Dr Israa Helali

Family Medicine Specialist & Trainer in the Egyptian Fellowship Board

Breast Disorders
Puberty in girls

• Thelarche is the first stage of

puberty
• Occurs at 9-10 years of age in girls
• Followed by pubarche 6 months
later
• Menarche occurs 1.5 to 3 years
after thelarche
Puberty in boys

• Puberty occurs at 9-14 years

• Gynecomastia that occurs during
puberty in boys is usually benign
• Occurs due to an imbalance
between estrogen and
testosterone
• Requires follow up and
reassurance
• Usually resolves by 18 years of
age
Anatomy of the Breast

• A mound of fibrous stroma with

adipose, ductal and glandular
tissue overlying the anterior
chest wall.
• Extends to the axillary tail
• Cooper's ligaments anchor the
breast to the pectoralis major
muscle
• The nipple is located in the
midclavicular line at the level of
the 4th rib
Pathology of
the breast
 History includes the following:
• Presence and type of pain
• Presence and color of nipple discharge
Evaluation of • Presence of a breast lump
• Relation of symptoms to menses and
Breast pregnancy
• Presence of skin changes
Diseases: • Use of hormonal contraceptives or
menopausal hormone therapy
History • Date and results of last mammogram or
other breast imaging study
• Personal or family history of breast cancer
 • Breast Cancer

Differential • Fibrocystic breast disease

• Fibroadenoma
Diagnosis of • Infection: mastitis or abscess
• Galactocele
Breast Lump • Metastatic Cancer to the breast
• Breast fat necrosis
Evaluation of Breast Diseases: Examination
Examination of the Breast:

• Look for irregularities in shape, nipple

discharge or skin changes
• Irregularities in shape: bulging, irregular
contour
• Feel for lumps
• Nipple abnormalities: Inversion, retraction
(flat), discharge, crusting
• Skin changes: dimpling, retraction, edema,
erythema, scaling, ulceration
Peau d'orange
 • Asymmetry in size or density: normal in
many cases; need to rule out cancer
• Retracted or inverted nipple: difficult to
breastfeed

Normal Breast • Witch's milk: normal finding in newborns of

any gender, breast nodules slightly larger,
may persist till 2 months of age
Variants • Accessory nipple: usually presents in the
inframammary region, may be prone to
conditions as the main nipple
• Athelia: absent nipple
• Amastia: absent breast tissue
Accessory nipple

• More common in males

• Usually a benign condition
• Develops anywhere along the milk line
• Acts as the primary nipple
• May be removed surgically if needed
 Nipple
Retraction
 Hoffman
Technique

Nipple Inversion

Differential Diagnosis:
• Normal variation
• Aging
• Duct ectasia
• Carcinoma
• Paget's disease of the breast and
• Treatment: Underlying cause + Hoffman
Technique, breast stimulation, syringe
method etc.
Physiological Nipple Discharge:
• Usually bilateral, clear fluid, multiple ducts
Causes:
• Pregnancy
• Lactation
• Postpartum galactorrhea may last up to two years after delivery
• After spontaneous or intentional termination of pregnancy
• Fibrocystic changes of the breast
• Hormonal fluctuations associated with the menstrual cycle
• Duct ectasia
• Intraductal papilloma: most common cause of unilateral bloody nipple discharge
 • Usually unilateral, spontaneous, variable color, single duct and
other abnormalities of the breast
Causes:

Pathological • Infection (periductal mastitis)

• Breast abscess

Nipple • Neoplastic process of the breasts (e.g., intraductal carcinoma,

Paget disease of breast)
• Pituitary tumor/prolactinoma
Discharge: • Thoracic/breast trauma
• Systemic disease/endocrinopathies that elevate prolactin level

Causes (e.g., hypothyroidism, disorders of the pituitary gland or

hypothalamus, chronic kidney or liver disorders)
• Medications that inhibit dopamine secretion (e.g., opioids, oral
contraceptives, antihypertensives (methyldopa, reserpine,
verapamil), antidepressants, and antipsychotics)
Nipple Discharge

• Any fluid that leaks out of the nipple in non-pregnant and non-breastfeeding women
• May be unilateral or bilateral
• Physiological or pathological
• Spontaneous or stimulated
• Milky, bloody, serous or purulent
• Nipple discharge is pathological in men and in postmenopausal women
• Women 40 years or older: mammogram is indicated
Workup of Nipple Discharge
• Patients with physiological discharge: TSH and Prolactin levels
• Pathological Discharge -ve
Mammogram / MRI
US

