such as dicloxacillin. Alternative antibiotics include cephalexin and erythromycin. The mastitis should

improve within 24 to 48 hours after initiation of antibiotics. If symptoms or fever persists, an abscess

should be ruled out. For small or superficial abscesses, needle aspiration may be attempted. However,

incision and drainage should be considered for large or complex abscesses, understanding the risks

associated with milk fistula formation.

Nonlactating breast infections can present as periareolar abscesses or less commonly as peripheral

abscesses. For small abscesses (less than 3 cm), needle aspiration and/or drain placement can be

performed. However, for larger and/or deeper abscesses, incision and drainage may be indicated. This

is commonly performed in the operating room under general anesthesia, although if the abscess is

superficial or small, it may be possible to perform the incision and drainage at the bedside with

infiltration of a local anesthetic. A preoperative ultrasound can be obtained to better evaluate the size

and location of the abscess. The patient is placed in supine position and the surgical site is prepped and

draped in the usual sterile fashion. Palpation of the abscess is performed, then using a no. 11 blade

scalpel, a skin incision is made directly over the abscess. Often, the abscess is not located directly under

the area of greatest erythema, and careful breast examination should be performed to localize the area

of greatest fluctuance. Using a Kelly or Burlisher clamp, loculations are broken up in the cavity to fully

drain the abscess. Biopsy of the cavity should always be considered, as breast infection may be an unusual

breast cancer presentation. The abscess cavity is then copiously irrigated. For a subareolar abscess,

removal of the sinus tract as well as the segmental duct should be considered. If the abscess is small, no

packing is necessary. However for larger abscesses, we advocate loosely packing the wound with wet to

dry gauze, which should be changed daily. Alternatively, an advanced wound care dressing can be used.

The amount of the packing should be decreased daily and usually after 1 week, no further packing is

needed. Alternatively, the incision can be loosely approximated with interrupted 4-0 nylon sutures

leaving a 1.5-cm opening for a Penrose drain to be placed. The drain and the sutures should be removed

within 4 to 7 days. Antibiotic, such as cephalexin 500 mg QID, is commonly prescribed for 7 to 10 days

postoperatively, although once a wound is properly drained and cellulitis subsides, the patient can

discontinue all antibiotics. For chronic subareolar abscesses, it may be necessary to completely excise

the involved duct. During an acute exacerbation, patients are first treated with antibiotics and during

the resolution phase, surgical excision is performed. Intraoperatively, the infected duct or fistula is

identified using a lacrimal duct probe. A radial elliptical incision is then made incorporating the entire

duct from the nipple to the subareolar breast tissue. Excision is then performed with care to fully dissect

the subareolar duct system from the underlying breast tissue. Interrupted suture of 4-0 plain gut is then

used to reapproximate the nipple from its apex to its base. The deep dermal layer of the skin is then

reapproximated with 3-0 Vicryl sutures and the skin closed in a subcuticular fashion with 4-0 monocryl.

The patient should be continued on antibiotics for an additional 2 weeks.

In the setting of recurrent or persistent abscess formation or inflammatory changes despite adequate

surgical management, other etiologies need to be considered including idiopathic granulomatous

mastitis, Wegener’s granuloma, sarcoidosis, tuberculosis, and histoplasmosis.

BENIGN BREAST DISEASE

Benign breast lesions can be classified into three groups: (1) nonproliferative breast lesions, (2)

proliferative breast lesions without atypia, and (3) proliferative breast lesions with atypia (Table 74-4).

Nonproliferative Breast Lesions

Nonproliferative breast lesions include breast cysts, papillary apocrine change, epithelial-related

calcifications, and mild hyperplasia of the usual type. These lesions are not associated with an increased

risk of breast cancer.62 Papillary apocrine change is characterized by proliferation of ductal epithelial

cells that show apocrine features and have eosinophilic cytoplasm. Benign calcifications found in normal

ducts, lobules, breast stroma, and blood vessel walls are referred to as epithelial- related calcifications.

