), which was a large cohort study of women receiving

HT after menopause, the risk of breast cancer (relative risk [RR]: 1.24; confidence interval [CI]: 1.02 to 1.5) is slightly increased with the use of a combination estrogen-progesterone regimen but not with estrogen alone. (The estrogen-only arm of the study actually showed a statistically insignificant decrease in risk, with an RR of 0.8 [CI: 0.62 to 1.04]). Women should consider their baseline risk of breast cancer before they take HT. A family history of breast cancer does not in itself preclude the use of HT.

Oral contraceptives have not been shown to increase the risk of breast cancer.

15. Is there anything a woman can do to reduce her risk of developing breast cancer? For women at average risk, no proven methods exist because most of the risk factors (e.g., family his-

tory, age at menarche) are not able to be modified. For women at very high risk, tamoxifen has been shown to reduce the incidence of new hormone receptor–positive breast cancers. It has not, however, been shown to reduce deaths or the risk of hormone receptor–negative cancers. Prophylactic oophorectomy has been shown to decrease breast cancer risk by 50%, and prophylactic mastectomy decreases breast cancer risk by 90%.

16. What are the current breast cancer screening guidelines? Mammography screening is associated with a 19% overall reduction of breast cancer mortality (≈15%

for women in their 40s and 32% for women in their 60s), but it has disadvantages of false-positive results and overdiagnosis. At this time, a discrepancy exists among major organizations regarding breast cancer screening. Recommendations from the American Cancer Society, the American College of Obstetricians and Gynecologists, and the U.S. Preventive Services Task Force are summarized in Table 19-1. Screening magnetic resonance imaging (MRI) scans should be reserved for high-risk (>20%) women such as BRCA carriers.

17. What initial diagnostic step should be taken to evaluate a newly discovered mass?

A diagnostic mammogram should be the first imaging study to be performed, even if a patient has had a recent negative mammogram. Ultrasound can be used to determine whether a mass is solid or cystic, and it is the first-line imaging method for a woman who is pregnant or lactating.


86 GENERAL GYNECOLOGY

18. If a breast cyst is aspirated, should the fluid be sent for microscopic examination? Only if it is bloody. Clear or yellow fluid does not need to be sent for cytologic analysis.

19. What characteristics of an aspirated cyst require further workup? Aspiration of bloody fluid or a residual mass remaining after aspiration. Further diagnostic studies

should also be performed if a cyst recurs.

20. What are the advantages and disadvantages of fine-needle aspiration (FNA) of a breast mass over a core or excisional biopsy?

Confirmation of any breast mass is made by either FNA or core biopsy. FNA is easily and safely performed in an office or clinic setting. It distinguishes cystic from solid masses and provides cells for subsequent cytologic evaluation. However, it requires considerable skill to obtain a satisfactory sample and has significant false-negative and false-positive rates. A core or excisional biopsy enables the pathologist to determine whether a malignant mass is invasive or in situ, whereas this determination may not be possible on the basis of an FNA.

21. Does a normal-appearing mammogram in a woman with a palpable mass exclude the possibility of cancer?

No. In general, the false-negative rate for mammograms is reported to be as high as 16%. Mammo-grams can be interpreted as normal even in the presence of clinically evident cancer; for this reason, any suspicious palpable mass should be examined by biopsy.

22. In what settings are mammograms particularly difficult to interpret? Dense or very large breasts are difficult for radiologists to evaluate. This problem is found in 25% of

women and is particularly common at younger ages.

23. What is the role of ultrasound in the evaluation of solid breast masses? Ultrasound is useful for differentiating solid from cystic masses. The study can be used in women with

large breasts who have deep, inaccessible lesions or who cannot undergo needle aspiration. It is also preferred in pregnant and lactating women as the primary workup.

24. What is the approach to a woman whose mammogram shows a nonpalpable lesion that is read as “probably benign” by the radiologists?

Two choices are possible: biopsy or repeat mammography within 6 months. Studies indicate that the second approach is probably safe, but it depends on the comfort of the physician with the mammo-graphic appearance and the patient’s ability to return for follow-up. The risk of malignancy in these cases is less than 2%.

