4. The NL and ANL Breast Flashcards
What are some of the risk factors for breast cancer?
- Age (50YO)
- No term pregnancies
- Never breastfed
- Recent and long-term use of OC’s
- Postmenopausal obesity (increased converion of andeostenedione => estrone)
- Alcohol (2-4 drinks/week = increased risk of dying)
- Hx of atypical hyperplasia, endometrial/ovarian cancer
Why does early periods (< 12) and late cessation of period ( >55) increase risk of breast cancer?
Because longer exposure to estrogen
Why is high breast tissue density increase risk of breast cancer?
More dense = less likely detected = diagnosed later
Do shorter or taller people have a higher risk of breast cancer?
Taller
What type of people have an increase risk of breast cancer?
- High SES
- Askenazi Jewish heritage
How to perform PE of breasts?
- Evaluate:
- Breasts
- Axilla
- Chest wall
Diagnostic tests for breasts
- Mammogram
- US
- MRI
- FNA
- Core biopsy
What diagostic tests would you perform if a pt has a palpable mass?
-
Biopsy; either,
- FNA (fine needle aspiration)
- Core biopsy
- Excisional
Mammograms are best in women of what age; how often?
40 YO or older
- What is a mammogram?
- What do we look for on mammogram?
- Screening and diagnostic tool used to detect lesions 2 years BEFORE they are palpable.
-
Detects
- Densities/calcifications
- Masses less than 1cm.
When/how is a mammogram performed for screening/diagnostic purposes?
-
Screening if no complaint/concerns;
- Take 4 images
- Can be done by standard radiograph vs digital enhacement
-
Diagnostic in women w/ a complaints/palpable mass or to adjunct an abnormal screening mammogram
- Check contralateral breast @ same time
Ultrasounds are performed when:
- Inconclusive mammogram
- Best for young women (age <40) and others w/ dense breast tissue
- Need guidance when performing a core needle biopsy
What do we look for on US?
- Differentiates between cystic vs. solid lesions ANDDDD solid tissue within or adjacent to a cyst that may be malignant
American College of Ob/Gyn (ACOG) recommendations for:
- Mammograms
- Clinical exams
- SBE (self-breast exam)
- SBA (self-breast awareness)
- Annually after 40YO
- 20 -39 (q 1-3 years); after 40 (annually)
- Do for high-risk patients
- Recommended
When is MRI useful for evaluating the breasts?
- Adjunct to diagnostic mammography if suspicious masses
- Staging a post-cancer diagnosis
- Women at high risk for breast cancer (BRCA carriers)
Fine needle aspiration (FNA) biopsy determines if the mass is _______
Solid vs cystic;
What is the next best step if fine needle aspiration (FNA) of a breast mass:
- Contains clear vs. bloody fluid?
- If the cyst reappears or does not go away?
- Clear = no further evaluation
Bloody = send to cytology and diagnostic mammogram/US
- Diagnostic mammogram/US & biopsy
What is core needle biopsy of the breast used for; how many samples taken?
- Get 3-6 samples about 2cm long tissue is retrieved from larger solid masses to diagnose
What are the 2 most common breast complaints?
- Breast pain (Mastalgia)
- Breast mass
What are the 3 types of benign mastlagia (breast pain)?
- Cyclic breast pain = usually cystic; starts at luteal phase of menstrual cycle and ends after onset of menses
- Noncyclic breast pain = usually tumors, mastitis, cysts and can be assoc. w/ some meds (anti-depressants/HTNs, hormonal meds (OCP’s))
- Extramammary breast pain = chest wall trauma, shingles, fibromyalgia
What is the only FDA approved treatment for benign mastalgia (breast pain) and what are the AE’s?
- Danazol
-
AE’s =
- Menstrual irregularities
- Benign intracranial HTN
- Alters blood sugar
- Deepens voice
- Unusual hair growth and weight gain
What are some recommendations for symptom relief of benign mastalgia?
- Properly fitting bra
- Lose weight
- Exercise
- ↓ caffeine intake
- Vit E & evening of primrose oil
______ is an off-brand treatment for mastalgia that can cause what side effects?
- Selective estrogen receptor modulator (SERM), tamoxifin
- DVT
- Endometrial hyperplasia
What should we worry about when we see nipple discharge?
- Usually benign could be sign of endocrine disorder or cancer
Non-spontaneous, non-bloody (can be clear, green or yellow) and bilateral nipple discharge is most consistent with what?
- Fibrocystic changes
- Ductal ectasia
Milky discharge from pregnancy indicates:
- Childbearing
- Hyperprolactinemia
- Hypothyroidism
- Medications (OCs/psychotropics)
_______ nipple discharge is CONSIDERED CANCER until proven otherwise.
What kind of cancer and if not cancer, what else could it be?
- Bloody
- Intraductal carcinoma or invasive ductal carcinoma
- Benign intraductal papilloma
Bloody nipple discharge
- Evalulate = ________
- Cure = ______
- Evaluate = breast ductography
- Cure = excise duct
What are the 3 categories of benign breast masses?
- Non-proliferative
- Proliferative w/o atypia
- Proliferative w atypia
What are the types of non-proliferative benign breast masses?