Mild hyperplasia of the usual type occurs when the number of epithelial cells within a duct is more than

two but not more than four cells in depth, and the epithelial cells do not cross the lumen of the involved

space.63

CLASSIFICATION

Table 74-4 Classification of Benign Breast Disease

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The most common nonproliferative lesions of the breast are cysts, which often present clinically as

solitary masses that can be associated with pain. They are fluid-filled round or ovoid structures arising

from the terminal duct lobular unit when fluid accumulates because of distension and obstruction of the

efferent ductule.64 Given that cysts arise from lobular pathology, they occur mainly during lobular

development, menstrual cyclic changes, and lobular involution in premenopausal and postmenopausal

women, with peak incidence between 35 and 50 years of age.65,66

The three types of cysts are simple, complicated, and complex. Simple cysts are well circumscribed

and on ultrasound have posterior acoustic enhancement. In addition, they are anechoic and do not have

solid components or Doppler signals. If simple cysts are diagnosed by ultrasound, they are by definition

benign and do not require further intervention, although cyst aspiration can be performed if the patient

is symptomatic. Alternatively, FNA can also be used to diagnose simple cysts. If the aspirated fluid is

nonbloody and the palpable mass completely resolves, this is also diagnostic of a simple cyst and no

further diagnostic evaluation is required. A follow-up CBE with or without ultrasound can be performed

in 3 to 6 months to document stability, and the patient may resume routine breast cancer screening.

Unlike simple cysts that are not associated with malignancy, complicated and complex breast cysts are

associated with malignancy in <1% and 1% to 23%, respectively.67–69 On ultrasound, complicated cysts

appear as masses with homogenous low-level internal echoes due to echogenic debris. However, there

are no solid components, thick walls, or thick septa. Complex cysts are defined as cysts with solid

components, thick walls, or thick septa. Complex cysts are characterized on ultrasound by the absence

of posterior wall enhancement and the appearance of anechoic and echogenic components. Complicated

cysts can be confirmed as benign by biopsy through FNA, core biopsy, or excisional biopsy.

Alternatively, ultrasound imaging and mammography (if the lesion was visualized on mammography)

with CBE every 6 months for 2 years can be performed to document stability. If complicated cysts

develop any concerning changes such as an increase in size or development of a solid component, biopsy

should be performed.70 Complex cysts mandate biopsy. If no fluid is aspirated by FNA, then core biopsy

under image guidance should be performed with care to biopsy the solid component. A metallic clip

marking the biopsy site facilitates surgical excision if necessary and facilitates follow-up imaging. If

pathology is concordant with imaging findings, then follow-up with CBE and ultrasound imaging every

6 to 12 months for 1 to 2 years can be performed to document stability. For any concerning changes in

the appearance of the lesion or increase in size, excisional biopsy should be performed. In patients who

may be noncompliant with follow-up care, surgical excision should be considered for complicated and

complex breast cysts.70

Proliferative Breast Lesions without Atypia

Proliferative breast lesions without atypia include ductal hyperplasia, intraductal papillomas, sclerosing

adenosis, radial scars, and fibroadenomas. Ductal hyperplasia is often an incidental finding noted on

biopsies obtained for mammographic abnormalities or for breast masses. Ductal hyperplasia is

characterized by an increased number of cells within the ductal space; however, the cells retain the

cytologic features of benign cells. Ductal hyperplasia is not associated with a significant risk for

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subsequent breast cancer and no additional treatment is necessary.63,71 Women with intraductal

papillomas often present with pathologic nipple discharge (see section on Nipple Discharge above).

These lesions consist of a monotonous array of papillary cells that grow from the wall of a duct or cyst

into its lumen. Given that intraductal papillomas can harbor areas of atypia or DCIS, surgical excision is

recommended when intraductal papillomas are diagnosed by core needle biopsy. If no atypia or DCIS is

found at the time of excision, then no further treatment is necessary.72–76 Sclerosing adenosis typically

presents as a mammographic abnormality or a mass and requires no further treatment following biopsy,

as it is a benign lobular lesion resulting from increased fibrous tissue and interspersed glandular

cells.77,78 Complex sclerosing lesions or radial scars are often found incidentally when a breast mass or

radiologic abnormality is biopsied or excised. These lesions are characterized by a fibroelastic core with

radiating ducts and lobules, and radial scars can appear spiculated on mammography.79 When diagnosed

on core biopsy, radial scars should be excised as 8% to 17% are associated with malignancy at surgical

excision.80–82 If the surgical excisional biopsy confirms a radial scar, no additional treatment is needed.

