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.

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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.

Gestational Trophoblastic Disease

On today’s podcast, we welcome Jenna Emerson, MD, the current 3rd year fellow in gynecologic oncology and alumnus of the residency at Brown University / Women and Infants! Jenna takes us today through the often confusing world of GTD (or GTN, or GTT).

GTD encompasses several distinct disease entities, including complete and partial molar pregnancy, invasive moles, gestational choriocarcinoma, and placental-site trophoblastic tumors (PSTT).

Molar Pregnancies are a form of non-invasive GTD, and will be encountered by the general OB/GYN. It’s estimated 1:600 TABs will pathologically be molar pregnancies. 20% will lead to malignant GTD and require treatment, with complete moles more often leading to malignancy than partial moles.

The distinction of complete versus partial moles make for great test questions, though the management is the same. There are two main distinctions:

• Karyotype – partial is triploid, complete is diploid

• Clinical features – complete is completely weird, while partial only partially weird. Though the ACOG PB 53 has since been retired, this table is helpful in going over the main differences:

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ACOG PB 53

Moles generally present with first trimester bleeding or characteristic US findings (“snowstorm appearance”). Initial management requires a number of steps for evacuation or hysterectomy. Be sure to check out the NCCN guidelines (membership required, but free!) for review.

Malignant GTD occurs post-molar if bHCG plateaus, increases, or is persistently positive. This ultimately requires staging per FIGO criteria:

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NCCN / FIGO

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NCCN / FIGO

If disease is low risk and local disease only, management is hysterectomy vs repeat D&C. A second curettage for low risk cures 40% of patient, and avoids need for chemotherapy. This is a change from traditional teaching, based on a prospective trial published in 2016.

If this surgical management is unsuccessful while following bHCG, then it’s time to move to chemotherapy. Low risk disease is treated with single agent chemo (MTX or Actin-D). Per GOG174, Actin-D has a higher complete response rate, but is more toxic than MTX. High risk disease is treated with EMACO. Check out the NCCN guidelines for more information on these regimens. 

Choriocarcinoma and Placental Site Trophoblastic Tumor

• Choriocarcinoma can follow term pregnancies (50%), moles (25%), or non-term histologically normal pregnancies (25%). They have early systemic mets, and require chemotherapy. The staging system is the same as above to decide single vs. multi-agent therapy. These are very vascular, so the classic CREOG answer is that you should not biopsy a suspected choriocarcinoma!

• PSTT, epithelioid trophoblastic tumor – both of these are very rare and can follow any pregnancy. These should be referred to specialized centers, and are most commonly treated with hysterectomy.

Diagnostic Dilemmas

We reviewed a number of scenarios that can pose diagnostic challenges. In brief:

• Malignant GTD following non-molar pregnancies

  • In the case of persistent AUB for > 6weeks after pregnancy, a bHCG should be checked to rule out new pregnancy or GTD

• Choriocarcinoma as malignancy of unknown primary 

  • Mets have been reported in pretty much every body site.

  • Serum beta (which will almost certainly be above discriminatory zone) and pelvic US to r/o pregnancy allow for diagnosis.

• Phantom hCG – heterophile antibodies

  • Positive serum hCG testing can result due to relatively non-specific circulating antibodies which bind to secondary antibody in a sandwich assay (antigen 🡪 primary antibody detects antigen-labeled secondary antibody, which detects primary antibody and has detectable indicator).

  • Several ways to identify: pos serum with neg urine (antibodies aren’t shed in the urine but bHCG glycoprotein is), value doesn’t decrease with serial dilutions, or can send to a separate lab which may use separate secondary assay.

• Postmenopausal hCG

  • Baseline small amount of hCG produced by the pituitary – rises in peri- and post-menopausal, during chemo. Typically beta is 5 or less but can occasionally be higher. Confirm by checking LH – if LH is consistent with menopause, this confirms pituitary source.

Trial of Labor after Cesarean (TOLAC)

In 2016, the US cesarean delivery rate was 31.9%. With ever increasing volumes of cesarean delivery, TOLAC has become a popular option for patients desiring vaginal delivery. On today’s episode, we examine TOLAC and share some counseling pointers in thinking about your patient. ACOG PB 205 is the requisite reading for the topic.

While there are no RCTs comparing TOLAC to planned cesarean, the relative benefits are easy to see: there is less recovery time, the patient avoids major surgery, and the potential sequelae of complications from major surgery — worsened bleeding, more opportunity for infection, more risk of complications requiring additional procedures. However, TOLAC is not without risk. We primarily counsel with respect to uterine rupture. Evaluations of “rupture” though have varied in the literature; it’s important to keep a discerning eye, as what is classified as rupture in some series is very different than what is in others. ACOG suggests the rate of uterine rupture in a patient with one low transverse cesarean delivery is around 0.5 - 0.9 %. Otherwise, maternal risks are fairly equal. Neonatal risks are also considered fairly equal, though with some increased risk associated with TOLAC.

