#164 Diagnosis and Management of Benign Breast Disorders

Question 1

What breast lesions are classified as nonproliferative type?

Answer 1

Simple cysts, mild hyperplasia (usual type), papillary apocrine change

Question 2

What is the aggregate relative risk of future breast cancer with nonproliferative breast lesions?

Answer 2

No increased risk. RR 1.17 (0.94-1.47)

Question 3

What breast lesions are classified as proliferative without atypia type?

Answer 3

Fibroadenoma, giant fibroadenoma, intraductal papilloma, moderate/florid hyperplasia (usual type), sclerosing adenosis, radial scar

Question 4

What is the aggregate relative risk of future breast cancer with proliferative without atypia breast lesions?

Answer 4

Small-to-moderate increased risk. RR 1.76 (1.58-1.95)

Question 5

What breast lesions are classified as atypical hyperplasia type?

Answer 5

Atypical ductal hyperplasia, atypical lobular hyperplasia

Question 6

What is the aggregate relative risk of future breast cancer with atypical hyperplasia breast lesions?

Answer 6

Increased. RR 3.93 (3.24-4.76)

Question 7

What is the aggregate relative risk of future breast cancer with lobular carcinoma in situ breast lesions?

Answer 7

Greatly increased. RR 6.9-11

Question 8

What is the most common type of nonproliferative breast lesion?

Answer 8

Simple breast cysts

Question 9

What proportion of women between 35-50 have to have a simple breast cyst?

Answer 9

up to 1/3

Question 10

What is management for simple breast cysts?

Answer 10

Expectant vs aspiration if bothersome to the woman

Question 11

What is seen on histology for breast mild hyperplasia of the usual type?

Answer 11

Focal thickening of the duct epithelial cell layers (four or fewer) that does not fill the duct

Question 12

What is seen on histology of breast simple papillary apocrine change?

Answer 12

Focal thickening of the epithelial lining of an apocrine cyst

Question 13

What is the most common cause of breast mass in adolescent girls and young women?

Answer 13

Fibroadenoma

Question 14

What is the median age of presentation of women with fibroadenomas?

Answer 14

25yo

Question 15

What percent of breast masses in menopausal women are fibroadenomas?

Answer 15

12%

Question 16

What are typical characteristics of fibroadenoma?

Answer 16

Small (1-2cm), firm, well-circumscribed, mobile mass composed of a proliferation of epithelial and stromal elements

Question 17

How can you distinguish a simple breast cyst from fibroadenoma?

Answer 17

Ultrasound is useful. Often similar on physical exam and mammography

Question 18

What are giant breast fibroadenomas?

Answer 18

Generally >10cm. Unusual variant of juvenile and adult fibroadenomas. Histologically, benign lesions, composed of same epithelial and stromal elements as adult fibroadenomas, tend to have more florid glandular elements with great stromal cellularity

Question 19

How do giant fibroadenomas present (breast)?

Answer 19

Enlarging masses that typically distort the breast, typically adolescents and young adults

Question 20

What percent of fibroadenomas are giant fibroadenomas (breast)?

Answer 20

4%

Question 21

What is seen on histology for moderate (AKA florid) hyperplasia of the usual type (breast)?

Answer 21

Multiple-duct epithelial cell layers (more than 4) that fill the entire duct, but do not have cytologic atypia.

Question 22

How is sclerosis adenosis characterized (breast)?

Answer 22

Increased numbers of size of glandular components within lobular units

Question 23

What are radial scars (breast)?

Answer 23

pseudoproliferative lesion and usually are incidentally found on biopsy

Question 24

What is the management of radial scars and why (breast)?

Answer 24

Excision. May harbor or facilitate the development of atypical proliferations

Question 25

What are intraductal papillomas?

Answer 25

Tumors in a lactiferous duct that may be solitary and centrally located near the duct opening or multiple and peripherally located in the breast

Question 26

How do intraductal papillomas present?

