Benign breasts disorders

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  • Copyright 2014 by Mosby, an imprint of Elsevier Inc.

  • Copyright 2014 by Mosby, an imprint of Elsevier Inc. Benign Breast DisordersMastalgiaBreast painMost common breast-related complaintCyclic mastalgia coincides with menstrual cycle and is related to hormonal sensitivityNoncyclic mastalgia can be constant or intermittentMay be due to trauma, fat necrosis, duct ectasia, costochronditis, or arthritic pain

    Copyright 2014 by Mosby, an imprint of Elsevier Inc.

  • Benign Breast DisordersMastitisLactational mastitisInflammatory condition that occurs most frequently in lactating womenLocalized area that is erythematous, painful, and tender to palpationFever is often presentOrganisms obtain access through cracked nippleCan be cured with antibiotics in early stages

    Copyright 2014 by Mosby, an imprint of Elsevier Inc.

  • Benign Breast DisordersLactational breast abscessFrom persistent lactational mastitisPalpable mass with red, edematous skin over involved breast; possibly feverDrainage of abscess is necessaryCultured and treated with appropriately sensitive antibioticsBreastfeeding can usually continue

    Copyright 2014 by Mosby, an imprint of Elsevier Inc.

  • Benign Breast DisordersFibrocystic changesBenign condition with tissue changesDevelopment of excess fibrous tissueHyperplasia of the epithelial lining of the mammary ductsProliferation of mammary ductsCyst formationExaggerated response to hormones

    Copyright 2014 by Mosby, an imprint of Elsevier Inc.

  • Benign Breast DisordersFibrocystic changesNot linked to breast cancer riskOccur most commonly in 35- to 50-year-old womenWomen with premenstrual abnormalities, nulliparity, history of spontaneous abortion, no use of oral contraceptives, with early menarche and late menopausePalpable round, well-delineated, freely movable lumps

    Copyright 2014 by Mosby, an imprint of Elsevier Inc.

  • Copyright 2014 by Mosby, an imprint of Elsevier Inc.

  • Nursing/Collaborative ManagementFibrocystic ChangesExcisional biopsyNo fluid on aspirationFluid is hemorrhagicResidual mass remains after fluid aspirationTreat with good support bra, dietary therapy, vitamin E, analgesics, danazol, diuretics, hormone therapy, antiestrogen

    Copyright 2014 by Mosby, an imprint of Elsevier Inc.

  • Benign Breast DisordersFibroadenomaCommon cause of discrete benign breast lumps in young womenOccurs between 15 and 40 years of ageMost frequent cause of breast masses in women younger than 25May be due to estrogen sensitivity

    Copyright 2014 by Mosby, an imprint of Elsevier Inc.

  • Benign Breast DisordersFibroadenomaEasily detected on physical examination Definitively diagnosed by biopsyTreat with Observation ExcisionCryoablation

    Copyright 2014 by Mosby, an imprint of Elsevier Inc.

  • Nipple DischargeGalactorrheaMilky secretion due to inappropriate lactationMay result fromDrug therapyEndocrine problemsNeurologic disordersIdiopathic causes

    Copyright 2014 by Mosby, an imprint of Elsevier Inc.

  • Nipple DischargeSerous, grossly bloody, or brown to green secretionsMalignant or benign diseaseCytology slide to determine diseaseMalignancies, cystic disease, intraductal papilloma, ductal ectasiaTreatment depends on causeUsually not related to malignancy

    Copyright 2014 by Mosby, an imprint of Elsevier Inc.

  • Intraductal PapillomaBenign, soft, wartlike growthIn mammary ductsUsually unilateralBloody discharge from nippleDifficult to palpateUsually found in 40- to 60-year-old womenMay be associated with risk of cancer

    Copyright 2014 by Mosby, an imprint of Elsevier Inc.

  • Ductal EctasiaDuct dilationBenign breast disease of perimenopausal and postmenopausal womenInvolves ducts in subareolar areaMulticolored, sticky nipple dischargeNot associated with malignancyTreatment: warm compresses and antibiotics

    Copyright 2014 by Mosby, an imprint of Elsevier Inc.

