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Common benign breast concerns for the primary care physician

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NIPPLE-AREOLAR RASH: CONSIDER PAGET DISEASE

A rash on the nipple or areolar region warrants careful evaluation because it may be the first sign of Paget disease of the breast.

In the clinical breast examination, assess the extent of the rash and the presence of any underlying breast mass or nipple discharge. Dermatitis often starts on the areola and resolves quickly with topical therapy. However, Paget disease tends to start directly on the nipple itself, is unresponsive or only partially responsive to topical therapy, and progresses gradually, leading to erosions and ultimately effacement of the nipple itself.

If the clinical examination suggests mild dermatitis and the results of breast imaging are negative, treat the patient with a topical medication because benign conditions such as dermatitis and eczema are common. However, continued follow-up is mandatory until the rash completely resolves: Paget disease sometimes initially improves with topical therapy due to its inflammatory nature.

If you suspect Paget disease or the rash does not fully resolve after 2 to 3 weeks of topical therapy, refer the patient to a dermatologist for full-thickness punch biopsy to establish the diagnosis.

Paget disease of the breast may or may not be associated with underlying ductal carcinoma in situ or invasive breast cancer.19 The absence of clinical or imaging abnormalities in a patient with Paget disease does not rule out underlying malignancy.20

DENSE BREASTS

BI-RADS breast density categories
From 35% to 50% of all women have dense breast tissue.21,22 Breast density is defined as the ratio of stromal and glandular tissues (which appear radio-opaque on mammography) to radiolucent fat. The Breast Imaging Reporting and Data System (BI-RADS), fifth edition, recognizes 4 categories of density, designated A through D (Table 2 and Figure 1).23
Breast density categories

Figure 1.

Nearly 80% of women fall into category B (scattered areas of fibroglandular density) and category C (heterogeneously dense), with significant interreader variation. One study showed that 13% to 19% of women were reclassified from dense to nondense or vice versa on subsequent mammograms.22

Increased breast density has been shown to be a risk factor for breast cancer and may be prognostically useful when combined with the Tyrer-Cuzick model or the Gail model of breast cancer risk.24

Additionally, increased density can mask cancers on mammography, significantly reducing its sensitivity. In women with heterogeneously or extremely dense breasts, the sensitivity of mammography for detecting cancer is only 25% to 50%.21 Due to this low sensitivity, supplemental imaging is helpful, particularly in women already at risk of breast cancer based on family history.

Supplemental screening

Digital mammography with tomosynthesis was approved by the FDA in 2011 for use in combination with standard digital mammography for breast cancer screening. Compared with traditional 2-dimensional mammography alone, adding 3-D tomosynthesis decreases the recall rate and increases the cancer detection rate.25

Tomosynthesis tends to perform better in women with heterogeneously dense breasts (BI-RADS category C). There is no significant improvement in cancer detection in women with extremely dense breasts (BI-RADS category D).26

Depending on the methodology, radiation exposure can be either higher or lower than with traditional mammography. However, in all forms, the very small amount of radiation is considered safe.

Whole breast ultrasonography. When whole breast ultrasonography is used to supplement mammography, the recall rate is higher than when mammography is used alone (14% vs 7%–11%).22 It also increases the cancer detection rate by 4.4 additional cancers per 1,000 examinations. However, the false-positive rate with whole breast ultrasonography is higher; the positive predictive value of combined mammography and ultrasonography is 11.2% vs 22.6% for mammography alone.22 Therefore, we do not generally recommend whole breast ultrasonography as a supplement to mammography in women with dense breast tissue unless other studies are not an option.

Molecular breast imaging is not widely available because it requires special equipment, injection of a radiopharamceutical (technetium Tc 99m sestamibi), and a radiologist who specializes in breast imaging to interpret the results. When it is available, however, it increases the cancer detection rate by 8.8 in 1,000 examinations; the positive predictive value is similar to that of screening mammography alone.21 It is particularly useful in patients with dense breasts who do not qualify for screening magnetic resonance imaging (lifetime risk of < 20% to 25%).

Technetium sestamibi is associated with a minimal amount of radiation exposure (2.4 mSv vs 1.2 mSV with standard mammography). However, this exposure is much less than background radiation exposure and is considered safe.21

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