- Fibrocystic changes
- Cysts
- Adenosis
- Lactation adenomas
- Fibroadenomas
- Galactocele
Describe the following non-proliferative benign breast masses:
- Fibrocystic changes (how commonly seen in NL breast)
- Cysts
- Adenosis
- Fibrocystic changes: Dilation of lobules => form cysts; cysts rupture and scar and inflame; seen in 50% of NL breasts
- Cysts = dilation of lobules
- Adenosis = Lobular growth w/ # of glands
Describe the following non-proliferative benign breast masses:
- Lactation adenomas
- Fibroadenomas
- Galactocele (secondary infection can cause what?)
- Lactation adenomas: occur d/t hormones
- Fibroadenomas: solid, rubbery, mobile and usually solitary that are usually 2-4cm (but can grow up to 15cm)
-
Galactocele: cystic dilation of duct filled w/ milky fluid that occurs near time of lactation.
- Secondary infection can produce acute mastitis
Most common benign tumor in female breast?
-When does it usually occur?-
- Fibroadenoma
- Late teens- early 20s
- Concerns for malignancy of breast masses (5)
- > 2 cm in size, immobile and firm
- Poorly defined margins
- Skin dimpling/retraction/color changes
- Bloody nipple discharge
- Ipsilateral lymphadenopathy
What are the types of proliferative benign breast masses WITHOUT atypia? (4)
How are they usually found?
Usually not palpable and found on imaging.
- Epithelial hyperplasia
- Sclerosing adenosis
- Complex sclerosing lesions (radial scar)
- Papillomas
Descibe the following proliferative benign breast masses W/O atypia?
- Epithelial hyperplasia
- Sclerosing adenosis
- Complex sclerosing lesions (radial scar)
- Papillomas:
- Epithelial hyperplasia: overgrowth of cells that line ducts
- Sclerosing adenosis: increased fibrosis of tissue within lobules
- Complex sclerosing lesions (radial scar): tubules trapped in dense stoma surrounded by radiating arms of epithelium
- Papillomas: intraductal growth that can cause serous or serosanguinous discharge typically seen in W 30-50
Which type of benign breast mass is an intraductal growth typically seen in women 30-50 y/o and causes serous or serosanguinous discharge?
Papillomas
What is proliferative lesions with atypia?
Types?
NL epithelium that lines ducts/lobules is replaced by malignant cells, forming a CIS. BM is intact, cannot metastasize
- Lobular carcinoma in situ (LCIS)
- Ductal carcinoma in situ (DCIS)
What is not a precursor to breast CA but RF for developing breast CA?
LCIS
What is DCIS?
Puts women at risk for _______.
- Ducts are filled w/ atypical epithelial cells
- Developing invasive dz or recurrence of DCIS
How are LCIS and DCIS treated?
- Excision
- Then, treat with SERMs.
- Breast cancer is the most common malignancy in women besides _____ cancer; 2nd leading cause of cancer deaths in US
skin cancer
Increased mammogram screening has ______ incidence of breast cancer.
increased
Who is at greatest risk of breast cancer?
(age and race)
White women over 50
Difference between BRCA1 and BRCA2?
If you had one, which one would you rather have?
- BRCA1— in ½ of early onset breast cancers and 90% of hereditary ovarian cancers
- BRCA2—~35% of early onset breast cancers and much lower risk of ovarian cancer
Radiation for what increases risk to breast cancer?
- Hodgkines disease
- Enlarged thymus
Using the Gail Model-Breast Cancer risk tool, which women are considered high risk and how should they be managed?
- Women w/ 5-year risk of 1.7% or more
- Counseled on prophylactic therapy (chemoprevention, mastectomy, oophorectomy)
70-80% of all breast cancers are what type and where does it spread?
Ductal
Spread: regional LN
Which type of breast cancer is more likely to be multifocal and/or bilateral?
Lobular
______ is a superficial skin lesion of the nipple and makes up 3% of breast cancers.
Pagets disease
What makes up swelling and redness of underlying skin and induration of surrounding tissues and makes up 1-4% of breast cancer?
Inflammatory Breast Cancer
What should be used in addition to staging to determine treatment of breast cancer?
- Presence of estrogen and progesterone receptor (positive finding)
- Present of Her2/neu oncogene
Which 2 surgical options for breast cancer have equivalent outcomes?
- Lumpectomy w/ radiation
- Mastectomy
______ has the WORST prognosis and is found in 20-30% of all invasive cancers.
Her2/neu (oncogene)
What type of therapy is used in ALL stages because it reduces the rest of reoccurancy by 1/2 and death by 30%?
Adjuvant therapy
- Chemotherapy = kills all cancer cells
- Hormonal therapy (tamoxifen)
- Aromatase inhibitors (arimedex, femara)
- Trastuzumab (herceptin)
Which drug can be used for Her2/neu-positive breast cancers; but what are the AE’s?
- Trastuzumab
- AE’s: heart failure, respiratory problems, serious allergic rxns
Which adjuvant therapy is used in premenopausal therapy vs postmenopausal?
- Premenopausal = hormonal therapy (tamoxifen) is a EST ANT that reduces risk in other boob as well
- Postmenopausal= aromatose inhibitors (arimedex/femara) prevents production of estrogen
What is the recommended timeline for treatment follow-up for breast cancer; when do the majority of reoccurrences happen?
- During the first 2 years after diagnosis: every 3-6 months
- After first 2 years: annually
- Most reoccurrences happen within first 5 years after tx
