02. Breast Disease Flashcards
What hormones cause cyclical breast changes?
Estrogen & progesterone
What is an independent factor of breast cancer risk?
Breast density (4-6x increase in breast cancer risk)
What is a better imaging modality for women with dense breasts?
MRI
What are the drawbacks of using MRI for breast imaging?
May lead to more interventions for benign conditions; Tricky get insurance coverage
Whatis the approach for analyzing a breast abnormality?
Triple test (triple negative)
What are the components of the triple test?
Breast exam; Imaging; Tissue sampling (FNA or Core needle bx)
4 Common Benign Breast Diseases
Fibrocystic Changes (FCC) including cysts; Fibroadenomas; Mastitis/Abscess; Nipple d/c
Fibrocystic Changes
Breast tissue response to cyclic hormonal changes; Changes are benign but frightening; Cyclic pain, nodularity, nipple d/c, microscopic & gross changes
Breast cysts
Painful, fluctuant, mobile masses, W/O REDNESS. Can be exquisitely tender; Confirm with U/S
Breast cyst tx
Aspirate with 23-25 gauge needle after injecting 1% lidocaine; send fluid to cytology if not clear
Fibroadenoma
MC tumon in women over 25; Firm, round, mobile, NONTENDER mass anywhere in breast. Dx with triple test.
Fibroadenoma tx
Remove if growing, >3cm, or bothersome
Breast abscess
Common in LACTATING women. PAINFUL, hard RED mass. Usually caused by S. aureus. Often chronic or recurrent, esp. retro alveolar.
Breast abscess dx & tx
Aspirate to confirm dx; I & D + bx to r/o CA; ABX if needed. During lactation, mechanically empty breast and temporily d/c nursing in affected breast only
Common etiology of milky nipple d/c
Lactation, prolactinoma, post-lactational changes
Common etiology of serous, brown, gray, green nipple d/c
Fibrocystic changes
Common etiology of bloody, blood-tinged, or SEROUS nipple d/c
Intraductal papilloma; CA
Milky, unlateral nipple d/c tx
No tx necessary
Milky, bilateral nipple d/c tx
If greater than 2 yr since lactation, check plasma prolactin
Bloody nipple d/c tx
Excisional bx of draining duct
Paget’s disease of the nipple
Rare form of breast CA that begins in the MILK DUCTS and spreads to the skin of the NIPPLE & AREOLA. Accounts for 1% of breast cancer. Breast skin may appear CRUSTED, RED, OR OOZING. Prognosis may be better if NIPPLE CHANGES ARE ONLY SIGN OF BREAST DISEASE and no lump is felt.
Fat necrosis presentation
Firm to hard palpable mass that feels like CA and can look like CA on mammogram. Caused by trauma or post-surgical. Usually doesn’t resolve or change. Bx proves non-malignant. Ask pt if she suffered any chest wall trauma. Common in elective reductions.
Mammary Duct Etasia
Dilation of the mammary ducts causing unilateral or bilateral d/c (green, black, brown & thick); Benign
Galactocele
“milk” tumor or cyst. Tx with fluid aspiration
Cancer in pregnancy
Hormone responsive tumors grow rapidly
Mastodynia/Mastalgia
Extremely common complaint. 7-10% of breast CA presents with this as only sx. R/O trauma, costochondritis; breast mass; CA; AMI. Left breast pain may be a sign of AMI.
Tx of mastalgia
Analgesics; warm showers/compresses; supportive bra; evening primrose oil
Gynecomastia
Do a testicular exam; may be a testicular tumor causing hormonal imbalance leading to breast development, esp. in older men. May also be d/t meds or liver disease.
Male Breast CA
Ask about breast pain, swelling, mass, family hx of breast and ovarian CA, esp. hx of male breast CA.
Risk factors for Male Breast CA
Family hx; Klinefelter’s syndrome (XXY); radiation exposure; liver dz; estrogen tx
Signs of early breast cancer on mammogram
Microcalcifications +/- nonpalpable mass
Clinical signs of breast cancer
Lump or thickening of breast or axillary LN; Change in breast size/shape; Nipple d/c, inversion, or axis change; Redness of skin, lymphedema
Lifetime risk of developing breast cancer
1 in 8 by age 85
What is the most common way of finding breast cancer?
