Office Management of Common Breast Complaints

Transcription

1 Annual Review of Family Medicine UCSF Mission Bay December 7, 2017 Office Management of Common Breast Complaints Michael Policar, MD, MPH Clinical Professor of Ob, Gyn, and Repro Sciences UCSF School of Medicine

2 There are no relevant financial relationships with any commercial interests to disclose

3 Learning Objectives List 5 treatments for cyclic bilateral mastalgia List 5 causes of galactorrhea, other than pregnancy Describe the 7 categories of BI-RADS reports in breast diagnostic imaging

4 Obstet Gynecol 2016;127 (6):e141-e156

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6 physician_gls/pdf/breast-screening.pdf

7 BIRADS: Breast Imaging Reporting and Data System Mammogram, Ultrasonography, MRI Assessment % pts Cancer risk Recommendation 0 Incomplete Further imaging 1 Negative 93.9 Essentially Routine screening 2 Benign finding 0% risk 3 Probably benign 5.6 >0% 2% Short-interval (6 month) follow-up

8 BIRADS: Breast Imaging Reporting and Data System Mammogram, Ultrasonography, MRI Assessment % pts Cancer risk Recommendation 4 Suspicious % Biopsy 4A Low suspicion 2% to 10% 4B Moderate suspicion >10% to 50% 4C High suspicion >50% to <95% 5 Highly suggestive 0.1 >95% Biopsy 6 Known biopsyproven malignancy N/A Surgical excision

9 Mammographic Breast Density 3-5x greater risk of breast cancer in women with high breast density on mammography vs. women with low breast density Breast density decreases with Advancing age Menopause Heavier body weight Earlier childbearing Higher density in women using hormone therapy Increase in mammographic breast density score over time is an important risk factor for breast cancer

10 BI- RADS BI-RADS Breast Density Reporting Categories and Breast Cancer Risk Description % of Pop Sensitivity % RR Breast CA 1 Almost all fat Scattered fibroglandular densities 3 Heterogeneously dense (compared to average density) 4 Extremely dense (compared to average density) Management of Women with Dense Breasts Diagnosed by Mammography. ACOG Committee Opinion #625 Obstet Gynecol 2015;125:750-1

11 Mammographic Breast Density Longitudinal Measurement of Clinical Mammographic Breast Density (K Kerlikowske JNCI 2007;99:386) Less density is associated with lower breast ca risk Increased density over time (average 3 years) is associated with increased in breast cancer risk 1 2 (5.6x risk) compared to cat (10x risk) Density changes should be factored into risk calculations

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13 CA Law: Breast Density Reporting 2013 CA law requires patients be informed if "dense breast tissue" on screening mammography When mammography is the only screening test, sensitivity decreases by 10-20% if "dense breasts Screening mammography recommendations the same for women with dense breasts as others If interested in options, a risk assessment is appropriate Other "screening options" include screening MRI, ultrasound, and tomosynthesis ("3D mammography")

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17 Abnormal Breast Findings in Primary Care Breast nodularity Breast pain (mastalgia, mastadynia) Bilateral Unilateral Nipple discharge (spontaneous) Breast lump

18 FCC and Mastalgia: What s the Difference? FCC (morphology) Both Mastalgia (sydrome)

19 Fibrocystic Change (FCC) Pathology Cysts within ducts and increased fibrous tissue Epidemiology > 50% of reproductive aged women 10% of women under 21 years old Abates with menopause; fat replaces fibrous tissue Symptoms Either cyclic mastalgia or asymptomatic Pain, tenderness in lumpy areas of breast

20 Fibrocystic Change (FCC) Findings Symmetric (mirror image) nodularity Consistency commonly like a bag of beans Nodularity often prominent in upper outer region Cancer risk depends upon biopsy findings Non-proliferative (70%): No increased risk Proliferative (25%): 2x risk Atypical ( 4%): 5x risk Atypical + family hx 11x risk

21 Cyclic Bilateral Mastalgia (Mastadynia) 47% of breast-related visits in women yo Symptoms Pain maximal pre-menstrually, wanes with menses Dull, full, achy, or heavy Tender (equal or asymmetric); usually worse in UOQ

22 Cyclic Bilateral Mastalgia Non-medical management Reassure patients that they do not have cancer Well-fitting bra, especially for exercise and athletics Elimination of caffeine (coffee, tea, cola, chocolate) has not been shown to decrease symptoms Consider Evening primrose oil (EPO) 1,500 mg BID RCT: 45% had some improvement (vs. 19% placebo) Vitamin E (600 U/day) not supported in RCT Vitamin A (150,000 IU/ day) no RCT

23 Cyclic Bilateral Mastalgia: Drugs Topical diclofenac 50 mg gel TID Mild oral analgesics, starting premenstrually OC s help 70-90% of women Continuous OC regimen (no hormone-free interval) Bromocriptine (5 mg QD): 80% had less pain, nodularity Danazol (200 mg QD): 90% had reduction in pain Tamoxifen (10 mg QD): 90% had reduction in pain All treatments: 50% relapse rate