  • Gynecomastia in MenTransient, noninflammatory enlargement of 1 or both breastsMost common breast problem in menUsually a temporary, benign conditionNot a risk factor for breast cancerMay signal hormonal problems or drug effects

    Copyright 2014 by Mosby, an imprint of Elsevier Inc.

  • Copyright 2014 by Mosby, an imprint of Elsevier Inc.

  • Copyright 2014 by Mosby, an imprint of Elsevier Inc.

  • Senescent GynecomastiaOccurs in many older menProbably caused by plasma estrogen elevationTender, firm, centrally located enlargementUsually regresses in 6 to 12 monthsBiopsy can rule out breast cancer

    Copyright 2014 by Mosby, an imprint of Elsevier Inc.

  • Gerontologic ConsiderationsPendulous breastsLoss of subcutaneous fatLoss of structural supportAtrophy of mammary glands Glandular tissue density Incidence of breast cancer

    Copyright 2014 by Mosby, an imprint of Elsevier Inc.

    * Cyclic mastalgia is described as diffuse breast tenderness or heaviness and may last from 2 to 3 days or most of the month; symptoms often decrease with menopause. Noncyclic mastalgia has no relationship to the menstrual cycle and can continue into menopause. Symptoms include a burning sensation, aching, or soreness in the breast. Mammography and targeted ultrasonography are frequently done to rule out cancer and provide information on the etiology of mastalgia. Some relief for cyclic pain may occur with reduction in caffeine and dietary fat; taking vitamins E, A, and B-complex and gamma-linolenic acid (evening primrose oil); and the continual wearing of a support bra. Compresses, ice, analgesics, and antiinflammatory drugs may also help. Drugs may be used, including oral contraceptives and danazol (Danocrine). The androgenic side effects of danazol (acne, edema, hirsutism) may make this therapy unacceptable for many women.

    * The infection develops when organisms (usually staphylococci) obtain access to the breast through a cracked nipple. Breastfeeding should continue unless an abscess is forming or a purulent drainage is noted. The mother may wish to use a nipple shield or to hand-express milk from the involved breast until the pain subsides. The woman should see her health care provider promptly to begin a course of antibiotic therapy. If the breast remains red, tender, and unresponsive to antibiotics, follow-up care and evaluation for inflammatory breast cancer are required.** The most frequently occurring breast disorder Most accurately referred to as fibrocystic condition or complex* Masses or nodularities are often found bilaterally in the upper, outer quadrants. Fibrocystic changes often begin as early as 20 years of age. Pain and nodularity often increase over time but tend to subside after menopause unless high doses of estrogen replacement are used. Symptoms related to fibrocystic changes often worsen in the premenstrual phase and subside after menstruation. Manifestations of fibrocystic breast changes include one or more palpable lumps that are often round, well delineated, and freely movable within the breast (see Table 52-1). Changes produce pain by nerve irritation from edema in connective tissue and by fibrosis from nerve pinching. Discomfort ranging from tenderness to pain may occur. The lump is usually observed to increase in size and perhaps in tenderness before menstruation. Cysts may enlarge or shrink rapidly. Nipple discharge associated with fibrocystic breasts is often milky, watery-milky, yellow, or green. Mammography may be helpful in distinguishing fibrocystic changes from breast cancer. However, in some women the breast tissue is so dense that it is difficult to obtain a mammogram. In these situations, ultrasonography may be more useful in differentiating a cystic mass from a solid mass.