Answer 26

Solitary papillomas can present as nipple discharge (blood, serous, or clear), or, less often, as a palpable mass. Women aged 30-50yo, typically 2-4mm

Question 27

What is the risk of coexisting or subsequent breast cancer in women with multiple peripheral intraductal papillomas

Answer 27

One third

Question 28

What are the histologic characteristics of atypical ductal hyperplasia?

Answer 28

Ductal elements with uniform cells and loss of apical-basal cellular orientation

Question 29

What are the histologic characteristics of atypical lobular hyperplasia?

Answer 29

Lobular elements with uniform cells and loss of apical-basal cellular orientation

Question 30

How do tubular adenomas present? Histology? (breast)

Answer 30

Can present as a breast mass or may be seen on routine breast imaging. Consists of benign glandular cells with minimal stromal elements.. Tissue bx required for diagnosis

Question 31

What percentage of breast tumors are phyllodes tumors?

Answer 31

0.3-0.5%

Question 32

What percent of phyllodes tumor exhibit aggress sarcomatous behavior?

Answer 32

5%

Question 33

What is the median age at presentation for phyllodes tumor?

Answer 33

40yo

Question 34

What is the usual presentation for phyllodes tumor?

Answer 34

Single enlarging breast mass

Question 35

What are physical characteristics of phyllodes tumor?

Answer 35

Larger than other fibroadenomas, but are firm, circumscribed, and mobile. Rapid growth causes stretching of overlying skin

Question 36

True or false: phyllodes tumor has high risk of local recurrence?

Answer 36

True

Question 37

True or false: lobular carcinoma in situ is a precursor lesion for breast cancer?

Answer 37

False, it is a risk marker for future development of breast cancer

Question 38

What is the 15 year risk of developing invasive ductal or invasive lobular breast cancer after LCIS diagnosis?

Answer 38

10-20%

Question 39

True or false: nipple discharge is most often associated with malignancy?

Answer 39

False

Question 40

What are the characteristics of benign nipple discharge?

Answer 40

More likely to be bilateral, only present when expressed, milky or green in color, multiductal

Question 41

What characteristics of nipple discharge are more concerning for malignancy?

Answer 41

Unilateral, uniductal, and spontaneous

Question 42

What are causes of non-cyclic mastalgia?

Answer 42

Mastitis, trauma, thrombophlebitis (Mondor disease), cysts, tumors, and cancer

Question 43

What are extramammary causes of mastitis?

Answer 43

Costochondritis, chest wall trauma, rib fractures, fibromyalgia, cervical radiculopathy, herpes zoster, angina, GERD, pregnancy

Question 44

How are nonpuerperal breast infections separated?

Answer 44

Periareolar and peripheral infections

Question 45

What are most cases of mastitis related to?

Answer 45

Lactation (puerperal mastitis)

Question 46

What is a risk factor for periareolar infection?

Answer 46

Smoking

Question 47

How is periareolar infection characterized?

Answer 47

Inflammation around nondilated subareolar ducts. Periareolar inflammation and can have an abscess.

Question 48

What are peripheral infections associated with (breast)?

Answer 48

Trauma and conditions that impair immunity (eg diabetes, steroid use, RA, granulomatous lobular mastitis)

Question 49

How does mammary duct ectasia present clinically?

Answer 49

Nipple discharge, nipple inversion, palpable subareolar mass, noncyclic mastalgia, or infection

Question 50

How is mammary duct ectasia managed?

Answer 50

Conservatively, does not require surgery

Question 51

At what age does mammary duct ectasia occur?

Answer 51

Middle-aged and elderly women

Question 52

How does mammary duct ectasia present on mammogram?

Answer 52

Microcalcifications

Question 53

How does Paget disease of nipple clinically present?

Answer 53

Ulcerated, crusted, or scaling lesion on the nipple that can extend to the areola. Nipple can be retracted or hyperpigmented. Patient may have pain, burning, itching.

Question 54

What does BI-RADS 0 mean?