24 Non-Cyclical Mastalgia Less common, more likely pathologic Usually focal, unilateral Differential diagnosis Breast cyst Fibroadenoma Breast abscess Rarely, breast cancer (inflammatory carcinoma) Diagnostic imaging Breast ultrasound + diagnostic mammogram

25 #6: FOCAL Breast Pain qap.sdsu.edu

26 Breast Findings: Nipple Discharge Appearance Cause Clear, bilateral Physiologic or FCC several ducts Milky, bilateral Galactorrhea Green, yellow, brown Duct ectasia Purulent, unilateral Mastitis Inflammatory carcinoma Bloody, unilateral; localized to single duct Intraductal papilloma Ductal carcinoma

27 Intraductal Papilloma Solitary papillomas can present as bloody, serous, or clear nipple discharge Most common in women 30 50; typically 2 4 mm DCIS has been diagnosed in solitary papillomas, but usually not associated with cancer If atypia is present on core biopsy of an intraductal papilloma, surgical excision is recommended

28 ACOG Practice Bulletin #

29 Inappropriate Lactation: Galactorrhea % of cases Cause 45 % Idiopathic 20 % Pituitary tumors 10 % Estrogen-containing contraceptives Drugs (dopamine inhibitors) 5 % Primary hypothyroidism 20 % Miscellaneous Neurogenic (breast stim, post-herpetic) Parapituitary lesions Post-partum lactation, <1 yr of wean g

30 Galactorrhea: Idiopathic Diagnosis of exclusion 40-50% of all galactorrhea cases Normal or minimally elevated PRL Most have normal (ovulatory) menstrual pattern If galactorrhea + PRL < 50 ng/ml + regular menstrual cycling, further W/U is not necessary Management is expectant Repeat PRL annually if galactorrhea continues Dopamine agonist for infertility, breast discomfort

31 Galactorrhea: Pituitary Tumors Prolactinoma as cause of galactorrhea 20% of all galactorrhea cases 34% if galactorrhea-amenorrhea present Prolactinomas most common PRL secreting tumor Almost all are benign, rarely invasive Microadenoma (< 10 mm) Macroadenoma (> 10 mm): supra sellar growth Presence of adenoma is not a contraindication to either pregnancy or use of hormonal contraception

32 Galactorrhea: Hormonal Contraceptives Estrogen stimulates PRL + reduced dopamine (PIF) Galactorrhea most common during hormone-free days (loss of E+P brake on lactation) OC users have (average) 22% increase in PRL level, but usually in within normal range When PRL level is elevated Usually under 50 ng/ml Never more than 100 ng/ml PRL resolves within 6 months of discontinuation

33 Galactorrhea: Medications Act through reduction of hypothalamic dopamine Antipsychotics Clozapine, risperidone, olanzapine Antidepressants SSRIs: fluoxitine, citalopram, paroxitine Tricyclics: amitriptyline, imipramie Anxiolytics: alprazolam, buspirone, diazepam H 2 blockers: cimetidine, famotidine Others: metoclopramide, opiates, cocaine

34 Galactorrhea: Exam and Lab Evaluation Examine breasts for masses; nipple discharge Galactorrhea issues from multiple ducts Almost always bilateral (one side can be dominant) White or clear discharge Fat globules on microscopy Visual field examination not helpful Lab tests Prolactin (PRL), with no recent nipple stimulation TSH

35 Galactorrhea: Imaging Studies To image sella turcica, order either Thin section coronal CT scan with contrast Pituitary MRI MRI more accurate; but expense, time Skull film with cone down is no longer available Indications Menstrual abnormality + galactorrhea or PRL Prolactin > 100 ng/ml CNS symptoms: headaches, visual changes

36 Galactorrhea: Management (1) Galactorrhea PRL, TSH PRL < 100 ng/ml and Normal menses PRL > 100 ng/ml or Abnormal menses or HA, visual change Asymptomatic Expectant management Infertility OR Breast discomfort Dopamine agonist Sellar imaging Head CT or Pituitary MRI Fritz & Speroff. Clinical Gynecologic Endocrinology and Infertility, 8th ed

37 Galactorrhea Management (2) Galactorrhea + irregular menses or PRL >100 or headache, visual change Sellar imaging < 100 ng/ml and Normal imaging > 100 ng/ml or Abnormal imaging Elevated TSH Thyroid replacement Normal TSH Expectant management Normal pituitary Abnormal pituitary Next slide Fritz & Speroff. Clinical Gynecologic Endocrinology and Infertility, 8th ed

38 Galactorrhea Management (3) Abnormal Pituitary Prolactinoma Non- Prolactinoma Microadenoma Macroadenoma Expectant management Dopamine agonist further growth Surgery + Radiation

