6 - Breast Flashcards
Anatomy review
Milk made in alveoli cells of the lobules -> travels down the duct to the nipple
Appx 10-20 lubules per duct
One set of lobules with a single duct for collection is called a lobe
MC type of breast CA?
Ductal carcinoma
Lobular carcinoma is rare
Common breast complaints
Pain Mass Discharge Gynecomastia (dudes) Abnormal mammo
Imaging for breast complaints
Diagnostic MMG
US
Invasive testing for breast complaints?
Tissue dx - if prior biopsy, get report
Txt for breast complaints
Aspirate
Refer to surgery
Patient positions for clinical breast exam
Sitting leaning forward
Sitting with arms raised
Sitting with pectoralis muscles flexed
Supine
What to examine with CBE?
All four quadrants including tail of Spence
All tissue, nipple and lymph nodes
Features of benign breast pain?
Cyclical
Bilateral
No focal area
Diagnostic problem breast CA?
Often painless (hence the importance of screening)
Management for breast pain
Diagnostic MMG c f/u US
Oral contraceptives (stabilize hormones)
Encourage exercise
Avoid: narc, diuretics, iodine, tamoxifen, danazol
Decreased caffeine
Probably causes of breast pain:
Pregnancy Infection Fibrocystic breasts Costochondritis Mondor’s Dz
What is Mondor’s Dz?
Trauma of chest wall vein after trauma / surgery
Presentation of acute mastitis
Cellulitis around the nipple No mass (abscess)
Culture it out -> usually staph or strep
Workup for acute mastitis
Complete CBE
C and S
Txt for acute mastitis
ABX (staph and strep coverage)
Localized moist heat
Continue to drain breast (pump or continue to breast feed)
Breast abcess
Raised tender mass near the nipple
Fever chills swears leukocytosis
Acute? Normally lactating breast
Chronic? Normally duct ectasia (thick, green black sticky discharge, older women)
Txt for breast abscess
Stop nursing
Admit
IV ABX
I and D
What is Macromastia?
Breast hypertrophy
Bra staps dig into shoulders
Upper back pain, poor posture
Chronic dermatitis under breasts
Difficult to find fitting clothes
Complications of breast reduction
Infection
Bleeding
Numbness
Undesired cosmetic outcome
Extra nipples?
Yup, it’s a thing.
Supranumerary nipple
Often noticed during pregnancy - can occur anywhere along the milk line
Totally benign - just excise it
Are most breast masses serious?
80% are benign (i.e. fibroadenoma)
Fibroadenoma
Smooth or slightly lobulated
Appx 1-3cm in diameter
Txt fro for fibroadenoma
Leave it alone, as long is it’s benign by exam, MMG, and FNA
If they’re over 35yrs, excise it if the patient wants
Fibrocystic changes are common in:
Women during childbearing ages
Fibrocystic changes will present with:
Bilateral breast pain, nipple discharge and palpable mass
Correlate with menses and tenderness peaks during luteal phase
Usually concerned about CA - reassure pt that these are benign
Workup for fibrocystic changes:
CBE during different phases of menstrual cycle
MMG
Bx (FNA, core needle, or open)
Txt for fibrocystic changes
No caffeine (womp womp)
Support bras
NSAIDs
Vit E / Primrose oil
Rarely (tamoxifen, danasol, SubQ mastectomy)
Nipple discharge:
Pt hx important - unilateral or bilateral, color, spontaneous, relation to menses, meds, associated with a mass?
Workup for nipple discharge?
Inspection / palpation Palpable mass Diagnostic MMG Peri-areolar US Cytology HCG, prolactin, FSH, LH thyroid function Refer to surgery
Most nipple discharges are:
Benign - most intraductal papilloma or mammary duct ectasia
Less than 15% are ductal carcinoma in situ
What is galactorrhea?
Bilateral milky discharge in non-lactating women
Not associated with breast CA
Check for hyperprolactinemia or hypothyroidism
Diagnostic MMG and follow up US if warranted
Unilateral gynecomastia
Normally young dudes
Benign
Usually goes away on its own but for teenage boys this is hell, so you can do a subcutaneous mastectomy for them
Bilateral gynecomastia
Decreased androgen production as dudes age
Normally without discharge
Causes: testicular tumors, lung CA, starvation, thyrotoxicosis, klinefelters, roids, weeds, INH
MMG and US (if warranted)
Reassurance and routine consult with general surgery
Screening MMG
Not as detailed as a diagnostic MMG
Diagnostic MMG
Follow-up on lesion found during screening or abnormal exam
Goal of MMG’s
Detect breast CA before it becomes palpable and, theoretically, earlier detection relates to improved chance of survival
Is MMG a substitute for CBE/SBE?
No
What are the two standard views for MMG?
Craniocaudal (CC)
Mediolateral (CL)
Limitations of MMG?
Dense breasts -> difficult to image
Breast implants can obscure findings
Uses ionizing radiation
What is BI-RADS?
Breast Imaging Reporting and Data System
BI-RADS categories
0 - additional imaging needed
1 - negative or normal
2 - benign findings (vascular Ca++, stable lesions, etc…)
3 - probably benign (repeat in 6 mos)
4 - Suspicious (consider Bx)
5 - Highly suggestive of malignancy (definitely Bx)
6 - Biopsy proven malignancy
Features of a BI-RADS 2?
