Breast anatomy is complex, and everything from aging to implants can make exams tricky. Breast surgeon Shoko Emily Abe, MD, FACS, offers help with working up common issues that are often benign yet may require treatment or follow-up.
um, So I'll be discussing benign breast issues overall, including some of the benign tumors that, um, we see quite frequently, um, have no financial disclosures. And so specifically, the goals are to just a quick review of breast anatomy. We'll discuss different benign breast entities, including some of the most common things you might see, such as fibrous, cystic breast changes in fiber, Adenomas insists, Um, and we'll talk about the work up of benign breast conditions. Ultimately, this is a pretty busy slide, but basically the breast anatomy is broken up into the glandular part of the breast versus a support structure, if you will, or this Troma the breast tissue. The glandular part is made up of the La Buell's for milk production, and then the ducks that ultimately coalesce or lead up to the nipple. And there's about 10 to 15 duct orifice is at the nipple. Um, the stromal tissue, as we get older as women get older, becomes more intermingled with fat, and that leads to the toe sis of the breast. Um, and obviously there's the skin, the nipple and the areola and the glandular, um, structures that go along with that and sebaceous glands as well as hair follicles. Um, I just wanted to touch upon Breast Self Exam, because this is somewhat of a controversial topic over the years, as whether or not self breast exams are helpful or not. And I'm sure you get questions about this from patients. And certainly we've kind of gone away from saying monthly self breast exams are recommended for the average risk woman. But most guidelines still say that being familiar with your breasts and your body is still very helpful. Um, some of the disadvantages that have been noted with self breast exam is that it causes a lot of fear and anxiety of potentially feeling something. Or if they feel a lump, they they worry that it's a cancer. Um, and then there's so there's this false positive, um, that could happen with breast exams. There's also arguments that breast exams by yourself, an unexperienced person might not even help detect. But there are. There is data that shows that self breast exam actually does help women detect breast cancer earlier than then, if not done so. Ultimately, you know, we do recommend some form of self breast awareness because it does allow women control over their own health and to have knowledge and confidence about what's going on in their breast. And it's a fairly simple thing to do so the lumps and bumps that most commonly we see in women, um, are either solid masses that are usually fiber adenomas, especially in the younger woman. We also see cysts, which can be a simple cyst, fluid filled sac or sometimes there designated as complex or complicated cysts. And we certainly see a lot of women who come in with palpable abnormalities that are more due to fiber cystic changes where it's not an actual lump, but more a prominent area of glandular tissue. So fiber adenomas um, there are very common benign tumors, usually seen in younger women in their teens into their twenties. Certainly I've seen older women with fiber adenomas as well, um, and it's due to the overgrowth of the glandular and mostly the stromal, or supporting tissue of the breast. Um, up to 10% of women can have fiber adenomas, and for some women, they have multiple in multiple and bilateral sometimes. But those are the really rare situations. Most women have a singular fiber adenoma if it's ever found or palpate ID, and that's usually about it, Um, it is affected by the hormonal changes in a woman's body. So sometimes during pregnancy it could enlarge. And certainly after menopause, it tends to regress. It's usually a very smooth mobile firm mass. We oftentimes use the terminology rubbery mass, and it's usually painless unless it's sometimes enlarging due to hormonal changes, and it could be a bit uncomfortable in and of itself. Fire adenomas are not a marker of increased risk of breast cancer, and nor is it something that's considered cancerous or precancerous. But it certainly is very concerning. For women who first feel the slump in their breast. Ultrasound is really the key to diagnosing a fiber adenoma because they usually have a very, um, textbook. Look, if you will, on ultrasound, and this is a good example of it. It's usually very smooth and well circumscribed and usually very ovoid and flat versus taller than wide. Um, and the definitive diagnosis is really by an ultrasound guided core needle biopsy, where we get a core of tissue to really tell that this is a fiber adenoma, find new aspirations can be done on masses like this where you're pretty sure it's a benign entity, Um, but biopsy of a mass in the breast, usually as a core biopsy, because in the case that it is cancer, it does give us the architecture of the tissue, so that's pretty much the gold standard. For the most part, um, most fiber adenomas don't need any treatment at all. In fact, very rarely do we say that we should remove fiber adenoma surgically, Um, but some