All Breast Conditions Flashcards
Acute Mastitis - Cause?
Staph aureus (ass’d w/ breast feeding) enters & travels retrograde
(2nd most common is Streptococcal infection)
(Related to nipple fissures and milk stasis)
Acute Mastitis - Tx?
- Continue nursing
- Dicloxicillin (10-14 days)
(if not, then Cephalexin or Clindamycin)
Subareolar duct epithelium is lined by ______ cells.
columnar
Non-puerperal Mastitis - Tx?
- Broad spectrum antibiotics
- Surgical drainage if necessary
Mammogram indicated after treatment to rule out underlying carcinoma
Non-puerperal mastitis may be associated w/ _____
MRSA
also, may be related to nipple trauma or fissures
2 causes of fungal infection of the breast?
Candida Intertrigo
Tinea Versicolor
Fungal infection of the breast w/ Candidal intertrigo/tinea versicolor are associated w/ what 3 things?
Pendulous breasts
Skin maceration
Diabetes
Fungal infection of breast: Candidal Intertrigo - Tx?
Treat with skin care and topical antifungals
Fungal infection of breast: Tinea Versicolor - Tx?
Clotrimazole, selenium sulfide or other topical antifungals
Nipple cream or gentian violet
During breast development, when is glandular/alveolar development completed?
w/ pregnancy
Amastia:
a) Which is more common, bilateral or unilateral?
b) Is the nipple-areola complex usually intact?
a) Unilateral (bilateral often ass’d w/ other anomalies)
b) Nipple-areola complex usually intact
Most common breast anomaly?
Polythelia / Polymastia
- Supernumerary nipples / breasts
- Incidence of 0.5 – 2.5%
- Bilateral in 30 - 50%
- Develop along milk lines
Polythelia/Polymastia - Clinical importance?
- May show physiologic changes of normal breasts
- Subject to same spectrum of disease
- Excise p.r.n.
What congenital anomalies is Polymastia ass’d w/?
- Congenital syndromes affecting chromosomes 3 & 8
- Turner Syndrome(45,X)
Premature Thelarche:
__a__ age 2 usually resolves completely.
__b__ age 2 it may persist (precocious puberty).
a) Before
b) After
Gynecomastia - 3 typical causes?
Hyperestrogenism, Klinefelter’s, drugs
Juvenile breast hypertrophy - cause & clinical Sx?
- Failure of arrest of normal breast enlargement; may be estrogen hypersensitivity or altered progesterone release
- Usually bilateral, massive and idiopathic
Juvenile breast hypertrophy - Management?
- Treat surgically; support with tamoxifen
- Rule out drug exposure
What is “Fibrocystic disease” of the breast?
Physiologic nodularity of the breast
In whom is Fibrocystic disease of the breast normal?
Premenopausal females or any woman on exogenous hormone therapy
Fibrocystic disease is a common complaint in _____ (whom)?
Common complaint in peri-menopause/often cyclic
When is Mastalgia normal/abnormal?
Normal = when it is cyclic
Abnormal = Non-cyclic – imaging indicated if unilateral, progressive and intense
Extramammary Mastalgia – what should be considered?
Costochondritis, superficial thrombophlebitis of lateral thoracic vein (Mondor disease)
What is Mondor Disease & when is it most commonly seen?
- Rare thrombophlebitis of superficial veins on or adjacent to the breast
- Lesion is a palpable, tender cord
- Process is usually benign and self-limited
- Most commonly seen as complication of cosmetic surgery
Mondor Disease - Tx?
Heat & NSAIDS
Age appropriate imaging may be indicated
FDA-approved pharmacologic therapy for Mastalgia?
What are 3 other “potentially effective” Txs?
FDA-approved = Danocrine
Others:
- Change to monophasic OCP
- Evening Primrose Oil
- NSAID
Non-pharmacologic therapy for Mastalgia?
Appropriate fitting bra/avoid caffeine
Factors ass’d w/ “suspicious” nipple discharge?
- Spontaneous
- Unilateral
- Uniductal
- Clear, serous, or bloody
Diagnostic evaluation of nipple discharge?
- Exam
- Mammogram/ultrasound
No further work up if:
- Bilateral
- No mass
- Normal mammogram
Galactorrhea - causes?
Usually associated with elevated prolactin
- Breast stimulation
- Thyroid dysfunction
- Prolactin adenomas
- Medications
- Pregnancy
- Stress
(Not associated with intrinsic breast disease)
Activators & inhibitors of Prolactin secretion?
Serotonin → TRH→ ↑ Prolactin
Estrogen → ↑ Prolactin
Dopamine → ↓ Prolactin
Drugs Associated with Hyperprolactinemia or Galactorrhea?
