1- Breast Disorders Flashcards
What views are used for screening and diagnostic mammography?
Screening = 2 craniocaudal (CC) + 2 mediolateral oblique (MLO)
Diagnostic = CC + MLO + more views
What technique is used for mammography in women who have breast implants?
Implant displacement
Why is timely eval with mammography important?
R/o cancer and relieve pt anxiety
What are the indications for diagnostic testing with US? (breast disorders) (5)
Inconclusive MMG results, young women, dense breast tissue, differentiation between solid and cystic mass, guiding for tissue core-needle biopsies
When is an MRI used for diagnostic testing? (breast disorders)
Detecting breast CA in high risk women, staging disease in women w/ breast CA
When is MRI diagnostic testing NOT recommended? (breast disorders)
Eval of a breast mass
What is important to note about use of MRI that could have contraindications?
IV gadolinium dye used
(check BUN and creatinine)
What diagnostic test is the acceptable initial method for evaluating a mass with low pretest probability of CA and is useful in determining if a palpable lump is a simple cyst?
Fine-needle aspiration
What diagnostic test is used to obtain samples from larger, solid breast masses?
Core-needle biopsy
What are the 2 types of possible surgical biopsy? (breast disorders)
Incisional (portion of mass) and excisional (take entire mass)
What are 2 of the more important history questions to ask when evaluating breast sxs?
A/w menstrual cycle, RFs that increase likelihood of malignancy
What is mastalgia and what are its etiologies/ classifications?
Breast pain; cyclical, non-cyclical, extra-mammary
(non-cyclicalrelated to internal anatomical changes like injury, surgery, cyst)
What are the characteristics of cyclical pain (mastalgia)? (4)
Luteal phase, bilateral, diffuse, fibrocystic changes
What type of mastalgia may be unilateral or focal, and may be caused by meds (hormonal contraceptives, HRT, SSRIs, Spironolactone)?
Noncyclical
(ex. large, pendulous breast causes ligamentous pain)
Pt who is younger than 30 yrs presenting with focal breast pain should proceed with what diagnostic studies?
Targeted US
Pt who is older ≥ 30 yo and presents with focal pain should proceed with what diagnostic studies?
Targeted US and MMG
What is 1st line treatment for mastalgia if normal findings on exam and imaging? (4)
Reassurance, physical support, compresses, analgesics (acetaminophen/ NSAIDS)
What is 2nd line treatment for mastalgia (only if failed 1st line for > 6 mos)?
Danazol or Tamoxifen for 1-3 mos
(caution w/ SEs)
Woman who is lactating presents with hard, red, tender, swollen area of one breast. VS show fever. What are you concerned for?
Mastitis
What is the most common etiology of mastitis?
S. aureus
What is an important ddx for mastitis that you do not want to miss?
Inflammatory breast CA
What is the tx for mastitis?
Dicloxicillin or cephalexin
What pt edu should be provded for a woman with mastitis?
Continue breastfeeding
What is the management for breast abscess if there is evidence of skin compromise?
I+D
What is important to consider in the management of benign vs malignant breast masses?
PE cannot distinguish, need imaging
What characteristics are indicative of a benign breast masses? (5)
Discrete margins, no skin changes, smooth, soft to firm, mobile
What characteristics are indicative of a malignant breast masses? (4)
Poorly defined margins, possible skin changes, hard, immobile/ flexed
What is defined as a fluid-filled round or ovoid mass?
Breast cyst
Pt presents with smooth, firm (due to fluid), mobile mass that is well-defined on palpation and +/- tenderness. What are you concerned for?
(can also be ballotable- not firm)
Breast cyst
A cluster of cysts may palpate as what?
Ill-defined mass
What is the management for simple breast cysts?
Typicall no intervention unless:
- Sx, then FNA
- Recurrent, then repeat imaging
What is the management for complicated breast cysts (< 1% risk of malignancy)?
FNA or follow w/ imaging q 6 mos x 2 yrs
What is the management for complex breast cysts (1-23% risk of malignancy)?
Bx + possible surgical excision
What is defined as a benign, solid tumor containing glandular and fibrous tissue?
