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.
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.
In benign breast masses, the vast majority of patients in fact have fibrocystic change.
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.
Malignant Breast Dieases
Benign breast lesions can be divided in three categories: non-proliferative, proliferative without atypia and proliferative with atypia.
Non-proliferative lesions are not associated with an increased risk for breast cancer.
These include: breast cysts, papillary apocrine changes, epithelial-related calcifications,
mild hyperplasia of the usual type and apocrine metaplasia.
Proliferative lesions without atypia are associated with 1.5 to 2 times increased risk for breast cancer.
This category includes sclerosing adenosis, ductal hyperplasia, intraductal papillomas, radial scars and fibroadenomas.
Although fibroadenomas have been historically classified in the category of non-proliferative lesions,
they are now considered proliferative lesions.
They are associated with a slightly increased risk for breast cancer in the case of complex fibroadenoma pathology,
breast cancer history in the family or adjacent proliferative changes.
In the absence of these features the majority of women with fibroadenomas do not have an increased risk for breast cancer.
Proliferative lesions with atypia are associated with 4 to 5 times increased risk for breast cancer.
This category includes atypical ductal or lobar hyperplasia.
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.
Speaking of, we usually get tissue biopsies to help us guide the next step of management.
When we put all this information together, we can counsel the patient on the most optimal treatment plan.
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.
But for a nonpalpable lesion, how do we pursue biopsy? Well, that usually involves image guidance.
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.
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.
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.
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.
If you have an ultrasound in the office, you can perform this under ultrasound guidance.
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.