Galactogram = Ductogram
Usually done for spontaneous unilateral bloody nipple discharge. Sometimes it is done for serous (clear) discharge.
90% of the women with unilateral bloody nipple discharge = benign intraductal papilloma, a solitary discrete intraductal mass. However if multiple masses are discovered in the duct, the more likely the diagnosis will be ductal carcinoma in situ (DCIS).
Regardless of single mass or multiple mass, a surgical biopsy (excisional biopsy) is required for diagnosis. Methylene blue dye can assist the surgeon in removing the duct in the OR.
Fibrocystic breasts are made of tissue that feels bumpy and nodular in texture. It is a relatively common process. More than 50% of women experience fibrocystic breast changes during their lives. It used to be called Fibrocystic Breast Disease. Now it’s more common to call it Fibrocystic Breast Changes – which are considered normal changes. Symptoms may be pain and lumpiness and can be worse just before menstruation.
Treatment includes limiting caffeine, decreasing fat in the diet, and consider evening primrose oil which is a form of linoleic acid.
Gynecomastia of the male breast
- Gynecomastia is the benign hypertrophy of the male breast
- asymptomatic or painful
- unilateral or bilateral
- just below the areolar region
- transiently during neonatal period due to motherly estrogrens
Causes of Gynecomastia
- Illicit drug use, especially marijuana
- Renal, Liver disease
Gynecomastia’s association with cancer
- Testicular cancer
- BRCA2 genetic multation may lead to male breast cancer
Diagnostics for Gynecomastia
For the older patient with no obvious etiology consider:
- Thyroid hormone
- Prolactin level
- FSAH, LH, DHEA
- Bilateral mammorgram
- FNA (fine needle aspiration) can be diagnostic or core needle biopsy, usually not a need for excisional biopsy. Thus an excisional biopsy wouldn’t be a first line diagnostic tool in gynecomastia.
Paget’s Disease of the Breast
- Diagnosis can be confirmed with a punch biopsy the nipple areolar complex.
- Classically present with eczematous changes of the nipple which can progress to bleeding and ulceration.
- More than 90% of patients have underlying carcinoma (in situ or invasive)
- Cancer involving skin and nipple.
- Treatment: mastectomy traditionally. But could be nipple areolar excision with central lumpectomy with radiation therapy (breast conservation therapy) – similar results.
- 50% of patients with Paget’s disease will present with palpable mass.
- May be a role for MRI – deeper breast tissue disease may be missed radiographically and MRI can help detect.
What is breast conservation therapy?
A lesser amount of surgery than mastectomy. Lumpectomy
Paget’s diease of the breast is also known as?
- Paget’s disease of the nipple
- Mammary paget disease
Breast Masses in Children and Adolescence
Classification of the breast masses in children/adolescence
The process in parethesis below represents an example.
- Physiological (Gynecomastia)
- Inflammatory (Abscess)
- Benign neoplastic (Fibroadenoma, Cystosarcoma phyllodes)
- Primary malignant (Cystosarcoma phyllodes)
- Secondary malignant (Lymphoma)
Neonatal breast nodules
Usually due to stimulation by maternal hormones
- Fibroadenomas and cystosarcoma phyllodes are the most common lesions of the breast in childhood.
- Cystosarcoma phyllodes present as either benign or malignant but 95% in children are benign.
Best test for initial assessment in pediatric patients with breast mass?
Then what modality for diagnosis of the breast mass?
Fine needle aspiration. FNA is preferred over core needle biopsy because of the possibility of deformity of the breast in the future with core needle biopsy.
What about excision biopsy in the pediatric breast?
Excisional biopsy should be avoided as an initial diagnostic procedure because the developing breast bud can be mistakenly removed, leading to deformity.