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

• 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)

 

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Download the PDF version: here

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References:

• Dr Alriyees’s lecture
• Monte Reid