Fibroadenoma
Pt presents with round, well-defined, mobile mass that is firm and non-tender. Hx of increasing in size during pregnancy and w/ estrogen use. What are you concerned for?
Fibroadenoma
What is the management for a fibroadenoma?
Core needle bx +/- surgical excision/ cryoablation
OR
If benign features on US- 3-6 mo repeat CBE and US
If a fibroadenoma increases in size, what is the management?
Excision (r/o malignancy)
What should be considered with rapid growth of a fibroadenoma?
Phyllodes tumor
What is defined as a fibroepithelial tumor classified as benign, borderline or malignant?
Phyllodes tumor
Pt presents with suspicious breast mass. What is the next step?
Dx MMG and directed US → bx
Pt presents with indeterminate lesion/ breast mass and is ≥ 30 yo. What is the management?
Dx MMG w/ or w/o directed US
Each duct of the breast drains what?
A separate portion of the breast
What type of nipple discharge is typically spontaneous, unilateral, from a single duct, bloody, serous, clear, or a/w a mass?
Pathologic discharge
What is the most common cause of patholgic nipple discharge?
Intraductal papilloma
(others: duct ectasia, CA, infection)
What type of nipple discharge is typically bilateral, from multiple ducts, and associated with stimulation?
Physiologic discharge
What is the most common cause of physiologic nipple discharge?
Galactorrhea
(others: med related, neurogenic stimulation)
What characteristics of nipple discharge indicate a surgical referral?
Single duct or bloody
What are the strongest RFs for breast CA?
Female gender and advancing age
The following are RFs for what?
Female gender, advancing age, BRCA 1 and 2 genetic mutations, hx of DCIS, first birth > 30 yo or nulliparity, FH of breast/ ovarian CA, early menarche, late menopause, high BMI, postmenopausal hormone therapy
Breast CA
What are BRCA1 and BRCA2 genes are how are they linked to breast and ovarian CA?
Tumor suppressors, mutation linked to CA
What are the management options if BRCA + (mutation present)?
Increased surveillance, chemoprevention (Tamoxifen if > 35 yo), surgical prevention (prophylactic mastectomy)
Does BRCA (-) (mutation not present) mean the a female with NOT get breast CA?
NO
What are the methods of breast cancer screening and what is the most highly recommended?
“Breast awareness” (most recommended), clinical breast exam (CBE), screening MMG
When is the best time to perform a clinical breast exam (CBE) and what are the key features to the exam?
In follicular phase; systematic approach and cover entire area
What are the breast CA MMG screening recommendations for average risk women?
(no personal/ family hx of breast CA, no genetic mutation, no chest chest radiation < 30 yo)
- Consider @ 40-49 yo
- Screen all women @ ≥ 50 yo
- Stop screening @ 75 yo
- Frequency: every 1-2 yrs
When is annual breast CA screening w/ MRI recommended?
High risk of breast CA and high sensitivity of MRI
How is breast CA classified?
Anatomical location (lobular or ductal), hormone receptivity (E and P), HER2 expression
How does breast CA most commonly present clinically?
Palpable mass
(+/- skin changes, nipple discharge)
Breast lesions with malignant cells that have not penetrated the basement membrane of the mammary ducts or lobules is defined as what?
Noninvasive (in situ) breast CA
What are the 2 types of noninvasive (in situ) breast CA?
Lobular (LCIS) and ductal (DCIS)
(ductal localized inside mammary ducts)
What type of breast CA is treated as a malignancy because it has the potential to develop into invasive CA?
DCIS
What type of breast CA appears on MMG as clustered pleomorphic calcifications, has a PE WNL and can be multifocal or multicentric?
DCIS (ductal)
What type of breast CA does not become an invasive CA if left untreated?
LCIS (lobular)
What type of breast CA presents with PE and imaging WNL, is usually an incidental finding but can be an indicator for increased risk of invasive carcinoma?