25. If a lesion is regarded as suspicious on a mammogram but is not palpable, what is the next step?

Mammographic, ultrasound, or MRI localization techniques (including wires and dyes) can be used to perform an image-guided biopsy.

26. What pathologic findings on breast biopsy put patients at a higher risk for subse-quent development of breast cancer?

Lesions with a proliferative pattern are associated with an increased risk for subsequent cancer, and lesions that show atypical hyperplasia have the highest relative risk (fivefold increase).

Table 19-1. Current Breast Cancer Screening Guidelines

ORGANIZATION MAMMOGRAMCLINICAL BREAST EXAMINATION

BREAST SELF-EXAMINATION

American Cancer Society Age 40 years and older annually

Age 20-39 every 1-3 years, then annually ≥40 years

Optional for age 20 years and older

American College of Obstetricians and Gynecologists

Age 40 years and older annually

Age 20-39 years every 1-3 years, then annually ≥40 years

Consider for high-risk patients

U.S. Preventive Services Task Force

Age 50-74 years biennially

Insufficient evidence Not recommended


BREAST DISEASE 87

27. What are the major types of breast cancer? • Ductal: Most breast cancers involve ductal tissue. Ductal carcinoma is divided into infiltrating

ductal carcinoma and ductal carcinoma in situ (DCIS). DCIS identifies a woman at increased risk of invasive breast cancer. Most women with DCIS develop infiltrating carcinoma, and a few women have an invasive tumor present in the same breast at the time DCIS is diagnosed.

• Lobular: Approximately 10% of breast cancers are lobular. This category is subdivided into infiltrat-ing lobular carcinoma and lobular carcinoma in situ (LCIS). LCIS is associated with an increased risk of invasive breast cancer in either the ipsilateral or contralateral breast. Compared with DCIS, the time to progression of LCIS is longer.

BiBliography

1. American Cancer Society. Breast cancer early detection, 2014. Available at http://www.cancer.org/acs/groups/cid/documents/webcontent/003165-pdf.pdf. Accessed November 18, 2014.

2. Dizon DS, Tejada-Berges T, Steinhoff MM, et al. Breast cancer. In: Barakat R, Markman M, Randall M, eds. Principles and Practice of Gynecologic Oncology. 5th ed. Baltimore: Lippincott Williams & Wilkins; 2009:897–945.

3. Grube BJ, Giuliano AE. Benign breast disease. In: Berek J, ed. Berek and Novak’s Gynecology. 14th ed. Philadelphia: Lippincott Williams & Wilkins; 2007.

4. National Comprehensive Cancer Network. Breast cancer risk reduction, 2014. Available at http://www.nccn.org/professionals/physician_gls/pdf/breast_risk.pdf. Accessed November 18, 2014.

5. National Comprehensive Cancer Network. Breast cancer screening and diagnosis, 2014. Available at http://www.nccn.org/professionals/physician_gls/pdf/breast-screening.pdf. Accessed November 18, 2014.

6. Pace L, Keating N. A systematic assessment of benefits and risks to guide breast cancer screening decisions. JAMA. 2014;311:1327–1335.

KEY POINTS: BREAST DISEASE

1. Breast pain occurs in more than two thirds of menstruating women; it tends to be diffuse, bilateral, and cyclic.

2. Fibrocystic changes are the most common benign breast conditions. Such changes are character-ized by fibrosis of breast stroma and the formation of cysts, and they typically affect women of reproductive age.

3. The Gail model combines risk factors such as age, family history, personal history of breast biopsies, age of menarche, and age of menopause to assess an individual’s breast cancer risk.

4. A palpable breast mass is initially evaluated with mammography or ultrasound, or both. FNA can be done to assess whether the mass is cystic or solid; if bloody fluid or solid tissue is obtained, it should be sent for cytologic examination. A core or excisional biopsy can enable a pathologist to determine whether a malignant mass is invasive.


http://www.cancer.org/acs/groups/cid/documents/webcontent/003165-pdf.pdf

http://www.nccn.org/professionals/physician_gls/pdf/breast-risk.pdf

http://www.nccn.org/professionals/physician_gls/pdf/breast-screening.pdf

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