Breast self examination (70%).
Bx method for diagnosing breast abnormalities
Core biopsy is accepted method
DCIS
Ductal carcinoma in situ; Bx result that is tx like a cancer. MOST COMMON type of non-invastive breast CA. CONFINED TO DUCTS OF BREASTS. Detected as microcalcifications on mammography. 30% total lifetime risk of developing invasive carcinoma w/o tx.
LCIS
Lobular carcinoma in situ; Bx result that is NOT TX like a cancer. HIGH RISK MARKER! Sharp increase in # of cells within the milk glands (lobules) of the breast. Carries 30% lifetime risk of invasive carcinoma, but can develop anywhere in breast.
IDC
Infiltrating Ductal Carcinoma; AKA Invasive ductal carcinoma. Bx result showing ductal cancer. MOST COMMON invasive breast cancer. Begins in milk ducts of breast and penetrates wall of the duct, invading fatty tissue.
ILC
Infiltrating Lobular Carcinoma; Bx results confirming lobular cancer
In what tissue does breast cancer most commonly present?
Ductal tissue
HER2 Receptors
Breast cancer tumor marker that helps ID meds that will work on the tumor, SPECIFICALLY Herceptin (trastuzumab) & predicts response to anthracyline based adjuvant or metastatic tx
Single greatest predictor of breast cancer survival
The presence or absence of axillary lymph node metastasis.
ALND
Axillary lymp node dissection - Remove LNs from level 1 & 2 of axilla & look for signs of metastatic disease.
ALND adverse effects
Significant lymphedema, parathesia, and limited arm mobility; no venipuncture of arm
When is ALND required?
Inflammatory breast CA & tumors >5cm
SLNB
Sentinel Lymph Node Biopsy - Sample the one node that drains the breast; much less risk of lymphedema.
SLNB indications
Small tumors (
Most common sites of breast cancer metastases
Brain, bone, liver & lung
Visceral mets
Worse prognosis;
Stage IIIA (T3, N1, M0) workup
Bone scan, Abdominal pelvis CT, U/S, or MRI; Chest imaging; Head imaging if brain met suspected
Who should be referred to genetic counseling? Why?
High risk pts. - Risk reduction strategies & tx
Breast cancer tx options (general)
Local (surgery; radiation) & Systemic (chemo; hormonal therapy)
Use of neoadjuvant chemo
Before surgery to shrink large tumors to make them operable or to make small tumors eligible for lumpectomy
Use of polychemotherapy
Infiltrating breast cancer; Usually a 3-4 drug regimen. Never just 1 drug. Improved outcomes in 15 yr recurrence & death rates.
Which women see more benefits from polychemotherapy?
Younger women benefit more than older women.
What is the overall purpose of chemotherapy?
Eradicated clinically occult metastases.
When is hormonal tx standard adjunct therapy?
In all patients with hormone receptor positive breast cancer; prevents breast cells from receiving endogenous estrogen stimulation
What SERM is approved for all stages of hormone responsive breast cancer?
Tamoxifen
What drug can be used for prevention of hormone responsive breast cancer in high risk patients?
Tamoxifen
What is the standard treatment regimen for Tamoxifen?
20 mg/day for 5 yrs after completion of chemo & radiation tx
What are side effects of tamoxifen?
Hot flashes & increased risk of thromboembolic events & endometrial cancer. Avoid use in smokers and post-menopausal women.
Aromatase inhibitors MoA and Use
Prevent conversion of androgens to estrogen in postmenopausal women; AIs are recommend adjuvant tx for post-menopausal breast cancer
When is radiation therapy indicated?
DCIS + lumpectomy + whole breast radiation; Invasive breast cancer + whole breast radiation following chemo; BCT & post-mastectomy indications
Most commonly used breast cancer treatment guidelines
National Comprehensive Cancer Network (NCCN)