Answer 54

Incomplete. Need additional imaging evaluation

Question 55

What is BI-RADS 1? Likelihood of malignancy?

Answer 55

Negative. Essentially 0% likelihood of malignancy

Question 56

What is BI-RADS 2? Likelihood of malignancy?

Answer 56

Benign. Essentially 0% likelihood of malignancy.

Question 57

What is BI-RADS 3? Likelihood of malignancy?

Answer 57

Probably benign. >0% but less than or equal to 2% likelihood of malignancy

Question 58

What is the recommended follow up for BI-RADS 3? (for mammo, ultrasound, MRI)

Answer 58

Short-interval (6 month) follow-up or continued surveillance

Question 59

What is the recommended follow up for BI-RADS 0?

Answer 59

Recall for additional imaging

Question 60

What is BI-RADS 4? Likelihood of malignancy?

Answer 60

Suspicious. >2% but <95% likelihood of malignancy

Question 61

What is recommended follow up for BI-RADS 4?

Answer 61

Tissue diagnosis

Question 62

What is BI-RADS 4A? Likelihood of malignancy?

Answer 62

Low suspicion for malignancy. >2% to less than or equal 10% likelihood of malignancy

Question 63

What is BI-RADS 4B? Likelihood of malignancy?

Answer 63

Moderate suspicion for malignancy. >10% to less than or equal to 50%

Question 64

What is BI-RADS 4C? Likelihood of malignancy?

Answer 64

High suspicion for malignancy. >50% to <95% likelihood of malignancy

Question 65

What is BI-RADS 5? Likelihood of malignancy?

Answer 65

Highly suggestive of malignancy. Greater than or equal to 95% malignancy.

Question 66

What is recommended follow up for BI-RADS 5?

Answer 66

Tissue diagnosis

Question 67

What is BI-RADS 6?

Answer 67

Known biopsy-proved malignancy

Question 68

What does BI-RADS stand for?

Answer 68

Breast Imaging Reporting and Data System category

Question 69

Next step in management for palpable mass in woman younger than 30, with clinical suspicion for malignancy?

Answer 69

Ultrasound

Question 70

Next step in management for palpable mass in woman younger than 30, with low clinical suspicion for malignancy?

Answer 70

Observe for 1-2 menstrual cycles, if mass persists > ultrasound

Question 71

Next step in management for palpable mass in woman 30 years or older?

Answer 71

Diagnostic mammography

Question 72

What are options for histologic evaluation (techniques to get specimen) of abnormal findings on diagnostic breast imaging?

Answer 72

1. Fine needle aspiration 2. Core needle biopsy 3. Excisional biopsy

Question 73

What patients need excisional breast biopsy?

Answer 73

1. Lesion not amenable to stereotactic or US-guided bx (location, imaging characteristics, impants) 2. Certain histologic findings on core needle bx (atypical hyperplasia, flat epithelial atypia, LCIS, mucinous tumors, possible phyllodes tumors, and radial scars) 3. If core needle bx nondiagnostic or discordant with clinical examination or imaging findings

Question 74

What is the next step in management if woman presents because of a breast mass, but patient and physician unable to identify the mass?

Answer 74

Clinical follow-up examination is recommended

Question 75

When can you discard the cyst fluid aspirated from a BI-RADS 3 cyst? What if does not meet criteria for discard?

Answer 75

When fluid is not bloody and the mass resolves with aspiration. If doesn't meet criteria then image-guided aspiration, core needle biopsy, or excision of mass is indicated.

Question 76

Can you aspirate BI-RADS 4-5 cysts?

Answer 76

No, require biopsy

Question 77

How is mastalgia associated with cancer typically described?

Answer 77

Unilateral, intense, noncyclic, progressive

Question 78

What is Mondor disease?

Answer 78

Superficial thrombophlebitis of lateral thoracic vein, a rare condition that causes noncyclic breast pain and tenderness.

Question 79

What are the typical physical findings in Mondor disease?

