Gynecomastia-Like Hyperplasia of Female Breast
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Common Breast Problems Guideline Team Team Leader Patient Population: Adults Age 18 and Older (Non-Pregnant)
Guidelines for Clinical Care Quality Department Ambulatory Breast Care Common Breast Problems Guideline Team Team leader Patient population: Adults age 18 and older (non-pregnant). Monica M Dimagno, MD Objectives: Identify appropriate evaluation and management strategies for common breast problems. General Medicine Identify appropriate indications for referral to a breast specialist. Team members Assumptions R Van Harrison, PhD Appropriate mammographic screening per NCCN, ACS, USPSTF and UMHS screening guidelines. Medical Education Generally mammogram is not indicated for women age <30 because of low sensitivity and specificity. Lisa A Newman, MD, MPH “Diagnostic breast imaging” refers to diagnostic mammogram and/or ultrasound. At most ages the Surgical Oncology combination of both imaging techniques yields the most accurate results and is recommended based on Ebony C Parker- patient age and the radiologist’s judgment. Featherstone, MD Key Aspects and Recommendations Family Medicine Palpable Mass or Asymmetric Thickening/Nodularity on Physical Exam (Figure 1) Mark D Pearlman, MD Obstetrics & Gynecology Discrete masses elevate the index of suspicion. Physical exam cannot reliably rule out malignancy. • Mark A Helvie, MD Breast imaging is the next diagnostic approach to aid in diagnosis [I C*]. Radiology/Breast Imaging • Initial imaging evaluation: if age ≥ 30 years then mammogram followed by breast ultrasound; if age < 30 years then breast ultrasound [I C*]. Follow-up depends on results (see Figure 1). Asymmetrical thickening / nodularity has a lower index of suspicion, but should be assessed with breast Initial Release imaging based on age as for patients with a discrete mass. If imaging is: November, 1996 • Suspicious or highly suggestive (BIRADS category 4 or 5) or if the area is assessed on clinical exam as Most Recent Major Update suspicious, then biopsy after imaging [I C*]. -
Approach to Breast Mass
APPROACH TO BREAST MASS Resident Author: Kathleen Doukas, MD, CCFP Faculty Advisor: Thea Weisdorf, MD, CCFP Creation Date: January 2010, Last updated: August 2013 Overview In primary care, breast lumps are a common complaint among women. In one study, 16% of women age 40-69y presented to their physician with a breast lesion over a 10-year period.1 Approximately 90% of these lesions will be benign, with fibroadenomas and cysts being the most common.2 Breast cancer must be ruled out, as one in ten woman who present with a new lump will have cancer.1 Diagnostic Considerations6 Benign: • Fibroadenoma: most common breast mass; a smooth, round, rubbery mobile mass, which is often found in young women; identifiable on US and mammogram • Breast cyst: mobile, often tender masses, which can fluctuate with the menstrual cycle; most common in premenopausal women; presence in a postmenopausal woman should raise suspicion for malignancy; ultrasound is the best method for differentiating between a cystic vs solid structure; a complex cyst is one with septations or solid components, and requires biopsy • Less common causes: Fat necrosis, intraductal papilloma, phyllodes tumor, breast abscess Premalignant: • Atypical Ductal Hyperplasia, Atypical Lobular Hyperplasia: Premalignant breast lesions with 4-6 times relative risk of developing subsequent breast cancer;8 often found incidentally on biopsy and require full excision • Carcinoma in Situ: o Ductal Carcinoma in Situ (DCIS): ~85% of in-situ breast cancers; defined as cancer confined to the duct that -
CASODEX (Bicalutamide)
HIGHLIGHTS OF PRESCRIBING INFORMATION • Gynecomastia and breast pain have been reported during treatment with These highlights do not include all the information needed to use CASODEX 150 mg when used as a single agent. (5.3) CASODEX® safely and effectively. See full prescribing information for • CASODEX is used in combination with an LHRH agonist. LHRH CASODEX. agonists have been shown to cause a reduction in glucose tolerance in CASODEX® (bicalutamide) tablet, for oral use males. Consideration should be given to monitoring blood glucose in Initial U.S. Approval: 1995 patients receiving CASODEX in combination with LHRH agonists. (5.4) -------------------------- RECENT MAJOR CHANGES -------------------------- • Monitoring Prostate Specific Antigen (PSA) is recommended. Evaluate Warnings and Precautions (5.2) 10/2017 for clinical progression if PSA increases. (5.5) --------------------------- INDICATIONS AND USAGE -------------------------- ------------------------------ ADVERSE REACTIONS ----------------------------- • CASODEX 50 mg is an androgen receptor inhibitor indicated for use in Adverse reactions that occurred in more than 10% of patients receiving combination therapy with a luteinizing hormone-releasing hormone CASODEX plus an LHRH-A were: hot flashes, pain (including general, back, (LHRH) analog for the treatment of Stage D2 metastatic carcinoma of pelvic and abdominal), asthenia, constipation, infection, nausea, peripheral the prostate. (1) edema, dyspnea, diarrhea, hematuria, nocturia, and anemia. (6.1) • CASODEX 150 mg daily is not approved for use alone or with other treatments. (1) To report SUSPECTED ADVERSE REACTIONS, contact AstraZeneca Pharmaceuticals LP at 1-800-236-9933 or FDA at 1-800-FDA-1088 or ---------------------- DOSAGE AND ADMINISTRATION ---------------------- www.fda.gov/medwatch The recommended dose for CASODEX therapy in combination with an LHRH analog is one 50 mg tablet once daily (morning or evening). -
Breast Concerns
Section 12.0: Preventive Health Services for Women Clinical Protocol Manual 12.2 BREAST CONCERNS TITLE DESCRIPTION DEFINITION: Breast concerns in women of all ages are often the source of significant fear and anxiety. These concerns can take the form of palpable masses or changes in breast contours, skin or nipple changes, congenital malformation, nipple discharge, or breast pain (cyclical and non-cyclical). 1. Palpable breast masses may represent cysts, fibroadenomas or cancer. a. Cysts are fluid-filled masses that can be found in women of all ages, and frequently develop due to hormonal fluctuation. They often change in relation to the menstrual cycle. b. Fibroadenomas are benign sold tumors that are caused by abnormal growth of the fibrous and ductal tissue of the breast. More common in adolescence or early twenties but can occur at any age. A fibroadenoma may grow progressively, remain the same, or regress. c. Masses that are due to cancer are generally distinct solid masses. They may also be merely thickened areas of the breast or exaggerated lumpiness or nodularity. It is impossible to diagnose the etiology of a breast mass based on physical exam alone. Failure to diagnose breast cancer in a timely manner is the most common reason for malpractice litigation in the U.S. Skin or nipple changes may be visible signs of an underlying breast cancer. These are danger signs and require MD referral. 2. Non-spontaneous or physiological discharge is fluid that may be expressed from the breast and is not unusual in healthy women. 3. Galactorrhea is a spontaneous, multiple duct, milky discharge most commonly found in non-lactating women during childbearing years. -
Common Breast Problems BROOKE SALZMAN, MD; STEPHENIE FLEEGLE, MD; and AMBER S
Common Breast Problems BROOKE SALZMAN, MD; STEPHENIE FLEEGLE, MD; and AMBER S. TULLY, MD Thomas Jefferson University Hospital, Philadelphia, Pennsylvania A palpable mass, mastalgia, and nipple discharge are common breast symptoms for which patients seek medical atten- tion. Patients should be evaluated initially with a detailed clinical history and physical examination. Most women pre- senting with a breast mass will require imaging and further workup to exclude cancer. Diagnostic mammography is usually the imaging study of choice, but ultrasonography is more sensitive in women younger than 30 years. Any sus- picious mass that is detected on physical examination, mammography, or ultrasonography should be biopsied. Biopsy options include fine-needle aspiration, core needle biopsy, and excisional biopsy. Mastalgia is usually not an indica- tion of underlying malignancy. Oral contraceptives, hormone therapy, psychotropic drugs, and some cardiovascular agents have been associated with mastalgia. Focal breast pain should be evaluated with diagnostic imaging. Targeted ultrasonography can be used alone to evaluate focal breast pain in women younger than 30 years, and as an adjunct to mammography in women 30 years and older. Treatment options include acetaminophen and nonsteroidal anti- inflammatory drugs. The first step in the diagnostic workup for patients with nipple discharge is classification of the discharge as pathologic or physiologic. Nipple discharge is classified as pathologic if it is spontaneous, bloody, unilat- eral, or associated with a breast mass. Patients with pathologic discharge should be referred to a surgeon. Galactorrhea is the most common cause of physiologic discharge not associated with pregnancy or lactation. Prolactin and thyroid- stimulating hormone levels should be checked in patients with galactorrhea. -