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ACOG PB 205

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ACOG PB 205

We can think about patients who should be counseled against TOLAC:

• Those at high risk of uterine rupture: ie. those with classic uterine incision, T-incision, prior uterine rupture, or extensive prior uterine fundal surgery like a myomectomy.

• Women who are not otherwise candidates to have vaginal deliveries: ie. previa.

• Women who desire homebirth: While ACOG does not definitely say that you cannot TOLAC in this instance, if you don’t access to emergency cesarean delivery, it is recommended that these patients have a discussion regarding the hospitals resources and possibly referral to a hospital that does have access to emergency cesarean delivery.

We can also consider patients for whom there may be a question of whether TOLAC is appropriate:

• Low vertical incision? 

  1. Few studies, but those that have looked at them have shown similar rates of vaginal deliveries as low transverse. Can consider TOLAC!

• Twins? 

  1. Studies show similar rates of successful VBAC in twins as in singleton gestations 

• Obesity 

  1. Unfortunately, higher BMI seems to have an inverse relationship with success of VBAC. 85% of normal weight women achieve VBAC while only 65% of morbidly obese women do. However, morbidly obese women also can have more complications with an elective repeat cesarean, so counseling should be individualized

• Induction and augmentation of labor 

  1. Mechanical dilation can be used - ie. cervical foley 

  2. Misoprostol has been shown to have increased risk of uterine rupture, so should not be used in term patients who have had c/s or other major uterine surgery for induction 

  3. However, in women undergoing second trimester labor inductions (ie. for missed abortion, induction of labor for stillbirths), use of prostaglandins have shown similar results in women who have had scars on their uterus and those without; so these women can still have prostaglandins, especially because no fetal considerations 

• What if they’ve had a uterine rupture? 

  • If the site of rupture or dehiscence is in the lower part of the uterus, their risk of uterine rupture in labor is 6%. If it is in the upper segment of the uterus, the rate of dehiscence in labor is up to 32%. While there is no high quality data to guide this, recommendations are generally for subsequent pregnancies to be delivered by cesarean between 36-37 weeks.

Counseling should be individualized, and the MFMU has excellent calculators to help guide you and your patients to a decision about TOLAC:

(not in labor) https://mfmunetwork.bsc.gwu.edu/PublicBSC/MFMU/VGBirthCalc/vagbirth.html

(at admission) https://mfmunetwork.bsc.gwu.edu/PublicBSC/MFMU/VGBirthCalc/vagbrth2.html

#MedEd: How to Give Feedback

We’re starting into a new miniseries at CREOGs Over Coffee that will be devoted to topics specific to medical education! To help us kick this off, we’ve invited Dr. Dayna Burrell, assistant professor and OB/GYN residency program director at Brown / Women and Infants, as well familiar voice Liz Kettyle, CNM, clinical instructor at Brown / Women and Infants. Now well into a new academic year, the dreaded topic on the front of everyone’s minds is delivering feedback. The word ‘feedback’ itself probably conjures up a lot of negative emotion, and Dr. Burrell and Liz are here to help change the spin on that and set you up to both receive and give feedback effectively.

For the website today, we’ll devote space to their seven tips for effective feedback:

1. Define the time: Plan in advance. Set expectations that feedback will happen on a regular basis - after each procedure, after each delivery, on a weekly basis - whatever makes the most sense for that learning environment. When people know what to expect, and time is defined, both the person giving feedback and the person receiving it will be less anxious, and it will be more likely to have an impact.
   

2. Create a positive learning environment: Setting the stage for a positive learning environment can really optimize your ability to give and the learner’s ability to receive the feedback that’s coming.  If possible, try to find a private space away from the direct clinical area. Try to pay attention to the learner’s needs -- has he been in the OR all day? Would it help to get water, coffee, a sandwich before the feedback session?  Pay attention to the small talk you’ve had with him. Do you remember any relevant details in his world? How’s that patient from yesterday doing? Is your baby sleeping through the night yet? Are you getting settled into your new place? You are demonstrating that you care about the learner as a person. You are providing feedback because you care! You are invested in his development and really want him to be successful! 
   

3. Define that this is feedback happening now: When Dayna started as an APD, she was given the advice to start defining the feedback, by starting each meeting with, “This is your feedback session.” At her program, this immediately improved the perception of the quantity and quality of feedback given. It seems silly, but meetings with someone who is senior to you can be stressful and anxiety provoking and the messaging can be lost in that stress. Take the time, acknowledge the purpose of the meeting in a relaxed manner and move forward. 
   