+ve

Biopsy

• Bloody discharge: Fluid cytology

Breast Cancer Screening
• Screening Mammography: All women 45 to 75 years of age annually or biannually
• Clinical breast examination: only recommended where mammography is not
readily available
• MRI in conjunction with mammography: In high risk women as:
• Have a lifetime risk of breast cancer of about 20% to 25% or greater, according to risk
assessment tools that are based mainly on family history (see below)
• Have a known BRCA1 or BRCA2 gene mutation (based on having had genetic testing)
• Have a first-degree relative (parent, brother, sister, or child) with a BRCA1 or BRCA2 gene
mutation, and have not had genetic testing themselves
• Had radiation therapy to the chest before they were 30 years old
• Have Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome,
or have first-degree relatives with one of these syndromes
Breast Cancer
• Mainly an epithelial tumor originating
from the ducts or lobules
• Divided into: carcinoma in situ and
invasive cancer
• Carcinoma in situ (DCIS, LCIS): Cancer cells
are contained within the ducts or lobules
and do not invade the surrounding stroma
• Invasive carcinoma: adenocarcinoma
arising from epithelial cells of the ducts
(75%) or lobules (10%)
• Paget's Disease of the Breast: located on
the nipple
• Inflammatory breast cancer: fatal
Breast Cancer

• Breast cancers invade locally, through lymph nodes, or bloodstream or both

• Metastasis can occur anywhere in the body especially: lung, bone, liver and brain
Hormone receptors
• Epithelial tumors usually express receptors on their surface
• Estrogen receptors (ER +ve or –ve)
• Progesterone receptors
• HER-2 receptors: presence of receptors indicate a worse prognosis
• The majority of cancers are hormone receptors positive and HER-2 negative
Breast Cancer: Risk Factors
• Age
• Race
• Family history
• Genetics: BRCA1 & BRCA2 genes
• Personal history of breast cancer
• LCIS
• Dense breast tissue
• Hormonal drugs
• Obesity
• Radiation
• Smoking and alcohol
Breast Cancer: Clinical Picture
• Asymmetry of the breast
• Mass
• Pain: rarely the sole symptom
• Skin changes
• Paget's Disease of the nipple: appears as a benign lesion of erythema,
scaling or crusting, but is usually associated with an underlying mass
• Inflammatory breast disease: fast growing disease. Cancer cells block the
lymph nodes causing erythema,thickened skin and hard axillary lymph
nodes. No mass is usually present. Nipple discharge is present. Typical
peau-d'orange appearance.
 Breast
Cancer
Diagnosis
Post-diagnosis Workup & Management
• Receptor analysis
• Genetic testing if appropriate
• Staging: Bone scan, CT abdomen, Chest CT, MRI
• Treatment: Surgery, chemotherapy, radiotherapy, adjuvant endocrine
therapy
Prognosis of
Breast Cancer
Fibrocystic changes of the breast
• Most common benign breast disease
• During reproductive life, the main breast components are prone to
fribrocystic changes due to hormonal fluctuations
• More common in women 30-50 years of age
• Associated with estrogen treatment, hyperestrogen states and anovulation
(e.g PCOS)
• Multiple mobile cysts are present in the upper outer quadrant of the breast
• Firm and rubber-like
• May be tender
• Symptoms increase before the menstrual cycle
• Not associated with breast cancer
Fibrocystic breast disease: Workup
• Triple screening
• Wear a supportive bra
• Decrease salt and water in diet
• Apply warm or cool compresses
• Discontinue HRT if applicable
• Analgesics for tenderness
• Evening primrose oil for 3-6 months
• Metformin: reduces cell proliferation by hormones
• Last resort: fluid aspiration to relieve symptoms
 Fibroadenoma
• Painless, unilateral, benign, solid lump in the upper outer
quadrant of the breast
• The mass is mobile, firm, rubbery and has discrete and regular
margins
• Comprised of both stromal and epithelial tissues
• Referred to as "breast mouse"
• Main causes: Increased sensitivity to estrogen, OCP use before
20 years
• Increases during pregnancy and shrinks after menopause
• More common in females 14-35 years of age
• 3 subtypes: simple, complex and juvenile (continue to grow
over time)
Fibroadenoma : Management
• Triple assessment
• Usually no treatment required
• Follow up is necessary
• Risk of malignancy is increased in complex fibroadenoma that contain
calcified breast tissue
• Surgery may be indicated in cases of rapid growth, size > 2 cm or if
the patient requests
 Fibrocystic
breast disease
vs
Fibroadenoma
Breast Fat Necrosis