of the criteria to remove fiber adenomas if they're grown in size or growing bigger than 33 centimeters size, or if they're causing a lot of discomfort or disfigurement. Or if there's a question on the core needle biopsy of whether this is a fiber adenoma or not. And you might see the term fi bro epithelial lesion on the core biopsy report because that's kind of a blanket term that includes fiber adenomas but also Floyd's tumors. And that's the key here of when we decide to excise it, this growing mass larger than three centimeters in size. Basically, we're thinking the chances of this being Floyd's is a little bit higher, although Floyds are on the other hand, very rare. And so that's the reasoning behind recommending surgical excision if it starts changing in any way and increasing in size because of Floyd's tumor, on the other hand, may grow pretty rapidly to a size larger than four centimeters if we decide not to remove it, which again is totally a good option for many women. Uh, we'll follow it every six months with ultrasound to document stability, and essentially, at that point, no further close. Follow up is needed unless someone notices that again that it's enlarged or changed in any way. Another common finding that sometimes it's a palpable finding in women is assist, um, and again, usually just a fluid filled sac. And some women do have multiple cysts in their breasts. And sometimes it can be painful, mostly because of the pressure that it causes from assist that may be enlarged again, usually due to hormonal changes in the body. And 25 to 30% of women will have cysts at some point in their life, and 25% of them will be large enough to feel if you scan and ultrasound enough women, you will find cyst randomly oftentimes very small, Um, but again, it's a benign entity that's not concerning for cancer in and of itself, especially a simple cyst, which is a good old shot picture of a simple cyst where it's completely antique OIC or dark in the middle, which tell us it's fluid filled. There's also no posterior acoustic shadowing, which that sometimes is an indication that we need to be concerned for a solid mass, perhaps even a cancerous mass. So this is a good example of an ultrasound showing a simple cyst. This, on the other hand, is what we call the complex. This it's cept ated. There's questionable solid components to this and the complex. This is something that you might want to follow up a little bit more closely, and oftentimes, the radiology report will recommend a six month follow up ultrasound and again, usually maybe followed for about two years to document stability. If at any point there's growth or growth in the solid component of this, then according it'll biopsy for tissue diagnosis may be warranted. Uhm, for simple cysts, otherwise you could offer us, uh, an aspiration, a simple aspiration in the office. If it is symptomatic and the patient wishes that, um and if it Rikers, then sometimes that's reason to say, Maybe we should do a core biopsy to a remove the cyst wall to decrease the chance of recurrence, but also be to get some tissue to make sure this recurrent cyst that keeps filling up isn't due to some other abnormality very rarely cancerous. But that is something to roll out for someone who has repeat aspirations of the same cyst, and it keeps refilling up again. Um, when the cyst aspiration shows, um, grossly bloody fluid or at least blood tinged fluid. That's a reason to send the fluid for cytology again just to rule out carcinoma fibrous, cystic, dense breast tissue. Another big reason that women become very concerned from doing their own breast exam because they'll feel these lumpy, bumpy areas. And a lot of the complaints I hear from women is that they don't know what they're feeling because their breasts always feel lumpy and bumpy. Um, and it's certainly, uh, you know, a distressing thing for some women, and what I recommend is that they consider, or they realize that it's good that they know what their normal lumpy, bumpy breast feels like. And to be mindful of any changes or persistent mass that feel different than what they normally feel. And once I tell patients that they usually feel pretty comfortable about doing their own breast exams. Yeah, um, this is a good kind of mammographies picture of what dense, fibrous, cystic breast tissue looks like versus one that is almost entirely fatty replaced. So this is the category a almost entire fatty replaced breast where obviously, it's a very easy mammogram to read, where we're not concerned that there's some density or mass hiding behind there that we're missing versus this. On the other extreme is the extremely dense breast tissue. Um, where on exam, you also feel that it's very dense and lumpy. Um, there has been some talk about making em re screening as part of the routine screening for any woman with dense breast tissue. I would say that's not necessarily standard of care at this point. It is something to consider and discuss with patients, um, and certainly women who've had a cancer diagnosis who have extremely dense breast tissue. MRI screening on top of the mammogram screening is the current recommendation um, just to mention ultrasound