Benign Breast Disease

Today’s episode suggestion comes to us from Shadae Beale, a resident at Meharry Medical College. Thanks for listening! And be sure to send us your ideas through the website or via email!

We kicked off today’s episode with a vignette:

24 yo F G1P1 with 10 year history of type 1 diabetes presents with right breast mass that she palpated in the shower. She is currently breastfeeding her 9 mo old baby. She states that she has had some pain in her right breast, though no redness or swelling, and that she has always had “lumpy breasts.” She is worried because her 78 yo grandmother was recently diagnosed with breast cancer. No other breast or ovarian cancer in her family. On exam, she has lumpy, cobblestone texture of both breasts, with free-moving tissue throughout. There is one 2x2cm firm, mildly tender, mobile mass in the R breast at the 2 o’clock position, approximately 1 cm from the nipple. No axillary lymphadenopathy. 

Now we imagine that if this isn’t a likely scenario in your clinic time, it is on your test prep questions. What do you do with this patient? Let’s first review a broad differential diagnosis for a likely benign mass:

Nonproliferative Breast Lesions 

  • Breast cysts 

    • Simple cysts - benign, fluid filled mass; usually discrete, compressible, or ballotable solitary mass 

    • Galactocele - milk retention cyst common in women who are breastfeeding 

  • Fibrocystic changes - common, especially in premenopausal women; may cause breast pain 

  • Lipoma - mature fat cells 

  • Fat necrosis - can develop after blunt trauma to the breast; can also occur after surgery (ie. breast reconstruction, radiation therapy); associated generally with skin ecchymosis 

  • Breast abscess - localized collection of inflammatory exudate; can develop alongside mastitis or cellulitis; usually will have all the signs of infection! 

  • Diabetic mastopathy 

    • Usually in women with longstanding T1DM 

    • Suspicious fibrous breast lumps, usually multiple 

    • Need to biopsy for diagnosis

  • Idiopathic granulomatous mastitis 

    • Rare inflammatory disease of the breast - usually presents as a painful, firm and ill-defined mass that can have erythema and edema of the skin 

Proliferative Breast Lesions without Atypia 

  • Intraductal papillomas 

    • Monotonous array of papillary cells that grow from the wall of a cyst into its lumen.

    • Most common cause of bloody nipple discharge (key to any vignette!)

    • Generally not concerning, but CAN harbor DCIS; can be solitary or multiple lesions. If bothersome or concern for atypia, surgical excision is performed.

Intraductal papilloma. (C) WebPathology.

  • Sclerosing adenosis - lobular lesion with increased fibrous tissue; no need to treat.

  • Radial scar - complex sclerosing lesions; usually diagnosed after biopsy. Recommend excision, but no other treatment .

  • Fibroadenoma 

    • Most common benign tumor in the breast, accounting for ½ of all breast biopsies 

    • Glandular and fibrous tissue, presenting as a well defined, mobile mass on exam.

Atypical Hyperplasia 

  • Atypical ductal hyperplasia (ADH)

    • Proliferation of uniform epithelial cells with round nuclei fill part of the duct.

    • Standard of care after biopsy-proven diagnosis is surgical excision, due to risk of upgrade to ductal carcinoma.

  • Atypical lobular hyperplasia (ALH)

    • Monomorphic, evenly spaced dyshesive cells fill part of the lobule; can also involve ducts.

    • Referral to breast onc should occur, as management varies based on other clinical risk factors.

OK, so now you have a differential — what do we still need to do for this patient in front of us?

Always starting off with a history is important. With respect the HPI, it’s important to know not only about the characteristic of the mass, but any changes to the mass and the timiing of changes. For instance, is it painful, but cyclically painful with menses? That would argue more for fibrocystic changes. Has it grown in size over the last 3 months and caused nipple inversion in the meantime? That’s more worrisome for malignancy.

Family history and social history are also exceptionally important. Smoking increases risks of certain breast pathologies. And family history is obviously tantamount to determining a patient’s risk for particularly early-onset breast cancer.

Physical examination should include both breasts, examined in both a sitting and recumbent position. Note asymmetry, skin changes, nipple changes, and the location of masses. Generally using clock face language is most helpful for your referral: i.e., “12:00 position, 3cm from nipple” is highly descriptive. Finally, a regional lymph node exam should also be performed. Generally this includes axillary and supraclavicular nodes.

Imaging is what we will turn to next. For the younger patient, targeted breast ultrasound is an excellent choice, as it’s more sensitive than mammogram in this population with denser breast tissue. It also allows for immediate biopsy should the reading radiologist decide it’s indicated. Diagnostic mammography is also a standard of care in anyone with a palpable breast mass who meets criteria for screening. Definitive diagnosis is achieved with biopsy — core biopsy for solid lesions, fine needle aspiration for cysts, or excisional tissue biopsy as another option.

Breastfeeding Part II: Facts and Myth-busting

Today we (finally!) sit down with Part II of our breastfeeding special with Dr. Erin Cleary to cover myths, facts, and advantages of breastfeeding.

There are only three main contraindications to breastfeeding:
1. In infants with galactosemia.
2. In mothers who are HIV+ in high-resource settings.
3. In mothers with human T-cell lymphoma virus.

There are a number of relative contraindications to breastfeeding:

  • In a mother with Hepatitis A until she receives gamma globulin.

  • In a mother with Hepatitis B until the infant receives HBIG and HepB vaccine.