• Scar tissue in the breast that follows trauma or ischemia

• Presents as a palpable nodule
• The main reason is operative trauma
• In the absence of trauma rule out cancer
• Requires follow up
• Investigations: Mammogram +/- US
• Biopsy may be required
Mastitis
• Inflammation of the breast with staphylococcus aureus +/- MRSA
• Most commonly associated with breastfeeding
• Non-lactational mastitis occurs as well due to : periductal mastitis and
idiopathic granulomatous mastitis
• Prolonged engorgement of breast milk and bacterial entry through
skin breaks
• Risk factors: first 6 weeks of lactation, prior history of mastitis, nipple
cracks and fissures, milk engorgement, maternal stress, lack of sleep,
use of antifungal cream and tight-fitting bras
Mastitis: Clinical Picture
• Engorgement of the breast or ductal obstruction followed by:
• Unilateral, erythematous, tender and hot, focal, firm and swollen
breast area
• Associated with fever, chills and myalgia
• Periductal mastitis: subareolar painful, erythematous mass associated
with nipple inversion, thick nipple discharge and breast abscess
• IGM: unilateral firm mass, many features mimin breast cancer,
associated with arthralgias, episcleritis (autoimmune aetiology)
Mastitis: Workup
• Lactational: clinical diagnosis
• Breast abscess suspicion (no improvement after 24-48 hours): breast
ultrasound +/- culture of breast milk
• Periductal mastitis: Clinical diagnosis, mammography if mass is
present +/- culture of nipple discharge
• IGM: Mammography/US + Core-needle biopsy, prolactin levels
Mastitis: Management
Lactational mastitis:
• Initial management: symptomatic treatment for 12-24 hours
• Continue breastfeeding
• Empty the breasts fully with a breast pump/hand express
• Heat compresses before emptying the breast & cold compresses afterwards
• NSAIDS for pain
• If symptoms persist beyond 12-24 hours, antibiotics should be initiated
• Mild & no MRSA risk factors: outpatient treatment with dicloxacillin or cephalexin for 10-14 days
• MRSA risk factors: Clindamycin or TMP-SMX(no in women breastfeeding infants less than 1 month of age /
jaundiced child)
Periductal mastitis: Amoxicillin - clavulinic , dicloxacillin + metronidazole, cephalexin + metronidazole, surgical
excision
IGM: corticosteroids +/- antibiotics +/- immunosuppressants
Abscess: US-guided drainage + 4-7 day antibiotic course + discontinue breastfeeding
 Case 1
A 66-year-old woman presents with breast nipple discharge. She first
noticed the discharge 3 weeks ago and admits losing 10 pounds (4 kg) over
the past 6 months. She was diagnosed with uterine fibroids at 25 years of
age and underwent a myomectomy. She has also been diagnosed with
benign ovarian cysts, for which she undergoes regular follow-ups. Vitals are
85 bpm, blood pressure 105/80 mm Hg, and temperature 98.6 F (37 C).
Which of the following characteristics of nipple discharge would most
suggest basement membrane invasion of breast ductal or lobular cells?

• Unilateral bloody discharge

• Unilateral serous discharge
• Bilateral greenish-brown discharge
• Discharge associated with serum prolactin level elevation
 Case 2
A 29-year-old woman presents with a 2-week history of a serous, spontaneous,
nipple discharge from both nipples. A history of present illness reveals that she was
prescribed an oral contraceptive pill 3 months ago. Her mother has a history of
breast cancer treated with mastectomy and postoperative chemotherapy. Her vital
signs are heart rate 78 bpm, blood pressure 110/80 mm Hg, and temperature 98.7
°F (37 °C). The physical examination shows serous, non-bloody nipple discharge
bilaterally. What is the best next step in management?

• Educate the patient regarding the benign nature of her symptoms and advise a
change in the oral contraceptive pill
• Perform an ultrasound of the breast
• Perform unilateral ductography of the breast
• Intermittent treatment with danazol and bromocriptine
 Case 3
A 33-year-old G1P0 at 32 weeks of gestation presents with bloody nipple discharge and an
immobile mass in the upper outer quadrant of her right breast. Her past medical, surgical, and
family history are unremarkable. The physical examination demonstrates a firm, nontender mass
palpated in the right breast at the 11 o'clock position, 5 cm from the nipple.
Mammography findings are consistent with breast cancer. Which of the following best describes
women diagnosed with breast cancer during pregnancy compared to age-matched women who
are not pregnant?

