1DDX: LECTURE 32 – FEBRUARY 2nd, 2007

BREAST AND AXILLA

CASE:
36 year old female presents with watery, thin, daily discharge from left breast. It has been going on for 4 months. Stains yellow, and much worse the
week prior to her period. Upper breast and back feel achy during this time.
What is going on? See notes at end of this lecture: look at this before next class.

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• Genetic factors: BRAC1, BRAC2
• Hormonal: women with more ovulation cycles are at higher risk for breast cancer.
• Reproductive:
o Pregnancy: early in life: protective
o Lactation: can have a protective effect.
• Sex (gender): women have 100X rate of breast cancer compared to men.
• Environmental: living near toxins, xenoestrogen.
• Lifestyle: exercise, diet.

Assessment:
Age is the most defining risk factor for breast cancer
Medical procedures and dates: mammograms, ultrasound, fine-needle aspirates
Diet: Alcohol: any amount of alcohol is a risk factor for breast cancer.

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LACTATIONAL MASTITIS
• Baby may not be latching properly
• M/C breast infection, it is on the decline.
• Most common at 5-6 weeks after delivery.
• Simple breast engorgement: milk stasis. Feels hot. 10% turn into systemic symptoms and can turn into abscess.
• Cellulitis may develop from systemic symptoms.
• If a female gets mastitis in first 4 weeks, could be nosocomial infection (obtained while in hospital: could be antibiotic-resistant). Bacteria will
normally not be transmitted to the child.
• Typhoid can also cause a breast abscess (if in Africa, consider this).

NON-LACTATIONAL MASTITIS
• May see with low immune system: patient having had lumpectomy and radiation, diabetes, chronic fatigue…
• Would present more diffusely: more of a reddened area on the breast. Much less common than lactational mastitis.
• May be due to an organism that was already in the body

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CHRONIC SUB-AREOLAR MASTITIS (AKA PERIDUCTAL MASTITIS)
• Occurs in women in their 20s and 30s, common in SMOKERS
• Can be chronic and recurrent, and require surgery, removing segment of breast seems to stop it.
• Typically close to areolar border.
• (patient in slide: had recurrent mastitis on both breasts: had surgery on both breasts. Had inverted congenitally nipples-this may be a risk factor for
breast pathology: not clear.)
• Infection and cancer: a breast infection doesn’t cause cancer, but some cancers can cause necrosis and infection, and some cancers may appear
as an infection.

FURUNCLES (BOILS)
• Boils occur in breast tissue: benign but is frightening for patient.
• Poultice to draw it out.

Sebasceous cycts, inflammation of sweat glands can present on breast.

HIDRADENITIS SUPPURATIVA
• Hidradenitis suppurativa: Appocrine glands become infected: often happens in axilla and groin, but can happen in breast as well.
• Numerous lesions, irregular fashion. Requires surgery.
• (will discuss this condition more in Axilla section.)

Intertrigo: happens in folds of skin. Predisposes patient to candida under breasts.

ECZEMA
• Can get eczema anywhere on the body. How do you know that eczema on vulva, breast is eczema? PATIENT HISTORY and presentation
• Can be red, scaly on nipple. Can mimic Paget’s disease: an atypical type of cancer. Looks like eczema on the nipple. Whenever you see eczema
on nipple, have to rule out Paget’s
• If presentation is bilateral, it is more likely to be eczema. Eczema will be more itchy than Paget’s (although Paget’s is itchy too)
• Cortisone cream will not resolve Paget’s, but will resolve eczema.

DDX LECTURE 32, FEBRUARY 2ND, 2007 – PAGE 1

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TRAUMA
• Most common cause of contusion to the breast: from seat belt
• Contusion: no break in the skin: it is a closed wound. Get changes to subQ tissue: will see bruising.
• Cells break down, release fatty acids to tissue: irritant. Healing by fibrosis, can lead to fat necrosis.

FAT NECROSIS
Irregular, hard mass, can mimic cancer. Can cause retraction or dimpling in the skin.

GYNOMASTIA (HYPERTROPHY)
• Enlargement of breast tissue. More common in boys and men than in women.
• Age 10-16 years, not uncommon: due to testosterone levels. (Estrogen gets formed from testosterone)
• Usually resolves itself in 12 months. Can be unilateral.

Can happen in older men too: this is a different situation, different reason.
• LIVER FAILURE: Can’t conjugate estrogen: can’t be eliminated by body!
• Testicular tumour (can produce estrogen)
• Pituitary tumour can produce prolactin
• Genetic disorders: not enough testosterone, relative dominance of estrogen.
• Treatment for testicular cancer can involve estrogen.

Lots of drugs can contribute to gynecomastia: increase estrogen, prolactin, decrease testosterone.

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LIPOMA
• Round, soft, movable fatty tumour. Common. Often a genetic link.
• Can get them anywhere on the body, don’t rule it out from breast.
• Very slow-growing, well-encapsulated.

GALACTOCELE
• Contains inspissated milk: milk that has thickened: has lost its fluid component.
• Can draw milk out with needle sometimes, or it has to be excised. Can cause duct obstruction. Only occurs in lactating women: can obstruct duct.

