Instructions: Listen to the podcast episode available below, and then submit your answers to the multiple choice questions. You will review the answers and the material covered during your next Continuity Clinic Session.
Benign Breast Disease
1. A 54 yo menopausal woman comes to the office with 2 weeks of spontaneous blood nipple discharge. On exam, you note no palpable masses. She has no tenderness. You see no retraction or dimpling of the breast. The nipple is in normal position. There are no skin changes. You find no palpable lymph nodes. Circumferential palpation around the areola elicits a bloody discharge from a single ductal orifice. Diagnostic mammography is negative for malignancy. What is the most likely diagnosis?
Any breast discharge is more worrisome if it is associated with an underlying mass
Fibrocystic changes causes a thick green discharge
Galactorrhea is usually bilateral with secretions that are clear or milky
Intraductal papilloma are epithelial proliferations that frequently occur with bleeding
Rarely associated with malignancy
Excision is the only way to exclude atypia/carcinoma
Usually isolated lesions within a single ductal system so bloody discharge comes from a single ductal orifice
Ductal ectasia is when a ductal wall becomes dilated and fills with inflammatory secretions- usually causes thick, sticky and green or black discharge that can become bloody
Bloody discharge associated with a 3-6% risk of underlying cancer
Paget disease is an intraductal carcinoma that presents with scaly skin similar to eczema on the nipple. This is usually associated with pruritus, burning, pain and sometimes bleeding.
Evaluation of blood discharge should include history, breast and axillary exam, Hemoccult test can be used to exclude blood if needed, Bilateral mammogram, can do subareolar ultrasound
2. A 24 yo G2P2 who is 3 weeks postpartum presented 4 days ago with fever, chills and left breast pain. Mastitis was diagnosed. She received oral dicloxacillin. Today, she reports continued fever and worsening left breast pain. On exam, a 4 cm fluctuant area of induction, erythema and warmth is noted. What is the next best step in management?
Lactational mastitis is the infection of the skin and/or parenchyma of the breast in breastfeeding women (happens in 2-10%)
The most common organism is Staph aureus, including strains of MRSA. Strep and Staph epidermidis are also frequently identified
Treatment of mastitis: anti-inflammatory medications, antibiotics and complete emptying through nursing or pumping
Antibiotic options: dicloxacillin, cephalexin, clindamycin
If concerned about MRSA, can add Bactrim
Inpatient treatment recommended if there is sepsis or outpatient therapy fails to relieve symptoms
Lactational mastitis rarely progresses to an abscess (5-10%), can confirm with ultrasound
Treatment of breast abscess is drainage- can try needle drainage first, then I&D if does not resolve
Can do culture of drainage to guide antibiotic therapy
3. A 47 yo woman presents for routine bilateral screening mammography. She is found to have fibrocystic changes and a small mass that, on biopsy, is consistent with ductal hyperplasia without atypia. What is the most appropriate next step?
Benign breast epithelial lesions can be classified as non-proliferative, proliferative with atypia and Atypical hyperplasia depending on the degree of proliferation and atypia
Nonproliferative breast lesions: Fibrocystic changes, fibrocystic disease, chronic cystic mastitis, mammary dysplasia, breast cysts – NOT associated with increased risk of breast cancer
Proliferative breast lesions without atypia: Ductal hyperplasia, intraductal papilloma, sclerosing adenosis, radial scars, fibroadenomas – SLIGHT increase in the risk of breast cancer (usually more for complex fibroadenomas than simple fibroadenomas).
Ductal hyperplasia is often an incidental finding on histology after biopsy for mammogram abnormality or breast mass- means increased number of cells within the ductal space; requires no treatment or chemoprevention
Proliferative lesions with atypical hyperplasia- includes atypical ductal hyperplasia and atypical lobular hyperplasia. Often found at time of biopsy for mass or mammogram abnormality
Associated with increased risk of breast cancer
Should do semiannual breast exams and yearly mammograms
Some patients may quality for chemoprevention with selective estrogen receptor modulator or aromatase inhibitor