LCIS (lobular)
What is the treatment for DCIS? (ductal)
- Breast- conserving surgery w/ radiation vs mastectomy +/- sentinel lymph node bx
- Adjuvant hormone therapy if E+P positive (Tamoxifen and Arimidex)
What is the treatment for LCIS? (lobule)
- Typically none recommeded (not a true CA)
- Lifelong surveillance
- Chemoprevention (Tamoxifen, Arimidex)
- Bilateral prophylactic mastectomy
What is the most common breast malignancy (80%)?
Infiltrating ductal carcinoma (IDC)
How does infiltrating ductal carcinoma (IDC) typically present?
Palpable mass or MMG abn
“Oh damn, not good”
What type of breast CA usually presents as a palpable mass or MMG abn, is more apt to be bilateral, and is usually hormone receptor positive?
Infiltrating lobular carcinoma (ILC)
“You’re lucky”
Stellate lesions, irregularly shaped mass, spiculation, pleomorphic calcifications and anatomical distortion of MG + taller than wide on US is indicative of what?
Invasive breast carcinomas
Pt presents with unilateral scaly, raw, vesicular or ulcerated lesion that begins on the nipple and spreads to the areola +/- blood discharge. Pt notes hx of pain, burning and pruritis before the lesions appeared. What are you concerned for?
Paget Disease of the Breast (PDB)
(rare cause of breast CA but majority have underlying breast CA)
What type of breast cancer is very aggressive and presents clinically as pain w/ rapidly progressing, tender, firm, enlarged breast, skin warm, thickened, peau d’orange appearance, and erythema?
Inflammatory breast CA (IBC)
Inflammatory breast CA (IBC) is typically considered very aggressive with almost all having what?
Lymph node involvement, 1/3 with distant metastasis
What is the primary location for lymphatic spread of breast CA?
Axillary
(also can spread to internal mammary nodes, supraclavicular w/ late disease)
What are the most common locations for hematogeneous spread of breast CA?
Lung and liver
(can also go to bone, ovaries, brain)
What is the management for breast CA?
Surgery (BCS- lumpectomy, mastectomy), radiation, chemo, endocrine therapy
The following characteristics of breast CA determine what?
Tumor size, lymph node involvement, mets, E+P status, HER2 status, oncotype dx breast recurrence score, BRCA status
Surgical management
What surgical management of breast CA is defined as part of the breast containing the CA is removed w/ or w/o selective sampling of axillary nodes?
BCS (breast conserving surgery) = lumpectomy
What is typically considered to be the appropriate treatment for stage I or II breast CA due to decreased morbidity and comparable survival/ recurrence rates compared to more invasive procedures?
BCS with post-op radiation
What is removed in a simple (aka total) mastectomy?
Entire breast including nipple and areola
What is removed in a modified radical mastectomy?
Entire breast including nipple and areola + axillary lymph nodes
What is removed in a radical mastectomy?
Entire breast, lymph nodes, pec muscle
(rarely performed)
Radiation is almost always used (more commonly after surgery) in the treatment of breast CA. WHat are the 2 types?
External beam and brachytherapy
(radiation to breast, chest wall, regional LN/ axillary)
When is chemotherapy included in the management of breast CA?
Primary and metastatic breast cancers, (+) lymph nodes, high oncotype dx recurrence scores
When is neoadjuvant chemo?
Given before surgery to shrink size of tumor
(may allow for breast conservation surgery)
What is adjuvant chemo?
After surgery, kills CA cells left behind
What type of breast cancer is responsive to HT?
Estrogen (+) and progesterone (+) breast CA
(as compared to hormone negative CA)
What HT drugs are included in the management of breast cancer as a supplement to chemo and radiation?
- SERM- Tamoxifen (if pre-menopausal)
- Aromatase inhibitors- Arimidex (if post-menopausal)
How long is endocrine/ hormone therapy typically given for in the treatment of breast CA?
5-10 years
What is HER2 and what is it’s association to breast CA?
Growth-promoting protein; CA a/w overexpression of HER2
What breast CA treatment targets HER2 and when is it effective in combo with chemo?
Herceptin; effective in early stage CA’s and metastatic disease
When is chemoprevention recommended for breast CA prevention?
Asx women aged ≥ 35 w/o a prior dx of breast CA who are at increased risk
Give Tamoxifen or Arimidex/ Raloxifene
