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. 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.
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.