Rosen & Barkin's 5-Minute Emergency Medicine Consult (272 page)

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Authors: Jeffrey J. Schaider,Adam Z. Barkin,Roger M. Barkin,Philip Shayne,Richard E. Wolfe,Stephen R. Hayden,Peter Rosen

Tags: #Medical, #Emergency Medicine

BOOK: Rosen & Barkin's 5-Minute Emergency Medicine Consult
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DESCRIPTION
  • Generalized term for benign breast changes that are poorly defined
  • No longer considered a pathologic disease process as they are found in the majority of healthy women
  • Most common of all benign breast conditions
  • Changes include:
    • Benign cysts
    • Breast pain (mastalgia or mastodynia), which may or may not be cyclic
    • Diffuse and focal nodularity
    • Palpable fibroadenomas
    • Nipple discharge—may be green or brownish, though usually nonbloody
  • Spontaneous, persistent discharge warrants further evaluation
  • Occurs in ∼60% of women
  • Symptoms of pain and tenderness become progressively worse until menopause
  • Pain is often most prominent during the premenstrual phase and improves with the onset of menses
    • Breast pain alone is a rare symptom of cancer and accounts for only 0.2–2% of cases
  • Synonyms: Adenosis, benign breast disease, cystic mastitis, cystic disease of the breast, fibroadenosis, fibrocystic disease, mammary dysplasia.
ETIOLOGY
  • Mechanism of development not well understood
  • Likely an enhanced or exaggerated reaction of breast tissue to cyclic levels of female reproductive hormones:
    • May be caused by imbalance of the estrogen to progesterone ratio
    • May occur secondary to increased daily prolactin production
  • Most common in women 30–50 yr old
  • Pain is most likely caused by rapid expansion of simple cysts
  • Symptoms may continue into menopause secondary to hormone replacement therapy
  • Incidence is decreased in women taking oral contraceptives
  • Risk factors include:
    • Family history of fibrocystic changes
    • Oral contraceptives
    • Hormone replacement therapy
    • Increasing age
    • Diet (high fat intake; caffeine/methylxanthines)
DIAGNOSIS
SIGNS AND SYMPTOMS
History
  • Mastalgia and tenderness:
    • Persistent or intermittent
    • Often occurs during premenstrual phase of normal menstrual cycle
    • Usually bilateral
    • Pain may radiate to shoulders and upper arms
  • Lumpiness, nodularity:
    • May be localized or generalized
  • Increased engorgement and breast density:
    • Breasts described as being dull and heavy
    • Caused by fluctuations in the size of the cystic areas
  • Spontaneous or expressible nipple discharge
  • Abnormal nipple sensations, including pruritis
  • Family history of cysts is common
Physical-Exam
  • Palpate the 4 breast quadrants while patient is sitting and then while lying down
  • Note any changes from normal, including overlying erythema and warmth that may suggest an alternative diagnosis
  • Examine for regional nodes (axillary, clavicular, etc.)
  • Fibrocystic changes feel doughy with vague nodularity
  • Nodules are typically discrete and mobile
  • Usually more marked in the superior and lateral quadrants
  • Small groups of cysts often described as palpating a “plate full of peas”
  • Large cysts have consistency of a balloon filled with water
  • Breast exam is most sensitive 7–9 days after 1st day of menses when the breasts are least congested
DIAGNOSIS TESTS & NTERPRETATION
Lab
  • A detailed lab evaluation is usually not necessary in the emergency department
  • Prolactin and thyroid-stimulating hormone may be helpful if galactorrhea is present
Imaging
  • Ultrasound if <30 yr old
  • Mammography if >30 yr old
  • Ultrasound:
    • Can differentiate cystic from solid masses
    • Benign cysts:
      • Typically demonstrate a uniform outer margin without asymmetry or irregular thickness of the cyst wall
      • Have no central echoes
      • Posterior wall enhancement is normal
    • Can assist in aspiration of deep and nonpalpable cysts
    • Also used to conservatively follow cyst size
    • Performed at a specialized breast center with trained techs and interpreting radiologists
  • Mammography:
    • Benign changes may falsely appear malignant
    • Difficult to interpret in women <30 yr old due to breast tissue density
    • Should be performed either before aspiration or 7–10 days afterward to avoid artifact
Diagnostic Procedures/Surgery
  • Fine needle aspiration:
    • Usually performed by a specialist
    • May be performed therapeutically for symptomatic or large masses