• Women diagnosed with breast cancer during pregnancy have a higher likelihood of negative nodes.
• Women diagnosed with breast cancer during pregnancy have a higher likelihood o a larger primary tumor only.
• Women diagnosed with breast cancer during pregnancy have a higher likelihood of positive nodes only.
• Women diagnosed with breast cancer during pregnancy have a larger primary tumor and a higher likelihood of
positive nodes.
 Case 4
A 51-year-old woman presents for a right breast evaluation. She is gravida 2 and
para 2, her last menstrual period was 2 years ago, and she has no significant
family history of cancer. Her vitals are heart rate 86 bpm, respiratory rate 17
breaths/min, blood pressure 125/75 mmHg, and temperature 98.6 °F (37 °C). The
physical examination demonstrates erythema in the periareolar region of the
right breast, along with bloody discharge from the nipple and a characteristic
peau d'orange appearance. Given the likely diagnosis, what causes the peau
d'orange appearance in this patient's condition?
• Involvement of intramammary lymph nodes only
• Involvement of the skin only
• Involvement of mammary glands only
• Involvement of Cooper ligaments and intramammary lymph nodes
 Case 5
A 49-year-old woman presents with a bloody nipple discharge from the left breast, an
eczematous rash on the areola, and a palpable lump discovered on self-examination. Her
history is significant for fibrocystic breast disease and breast augmentation. The patient
obtained annual screening mammograms beginning at age 40. This year, the radiologist,
identified a new cluster of microcalcifications and a 3-cm mass. The radiologist interpreted the
spot films to be benign. His report states that “15% of breast cancers are not detected by a
mammogram, and breast self-exam is recommended monthly from 40 years of age.” Which
diagnosis should be included in the differential?

• Retro-areolar cyst
• Galactocele
• Paget disease
• Fibrocystic breast condition
 Case 6
A 25-year-old woman presents with a lump in the right breast, noted 2
weeks ago on self-examination. Physical examination findings include a
lump in the upper-outer quadrant of the right breast, which is freely
mobile, 2×1 cm in size, rubbery in consistency, and with smooth
margins. There was no inversion of the nipple, redness or retraction of
the skin, or change in the contour of either breast. What is the
diagnostic investigation of choice?
• Mammography
• Ultrasonography
• Computerized tomography
• Magnetic resonance imaging
• Submi
 Case 7
A 17-year-old female presents with a round mass in her right breast. She detected
the mass two weeks ago while taking a shower. It is painless and has not increased
or decreased in size. She is worried that she might have breast cancer. Her family
history is positive for HER2-negative breast cancer in a maternal aunt. She is
sexually active, and her last menstrual period was seven days ago. On
examination, the mass is mobile, soft, and rubbery. What is the best next step in
the management of this patient?

• Fine needle aspiration cytology

• Reassurance
• Ultrasound
• Mammogram
 Case 8
A 65-year-old female has a 2 cm mass in her left breast. Fine-
needle aspiration was done, but the results were inconclusive.
Two months later, the patient returns with the same mass, which
appears unchanged. What is the next step in the management of
the patient?

• Continued observation
• Mammogram
• Repeat fine needle aspiration
• Core biopsy
 Case 9
A 28-year-old woman presents with 5 days of pain and redness in her right breast. Five weeks
before, she had an uncomplicated vaginal delivery, and her postnatal course is uneventful. She
is breastfeeding her infant, but now only uses the left breast for fear of worsening the pain in
the right breast. She denies a family history of breast cancer, as well as similar symptoms in the
past. Physical examination reveals a small fluctuant mass in the upper-outer quadrant of the
right breast that is tender to touch. The skin overlying the mass is erythematous and warm,
with no breaks noted. An ultrasound is performed and shows an ill-defined mass with internal
septations. In addition to drainage of the mass, which of the following is the most appropriate
next step?

• Mammography
• Nafcillin and clinical follow up
• Ceftriaxone
• Core needle biopsy of the mass
 Case 10
A 28-year-old Para1 who recently started breastfeeding presents with
pain and redness in her right breast, lasting over 24 hours. Her vital
signs are within normal limits except for her temperature, which is 101
F (38.3 C). Her body mass index is 35 kg/m2. Examination of the right
breast is remarkable for localized erythema and tenderness. Given the
likely diagnosis, which of the following has increased her risk for this
condition?

• Breastfeeding every 2-3 hours

• High body mass index (BMI)
• Nipple fissures