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Getting a thorough history is very important – ask about
medication use, sexual practices, etc. Herpes zoster
causes galactorrhea from breast stimulation by increased
prolactin. A prolactin secreting pituitary tumor can do
this too. Some medicines that cause dopamine depletion
are anti-depressants, tricyclics, anticyclotropics,
methyldopa (HTN), metaclopamide (GI drug). Digitalis
can cause a prolactin increase because it is
anti-estrogenic. This pt will usually present as a
woman who started on medication some months prior and
now has irregular periods and nipple discharge.
Generally when you see a pt w/galactorrhea, think
pituitary tumor and send them for a CT scan of their
head, specifically the sella turcica. Look for a
pituitary micro or macroadenoma. Visual field tests can
also be done on physical exam, but it’s usually a very
late finding.
Pathologic discharge comes from one duct.
On exam, you will see that one drop comes from only one
duct. (Whereas with physiologic discharge, many beads
come up on the nipple.) The pathologic discharge can be
milky, bloody, or serous. Usually it represents a
benign process, most of the time an intraductal
papilloma. However, keep in mind that 10% of
malignancies present with a nipple discharge – it’s
usually bloody, but sometimes black. Ductal ectasia can
present as discharge, but the patient will be older
(40s-50s). In rare instances, discharge can be caused
by fibrocystic change. Treatment of pathologic
discharge is usually excision of the duct.
Mastalgia
Mastalgia
(aka mastadynia) is a technical term for breast pain.
If it is cyclical, it’s mediated by estrogen and is
benign. Most patients will have resolution in 3-6
months, so continue with routine screening. If there is
persistence, recommend lifestyle changes – wearing a
supportive bra and avoiding methylxanthines (coffee).
There’s no studies proving it helps mastalgia resolve
but for over 60% of women, it buys them 6 more months to
wait around and see if it does. If so, they can go onto
routine screening.
If
the mastalgia persists despite lifestyle changes, treat
them first with evening primrose oil, an
essential fatty acid (gamma-linoleic acid). It must be
eaten, not rubbed on breasts
à
half of them will have resolving of the pain. If there
is persistence, treat them with Danazol
(testosterone derivative) which decreases the estrogen
effect on the breast. There’s a lot of side effects
including hirutism, deepening of voice, aggression, and
acne. However, it works very well and 70-80% of the
remaining women have resolving of the pain after several
months. Bromocriptine and tamoxifen will also
work. LH (leutenizing hormone) agonists will also work
by putting women into menopause and stopping estrogen
release. In very rare cases, a mastectomy will be done
if the woman requests it.
Noncyclical breast pain indicates an underlying
malignancy.
If the physical exam is abnormal, the pt must be
biopsied. If the physical exam is normal, send them for
a mammogram. If the mammogram is normal, most likely
they have a benign condition so send them over to the
cyclical part of the flowchart and follow that down. If
the mammogram is abnormal, a biopsy must be done.
Breast Infections
There are 2 types of breast infections, those in
women who are lactating (breast-feeding) and those in
women who aren’t. Most of the time breast
infections don’t indicate malignancy, but some
inflammatory cancers can present this way.
For
example, the patient can come in presenting with a 2
week history of mastalgia during the time she’s breast
feeding; her breast is very red and tender and she can’t
feed the baby because it’s very painful. This is
usually a case of cellulitis which will move into the
abscess phase 70% of the time. In the cellulitic
phase, the patient will have a low-grade fever and no
distinctive mass is palpable. Treat her with oral
antibiotics and warm compresses. The baby can feed
on the breast during this time if it’s not too
painful. If it is, tell her to express her breast
(squeeze the milk out it, not walk around topless)
because this is the only feedback the body has so that
the breast can continue lactating. If she has
resolution, she can continue to routine screening.
If
the patient goes onto abscess phase, they must have
incision and drainage of the abscess.
***Remember this! All abscesses must be drained!***
Any patients with an abscess has a high fever. They
will have a breast mass but it is too painful so they
won’t let you palpate it.
Most
breast infections are caused by Staph, so treat her with
nafcillin.
If she moves to the abscess phase, then drain it!
The patient cannot breast feed off of the breast when in
abscess phase. The inoculum of bacteria is so high
in the abscess that the baby can develop aspiration
pneumonia from feeding. Lactating patients with
breast infections almost never represent underlying
cancer.