screening. I know this is not part of the review of the topic Foot, since I'm touching upon screening. Um, I wanted to mention that ultrasound screening, um, even for dense breast tissue has not been really picked up as definitely not as a standard of care or the gold standard for breast cancer screening. Um, there have been some studies that show that as a supplement to mammogram, it might pick up more cancers. But on the other hand, there was also an increase in false positives. So there's that to consider. And this study was certainly one of the study was out of Japan. And so they're patient population in the density of the patients for us, and the size is certainly different. So whether we could directly apply that to our patient population, here is also another question, um, so fiber cystic breast, as you can imagine, it affects many women. At least half of women in their lifetime is going to have fibrous cystic, dense breast tissue. Um, and it could lead to breast pain, tenderness, fluctuating size of breast, and also could lead to some nipple discharge of multiple colors green, yellow, dark brown. Um, usually from multiple duct orifice is. And when we see that we can usually reassure patients that it's from fiber cystic changes, and obviously we see this in mostly premenopausal woman. But we also see this in post menopausal woman, and especially if they're on hormone replacement therapy. So going into work up of a breast mass. So in general, we're breaking this up into women who are younger than 30 years of age and those who are older, basically the main difference being and women who are younger than 30. Ultrasound is really the first key part of work up of a breast mast, mostly because diagnostic mammograms or mammograms and a younger woman and dense breast tissue. Oftentimes it's not that helpful, as well as the questioning of starting the radiation dose that early. Granted, if it's a one time imaging, it's probably not that big of a deal. So it's ultrasound plus or minus diagnostic mammogram, and certainly close observation is reasonable, because again, the chance of that asked, being a cancer is very low. But ultrasound is definitely the key, and a woman older than 30 years of age, diagnostic mammogram and ultrasound is the first step. And really, this allows us to differentiate whether the lump is a solid mass. Or is it a cystic mass? Possibly just a simple cyst where simple aspiration might get rid of it. And we really don't have to follow that closely at all. Or is it just showing normal, dense, fibrous, cystic tissue, which on ultrasound? Sometimes we could see that a palpable area corresponds to a really prominent area of dense, fibrous, cystic tissue. And that is a nice way to reassure patients again that what they're feeling is part of their normal breast tissue. I wanted to mention the bi rads classification of any breast imaging because that really helps us guide us into the next step of the work up process. Certainly benign or negative buyer, as the bride's ran into. There's really nothing further you need to do. Usually, the recommendation is to return to normal screening with the rods three, where they're saying it's probably benign. Usually the recommendation is six month follow up imaging to follow that area. Um, that was noted, and sometimes this will be done again for fiber adenomas in other benign entities. Um, like a complex cyst. Anything that's pirates four or five, basically, where it's suspicious for malignancy, that's what leads to a biopsy and a core needle. Biopsy again is really the standard of care at this point. So with a solid mass that turns out to be a buyer s three probably benign. As I mentioned, six month follow up versus you can certainly perceived core biopsy as a patient is very anxious. Or if they have any other history that's concerning legacy. They couldn't family history of breast cancer Breast cancer in young family members if it's four or five again, core biopsy is the definitive next step if they see a complex cystic mass again six month follow up. Usually it's a key. But for standing with core biopsy right then and there is always an option. But pirates for again biopsy a simple cystic mass will be given a buyer. It's too usually where we could pretty much categorically say this is benign and no real close follow up is needed. And that's at the point where you can and as breast surgeons, we oftentimes offer a cyst aspiration. But this could also be done by the radiologist if they are symptomatic and want that cyst aspirated and again standing for live for a psychologist optional usually only done if the fluid is from a recurrent cyst or if it's bloody, um, this kind of just repeat what I have already mentioned about bi rads. One negative findings. There's nothing really you have to do. Um, but certainly following them up with them clinically, um, is helpful in terms of reassuring the patients that were not just blowing them off, saying, You're fine, everything's fine. Um, I think a lot of patients do appreciate what I say. Hey, everything looks fine, but I'm still going to see you back in six months for just one more follow up in an exam. Very rarely do we pick up something at