Evaluation of Nipple Discharge
New 2016 American College of Radiology ACR Appropriateness Criteria® Evaluation of Nipple Discharge Variant 1: Physiologic nipple discharge. Female of any age. Initial imaging examination. Radiologic Procedure Rating Comments RRL* Mammography diagnostic 1 See references [2,4-7]. ☢☢ Digital breast tomosynthesis diagnostic 1 See references [2,4-7]. ☢☢ US breast 1 See references [2,4-7]. O MRI breast without and with IV contrast 1 See references [2,4-7]. O MRI breast without IV contrast 1 See references [2,4-7]. O FDG-PEM 1 See references [2,4-7]. ☢☢☢☢ Sestamibi MBI 1 See references [2,4-7]. ☢☢☢ Ductography 1 See references [2,4-7]. ☢☢ Image-guided core biopsy breast 1 See references [2,4-7]. Varies Image-guided fine needle aspiration breast 1 Varies *Relative Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate Radiation Level Variant 2: Pathologic nipple discharge. Male or female 40 years of age or older. Initial imaging examination. Radiologic Procedure Rating Comments RRL* See references [3,6,8,10,13,14,16,25- Mammography diagnostic 9 29,32,34,42-44,71-73]. ☢☢ See references [3,6,8,10,13,14,16,25- Digital breast tomosynthesis diagnostic 9 29,32,34,42-44,71-73]. ☢☢ US is usually complementary to mammography. It can be an alternative to mammography if the patient had a recent US breast 9 mammogram or is pregnant. See O references [3,5,10,12,13,16,25,30,31,45- 49]. MRI breast without and with IV contrast 1 See references [3,8,23,24,35,46,51-55]. -
Clinical Management of BCCCP Women with Abnormal Breast
Follow-up of Abnormal Breast Findings E.J. Siegl RN, OCN, MA, CBCN BCCCP Nurse Consultant January 2012 Abnormal Breast Findings include the following: CBE results of: Nipple discharge, no palpable mass Asymmetric thickening/nodularity Skin Changes (Peau d’ orange, Erythema, Nipple Excoriation, Scaling/Eczema) Dominant Mass ? Unilateral Breast Pain Mammogram results of ACR 0 – Assessment Incomplete ACR 4 – Suspicious Abnormality, ACR 5 – Highly Suggestive of Malignancy Abnormal CBE Results Nipple Discharge Third most common breast complaint by women seeking medical attention after lumps and breast pain During breast self exam, fluid may be expressed from the breasts of 50% to 60% of Caucasian and African-American women and 40% of Asian-American women Nipple Discharge cont. Palpation of the nipple in a woman who does not have a history of persistent spontaneous nipple discharge - not recommended Rationale: Non-spontaneous nipple discharge is a normal physiological phenomenon and of no clinical consequence Infections (E.g. abscess) should be treated with incision and drainage or repeated aspiration if needed (consider antibiotics) Nipple Discharge is of Concern if it is: Blood stained, serosanguinous, serous (watery) with a red, pink, or brown color, or clear 90% of bloody discharges are intraductal papillomas; 10% are breast cancers) appears spontaneously without squeezing the nipple persistent on one side only (unilateral) a fluid other than breast milk Nipple Discharge cont. Non-lactating women who present with a unilateral, -
Pseudoangiomatous Stromal Hyperplasia of the Breast: a Rare Finding in a Male Patient
Open Access Case Report DOI: 10.7759/cureus.4923 Pseudoangiomatous Stromal Hyperplasia of the Breast: A Rare Finding in a Male Patient Lynsey M. Maciolek 1 , Taylor S. Harmon 2 , Jing He 3 , Sarfaraz Sadruddin 1 , Quan D. Nguyen 1 1. Radiology, University of Texas Medical Branch, Galveston, USA 2. Radiology, University of Florida College of Medicine, Jacksonville, USA 3. Pathology, University of Texas Medical Branch, Galveston, USA Corresponding author: Quan D. Nguyen, [email protected] Abstract Pseudoangiomatous stromal hyperplasia (PASH) in male patients is a rare condition that represents a hormonally-induced proliferation of mesenchymal tissue of the breast. This benign pathology is often undiagnosed due to many