Typical antipsychotics
- Phenothiazine drugs (Chlorpromazine, Thorazine)
- Haloperidol
- Pimozide
Atypical antipsychotics
- Risperidone
- Molindone
- Olanzapine
Antidepressant agents
- Clomipramine
- Desipramine
Gastrointestinal drugs
- Cimetidine (Tagamet)
- Metoclopramide (Reglan)
Antihypertensive agents
- Methyldopa (Aldomet)
- Reserpine (Hydromox, Serpasil, others)
- Verapamil (Calan, Isoptin)
Opiates
- Codeine/Morphine
What is the most common non-proliferative breast lesion & where does it arise from?
Breast Cysts
- Arise from the terminal ductal lobular unit
(“smooth, mobile, non-tender”)
Management of smooth, mobile, non-tender breast lesion?
- Repeat exam 4-6 weeks after aspiration to rule out recurrence
- Cyst Aspiration
Dx?
Smooth, mobile, non-tender lesion.
On mammogram, spicules extending into surrounding tissue.
Breast Cyst
Fat necrosis - Presentation? Diagnosis?
- Uncommon lesion: isolated, sharply demarcated mass, tender
- Follows direct breast trauma
- Early stage cases present with erythema and edema
- Late stages mimic carcinoma
- Diagnosis by history and mammogram; treatment is symptomatic
Most common benign tumor of the breast?
Peak incidence?
Fibroadenoma (occurs in 10% of women)
Peak incidence between 20-40
Fibroadenoma - basic characteristics?
- Contain benign epithelial and stromal components
- Painless, spherical, smooth, and mobile
- Estrogen sensitive
Fibroadenoma - Tx?
Observation
Excise if :
- Double in size in less than 1 year
- Exceed 5 cm in size
The most common cause of spontaneous nipple discharge from a single duct?
Intraductal Papilloma
- Can be solitary or multiple
- Occurs most often in women ages 35 - 55
- Etiology and risk factors unknown
- Slight increase risk of malignancy (1.5-2.0%)
Low risk factors for Breast Cancer?
- Female Gender- Menarche by age 11- No live births before 35 - Post menopausal hormone replacement- Race: Non-hispanic white females- Age (increasing)
Moderate risk factors for Breast Cancer?
- Personal Hx of breast cancer2. Biopsy proven precancerous lesion3. Hx of breast cancer in 1st degree relative4. Dense breasts
High risk factors for Breast Cancer?
- Hx of chest radiation btwn ages 10-30- BRCA gene mutation- Li-Fraumeni syndrome- Cowden syndrome- BRCA gene mutation, Li-Fraumeni syndrome or Cowden syndrome in 1st degree relative
BRCA gene mutations
- Most common hereditary cause of breast cancer- Tumor suppressor genes on the long arm of chromosome 17
______ gene increases the risk of developing male breast cancer
BRCA2
_____ gene mutation increases the risk of developing breast cancer (80%) and ovarian cancer, usually serous type (50%)
BRCA1
BRCA gene breast cancer - Presentation?
Young woman with a high-grade (poorly differentiated) breast cancer
Breast Cancer Screening methods
- Monthly self breast exam.- Annual breast exam by healthcare professional.- Annual mammogram starting at age 40.- + MRI for high-risk patients
In-situ Breast carcinomas – types?
- Ductal carcinoma in-situ- Lobular carcinoma in-situ- Paget’s disease
Dx?- Almost always detected by mammogram- Usually presents as micro calcifications- Represents up to 30% of breast cancers
Ductal Carcinoma In-Situ (DCIS)
Lobular Carcinoma in-situ – Tx?
Anti-Estrogen
Dx?- Always an incidental finding- More common in PREmenopausal women- Not associated with calcifications
Lobular Carcinoma in-Situ (LCIS)
Dx?- A form of in-situ carcinoma, where tumor cells grow within the epidermis of the nipple and/or areola.- Present 1-4% of breast carcinoma.- Almost always associated with underlying high-grade DCIS or invasive carcinoma
Paget’s Disease
Dx?Presents as an eczematous, red, crusted nipple lesion.
Paget’s Disease
How does Paget’s Disease present?
Presents as an eczematous, red, crusted nipple lesion
DCIS - Almost always detected by ______
mammogram
DCIS - Usually presents as ______
microcalcifications
DCIS - how is it characterized prognostically?
- Comedo (grossly, if you squeeze the cut surface of the lesion, the necrotic material is pushed out like comedons) or Non-Comedo2. Low, Intermediate, or High Grade — based on degree of nuclear atypic
Intraductal proliferation with punched out spaces “cookie cutters” – this sub-type of DCIS is referred to as ______ type.
DCIS: Cribriform type
What sub-type of DCIS is described below?The duct is completely filled with a monotonous population of cells; also note associated microcalcification.
DCIS: Solid type
How does invasive breast cancer present clinically?
- Presents as a mass, either palpable or mammographically detected- Central tumors may cause retraction of the nipple
________ is a high grade carcinoma by default.
Inflammatory carcinoma
Inflammatory Carcinoma - characteristics?