    • Allows differentiation between cystic and solid masses
    • Obtain cytology studies to evaluate for malignancy
  • Excisional biopsy:
    • Performed by surgeon
    • Indicated for solid lumps that are not proven benign
DIFFERENTIAL DIAGNOSIS
  • Benign breast masses:
    • Breast abscess
    • Duct ectasia
    • Mastitis
    • Simple fibroadenomas
    • Solitary papillomas
  • Malignant breast masses:
    • Atypical hyperplasia
    • Complex fibroadenomas
    • Diffuse papillomatosis
    • Ductal hyperplasia without atypia
    • Sclerosing adenosis
TREATMENT
ED TREATMENT/PROCEDURES
  • Majority of women will not require any medical treatment
  • Conservative therapy:
    • Support bra:
      • Reduces tension on supporting ligaments of the breast
      • May reduce inflammatory response and edema
    • Low dose diuretic for 2–3 days before onset of menses
    • NSAIDs
  • Dietary changes are somewhat controversial:
    • Restricting dietary fat (to 25% of total calories) and eliminating caffeine
    • Increasing vitamin E and vitamin B
      6
    • Herbal preparations such as primrose oil
  • Hormonal therapy:
    • Should be initiated by PCP to enable follow-up during course of treatment
    • Oral contraceptives:
      • May decrease symptoms, particularly after 1 yr of use
    • Danazol (synthetic androgen) and Tamoxifen (partial estrogen antagonist):
      • Shown to be equally effective for treatment of severe cyclical mastalgia
      • Use may be limited by side effects (acne, hirsutism, weight gain, teratogenicity)
    • Bromocriptine (inhibits prolactin production):
      • Use also limited by side effects (headache, dizziness, nausea, constipation, weakness)
  • Surgical intervention:
    • If a persistent nodule exists, excision is recommended regardless of findings on diagnostic imaging
    • If a large cyst recurs after aspiration on 2 occasions, it should be excised and sent for pathology
MEDICATION
  • Bromocriptine: 2.5–5 mg/d BID
  • Danazol: 100–400 mg/d BID for 6 mo
  • Tamoxifen: 10–20 mg/d
  • Oral contraceptive pills (vary)
FOLLOW-UP
DISPOSITION
Discharge Criteria
  • Patients with fibrocystic changes are appropriate for discharge with outpatient follow-up
  • Encourage patient to keep a breast pain record to determine whether pain is cyclic
  • The importance of follow-up should be stressed to ensure patient health, disease prevention, and patient satisfaction
  • Encourage regular breast self-exam, annual physical exams, and annual mammograms when appropriate
Issues for Referral
  • Practically speaking, all breast masses evaluated in the ED need referral to a primary provider or specialized breast clinic
  • Further investigation with imaging and possible biopsy are required for masses that persist throughout menses and are not cyclical
  • Referral to a general surgeon may be required in certain cases where tissue biopsy is necessary
PEARLS AND PITFALLS
  • Breast cancer may coexist with benign breast disease and fibrocystic changes:
    • Consider all cancer risk factors
    • Confirm follow-up plan
  • Mastitis in a nonlactating patient should be treated as inflammatory carcinoma until proven otherwise
  • Fibrocystic changes are usually bilateral; unilateral changes are suspicious for cancer
  • Fear of breast cancer is high in all patients:
    • Give reassurance that fibrocystic breast changes are not cancerous
    • Have a low threshold for referral to a specialist
ADDITIONAL READING
  • Grube BJ, Giuliano AE. Benign breast disease. In: Berek JS, ed.
    Berek & Novak’s Gynecology
    . 14th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:652–654.
  • Institute for Clinical Systems Improvement (ICSI).
    Diagnosis of Breast Disease
    . Bloomington, MN: Institute for Clinical Systems Improvement; 2005.
  • Katz VL, Dotter D. Breast diseases: Diagnosis and treatment of benign and malignant disease. In: Lentz GM, Lobo RA, Gershenson DM, et al., eds.
    Comprehensive Gynecology.
    6th ed. Philadelphia, PA: Elsevier; 2012:304–306.
  • Marchant DJ. Benign breastdisease.
    Obstet Gynecol Clin North Am.
    2002;29:1–20.
  • Parikh JR. ACR appropriateness criteria on palpable breast masses.
    J Am Coll Radiol.
    2007;4:285–288.
  • Parikh JR, EvansWP, Bassett L, et al.Expert Panel on Women’s Imaging—Breast. Palpable Breast Masses. Reston, VA: American College of Radiology (ACR);2006.
  • Rastelli A. Breast pain, fibrocystic changes, and breast cysts.
    Probl Gen Surg.
    2003;20:17–26.
  • Santen RJ, Mansel R. Benign breast disorders.
    N Engl J Med.
    2005;353:275–285.

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