    * With the initial discovery of a discrete mass in the breast by a woman or her health care provider, aspiration or surgical biopsy may be indicated. If the nodularity is recurrent, a wait of 7 to 10 days may be planned in order to note any changes that may be related to the menstrual cycle. With large or frequent cysts, surgical removal may be favored over repeated aspiration. Biopsy for fibrocystic disease may be indicated in women with an increased risk for breast cancer. Atypical hyperplasia discovered on breast biopsy increases a womans risk of developing breast cancer later in life. Encourage the woman with cystic changes to maintain regular follow-up care. Also teach her BSE to self-monitor changes. Severe fibrocystic changes may make palpation of the breast more difficult. Teach her to report any changes in symptoms or changes found during the BSE so they can be evaluated. Treatment for a fibrocystic condition is similar to that described earlier for mastalgia. Teach the woman with fibrocystic breasts that she may expect a recurrence of the cysts in one or both breasts until menopause and that the cysts may enlarge or become painful just before menstruation. Reassure her that the cysts do not turn into cancer. Advise her that any new lump that does not respond in a cyclic manner over 1 to 2 weeks should be examined by her health care provider.*The possible cause of fibroadenoma may be increased estrogen sensitivity in a localized area of the breast. Fibroadenomas are usually small (but can be large [2 to 3 cm]), painless, round, well-delineated, and very mobile. They may be soft but are usually solid, firm, and rubbery in consistency. There is no accompanying retraction or nipple discharge. The lump is often painless. The fibroadenoma may appear as a single unilateral mass, although multiple bilateral fibroadenomas have been reported. Growth is slow and often ceases when the size reaches 2 to 3 cm. Size is not affected by menstruation. Pregnancy can stimulate dramatic growth.

    *Fibroadenomas may be visible on mammograms and ultrasonound images. Definitive diagnosis requires FNA, core needle biopsy, or surgical biopsy and tissue examination by a pathologist to rule out other tumors. Treatment of fibroadenomas can include observation with regular monitoring after a malignancy has been ruled out or with surgical excision. In women older than 35 years, all new lesions should be evaluated with breast ultrasonography and possible biopsy.As an alternative to surgery, tumor removal can be done with cryoablation. A cryoprobe is inserted into the tumor under ultrasound guidance. Extremely cold gas is piped into the tumor. The frozen tumor dies and gradually shrinks.* Nipple discharge may occur spontaneously or as a result of nipple manipulation.

    ** Bloody discharge from the nipple can be intermittent or spontaneous. Most intraductal papillomas are beneath the areola, and they may be difficult to palpate. A single duct or several ducts may be involved. Treatment includes excision of the papilloma and the involved duct or duct system. * Usually several bilateral ducts are involved. Primary symptom is the nipple discharge, which can become bloody in more advanced disease. It is usually painless initially, but discomfort may progress to burning sensation, itching, and pain around the nipple, as well as swelling in the areolar area. Inflammatory signs are often present, and the nipple may retract. Treatment is usually initiated if an abscess develops, with close follow-up examinations or surgical excision of the involved ducts. * The most common cause of gynecomastia is a disturbance of the normal ratio of active androgen to estrogen in plasma or within the breast itself. Gynecomastia may be a manifestation of other problems. It is seen in developmental abnormalities of the male reproductive organs. It may accompany diseases such as testicular tumors, adrenal cancer, pituitary adenomas, hyperthyroidism, and liver disease. Gynecomastia may occur as a side effect of drug therapy, particularly with estrogens and androgens, digitalis, isoniazid (INH), ranitidine (Zantac), and spironolactone (Aldactone). The use of heroin and marijuana can also cause gynecomastia.* Increased conversion of androgens to estrogens in peripheral circulation results in elevation of plasma estrogen levels. The condition is initially unilateral but may become bilateral. When gynecomastia is characterized by a discrete, circumscribed mass, it must be biopsy is necessary to differentiate it from the rarer breast cancer in men. Senescent hyperplasia necessitates no treatment.* A well-fitting bra will provide adequate support, can improve physical appearance, and can reduce pain in the back, shoulders, and neck. It can also prevent intertrigo (dermatitis caused by friction between opposing surfaces of skin). Sagging breasts can be surgically lifted (mastopexy) and in conjunction with breast reconstruction after a mastectomy is performed. The decrease in glandular tissue, probably related to age-related decreases in estrogen, makes a breast mass easier to palpate. Because the incidence of breast cancer increases with age, encourage older women to continue BSE, to have annual mammography and clinical breast examinations, and to have any breast mass evaluated by their health care provider.*