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reviewed 8/03

• Mastalgia/Fibrocystic changes
• Breast Lumps/Breast Cancer
• Staging of Breast Cancer
• Handouts

Mastalgia and Fibrocystic Changes

Definition: Benign breast disorders characterized by lumps or pain. The lumps are physiologic nodularity , a ropy, thickening, or distended fluid filled cysts They are mobile. The pain may be cyclic or noncyclic. Pain may be unilateral or bilateral.

Common Complaints: "My breast are painful, particularly just before my period." I have lumps in my breasts and they hurt."

History

• Elicit history of pain. When is the onset, duration, relation to menstrual period, constant or intermittent, location?
• What has the patient tried to alleviate the pain? What has worked, such as NSAIDS?
• Family history of breast pain, lumps or cancer?
• Has there been trauma such as being hit or rough experience during sex?
• Any breast surgery or biopsy?
• Medications history such as oral contraceptives or phenytoin?

 

Physical exam and tests:

Signs/Symptoms

• Breasts are tender to palpation. There may be rope like masses, usually bilateral with mobile, well circumscribed masses that are cystic or rubbery.

Physical Exam

• Inspect: for masses, dimples, changes in the skin, changes in the way the nipples are pointed while your patient is in the sitting position with arms in neutral position in lap, with arms above the hear, pressing in on hips. Breast may normally be of different sizes. It is a change that is significant. Thorough breast exam with findings as in S/S. No hard, fixed mass or skin changes.
• Measure masses and describe in the patient’s record. Use a clock face describe location.

Diagnostic Tests

• Mammogram. Note. May be difficult to interpret in women under 35 years.
• Ultrasound. To differentiate cystic from solid masses.
• Fine needle aspiration and biopsy.
• Excisional biopsy for solid lumps.

Differential Diagnoses:

• Fibrocystic breast changes with mastalgia.
• Benign breast masses (fibroadenoma, duct ectasia).
• Nipple discharge: duct ectasia, prolactin secreting pituitary tumors.
• Pain: costrochondritis, chest wall muscle pain, neuralgia, from Herpes Zoster, fibromyalgia.. Heart: angina pectoris.
• GI: GERD.

Review Johnson, et al. p 341, Clinical Features of Cyclic and Noncyclic Breast Pain

Not to be Missed: Lump or mass that could be cancer of the breast.

Plan:

General

• Refer to surgeon if suspicious mammography study, abnormal needle biopsy, solid mass per sonogram.
• Education. use term fibrocystic changes rather than fibrocystic disease to stress functional nature of the problem. Stress that pain is real, but not a disease state. Teach self breast examination.
• Symptomatic measures
• Good supporting bra
• Local heat or cold, whatever works best
• Vitamin E 600-800 mg per day
• Vitamin B6 25-50 mg per day
• Vitamin A 150,000 IU per day for 3 months.
• Diet:. Elimination of methylxanthines is a good idea, but unproven in research studies. Salt restriction.
• Herbs. Evening primrose oil.

Pharmacological Therapy

• Diuretic
  • Spironolactone (Aldactone) 10 mg BID premenstrually.
• Oral contraceptive pills.
• Anti-estrogen
  • Danazol (Danicrine) 100 mg BID for 6 months. Note. Doses below 400 mg daily may not inhibit ovulation. Use barrier contraceptive or IUD contraceptive measure. Note: Although the side effect profile is significant, long term symptomatic relief and histological changes may be achieved.
• Methyltestosterone 5 mg every other day during period of discomfort
  • Tamoxifen 20 mg per day
• Bromocriptine (Parlodil) 2.5 - 5 mg BID for 3 months.

Follow-up

• Women with atypical hyperplasia on biopsy need close follow-up as indicated by protocol
• Young women with fibrocystic changes need to be seen after one to two months of pharmacological therapy to assess for complications and efficacy.

Primary Points:

• Consult or confer with a physician when breast masses are identified.
• Even if low risk, continue self breast examination monthly.
• Clinical breast examination annually.
• Mammography every two years from age 40-50 years and annually after 50 years of age.
• When clinical breast examination, mammography and needle aspiration biopsy are used, breast cancer detection rates are 93-100%.
• Pain may inhibit sexual activity involving the breast

Pregnancy: Consider blocked duct or mastitis.

Geriatric: Breast pain should be worked up as possible cancer

Incidence: This is a very common problem. Fifty percent or more of menstruating women experience breast pain. Two-third of breast pain is cyclic which occurs in women in their 30’s and non cyclic which may occur at any age but tends to occur in women closer to menopause.

Pathogenesis: Dysplastic, benign histological changes in the breast such as hyperplasia of the breast epithelium, adenosis microcysts and macrocysts , duct ectasia ad apocrine metaplasia.

Predisposing Factors: Menstruating female. There has been clinical observation that methylxanthines present in coffee, tea, chocolate and cola drinks are contributory, however research has not supported this thesis.(Speroff, et al, 1994).

ICD 9610.1 Diffuse Cystic Mastopathy

Breast Lumps/Breast Cancer

There is an excellent algorithm for working up breast lumps at www.medline.com  or more specifically www.medline.com/home/topics/womenshealth   and an article listed in your bibliography and available on line for you.

If you can not directly access this site, type in the URL.

History:

Chief Complaint:  "I feel a lump in my breast and it scares me to death"

Family history or breast cancer or other cancers?

What is the age of the patient?  The incidence of a mass being a cancer increases with age, with a big jump in incidence at age 50.

Menstrual history?  Menopausal? 

What are the characteristics of the mass?  Painful/Nonpainful.  Slow growing/rapid growth.  Mobile/nonmobile. 

Physical:

Characteristics:  where? use clock face to describe where lesion is.   Size? Shape, regular or irregular.  Cystic or solid.  Mobile or immobile.   Painful or nonpainful?  Lymph node palpable?  Single or multiple masses?    Skin changes?  Nipple discharge?

Differential Diagnoses:

• Malignant tumor
• Fibrocystic changes
• Fibroadenoma
• Intraductal papilloma
• Fat necrosis
• Infection, mastitis

Tests:

• Ultrasound of breasts.  Good at differentiating cystic from solid masses at all ages.
• Mammogram.
• Fine needle aspiration.  Cystic or solid?
• Biopsy
• If tumor is malignant, estrogen receptor positive or negative

Plan:

• Begin testing as described above. 
• Refer immediately to surgeon if symptoms clearly malignant.
• If patient is young, mass is cystic, reexamine after next menstrual period and monthly.   Refer if increase in size or no resolution.
• Screen the daughters of women with breast cancer with mammogram and other screening measures 10 years prior to the mother's diagnosis of breast cancer.
• Cytological examination of discharge or cyst fluid

Risk Factors

• Age, the older we are, the greater the risk
• Family history.  First degree relatives with breast cancer increase the risk.  Certain BRACE genes raise the risk even higher.
• One out of nine women.
• Note:  There is no history of breast cancer in 80-90% of women diagnosed with breast cancer.
• Atypical hyperplasia increases risk.
• 45-5-% of cancers are in the upper, outer quadrant

Staging of Breast Cancer Tumors

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