DDX OF NIPPLE DISCHARGE

• It is only relevant if it is initially spontaneous. You may subsequently get discharge if nipple is manipulated.
• Discharge from multiple ducts is rarely due to cancer. Discharges are more often due to a benign condition.
• Discharge from single duct: more useful in indicating pathology
• Most bloody discharges are normally benign in cause.

GALACTORRHEA
• It is spontaneous, from both breasts, multiple ducts.
• Milky discharge. Cloudy.
• Have to establish that patient has not been pregnant or breastfeeding in past year (this would increase prolactin levels, but would not be a cause of
galatorrhea. Galactorrhea occurs when prolactin levels or high but NOT due to breastfeeding or pregnancy)

TSH (thyroid stimulating hormone) will increase prolactin levels, could be a cause of galactorrhea.

INTRADUCTAL PAPILLOMA
• Usually in lacteal sinus. M/C cause of bloody discharge.
• Can occur in 30s as well as 40s.
• Can be slow-growing, located just below areolar skin.
• Treatment: removing growth.

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DUCT ECTASIA
• Collection of material that creates inflammation or infection.
• May feel like a cancerous lesion.
• 2 things that can mimic cancerous lesion: fat necrosis, duct ectasia
• Test: ductogram. Dye is injected into ducts. See dilated ducts on test.
• Can end up getting nipple retraction, dimpling of breast tissue. May evolve to abscess, which would require surgery.

DUCTAL CARCINOMA IN SITU (DCIS)

• There are cancerous cells in breast, but it has not invaded the basement membrane.
• Can go on to become invasive ductal carcinoma.
• 1 perspective: they are cancerous cells, they are fine there, don’t need to do anything.
• Can get whitish or cheesy discharge (probably not common)
• Discovered on mammogram, lumpectomy done.
• How do you DDx this from benign microcalcifications that you would see on mammogram? Would require biopsy.
• What do you do if a patient doesn’t want to treat it? Have to decide what you want to do as a practitioner. May get the patient to do other therapies,
but they should sign a release form… Dr. Proctor would recommend treatment.
DDX LECTURE 32, FEBRUARY 2ND, 2007 – PAGE 2
• Dr. Susan Love: doesn’t feel that this is something that needs to be treated. http://www.susanlovemd.com/

INVASIVE CANCER
Only 4% of bloody discharge cases. Bloody discharge isn’t usually cancer.

PAGET’S DISEASE
• Atypical form of breast cancer.
• Slide: Areola and nipple looks moist: there is a discharge that is clear or yellowish. Nipple looks red, eroded. It will be unilateral. Itchy, but not as
itchy as eczema. Will not clear with cortisone. Will destroy nipple if left: erodes the nipple.
• Starts in nipple, makes its way up the ducts.
• Diagnosed with biopsy.
• Distinct from inflammatory breast cancer: doesn’t progress from Paget’s

• Fibrocystic breast disease: should be called fibrocystic changes in the breast tissue. Misunderstanding among clinicians about what breast tissue
should feel like on palpation. Variety of tissue in breast: does not feel homogeneous.
• Recognize that some of the fibroses, thickening, even cysts are normal to some degree (hard to know what is normal, what is pathology, but
important to recognize what is normal for a patient. Self-breast exam.)
• 70%-80% of women were diagnosed in 70s and 80s as having FBD, told it was pre-cancerous.
• Later decided that 80% of these women were just undergoing normal changes. Big change in perspective.
• In SOME cases there is a predisposition to cancer: lots of fibrous tissue, lots of cysts, may take needle biopsy:
o Page 10: see progression from normal duct to atypical cells. Small percentage of women with FBD have atypical cells, and they can
be identified on needle biopsy.
o FBD may cover up another cancer and allow it to progress: dense tissue.

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PHYSIOLOGIC CYCLICAL PAIN AND SWELLING: MASTALGIA
• A problem in some women: have to wear bra to bed. Painful. Some women will have breast reduction surgery: can’t do sports without pain.
• Most of the time related to estrogen: may have liver not conjugating estrogen. Even if the liver is functioning well, if there is GI stasis, the estrogen
may be reabsorbed.
• Estrogen dominance. Look for this if patient presents with breast pain.
• Is diet supporting detoxification?
• Exogenous sources of estrogen: water, food, plastics.
• In case of anovulation, the progesterone isn’t balancing the estrogen effect on the tissue.
• Cyclic and recurring pain in breast is usually not associated with cancer. Can reassure patient that cancer doesn’t present like this.

SELF-BREAST EXAM
A study a few years ago said that breast exam doesn’t affect mortality rates. What are our thoughts?
• Have to decide what we feel about this (find study on Pubmed)

DOMINANT VS. NON-DOMINANT MASS

Dominant: Discrete all the way around the mass. Not cyclic, doesn’t change shape, pain.

Non-dominant: some areas of the borders blend into the rest of the breast tissue: would find this in fibrocystic breast. Tend to be more cyclic in nature in
terms of pain, shape.

DDX list
What tests would you have done?
What do you think is going on?

DDX LECTURE 32, FEBRUARY 2ND, 2007 – PAGE 3