Fibroadenomas typically present as well-circumscribed mobile masses that are not fixed to the

surrounding breast tissue. They are benign solid tumors made of glandular as well as fibrous tissue and

are found most commonly in women between the ages of 15 and 35 years.83 Fibroadenomas with

benign imaging characteristics can be followed with serial CBE and ultrasound imaging to ensure

stability. Alternatively, core needle biopsy can be performed to confirm the diagnosis. If a

fibroadenoma is asymptomatic, surgical excision is not necessary. However, if the presumed

fibroadenoma is symptomatic or increases in size, excision can be performed for symptomatic relief or

to rule out a malignancy such as a phyllodes tumor.84 Fibroadenomas that are associated with

proliferative changes such as sclerosing adenosis, ductal epithelial hyperplasia, epithelial calcification,

or papillary apocrine changes are referred to as complex fibroadenomas. Surgical excision of these

lesions is often recommended to exclude a diagnosis of breast cancer,85,86 although this is controversial

as some advocate that these lesions can be followed similarly as simple fibroadenomas.87

A fibroadenoma that is greater than 10 cm in size is referred to as a giant fibroadenoma and excision

is recommended, as these lesions are hard to differentiate from a phyllodes tumor.63 Juvenile

fibroadenomas occur in young women between the ages of 10 and 18 years and can vary in size from 5

to 20 cm in diameter. Surgical excision is recommended as these lesions can be cosmetically distressing

for the young patient and are difficult to differentiate from a phyllodes tumor, although risk to the

prepubertal breast bud is a potential complication.88

Proliferative Breast Lesions with Atypia

Proliferative breast lesions with atypia include ADH, ALH, flat epithelial atypia (FEA), and LCIS.

Although these lesions are not considered premalignant, they are associated with an increase in the

patient’s future risk of developing breast cancer (Fig. 74-14).

ADH is characterized by a proliferation of uniform epithelial cells with monomorphic round nuclei

filling part, but not all, of the involved duct. ADH often presents as suspicious microcalcifications seen

on mammography. In contrast, ALH is often an incidental finding found on breast biopsies performed

for other reasons, such as an abnormal mammogram or breast mass. ALH is characterized by a

proliferation of monomorphic, evenly spaced, dyshesive cells filling part, but not all, of the involved

lobule.63 Atypical hyperplasias are associated with an increased risk of subsequent breast cancer

(relative risk [RR] 3.7 to 5.3) in both the ipsilateral breast and the contralateral breast.89–93 In the past

atypical hyperplasias (both ductal and lobular) that are diagnosed on core needle biopsy mandated a

surgical excisional biopsy to exclude a diagnosis of malignancy. In case of atypical ductal hyperplasia, a

surgical excisional biopsy is still recommended as an upgrade to DCIS or invasive breast cancer can

occur in 10% to 20% of cases. However, in regards to lobular neoplasias (atypical lobular hyperplasia

and LCIS), more recent evidence suggests that an association with malignancy may be as low as 1%

(central pathology review) and 3% (local pathology review) and as such surgical excision for these

lesions are no longer indicated.94 If the diagnosis of atypical hyperplasia is made by excisional biopsy

and the area is adequately sampled, reexcision is not necessary or recommended. Instead, the patient

should be counseled toward risk reduction strategies that include CBE every 6 to 12 months, annual

screening mammography, and consideration for chemoprevention with a selective estrogen receptor

modulator (SERM) or an aromatase inhibitor (AI).70 In addition, the patient should be counseled to

perform consistent breast self-examinations (BSEs) such that she will become familiar with her breasts

and report changes promptly to her provider (see the section on Management of Patients at High Risk

for Breast Cancer later).

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Figure 74-14. Cumulative risk for the development of invasive breast cancer after a biopsy for benign breast disease. Women with

atypical hyperplasia (ductal or lobular type) are at a significantly increased risk for the development of breast cancer. (Reproduced

with permission from Page DL, Dupont WD. Anatomic markers of human premalignancy and risk of breast cancer. Cancer

1990;66:1326.)

Lobular Carcinoma In Situ

LCIS is a noninvasive lesion that arises from the lobules and terminal ducts of the breast. It is

characterized by solid proliferation of small cells, with small, uniform, round to oval nuclei, and

variably distinct cell borders. The cytoplasms of the cells are clear to lightly eosinophilic and

occasionally there are intracytoplasmic vacuoles that may be large enough to produce signet ring cell

forms. LCIS tends to have a very low proliferative index and is estrogen-receptor positive.95 LCIS is

more prevalent in premenopausal women and white women.96,97

3 LCIS is often diagnosed as an incidental finding on a breast biopsy that has been performed for

another reason, such as an area of fibrocystic change or mammographic abnormality. Traditionally, if

LCIS is identified on core biopsy, surgical excision is performed to exclude an associated cancer.97–101

However, more recent data suggests that this potential upgrade to DCIS or invasive cancer is likely 1%

to 3% and as such surgical excision is no longer indicated.94,98–102 If LCIS is found on excisional biopsy,

no further surgical intervention is needed. However, if pleomorphic LCIS is identified at a surgical

margin on excisional biopsy, wide excision with negative margins is recommended as pleomorphic LCIS

can be hard to differentiate from DCIS.103–105

RESULTS

Table 74-5 Risk for Breast Cancer Development After Lobular Carcinoma in Situ

Although it is not a premalignant lesion, LCIS conveys a substantial increased risk for breast cancer.