4. Allow the learner to self assess: Having the learner tell you about what she thinks went well and what could be improved upon lends tremendous insight that can make your ability to deliver feedback much more impactful.  If your views align, it can be mutually rewarding, thereby strengthening your relationship. You can validate her observations which in turn strengthens her confidence. If there is a discrepancy, a deeper dive will be required to understand how, where and why you perceive the performance differently and this may guide how you decide to approach your delivery.  
   

5. The feedback sandwich, or your food analogy of choice:

   1. The traditional sandwich: positive - area for improvement - positive. A great place to start when you are giving feedback- it is very concrete. 

      • So what is the content? Start with a positive, and roll into an area for improvement- remember you aren’t trying to criticize, you are aiming to provide specific information to reinforce or change a behavior. And you can’t change someone’s personality! Focus on behaviors that you can impact. End with a positive, or a goal to accomplish. 

      • The sandwich is getting a bad wrap per the literature of being overused, and students complaining about it being predictable. So spice it up. Add condiments, maybe some dill pickles, maybe some pesto!

   • The sushi roll: the sushi rice on the outside represents the background/the positive, the tougher nori represents the area for improvement, the spicy tuna on the inside represents the end goals, the part of the bite that makes it all come together

   • The sundae: the ice cream represents that background/the positive- comes in many flavors! The toppings represent areas for improvement- also many varieties- some small and concise(sprinkles), some more wide spread (hot fudge). The whipped cream and cherry are the bonuses on top- the plans, the goals. 
     

6. Engage in a dialogue: Now we need to close the loop and ask about barriers she perceives with respect to accomplishing the identified objectives. Listening openly to her perspectives on how her learning and performance can be optimized is crucial. Be prepared, the dialogue may include feedback on your institution and teaching style. 
   

7. Set Goals: This is it. Arguably the most important part of the whole feedback session. Set goals to improve! How do you meet those goals, what tools do you need for success, how do you measure success. As the person giving feedback- make sure you follow up. Recognize when someone is meeting those goals, or acknowledge their effort to get there, for the sake of positive reinforcement. 

Considerations for Planned Singleton Breech Vaginal Delivery

Today’s episode dives more into the realm of expert opinion rather than hard science, and we hope some of our listeners will share their own experiences and criteria for offering planned breech labor!

ACOG CO 745, in addition to PB 161 on external cephalic version, deal with this topic, but there is much variation in the literature available. In particular, international guidelines on this topic are rather variable. The ObG Project has a great summary and links to these varying resources that is worth checking out.

There are particular risks to breech labor, and experienced provider hands are necessary, which is why almost 90% of planned term breech birth in the USA is performed by cesarean section. The 2000 Term Breech Trial, a multicenter randomized trial, noted perinatal morbidity and mortality was overall reduced with planned cesarean delivery than with planned vaginal delivery of term breech (1.6% vs 5.0%), with no differences in reported maternal morbidity or mortality. Follow up studies to the Term Breech Trial, however, have noted no differences in maternal or neonatal outcomes at 2 years.

Additional studies performed since this time have been mixed. While some prospective studies demonstrated excellent maternal and neonatal outcomes, both short- and long-term, they utilized very strict criteria and protocols for the selection of candidates offered a trial of breech labor. Cohort studies of breech birth in general populations demonstrates at least short-term risk of neonatal morbidity, including birth injury, nerve injury, and need for assisted ventilation. This risk is present with any trial of breech labor, including if intrapartum cesarean is performed, versus planned cesarean delivery.

Below is a sample protocol based on some of these studies with stricter inclusion criteria. We recognize there is likely some significant debate to be had on these criteria, and in particular clinical scenarios, so be sure to discuss with experienced obstetricians in your area as well as check your hospital’s own breech birth protocol.

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(c) CREOGs over Coffee, 2019. Adapted from Hofmeyr/UpToDate, 2019.

Finally, intrapartum management should proceed according to usual obstetric practice. However with breech presentations, providers should closely consider a number of factors outlined below. Notably, these factors are largely based on expert opinion and guidelines from international societies.

• Avoidance of early amniotomy, and preference for spontaneous rupture of membranes.

• The progress of labor in the active phase, and progress of descent during active pushing. 

  • Cesarean delivery should be recommended with a protracted labor course, particularly in the active phase, as this may be indicative of fetopelvic disproportion. 

  • Use of oxytocin in the active phase of labor is discouraged.

  • With the achievement of full cervical dilation, the breech should reach the pelvic floor.

  • Passive descent should not be permitted for more than 90 minutes after achieving full cervical dilation.

  • With onset of active pushing, delivery by cesarean should be considered if the infant has not delivered within 30-60 minutes.