that point that was missed from the initial, um, work up. But I think it is a good practice to have that kind of follow up. And we're always happy to do that for our patients. Um, the role of M. R. I, um, at the bottom there that I mentioned, um, you know, it's somewhat controversial in a sense that the gold standard is certainly diagnostic mammogram and ultrasound. But if there's any suspicion that we're missing in that we're not picking it up on mammogram and ultrasound, a breast MRI could be very helpful as a next step in the diagnostic work up. Yeah, so the backs of the papal Mass if it shows a malignant result and actually that's pretty straightforward. You send them to the oncologist and the breast surgeon usually, and they start their treatment. Um, and if it's a benign result and they consider it concordant, meaning what they see on the imaging definitely agrees with what they see on the pathology report. You know, as in it looks, smells, acts like a fiber adenoma, and the biopsy comes back as a fiber adenoma again. Pretty straightforward. You follow it as a fiber adenoma with the follow up clinical exam in ultrasound. And if it's enlarging or any issues, then you could consider excision biopsy at that point if it comes back discordant. But the results are benign, meaning they went in suspecting potentially a cancerous mass, or at least a very atypical looking mass, and the biopsy came back is just benign breast tissue, for instance. Then we're left with a situation where it's a discordant result, and oftentimes the radiologist will make note of this. And that's oftentimes a point where we become involved as breast surgeons to talk to the patient about potentially proceeding with a surgical excision for definitive diagnosis. Because we are just that suspicious. These situations, I think, are fairly rare. In this day and age with the coordinator biopsy, the chance of a false negative are pretty low. And then there's the other biopsy results, which could show these high risk lesions. And again, this is kind of a topic for a whole nother talk, but showing a tibia or things like lobular carcinoma in side to these high risk lesions. The standard, um, answer has been proceeded with surgical excision because the rate of upgrade to a cancer is somewhere between 5 to 10%. But certainly observation is an option for a lot of these patients. Um, when a palpable mass shows a tipi or L C. I s sometimes were a little bit more concerned and might recommend a surgical excision. But again, these are not obligate precursors to cancers, So close observation is certainly a good option for many women and that only if there is a growth or change. Do we consider surgical excision. I didn't want to mention nipple discharge because this is something that probably many of you see patients for. Um, and as you know, it's a normal part of the breast function. For most women, um, and a man, it's really never normal. So that requires a formal work up again, usually involving mammogram and ultrasound and nipple discharge. You could pretty much say it's physiologic if it's non spontaneous and if it's from multiple ducks and multiple duct orifice is on the nipple and usually multi colored yellow, white, grey, green, like all kinds of colors. Obviously, if someone's lactating, you're going to have some destruction. Um, but certainly any manipulation of the breast and the nipple could cause nipple discharge. So if someone says it happens only when I squeeze only when I massage breast. Then again, that's something that we're particularly concerned about. There are other hormonal issues or thyroid issues that could lead to nipple discharge and prolactin Omagh's and those things should be worked up, um, in certain medications that could cause nipple discharge, but the ones that are unilateral, spontaneous clear or bloody. Those are the ones that were a little bit more concerned about for breast cancer. And those are the ones where we definitely will recommend a diagnostic workups, starting with a diagnostic mammogram and ultrasound. Um, and certainly a lot of nipple discharge is still mostly due to benign things such as papilloma is one of the most common causes of bloody nipple discharge, along with duct taped Asia, another very common cause of bloody nipple discharge. And it's for me personally, based on the evidence I've seen. Clear, spontaneous unilateral nipple discharge is probably the most concerning for possible underlying cancer. So again a full work up is needed, and in some cases the mammogram and ultrasound will not show any abnormalities. And for these patients, usually the next step is, um, a breast MRI. Um, now Dr Graham's have been used in the past, Um, and it's still a good study to use with nipple discharge that's persistent. Despite mammogram and ultrasound being negative, however, Dr Graham's as good of an imaging. It is to show a mass within the duck structure that's inhibiting the contrast from going through. It still doesn't lead to us being able to definitively identify where that is in the breast and to biopsy it to get a definitive diagnosis. And I think that's why we've moved towards breast MRIs for the work up of nipple discharge on