- Carcinoma that presents with swollen erythematous breast.- Invasion of the dermal lymphatics blocks drainage leading to lymphedema, swelling and thickening of skin- Tethering of the skin of the breast to the Cooper ligaments mimics an orange peel “peau d’orange”
Dx?Carcinoma that presents with swollen erythematous breast
Inflammatory Carcinoma
What causes Inflammatory Carcinoma to mimic an orange peel (“peau d’orange”)?
Tethering of the skin of the breast to the Cooper ligaments
What causes Inflammatory Carcinoma to present w/ lymphedema & swelling?
Invasion of the dermal lymphatics blocks drainage leading to lymphedema, swelling and thickening of skin
Invasive Lobular Carcinoma:a) Usually ____ Gradeb) Usually focal or multifocal?c) Prognosis similar to ____ of same grade and stage
a) Lowb) Multifocalc) IDC
What are the most characteristic histologic features of invasive lobular carcinoma?
- Infiltration of tumor cells in single files- They are commonly arranged circumferentially around benign residual ducts in a “targetoid” fashion (arrow)
Dx?Small, low grade tumor composed entirely of small tubules, with pointed ends “tear-drop shape”
Tubular Carcinoma
Tubular Carcinoma - Prognosis? Risk of metastases?
- Low risk of metastases- Excellent prognosis
T or F?In Tubular Carcinoma, the tubules are lined by a single layer of bland tumor cells with hardly any mitotic activity.
True
Dx?Composed entirely of aggregates of tumor cells floating in pools of mucin.
Mucinous (Colloid) Carcinoma
Mucinous (Colloid) Carcinoma:a) ____- Grade tumorb) Demographic?c) Prognosis?
a) Low-grade tumorb) Elderly womenc) Good prognosis(Composed entirely of aggregates of tumor cells floating in pools of mucin)
Medullary CA:a) Gross appearance?b) Histology?c) Genetics?
a) Sharply-circumscribed, soft fleshy tumorb) Malignant cells admixed with intense lymphocytic infiltration.c) More common in BRCA1 carriers
________ typically has a well-circumscribed pushing (as opposed to infiltrating) border and syncytial sheets of tumor cells in a stroma rich in lymphocytes and plasma cells.
Medullary carcinoma
Dx?Adenocarcinoma but not forming glands!
Metaplastic CA(Metaplastic component may be squamous, spindle cells, fibroblasts, bone, cartilage, etc…)
Metaplastic CA:______ outcome than other types
Worse
What are the Modified Bloom-Richardson Criteria for tumor prognosis?
- % of tubule formation2. Degree of nuclear atypic3. # of mitotic figures in 10HPFLow grade = More tubules, less nuclear atypia, fewer MFThe higher the grade, the worse the prognosis
How is tumor “Stage” determined?
TNMT = Tumor Size.N = lymph Node metastasesM = distant MetastasesRule #1: Inflammatory carcinoma is considered T4Rule #2: Distant metastases is stage IV
For TNM staging, inflammatory carcinoma is considered ____.
T4
The most important prognostic factor for Breast cancer?
Axillary Lymph Node metastases
Molecular Classification - 3 classifications & prognosis of each?
- Luminal-type Carcinomas express Estrogen and have the BEST prognosis. 2. Her2-type cancers do not express ER or PR but show Her2-gene amplification. They have a BAD prognosis3. Basal-like breast cancer are negative for all 3 markers & have the WORST prognosis(more common in African-American women)
What are “Triple Negative” breast cancers?
Basal-like breast cancers, which are negative for all 3 markers (ER, PR, & HER-2). Of the 3 molecular classifications, these have the WORST prognosis.
What are “Triple Negative” breast cancers?
Basal-like breast cancers, which are negative for all 3 markers (ER, PR, & HER-2). Of the 3 molecular classifications, these have the WORST prognosis.
Pathologic features of Luminal-type-A breast cancers?
- WD IDC- Lobular cA- Tubular CA- Mucinous CA
Pathologic features of Luminal-type-B breast cancers?
- MD IDC- Lobular CA
Pathologic features of Basal-like breast cancers?
- Poorly-differentiated IDC- BRCA1- assoc- African-American women
Pathologic features of Basal-like breast cancers?
- Poorly-differentiated IDC- BRCA1- assoc- African-American women
Luminal Type A breast cancer – Tx?
Tamoxifen
Luminal Type B breast cancer – Tx?
Tamoxifen
Basal-like breast cancer – Tx?
Chemotherapy
Basal-like breast cancer – Tx?
Chemotherapy
Trastuzumab - MOA?
Monoclonal antibody to HER-2 receptors- binds receptor on tumor cells to induce an antigen-antibody-reaction leading to cytotoxicity of tumor cells.