Well-circumscribed homogenous mass
Large / macrocalcifications
Dense calcifications
Calcified blood vessels
Stable benign findings which have not changed form previous MMG
When is breast US normally used?
If there is a mass found on MMG
Helps distinguish between cystic or solid mass (smooth-walled = likely benign, irregularly-shaped = needs further workup)
Can also be used to guide needle Bx or aspiration
Is breast US useful in screening?
No
MRI is helpful for:
Evaluating tumor size
Guiding surgical treatment plan
Doesn’t require compression of the breast
Good for dense tissue or those with implants
Risk factors for breast CA:
Females (100x more common than men)
Advancing age
First-degree relative with breast CA
High dietary fat
BRCA1 - 60% lifetime risk
BRCA 2 - 30% lifetime risk
Not necessarily risk factors for breast CA:
Breastfeeding More distant relative with breast CA OCP’s Boob job Hx of mastitis Fibrocystic breast
MC presentation of breast CA:
Found lump during SBE
Painless, unilateral, without nipple discharge
Hard mass with irregular margins
Later signs of breast CA:
Skin dimpling Nipple retraction Fixation to chest Axillary lymphadenopathy Peau d’ orange
Workup for breast CA
Focused H and P
Diagnostic MMG with f/u US
Bx (FNA, Core Bx, incisional or excisional Bx)
MRI prior to surgery
Difference between incisional vs excisional Bx?
Inc - take a piece of the mass
Exc - take whole mass (lumpectomy)
Core Bx
Spring-loaded
Can be done with or without US-guidance
“Fired” through the mass, sample sent to pathology
Needle localized Bx
For non-palpable mass
Two parts:
1- in clinic - wire inserted under US or CT guidance
THEN
2 - taken to OR for excision of tissue
Incisional and excisional Bx
Both for palpable mass
Performed in OR
Incisional - piece taken - better cosmetic outcome
Excisional - entire mass removed with “clean margins” - sent to pathologist - can remove in-situ or non-metastisized mass in one surgery
Pathology - estrogen receptor (ER) treated with:
Antiestrogens
Pathology - progesterone receptor (PR) treated with:
Antiprogesterones
Pathology - Human epidermal growth factor receptor (HER2) treated with:
Anticlonal antibodies
Poor prognosis 2/2 rapid metastasis
Triple negative breast CA:
Most are BRCA1 (+)
Negative for ER, PR, and HER2 (hence “triple negative)
Most aggressive breast CA, worst prognosis
Mainstay txt with chemotherapy
MC breast CA type:
Infiltrating ductal carcinoma
What is lobular carcinoma in situ?
Marker for CA
Still encapsulated in the lobe
30% chance of developing CA
What is ductal carcinoma in situ?
Cancerous lesion and must be removed
After excision, XRT to remaining breast tissue
What’s the deal with Paget’s dz of the breast?
Ductal carcinoma involving the nipple
May or may not have palpable mass
Nipple itching/burning
Eczematoid / crusted lesion on the nipple or areola
Any lesion refractory to topical abx or steroids >1 week should be referred to surgery
Inflammatory breast CA presents with:
Erythema and edema of breast tissue usually without palpable mass
Can be confused with mastitis - does NOT respond to ABX
Non-lactating women
Highly malignant
Male breast CA:
<1% of breast all breast CA cases occur in men
Usually older guys
BRCA2
Often involves the nipple
Sentinel node bx and lumpectomy
Inject dye
See hot spots in mass and nodes
Go in and take the node, if it has CA, gotta remove the axillary lymph node chain
If negative, no dissection necessary - external beam radiation is used, instead
Modified radical mastectomy:
MRM
Remove all breast tissue, nipple, axillary nodes
Spares underlying muscle
Retains some skin for reconstruction
Radical mastectomy
Removes all of the breast, overlying skin, pectoralis muscles, and lymph nodes
Usually major blood loss
Decreased function of arm
More lymphedema of the arm
Neoadjuvant chemo/XRT
Txt prior to surgery to debulk tumors
Adjuvant chemo/xrt
Txt after surgery
What is the most important prognostic variable concerning breast CA txt?
Whether the tumor has metastasized to the axillary lymph nodes
What normally left in place after lumpectomy?
Drains, to prevent seromas
Drains are pulled out when drainage is less than _____ ml/24H
30
What happens if you injure the long thoracic nerve?
Winged scapula
What happens if you injure the thoracodorsal nerve?
Latissimus dorsi (issues with that muscle, I guess - doesn’t specify)
Describe XRT
Radiation therapy - targeted (tangential)
2 to 6 weeks AFTER surgery,
5 times a week,
For 6 to 8 weeks
SE’s of XRT
Lethargy N/V Dry skin Breast tenderness Lymphedema of the arm Lung scarring Cardiomyopathy Myalgias
TRAM
Transverse Rectus Abdominus Muscle
Flap can be used to reproduce the breast mound after mastectomy
Other reconstruction / cosmetic option (besides TRAM)
Tissue expander
Gradually increase saline content, then once the size is where you want it, permanent implant is placed
Of course my breasts are fake
The real ones tried to kill me