Answer 79

Palpable cord, initially red and tender and subsequently is accompanied by linear skin dimpling. [Mondor disease = superficial thrombophlebitis of lateral thoracic vein]

Question 80

What work up should be done for Mondor disease?

Answer 80

Age-appropriate breast imaging. Association with breast cancer. [Mondor disease = superficial thrombophlebitis of lateral thoracic vien]

Question 81

What is the only medication with FDA approval for treatment of mastitis?

Answer 81

Danazol

Question 82

What pharmacologic agents can be considered to treat mastalgia?

Answer 82

NSAIDs, tylenol, Danazol, continuous OCPs (if cyclic pain), tamoxifen, bromobriptine

Question 83

How is breast atypical hyperplasia managed? Why?

Answer 83

Surgical excision. Either DCIS or invasive cancer is detected at the time of surgical excision in 10-20% of cases. Risk-reduction therapy strongly recommended: include tamoxifen, raloxifene, aromatase inhibitors

Question 84

What are screening recommendations for women with breast atypical hyperplasia?

Answer 84

Annual mammography, clinical breast exam q6-12mo, breast self-awareness. Annual MRI can be considered for 30yrs or older.

Question 85

How is lobular carcinoma in situ managed? Initial, further screening, role for further medical management?

Answer 85

Excision to rule out adjacent more serious lesions such as DCIS or invasive carcinoma. Screening: annual screening mammography and clinical breast exam every 6-12mo, but not before age 30; consider annual MRI. Recommend risk-reduction therapy: tamoxifen, raloxifene, aromatase inhib. Prophylactic mastectomy is an option.

Question 86

Would you offer prophylactic mastectomy to patient with LCIS?

Answer 86

Is a possible option.

Question 87

What medications are associated with galactorrhea?

Answer 87

Phenothiazines and other antipsychotics, metoclopramide, domperidone, methyldopa, reserpine, verapamil, and combined oral contraceptives

Question 88

True or false, a small amount of expressible clear discharge from the female nipple is physiologically normal?

Answer 88

True

Question 89

True or false, all women presenting with spontaneous, unilateral, uniductal nipple discharge (clear, serous, or bloody) should be worked up with ultrasound?

Answer 89

True. Women over 30 should also get diagnostic mammography

Question 90

For women with BI-RADS 1-3 imaging with work up for persistent, spontaneous, unilateral, single duct nipple discharge (serous, sanguineous, or serosanguineous) what is the next step?

Answer 90

Duct excision

Question 91

What organism is most common in puerperal infectious mastitis?

Answer 91

Staphylococcus aureus

Question 92

What organisms cause infectious mastitis?

Answer 92

Staph aureus, streptococcus, staph epidermidis, enterococcus, and anaerobes

Question 93

How do you treat skin-associated breast infections in nonlactating women?

Answer 93

Treat empirically with amoxicillin and clavulanic acid or for PCN allergic patients, erythromycin and metronidazole

Question 94

How should you treat a breast abscess?

Answer 94

Aspiration or incision and drainage, with culture to guide antibiotic therapy

Question 95

What is the typical presentation of a patient with inflammatory breast cancer?

Answer 95

Pain, progressive breast tenderness, and skin discoloration (erythema, "bruising") and often have a firm and enlarged breast

Question 96

What is the work up for suspected inflammatory breast cancer?

Answer 96

Diagnostic mammography and ultrasound are appropriate first steps, and a punch biopsy of breast skin when findings suggestive of malignancy and not responsive to antibiotic therapy

Question 97

How does periductal mastitis present?

Answer 97

Focal inflammation of the periareolar area and may be accompanied by abscess formation or even mammary duct fistula. Usually seen in young smokers, may be recurrent

Question 98

What is the treatment for periductal mastitis?

Answer 98

Empiric antibiotics including anaerobic coverage, and supported by culture results if available. Ultrasonography should be performed and abscesses should be aspirated or I+D'd

Question 99

What percentage of cases of Paget disease are associated with an underlying invasive breast carcinoma or DCIS?

Answer 99

85%