The RR of developing an invasive cancer in women with LCIS is approximately two- to threefold higher

than that in women without LCIS (Table 74-5).112 LCIS also conveys an increased risk for breast cancer

to the contralateral breast. Historically, women diagnosed with LCIS were treated with bilateral

prophylactic mastectomies. Most experts today consider this approach to be too aggressive given that

most women with LCIS who do not have other contributory factors (e.g., family history of

premenopausal breast cancer) will not develop an invasive breast cancer. Instead, a careful lifetime

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surveillance protocol similar to that described above for atypical hyperplasias can be followed.

Chemoprevention with a SERM and/or AI can also be discussed with the patient. There are currently no

randomized trials to compare the efficacy of surveillance protocol versus prophylactic mastectomy in

women with LCIS.

FEA is an intraductal finding that is characterized by the replacement of native epithelial cells by a

single layer, or up to 3 to 5 layers of mildly atypical cells (World Health Organization definition).113

When diagnosed on core biopsy, the risk of upgrade to a malignancy at surgical excision is 5% to

15%.114–116 When FEA is diagnosed by excisional biopsy, no further surgery is warranted. However, if

FEA is diagnosed by core needle biopsy, excisional biopsy should be performed. Alternatively,

radiologic surveillance can be performed and if there is absence of a residual mammographic

abnormality and core biopsy was felt to be adequate, no further surgery is needed. Excisional biopsy

must be performed for any residual lesions seen. When FEA is found at the margins, wider excision is

not needed.114–117 Although FEA is an atypia, it conveys the same risk of breast cancer that is associated

with benign proliferative disease without atypia and as such, patients should continue routine

surveillance.118 There are also no data to support the use of chemoprevention.

BREAST CANCER SCREENING

Breast Self-Examination

BSE has not been shown to have an impact on the rates of breast cancer diagnosis, stage at diagnosis, or

breast cancer mortality. In addition, BSE may result in higher rates of breast biopsy for benign disease.

The largest study conducted was the Shanghai randomized trial involving 266,064 women who were

assigned to either a BSE instruction group or a control group. The BSE group received instruction on

BSE with reinforcement sessions 1 and 3 years later, supervised self- examination every 6 months for 5

years, and ongoing reminders. Intensive instruction on BSE did not reduce mortality from breast cancer

but increased the rate of biopsy for benign disease.119 A review of eight other studies had similar

findings.120 The US Preventive Services Task Force (USPSTF), the Canadian Task Force on Preventive

Health Care (CTFPHC), the National Comprehensive Cancer Network (NCCN), and the World Health

Organization do not recommend that women receive instruction on BSE. The American Cancer Society

recommends that women be educated about the benefits and limitations of BSE. The American College

of Obstetricians and Gynecologists recommends breast self-awareness, which can include BSE. In women

who are not at high risk for breast cancer, we do not advocate for or discourage the use of BSE;

however, we do promote breast self-awareness. Proper examination technique should be reviewed for

women who are already routinely performing BSE, for women at high risk for the development of

breast cancer, and for breast cancer survivors.

Clinical Breast Examination

Women should undergo CBE as part of their annual physical examination. However, it is difficult to

determine the effectiveness of CBE as a screening tool as it is often performed with mammography. It

has been suggested that CBE may modestly improve early detection of breast cancer but at the risk of

increased false-positives.121,122 The effectiveness of CBE has not been proven by well-designed large

clinical trials.123 As such, the USPSTF, the Canadian Task Force on Preventive Health Care, and the

World Health Organization do not support CBE. The American Cancer Society and the American College

of Obstetricians and Gynecologists recommend CBE every 3 years. We feel that CBE is critical to the

evaluation of breast disease, as such, providers of women’s health have to become experts in this

technique.

Screening Mammography

Screening mammography is widely performed but is not without controversy. Although systematic

reviews of randomized trials have found a significant reduction in breast cancer mortality with

mammographic screening in women aged 40 to 69 years, most of these studies were conducted before

1990, and there is concern that the current reduction in mortality is less as these trials were performed

in an era prior to the adoption of modern treatment paradigms (multidisciplinary care and the use of

adjuvant systemic treatments). In 2012, a meta-analysis of 11 randomized trials determined that the RR

of breast cancer mortality for women undergoing screening mammography was 0.80 (95% confidence

interval [CI], 0.73 to 0.89) compared with controls. This correlates with a RR reduction of 20%.124 In

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