reasons. When PASH presents as a breast mass, it appears innocent, developing as a smooth and well-circumscribed tumor. Furthermore, it does not elicit suspicious findings on imaging. These points often halt further investigation of many breast abnormalities. Breast masses are statistically most likely to be gynecomastia when they arise in men. However, they are important to investigate because, although rare, breast cancer can occur in men. Furthermore, the benign conditions of the breast that commonly affect women can also impact male patients. It is oftentimes overlooked that men too can experience hormonal stimulation of the breast tissue. The following case describes this rare but important instance of a male patient diagnosed with PASH following a previous diagnosis of infiltrative ductal carcinoma in situ of the contralateral breast. Categories: Pathology, Radiology, Oncology Keywords: breast masses, interanastomosing, mammogram, breast angiosarcoma, breast radiology, pseudoangiomatous stromal hyperplasia, male breast cancer, invasive ductal carcinoma, gynecomastia, benign hypoechoic masses Introduction Approaching breast masses in male patients is often deemed unchartered territory, without a well-defined clinical algorithm. -
Severe Gynaecomastia Associated with Spironolactone Treatment in A
Journal of Pre-Clinical and Clinical Research, 2015, Vol 9, No 1, 92-95 www.jpccr.eu CASE REPORT Severe gynaecomastia associated with spironolactone treatment in a patient with decompensated alcoholic liver cirrhosis – Case report Katarzyna Schab1, Andrzej Prystupa2, Dominika Mulawka3, Paulina Mulawka3 1 1st Military Teaching Hospital and Polyclinic, Lublin, Poland 2 Department of Internal Medicine, Medical University, Lublin, Poland 3 Cardinal Stefan Wyszyński District Specialist Hospital, Lublin, Poland Schab K, Prystupa A, Mulawka D, Mulawka P. Severe gynaecomastia associated with spironolactone treatment in a patient with decompensated alcoholic liver cirrhosis – Case report. J Pre-Clin Clin Res. 2015; 9(1): 92–95. doi: 10.5604/18982395.1157586 Abstract Gynaecomastia is uni- or bilateral breast enlargement in males associated with benign hyperplasia of the glandular, fibrous and adipose tissue resulting from oestrogen-androgen imbalance. Asymptomatic gynaecomastia is a common finding in healthy male adults and does not have to be treated, while symptomatic gynaecomastia might be the symptoma of many pathological conditions and requires meticulous diagnosis and therapeutic management. The commonest causes of gynaecomastia in the Polish population include liver cirrhosis and drugs used to treat its complications. The current study presents the case of severe painless gynaecomastia in a patient with decompensated alcoholic liver cirrhosis, treated with spironolactone because of ascites. Breast enlargement assessed a IIb according to the Simon’s Scale or III according to the Cordova-Moschella classification, developed slowly over the two-year period of low-dose spironolactone therapy The course and dynamics of disease are described and the main mechanisms leading to its development discussed. -
Management of Common Breast-Feeding Problems Joy Melnikow, Ml), MPH, and Joan M
Clinical Review Management of Common Breast-feeding Problems Joy Melnikow, Ml), MPH, and Joan M. Bedinghaus, MD Sacramento, California, and Cleveland, Ohio The benefits of breast-feeding have been well docu Poor weight gain in the infant is managed by more mented in the literature: it reduces morbidity from frequent nursing. Neonatal jaundice or infant gastro many illnesses and is considered the ideal nutrition for enteritis rarely requires discontinuation of breast-feed the newborn infant. This paper reviews common breast ing. feeding problems that family physicians may be called Although physicians frequently recommend that upon to manage: maternal problems, infant problems, women discontinue breast-feeding because of the ad and problems related to the need for maternal medica ministration of some maternal medications, maternal ill tion. ness can often be managed with medications that do not Ensuring proper position of the infant at the breast interfere with nursing. and attention to the let-down reflex is the recom Given proper advice and support, many mothers con mended method for prevention and treatment of nipple tinue to breast-feed even after returning to work. soreness. Prompt identification and treatment of blocked ducts, mastitis, and mondial infection of the Key words. Breast-feeding; hyperbilirubinemia; mastitis; nipple can prevent complications and allow uninter abscess, review literature. rupted nursing. ( / Fam Pract 1994; 39:56-64) Breast-feeding, which is recognized as the ideal nutrition offer little guidance -