here. Obviously, you see that if they're squeezing and getting nipple discharge, you just tell them to stop squeezing. Um, but certainly otherwise, we do recommend the work up the full work up. Um, this already mentioned goes into the doctor Graham versus MRI. Um, when those studies are inconclusive, as in, they don't show any abnormalities that could account for the nipple discharge. The next step would be a surgical duct excision or a major duct excision, where we remove essentially the ductile tissue that's most approximately people or distal and closest to the nipple. Because if there's a papilloma or some abnormality leading to the nipple discharge, with all other imaging being negative, the offending entity, whatever it might be, is usually within that duck takes you. Um, having said that, I think with MRIs, especially, we've usually been able to identify the likely source of the nipple discharge and with a coordinator biopsy of that being able to identify if that's something that needs to be surgically addressed or not, Um, I will mention breast pain kind of goes along with the fibrous cystic breasts, but again a very common, um, complaint from usually premenopausal woman, um, typically associated with their menstrual cycles. And again, usually something that we could tell from physical exam, as well as a history taking that it's cyclical and related to Menzies and usually due to fibrous cystic breasts. And so these are some of the recommendations that we usually give patients in terms of helping with breast pain. Um, and very rarely do we need to go to surgery and do anything drastic regarding breast pain. Certainly, um, it's usually self limited, Um, and once I'm able to assure patients that it's not related to cancer, anything bad like that, they're usually a lot more comfortable. And they were just wondering why they were having breast pain, mastitis and other benign entity that we do see a lot of, um, a lot of them usually easily treated with antibiotics. But some become more persistent and troublesome, and that is often the time than that we get the referral, and when we see these patients. But mastitis obviously could be due to a number of different things commonly seen and women who are breastfeeding, but certainly anyone who has any trauma to the nipple nipple piercing and smoking is a big risk factor. Um, and like I said, usually treated very effectively with antibiotics. But sometimes we'll still develop into an abscess, at which point, usually we do aspiration of these abscesses instead of an I m. D, leaving a big open wound to pack. Um, and so as ultrasound guided aspiration is what we often times try to do. And it might take a number of different episode trials of aspiration. But usually we're able to effectively treat it, um, the abscess with the antibiotics when we aspirated and otherwise symptomatic support. Obviously, some of the other inflammatory, um, weird infection infective infectious diseases that we see in the breast are one is discussed disease. I'm hoping I'm saying that right? I never said it said it right, But this is when someone has recurrent abscesses usually very close to her underneath the nipple and oftentimes ends up specializing through the skin near the nipple areola. And it's common in women of child bearing age, and those who spoke, um, is particularly at high risk, and it's not really associated with the actual breast feeding itself. But it is due to plugging of the milk duct due to squamous meta play Asia. And again, it's not something that we consider cancerous but likely related to possibly a chronic underlying inflammatory thing related to possibly cigarette smoking and usually like with any breast infection. Treatment includes antibiotics, aspiration or drainage of any abscess and at the point that it's recurrent some a lot of times. The only definitive treatment is really surgical excision of that offending, UM, duct system, if you will, and that oftentimes allows us to just remove that area without removing the entire nipple and areola structure. Um, but obviously it's not a pleasant surgery to undergo, but often types that becomes the only curative way if they don't want to have repeated flare ups of this infection. And smoking cessation is obviously key. Idiopathic granulomas, mastitis, or GM is another entity that we see quite commonly as breast surgeons, although it's very rare in general only because this is that situation where mastitis keeps happening. You give them antibiotics multiple courses, different antibiotics, aspiration cultures. It's not growing anything, and you're kind of at your wit's end in your patients is at their wits end kind of thinking What is going on and certainly sometimes inflammatory breast cancer could be a concern because it's an inflammatory area or inflamed looking area that's not getting better. Despite antibiotics and idiopathic granulomas, mastitis is ultimately what we believe to be probably auto immune related. Um, there is no known cause of this, although it tends to be associated with, um, Corina Bacterium, possibly as an offending initial infectious agent. Um, and certainly there's another granuloma this disease that it can be associated