39 Breast Trauma

40 Breast Cyst: Background Pathology: variant of FCC; not precancerous Epidemiology Most common cause of mass in yo women Rare (but possible) < 30 and post-menopausally Symptoms Frequently, but not always, pain and tenderness Often worse pre-menstrually, then regresses Signs Unilateral smooth, spherical, ballotable mass

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42 Breast Cyst: Management Suspected breast cyst: (office) needle aspiration Mass deflates + clear fluid: no further evaluation Bloody fluid: send for cytology; biopsy Mass remains: manage as dominant nodule If needle aspiration unavailable, refer to radiologist for diagnostic mammogram + ultrasound If frequent recurrences or tenderness Attempt caffeine restriction, OC s,? Vitamin E If cyst recurs twice, consider excision

43 Fibroadenoma: Background Pathology: solid (fibrous) spherical benign neoplasm Epidemiology Av. age: 25; 12% of masses in menopausal women 10% of all breast neoplasms Findings 1-3 cm painless spherical dominant mass Rubber ball firmness; multi-lobed or grooved Mammographic characteristics Mass with clear borders ( halo effect ) Calcifies post-mp into popcorn pattern

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45 Fibroadenoma: Management Must differentiate from cancer; diagnosis based upon Tissue sample: FNAC or open biopsy, or Typical diagnostic mammogram findings Not diagnosed by clinical impression alone Management options include Surgical excision: unclear dx, older age group, large size, psychologically disturbing to woman, or Observation with yearly CBE + mammogram Hormonal contraceptives can be used in women with breast fibroadenomas

46 Breast Cancer: Presentation Often asymptomatic Early signs Unilateral non-tender breast nodule; most often UOQ Rarely, nodule can be tender if inflammatory changes Later signs Dimpling or peau d orange of overlying skin Fixation to underlying pectoral muscles Hypervascularity Unilateral, recent onset nipple inversion Palpable axillary or spraclavicular lymph adenopathy

47 Findings Procedures Diagnoses Outcomes Breast Nodule Office Aspiration Cystic Solid Clear Residual Mass Bloody Diagnostic MG + Ultrasound Cyst Follow CNB/FNAB Recur >1x No Follow Yes Result

48 CNB/FNAB Fibroadenoma (or other benign) Atypical or Non-diagnostic Malignant (breast cancer) Biopsy (Excisional, core cutting, stereotactic) Benign Malignant Sxs or fast growing? No Follow Yes Excisional Biopsy Oncologic Evaluation

49 Consult radiologist #6: New Palpable Breast mass

50 Which Type of Breast Biopsy? CNB: Core Needle Biopsy Large-bore (12 16 gauge) cutting needle Can be attached to vacuum-assist CNB now is preferred breast biopsy method Few complications Minimizes surgical changes to the breast Can place a clip to mark the lesion undergoing biopsy (reference in future imaging studies) ACOG Practice Bulletin #164, 2016

51 Which Type of Breast Biopsy? FNAC: Fine Needle Aspiration Cytology Small-bore (21 25 g) needle for cytologic specimen Inexpensive and minimally invasive but requires pathologist with expertise in interpretation Findings of atypia or malignancy require a follow-up tissue biopsy ACOG Practice Bulletin #164, 2016

52 Excisional biopsy Which Type of Breast Biopsy? Not as first line tissue diagnosis Not amenable to stereotactic or ultrasound-guided biopsy 2 o to location, imaging findings, or implants If CNB is non-diagnostic or discordant with clinical exam or imaging findings eg, a BI-RADS 4 or 5 mammography result with normal-appearing breast tissue on core needle biopsy ACOG Practice Bulletin #164, 2016

53 Palpable Mass: Clinical Evaluation Triple Diagnosis misses very few cancers Physical exam Diagnostic mammogram + breast ultrasound CNB or FNAB Management If all 3 negative, f/u exam q3-6 mos x 1 year If all 3 suggestive of malignancy, refer for definitive treatment If any one test suggestive of malignancy, refer for core or excisional breast biopsy

54 #7: Breast Biopsy

55 Breast Mass > 30 y.o. NCCN Algorithm

56 Br Mass Under 30

57 Breast Disease: US MEC 2016 OC/ P/R POP DMPA Impplant LNG- IUS Cu- IUC Undiagnosed breast mass Family history of breast cancer Benign breast disease Breast cancer; current Past breast cancer (no evidence of current disease for 5 years)

58 References ACOG Practice Bulletin #164. Diagnosis and Management of Benign Breast Disorders. Obstet Gynecol 2016;127 (6):e141-e156 ACOG Practice Bulletin #179. Breast cancer risk assessment and screening in average risk women. Obstet Gynecol 2017;130: e1-16 Cancer Detection Section, CDPH. Breast Cancer Diagnostic Algorithms for Primary Care Providers 4 th edition tools.html