Benign Breast Diseases

Symptoms:

  • Mass, nipple discharge, skin changes, pain

 

Triple Assessment:

  1. H&P
  2. Imaging
  3. Pathology
  • Any red flags in one or discordance between them -> take pt for excisional biopsy

 

BIRADS:

Is grading of the breast mass (not staging):

  • BIRADS 2 -> likelihood of it being benign 100%
  • BIRADS 3-> likelihood of being benign 98% + 2% malignant -> follow up every 6 mo for 2 yrs
  • BIRADS 4-> likelihood of being malignant 2-95%
  • 4A: 2-20% -> if biopsy is benign -> treat as BIRADS 3 (follow up every 6 mo for 2 yrs)
  • 4B: 20-50% -> mostly likely will require excisional biopsy
  • 4C: 50-95%v-> need excisional biopsy
  • BIRADS 5-> likelihood of being malignant 95%

 

Tissue Diagnosis:

  • Histopathology: core needle biopsy -> excisional biopsy if not conclusive
  • Cytology: FNA

 

CASE: A 20 yo pt w\ a 2-cm breast mass, what’s next?

  • Do US
  • If BIRADS 2 or 3 -> do FNA -> most likely fibroadenoma -> follow up every 6 mo

Indications for excisional biopsy for fibroadenoma:

  1. Larger than 4 cm
  2. Increasing in size
  3. Radiological indicated (BIRADS 4B and above)
  4. Clinically looks hard and not benign
  5. Radiology pathology discordance
  6. If you do core needle and it shows -> atypical ductal\lobular hyperplasia, florid epithelial hyperplasia, flat epithelial atypia, fibro-epithelial lesion, papillary lesion
  • Why we prefer to remove it? It might be phyllodes tumour (sarcoma of the breast but on FNA\core biopsy it resembles fibroadenoma morphologically)

 

CASE: A 35 yo pt w\ a 4-cm breast mass for the past 4 yrs, what’s next?

  • Do mammogram followed by US (b\c she’s above 30 yo)
    • If cyst -> only needs aspiration
    • If solid mass -> grade it:
      • If BIRADS 2 -> do core needle biopsy -> then do excisional (indicated b\c a 4-cm mass)
        • Why core needle biopsy if you’re doing to do excisional anyways? B\c you need a pre-op dx; if it’s phyllodes -> need margins
      • If it’s 1-cm mass + BIRADS 2\3\4A + core needle is benign -> counsel the pt and follow up

 

CASE: A 25 yo pt w\ a 6-cm breast mass, what’s next?

  • Do US
  • If BIRADS is 3 or 4a -> core needle biopsy -> then excisional biopsy based on size

 

Nipple Discharge:

  • Differentiate between pathological and physiological
  • Colour of the discharge doesn’t guide management
  • Bloody usually means intraductal papilloma
  • Malignant can be associated with both, but most are serous

Benign breast diseases 1

  • If imaging shows no findings or duct ectasia -> still do US for ductal system -> if negative -> do MRI
    • If MRI shows intraductal lesion -> do second-look US -> if intraductal papilloma -> do biopsy or vacuum
    • If MRI is negative -> microductectomy (the only time take to OR without biopsy, where the pt has pathological nipple discharge w\out apparent imaging findings)

 

Skin Changes:

  1. Inflammatory (mastitis) -> give appropriate abx (Clindamycin and Augment -> cover staph and strept + good penetration + appropriate duration) -> if doesn’t improve -> do skin biopsy (imaging will show skin thickening w\out mass)
  2. Neoplastic: locally advanced: direct infiltration to skin
  3. Paget disease: sometimes considered DCIS -> needs treatment like Ca (missed by GP -> giving cortisone on the basis of eczema)

 


Download the PDF version: here


References:

  • Dr Alriyees’s lecture
  • Monte Reid

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