with. But oftentimes these women are young women again in childbearing years, and we do commonly CNN, Latino women, Um, and they not only formed this painful abscess like mask, but again they could develop these fish fistulas tracks the skin, and they could have a waxing waning, Of course, Um, and interestingly, it is a self limiting disease where I have certainly had patients who explain to me the issues they've had their breast over the course of years, where they have inflamed painful masses that sometimes start draining and then they get better on their own, Um, but nevertheless very distressing and painful a condition to have an ultrasound guided core needle biopsy of the inflamed Mass really is what provides us with a definitive diagnosis, and the pathologist will usually note that they see granulomas on the core biopsy. The main street of treatment has so far been steroids now typically has been oral steroids, of course, of steroids. And if that didn't work, then methotrexate was often times the next step. There's a lot more data and evidence surrounding topical steroids now as well as international injection of steroids. So that's something we're doing more commonly for these women as the first line to avoid basically a systemic steroid, a steroid therapy, um, with varying degrees of success. Honestly. And like I said, it's a waxing waning disease processes. Some women might be clear of disease for months and years, but then then it could come back again. Um, so it's not an easy disease to deal with, Um, and there's no one curative, um, course of treatment. But certainly it's something that we are getting better at diagnosing and trading, um, another benign entity. I'll mention here. Gynecomastia. Um, we do see patients with gynecomastia referred to as frequently as well. And it's just a benign overgrowth of the breast tissue and a man usually due to hormonal imbalances. Again, um, in newborns, obviously, due to the residual estrogen for the mother and teenage boys going through puberty, um, we could see this as well. And an adult man. Usually it's due to declining testosterone levels, but also due to other comorbidities like renal disease, liver disease, um, medications that maybe they may be on. And drug and alcohol use could contribute to this, um, and so going through that history is really key to identify why they may have gynecomastia. And certainly when a man has got a capacity yet and on top of that has like a unilateral, palpable mass. That's certainly again requires work up in terms of diagnostic mammogram and ultrasound. Because, although rare in men, a man who is more obese and who has gynecomastia is at a slightly increased risk of developing breast cancer. Um, usually these do resolve on their own, especially for the newborn or the teenager. Um, if the offending issue might be medications and if they could stop that medication, then usually the gynecomastia will go away. And surgery is really reserved as a last resort. If it does not go away on its own, um, medications press cannot be stopped. Um, but again, some of these medications and their medical conditions that lead to the gynecomastia may preclude them to have from having elective cosmetic surgery. But certainly that's one of the last, um, philosophy resort to address kind of kamasutra. Um, one thing I did want to mention is just the difficult breast exam, which I'm sure a lot of you have been encountered again. The fiber cystic breasts, but certainly patients who've had breast augmentation. Um, I've gotten a lot of questions from my colleagues about like, you know, how good is a mammogram on a special patients who had breast augmentation? And are we able to really feel anything in the breast? Well, and the answer is, yes, we can, and we can certainly do mammograms. They do displaced views as well as, um, a mammogram of the entire breast, including the implant, as we see here in the middle picture. Um, one of the most difficult situations I've encountered are certainly patients who have had free silicone injections in their breast as part of breast augmentation. Most of these women had these procedures done outside of the US because I believe this is not approved of in the U. S. As a cosmetic procedure. And as you can imagine, these little silicone areas can become very modular parts of the breast. And it becomes nearly impossible to tell what is a normal part of their breast versus not for these women. Not only do we do mammograms, we certainly do breast MRIs as a screening modality. Um, this is another situation where patient has had prior breast reduction and they end up with some areas of fat necrosis which can be very concerning on initial exam, because they can become very hard and firm. Um, and one of the first things we think about is Oh, my gosh, is this breast cancer? But again, certainly a work up of diagnostic mammogram and ultrasound usually shows us this well, pretty well circumscribed mass. And again, sometimes we'll have a calcified rim around it. Um, that tells us that this is likely fat necrosis again, fairly commonly seen in women who have had breast reduction. And again a coordinated biopsy can always be done to get definitive diagnosis
