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Benign Breast Diseases

by Kevin Pei, MD
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    00:01 Welcome back. Thanks for joining me on this discussion of benign breast diseases in the section of general surgery. Let’s start with the question, when should women start screening for breast cancer? I’ll give you a second to think about this. Well, according to the United States Preventative Services Task Force which is the authority on such measures, women, 50 years of age to 74 years of age of average risk based on recommendation should start a mammogram every two years.

    00:32 It’s controversial what patients between the ages of 40 and 49 should do. That decision is left up to a discussion between the doctor and the patient. Breast masses are usually thought of as either benign or malignant. In this lecture module, we’ll focus on the breast masses that are benign.

    00:56 In benign breast masses, the vast majority of patients in fact have fibrocystic change.

    01:02 Fibrocystic change may be cyclical changes associated with one’s menstrual periods. We’ll discuss fibroadenoma in a little bit more detail. The most important decision regarding breast masses is to define whether or not this mass is benign or malignant. Very importantly and high-yield is the subset of diseases called the nonproliferative versus proliferative benign tumors. We will focus on proliferative benign breast tumors. The importance of proliferative benign breast tumors is that they may infer increased risk of breast cancer. Fibroadenoma is not a proliferative, it’s considered a nonproliferative disease because it does not infer increased risk of breast cancer. However, atypical ductal hyperplasia does infer increased risks as is intraductal papilloma. This is my general approach to patients with breast diseases. We want to start by obtaining a careful history. More than any other disease process, a careful history is very important in patients with breast disease particularly in patients with family history of breast cancer. Next, we perform a thorough examination, both of the breast itself as well as the lymph node draining basins. We then obtain age-appropriate diagnostic imaging. What do I mean by that? Young patients may have very dense breast tissue and may be more amenable to ultrasound imaging as opposed to age-appropriate patients undergoing mammograms. Regardless, one wants to get an image prior to disturbing the anatomy with biopsies.

    02:43 Speaking of, we usually get tissue biopsies to help us guide the next step of management.

    02:49 When we put all this information together, we can counsel the patient on the most optimal treatment plan.

    02:57 This is very important. Next steps in management are usually determined on whether or not the mass is palpable or nonpalpable. You can imagine for a palpable lesion, biopsy is easy.

    03:09 But for a nonpalpable lesion, how do we pursue biopsy? Well, that usually involves image guidance.

    03:16 Physical examination of the breast is very important. Not only do we want to do a thorough bilateral examination with the patient completely undressed, we also want to focus on the draining lymph nodes. These are lymph nodes both in the supraclavicular region as well as in the armpit and behind the pectoralis muscles. If you were to get routine laboratories, they’re unlikely to be helpful whether it’s chemistry or CBC. Particularly in young patients where the breast tissue may be too dense for mammograms to be useful, ultrasound is a primary modality. Here in this ultrasound, you see an anechoic lesion just below the surface of the probe. Remember, fluid-filled or anechoic masses on ultrasound appear dark.

    04:09 Here’s a typical mammogram. This is a normal mammogram. Mammograms are usually obtained in two different views. Let’s focus on fibroadenomas. Fibroadenomas are usually found in young women.

    04:25 The exact etiology is unknown. They may respond to hormones. And generally, there’s no increased incidence of cancers. Recall my discussion on proliferative versus nonproliferative benign breast diseases. Fibroadenoma is considered a nonproliferative disease.

    04:45 Here is an ultrasound image of a large fibroadenoma. Biopsy is usually not necessary for fibroadenomas. Let’s talk about specific biopsy options. When it’s a palpable lesion, one can actually perform the biopsy right in the office. This is called the core needle biopsy.

    05:08 If you have an ultrasound in the office, you can perform this under ultrasound guidance.

    05:14 If pathology demonstrates a fibroadenoma, no excision is needed. Remember, large excisional biopsies can result in poor cosmetic outcome. Just to remind you, excisional biopsy means that you’re removing the entire mass both at the same time as biopsy and potentially as the final therapy. What about giant fibroadenomas? These are described as lesions that are greater than 10 cm. We recommend excision in these situations because it is often difficult to distinguish from phyllodes tumors which may be precancerous.


    About the Lecture

    The lecture Benign Breast Diseases by Kevin Pei, MD is from the course General Surgery.


    Included Quiz Questions

    1. 50 to 74 year olds of average risk.
    2. 40 to 74 year olds of average risk.
    3. 45 to 75 year olds of average risk.
    4. 55 year olds and older regardless of risk.
    5. 50 to 80 year olds of high risk.
    1. Atypical ductal hyperplasia.
    2. Fibroadenoma.
    3. Fibrocystic changes.
    4. Nonproliferative tumors.
    5. All benign tumors infer an increased risk of malignancy.
    1. Obtain a breast ultrasound
    2. Obtain a mammogram.
    3. Core needle biopsy of the lesion.
    4. Full mass excision.
    5. Stereotactic biopsy of the lesion.
    1. If it measures greater than 10cm
    2. Never, fibroadenomas are nonproliferative benign masses.
    3. If the woman has a first degree relative with breast cancer.
    4. If the woman is less than 35 years old.
    5. If the woman has two or more distinct fibroadenomatous masses.

    Author of lecture Benign Breast Diseases

     Kevin Pei, MD

    Kevin Pei, MD


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