Nonlacting patients
with infection are more concerning. Treat with oral
antibiotics and abscess drainage. If they have
resolution, then go onto routine screening. If they
have persistent infection or reinfection, a biopsy must
be done – usually the duct will be excised. The
underlying cause in this case may be inflammatory
carcinoma or a mass occluding the duct forcing it to get
secondarily infected.
Screening for Breast Cancer
When
patients come in for screening, there are certain
recommendations from the National Cancer Institute (NCI)
that should be followed. Dr. Pompeo pretty much read
off the chart for this part, so know it fully. She then
gave a real-life example to discuss (names have been
changed):
Sandy’s
mother died of an unknown adenocarcinoma. Her mother’s
2 sisters died of breast cancer and her 3rd
sister died of an unknown adenocarcinoma.
Sandy’s older sister Mary was diagnosed w/breast cancer
at 30, she’s now 40 and doing well. When should Sandy
have started her mammogram? 25 y.o. (If you
follow the rule of subtracting 10 from age of the
youngest affected relative, you get 20 y.o. but doing a
mammogram earlier than 25 is useless because the breasts
are too dense to see anything.)
Mary
was tested for BRCA and she was BRCA 2+. When should’ve
Sandy
gotten her first mammogram? 25 y.o. If Mary was
42 when she was diagnosed and then died from the
disease, when should
Sandy have started mammograms? 32 y.o. If Mary
was diagnosed at 42, did not die from it but was BRCA
2+, when should she have started mammograms? 25 y.o.
Remember to always get a good family history!!
So
getting annual mammograms in women between 50-65 y.o.
definitely decreases morbidity. What do we do with
women older than 65? It is probably helpful in women
from 65-75 y.o., but beyond that we’re not sure. The
NCI recommends that if the patient’s prognosis for their
general medical problems is > 5 yrs life expectancy,
they should have yearly mammograms. If their life
expectancy is < 5 yrs, they’re not going to benefit from
mammograms because they only pick up small lesions that
are not likely to kill the patient in the next 5 years.
On
mammograms, look for new findings and biopsy them.
Patients who have spiculations or clusters of
microcalcifications should also be biopsied. When you
see linear calcifications that don’t go with the normal
radial pattern, also biopsy them.
Mammogram classification:
-
Birad 0 – there’s something wrong on the mammogram and
futher testing is needed
-
Birad 1 – normal
-
Birad 2 – benign findings: radial scarring, fat
necrosis
-
Birad 3 – look benign with some abnormal findings;
biopsy them and have a 6 month follow-up
-
Birad 4 – obvious signs of malignancy are seen
Clinical staging of breast cancer:
-
Take a detailed history focusing on symptoms
suggestive of metastatic disease (bone pain is
common).
-
Physical exam to determine extent of palpable disease
and do a complete lymph node survey.
-
Labs – CBC, LFTs ( look at alkaline phosphatase and
for evidence of bone turnover lending to
evidence of metastases)
-
Imaging:
-
Mammogram if it wasn’t done already to look for
synchronous lesions on the other breast
-
CXR to see lung and bone metastases
-
Bone scan if she has bone pain
-
CT scan of chest, abd, head
Tumor size, Nodes, and Metastases (TNM cancer stage
classification):
-
0
– confined to breast
-
1
– larger, palpable lesion but confined to breast
-
2
– small, confined to breast with nodal involvement OR
larger lesions
-
3
– massive nodal involvement, regardless of tumor size
-
4
– systemic metastases, regardless of tumor size
Remove the mass with a lumpectomy in these cases:
-
Primary tumor < 5cm (maybe larger in certain cases)
-
Tumor of lobular or ductal histology
-
Lumpectomy with clear margins yields a cosmetically
acceptable result
-
Mobile axillary nodes (if they’re immobile, a
mastectomy must be done)
Remove the mass with a mastectomy in these cases:
-
If
radiation therapy is contraindicated because all
lumpectomies have to follow-up with radiation
therapy. For example, a patient who was radiated when
she was younger for some cancer will have to have a
mastectomy because all of her organs have received the
maximum dose of lifetime radiation.
-
Lumpectomy yields a poor cosmetic result
-
Local recurrence is a risk
-
High-risk patient in whom prophylactic mastectomy is
appropriate. For example, if
Sandy
discovers a mass, she should probably have a bilateral
mastectomy instead of a lumpectomy because she has a
high-risk of recurrence.
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