  • In a mother with Hepatitis C if coinfections present, such as HIV.

  • In a mother with Varicella zoster (Chicken pox) while mother is infectious.

  • In a mother with Active TB until mother has received 2+ weeks treatment

  • In a mother with influenza

    • if the mother has been afebrile without antipyretics for >24 hours, and the mother is able to control her cough and respiratory secretions.

    • Oseltamivir or Tamiflu is poorly excreted in breastmilk

  • In patients abusing IV drugs.

  • In patients using marijuana:

    • (THC), the main compound in marijuana, is present in human milk up to eight times that of maternal plasma levels, and metabolites are found in infant feces, indicating that THC is absorbed and metabolized by the infant

    • Several preclinical studies highlight how even low to moderate doses during particular periods of brain development can have profound consequences for brain maturation, potentially leading to long-lasting alterations in cognitive functions and emotional behaviors

    • Breastfeeding mothers should be counseled to reduce or eliminate their use of marijuana to avoid exposing their infants to this substance and advised of the possible long-term neurobehavioral effects from continued use

Common Breastfeeding Myths/Misconceptions:

Infectious:

  • You should breastfeed if you have mastitis, emptying the breast prevents stasis of milk

You can breastfeed in setting of acute respiratory, urinary, GU infections, continuation of BF acceptable

Imaging Sudies

  • You can breastfeed if… You need medical imaging.

    • XRays do not affect milk

    • Mammograms may be harder to interpret when a patient is lactating, but this should not be a reason to defer recommended diagnostic imaging

    • CT/MRI with or without contrast do not impact breastmilk

    • XRays with contrast dye or imaging with radioactive material are also OK

    • Exception: thyroid scan using I-131

      • I-131 concentrates in breastmilk and at high levels can suppress baby’s thyroid function (or even destroy the thyroid) and increase risk of thyroid cancer.

      • Therefore it is important that breastfeeding be discontinued until breastmilk levels are safe (this depends upon the dose and ranges from 8 days to 106+ days). The half-life for I-131 is 8.1 days.

      • Hale recommends that when I-131 is used, breastmilk samples should be tested with a gamma (radiation) counter before breastfeeding is resumed to ensure that radiation in the milk has returned to safe levels.

  • You can breastfeed if… You are pregnant!  

    • Increasing progesterone will decrease supply and cause breast/nipple sensitivity.  

    • Mature milk will be replaced by colostrum in the 2nd trimester.

    • Tandem feeding includes breastfeeding a newborn and toddler

  • You can breastfeed if… You’ve had general anesthesia.  As soon as you are awake enough to hold the baby, the medication has metabolized and breastfeeding is safe.

  • You can breastfeed if… You are on maintenance medications such as methadone and buprenorphine

    • There is a reduction in severity and duration of treatment of NAS when mothers on these medications breastfeed

  • You can breastfeed if… You have an occasional alcoholic beverage

    • Alcohol concentration in the blood is in steady state with the milk, so delaying nursing or pumping until more alcohol is metabolized can limit exposure

  • If direct breastfeeding is interrupted due to temporary separation of mother and child for any reason, the breastfeeding mother should be encouraged and supported to regularly express her milk.

    • Expression and storage of milk allows the infant to continue to receive milk if appropriate, and prevents stasis of milk and mastitis

In the setting of infection, prior to expressing breast milk, mothers should wash their hands well with soap and water and, if using a pump, follow recommendations for proper cleaning.

Breastfeeding Part I

Today we start a two part series on breastfeeding with Dr. Erin Cleary, Assistant Professor of Obstetrics and Gynecology and Clinician Educator at the Warren Alpert Brown School of Medicine. She’s also the incoming MFM fellow at the Ohio State University — so look out for her in July, Buckeye listeners!

Also, thank you Dr. Daniel Ginn, our first Patreon sponsor — and apologies for the dad joke with your name!

We start today with a discussion of the anatomy of the breast, and in particular with lactation. At the bottom of this post is a corresponding Netter image to guide your listening.

The physiology of lactation is somewhat confusing, but in bulleted summary:
Lactogenesis I Early in pregnancy, human placental lactogen, prolactin, and chorionic gonadotropin contribute to maturation of the breast tissue to prepare for lactogenesis.

  • In the second trimester, secretory material which resembles colostrum appears in the glands.  A woman who delivers after 16 weeks gestation can be expected to produce colostrum.

  • Differentiated secretory alveolar cells develop at the ends of the mammary ducts under the influence of prolactin.  Progesterone acts to inhibit milk production during pregnancy. This makes sense from a viewpoint of energy expenditure- grow your baby first in utero, then switch to focus on growing it with milk.

Lactogenesis II is the onset of copious milk production at delivery.  In all mammals, it is associated with a drop in progesterone levels; in humans, this occurs during the 1st 4 days postpartum, with “milk coming in” by day 5

  • During the next 10 days, the milk composition changes to mature milk.  Establishing this supply is Lactogenesis III, and is NOT a hormonally-driven process like Lactogenesis I or II. Rather, this is supply/demand-driven with expression of milk

  • When the milk is not removed, the increased pressure lessens capillary blood flow and inhibits the lactation process.  Lack of sucking stimulation means lack of prolactin release from the pituitary.

Next week, we’ll be back again with Dr. Cleary discussing breastfeeding myths and contraindications, so stay tuned!

Netter’s Anatomy. Copyright Elsevier texts.