Updated: 7/8/2019

Benign Breast Conditions

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  • A 13-year-old boy presents to his pediatrician due to noticing a lump under the nipple of his left chest. He reports mild pain when touched. There is no breast discharge or changes in the skin. On physical examination, pubic hair is Tanner stage IV and has a testicular volume of 9 mL bilaterally. Palpation of the left chest shows a 3.5 cm mass beneath the nipple. (Pubertal gynecomastia)
Breast Abscess
  • Clinical definition
    • pus accumulation in breast tissue that can result from
      • mastitis or cellulitis that does not respond to treatment
  • Epidemiology
    • incidence
      • 0.4-11% in lactating mothers
        • can also occur in non-lactating women
  • Presentation
    • symptoms
      • localized pain of the breast
      • malaise
    • physical exam
      • fever
      • palpable mass that is
        • fluctant and tender
  • Treatment
    • drainage of abscess 
    • antibiotic therapy
      • empiric therapy should cover Staphylococcus aureus
Mastalgia
  • Clinical definition
    • breast pain
  • Etiology
    • cyclical mastalgia
      • typically diffuse and bilateral
      • causes include
        • physiologic
        • pharmacologic hormonal agents
    • noncyclical mastalgia
      • typically unilateral
      • causes include
        • inflammatory breast cancer
        • ductal ectasia
        • mastitis/abscess
  • Treatment
    • symptomatic
      • well-fitting brassiere
      • warm compresses, cold packs, and massage
    • medication
      • acetaminophen
      • nonsteroidal antiinflammatory drug (NSAID)
      • danazol
        • FDA approved for mastalgia
Fat necrosis
  • Clinical definition
    • breast lesion that can be seen after breast trauma or surgical intervention
      • can be confused for malignancy on physical exam and on mammography
  • Management
    • with any palpable mass, breast cancer must be excluded
      • ultrasound (< 30 years old) or mammogram (> 30 years old) 
        • oil cysts or (later) calcified oil cysts
      • if imaging suspicious or inconclusive
        • fine needle aspiration
          • oily fluid
        • biopsy
          • lipid-filled macrophages ("foamy macrophages"), fibrosis and inflammatory cells
    • conservative treatment (observation and reassurance)
    • excision only if symptomatic or disfiguring
Mondor's Disease
  • Clinical definition
    • thrombophlebitis of the superficial veins of the anterior chest wall which be seen in
      • complications after breast cancer surgery and breast augmentation
      • malignancy
  • Epidemiology
    • incidence
      • ~1% in patients after receiving breast cancer surgery and breast augmentation
    • demographics
      • mostly between 30-60 years of age
      • more common in females than males (3:1)
    • prognosis
      • typically benign and a self-limiting disease
  • Presentation
    • physican exam
      • cord-like thrombosed vein that can be tender or non-tender
  • Treatment
    • symptomatic management
Male Gynecomastia
  • Clinical definition
    • a benign condition that results in glandular proliferation in the male breast caused by
      • increased relative estrogen to androgen activity
  • Etiology
    • physiologic gynecomastia
    • pseudogynecomastia
      • due to obesity
      • there is no glandular proliferation
    • medications
      • spironolactone
      • ketoconazole
      • cimetidine
      • gonadotropin-releasing hormone (GnRH) agonists
      • 5α-reductase inhibitors
      • estrogens
    • drugs of abuse
      • alcohol
      • marijuana
      • heroin and methadone
      • amphetamine
    • idiopathic
    • cirrhosis
    • testicular malignancy
 

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Questions (4)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.GN.4747) A 13-year-old boy is brought to his pediatrician due to a left breast lump under his nipple. He noticed it last month and felt that it has increased slightly in size. It is tender to touch but has no overlying skin changes. There is no breast discharge. The patient has cryptorchidism as an infant and underwent a successful orchiopexy. In addition, he was recently diagnosed with ADHD and is currently on methylphenidate with improvement in his symptoms. He has a family history of type I diabetes in his father and breast fibroadenoma in his mother. On exam, the patient is at the 82nd percentile for height, 79th percentile for weight, and 80th percentile for BMI. He has tanner IV pubic hair. Testicular volume is 7 mL on each side, and both testes are smooth and freely mobile. Breast exam shows a normal right breast and a 3-centimeter round, firm, and slightly tender discrete mass under the left nipple. Which of the following is the most likely etiology of this patient’s condition? Review Topic

QID: 108673
1

Klinefelter syndrome

11%

(3/27)

2

Glandular tissue enlargement

59%

(16/27)

3

Lipomastia (pseudogynecomastia)

26%

(7/27)

4

Testicular cancer

0%

(0/27)

5

Medication side effect

4%

(1/27)

M2

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