Gynecomastia — a Difficult Diagnostic Problem Ginekomastia — Trudny Problem Diagnostyczny
SZKOLENIE PODYPLOMOWE/POSTGRADUATE EDUCATION Endokrynologia Polska/Polish Journal of Endocrinology Tom/Volume 62; Numer/Number 2/2011 ISSN 0423–104X Gynecomastia — a difficult diagnostic problem Ginekomastia — trudny problem diagnostyczny Marek Derkacz1, Iwona Chmiel-Perzyńska2, Andrzej Nowakowski1 1Department of Endocrinology, Medical University, Lublin, Poland 2Department of Family Medicine, Medical University, Lublin, Poland Abstract Gynecomastia is a benign, abnormal, growth of the male breast gland which can occur unilaterally or bilaterally, resulting from a prolife- ration of glandular, fibrous and adipose tissue. Gynecomastia is characterised by the presence of soft, 2–4 cm in diameter, usually discus- shaped enlargement of tissues under the nipple. It is estimated that this pathology occurs in 32–65% of men over the age of 17. Gynecoma- stia is a psychosocial problem and may lead to a perceived lowering of quality of life. The main cause of gynecomastia is a loss of equilibrium between oestrogens and androgens. Increased sensitivity for oestrogens of the breast gland, or local factors (e.g. an excessive synthesis of oestrogens in breast tissues or changes in oestrogen and androgen receptors) may cause gynecomastia. Also, prolactin, thyroxine, cortisol, human chorionic gonadotropin, leptin and receptors for human chorionic gonadotropin, prolactin and luteinizing hormone localised in tissues of the male breast may participate in the etiopathogenesis of gyneco- mastia. Usually three types of gynecomastia are distinguished: physiological, idiopathic and pathological gynecomastia. The latter is the consequ- ence of relative or absolute excess of oestrogens. In this paper, frequent as well as casuistic causes of gynecomastia will be described. A diagnosis of gynecomastia is usually possible after a palpation examination. -
Evaluation of the Symptomatic Male Breast
Revised 2018 American College of Radiology ACR Appropriateness Criteria® Evaluation of the Symptomatic Male Breast Variant 1: Male patient of any age with symptoms of gynecomastia and physical examination consistent with gynecomastia or pseudogynecomastia. Initial imaging. Procedure Appropriateness Category Relative Radiation Level Mammography diagnostic Usually Not Appropriate ☢☢ Digital breast tomosynthesis diagnostic Usually Not Appropriate ☢☢ US breast Usually Not Appropriate O MRI breast without and with IV contrast Usually Not Appropriate O MRI breast without IV contrast Usually Not Appropriate O Variant 2: Male younger than 25 years of age with indeterminate palpable breast mass. Initial imaging. Procedure Appropriateness Category Relative Radiation Level US breast Usually Appropriate O Mammography diagnostic May Be Appropriate ☢☢ Digital breast tomosynthesis diagnostic May Be Appropriate ☢☢ MRI breast without and with IV contrast Usually Not Appropriate O MRI breast without IV contrast Usually Not Appropriate O Variant 3: Male 25 years of age or older with indeterminate palpable breast mass. Initial imaging. Procedure Appropriateness Category Relative Radiation Level Mammography diagnostic Usually Appropriate ☢☢ Digital breast tomosynthesis diagnostic Usually Appropriate ☢☢ US breast May Be Appropriate O MRI breast without and with IV contrast Usually Not Appropriate O MRI breast without IV contrast Usually Not Appropriate O Variant 4: Male 25 years of age or older with indeterminate palpable breast mass. Mammography or digital breast tomosynthesis indeterminate or suspicious. Procedure Appropriateness Category Relative Radiation Level US breast Usually Appropriate O MRI breast without and with IV contrast Usually Not Appropriate O MRI breast without IV contrast Usually Not Appropriate O ACR Appropriateness Criteria® 1 Evaluation of the Symptomatic Male Breast Variant 5: Male of any age with physical examination suspicious for breast cancer (suspicious palpable breast mass, axillary adenopathy, nipple discharge, or nipple retraction).