Approach to a breast mass Flashcards
Differential diagnosis
Fibroadenoma Fibrocystic changes Fat necrosis Intraductal papilloma Breast abscess Atypical ductal/lobular hyperplasia DCIS Invasive breast cancer
Percentage of women presenting with a breast mass that are malignant
10%
Triple test
Physical examination
Imaging
Biopsy
Most common cause of breast mass
Fibroadenoma
Risk of breast cancer in women with fibroadenomas
Twice the risk
What does fibrocystic disease encompass, and when is it more common
Pre/perimenopauses
Are breast cysts common in post-menopausal
Cysts Epithelial hyperplasia Apocrine metaplasia Cystic dilation Fibrosis
Bloody nipple discharge, typical of what lesion
Intraductal papilloma
When are breast abscess more common
Breastfeeding
Types of premalignant breast lesions
Atypical ductal hyperplasia
Atypical lobular hyperplasia
What causes dimpling of the skin in breast cancer
Malignant infiltration of fibrous contraction of coopers ligaments
Arterial supply of the breast
Axillary artery
Internal thoracic
Lymphatic drainage of the breast
Axillary: Apical= infraclavicular Anterior= pectoralis major Posterior= subscapular Lateral= axillary vein Cantral= axillary fat
Internal mammary:
Drains medial breast
Proliferative (non-neoplastic) changes in breast
Metaplasia Adenosis Simple cysts Diabetic fubrous matopathy Fibrocystic
Management of likely benign lesion on USS
Clinical and ultrasonographic surveillance every 6 months for 2 years, to document stability
Core needle biopsy to make a definitive diagnosis while leaving the lesion in situ
Surgical removal of the mass, particularly if the lesion is bothersome to the patient.
Benign neoplastic proliferations
Fibroadenoma
Atypical ductal/lobular
Sclerosing adenosis
Ductal papilloma
What imaging method is preferred in women >30 and
Mammography preferred in women >30 yo
USS preferred in women
BIRADS categories, description and recommmendation
0= need more info, further imaging 1= normal, routine screening mammography 2= benign, routine screening mammography 3= probably benign, short term f/u in 6 months 4= highly suspicious, biopsy 5= malignant, biopsy 6= known cancer, treat malignancy
Algorithm for breast USS
Solid–>
- Suspicious= biopsy
- Probably benign= biopsy or f/u
Cystic–>
- Simple= follow or aspirate
- Complex= biopsy
Main types of biopsy
FNA
Core needle
Excisional
FNA advantages and disadvantages
A: easy, painless, office, small needle
D: expert cytopathologist, cannot evaluate histology
Core needle advantages and disadvantages
A: easy, painless, office, histopathology, tissue, receptor status
D: slightly larger needle
Excisional advantages and disadvantages
A: histopathology, tissue architecture, receptor status
D: need OT, larger incision, painful
When would cystic fluid be sent for cytology
When blood
Investigations for fibroadenoma
In women physical
In >35-> U/S, biopsy
Biopsy in fibroadenoma, when to review and management if stable vs growing
Review in 3 months
Stable->USS and review in 12/12->stable = d/c. Growth->refer for surgical
Growth->surgical opinion
Progress of fibroadenoma
Usually doesn’t change
Hormone responsive
Not in itself pre-malignant
What is phylloides tumor
Intralobular stroma, leaf like protrusions
+Cellularity, mitosis, pleomorphism, +infiltration
Does not regress
8% malignant
Causes of nipple discharge
Physiologic->pregnancy, lactation Galactorrhea Duct ectasia Ductal papilloma Cyst Malignancy Idiopathic
Relative risk of malignant breast disease when presenting with benign breast disease
Moderately increased risk (4–5×)
Atypical ductal hyperplasia
Atypical lobular hyperplasia
Radial scar
Slightly increased risk (1.5–2.0×)
Moderate or florid hyperplasia
Multiple papilloma
No increased risk Cysts Fibroadenoma Duct ectasia Mild hyperplasia Sclerosing adenosis Apocrine change
When is nipple discharge likely to represent a physiologic process
Clear
Yellow or green
Multiple ducts
On nipple stimulation
When is nipple discharge more suggestive of a pathalogic process and common etiologies
Spontaneous
Persistent
Bloody
Associated with a mass
- Ductal papilloma
- Ductal ectasia
- Cancer
- Infection
Definition of galactorrhea
Discharge of milk/serous fluid in the abscence of parturition or beyond 6 months post partum in a non-breast-feeding woman
Etiology of galactorrhea
stress,
physical irritation,
hypothyroidism,
chronic renal failure,
hypothalamic-pituitary disorders,
hormone-secreting neoplasms (most commonly pituitary adenomas), or
may be idiopathic but is not associated with breast cancer.
can block dopamine and histamine receptors, deplete dopamine stores, inhibit dopamine release, and stimulate lactotrophs.
Common medications and classes
of medications: SSRIs, TCAs, atenolol,
verapamil, antipsychotics, H2 histamine blockers (cimetidine), and opiates,
Estrogen in oral contraceptives can cause galactorrhea by suppressing the hypothalamic secretion of prolactin inhibitory factor and by direct stimulation of the pituitary lactotrophs
Investigations in galactorrhea
Discontinue offending agents UEC TSH Prolactin Pregnancy test in reproductive age MRI if ++prolactin
Management of glactorrhea
Manage underlying conditions
Bromocriptine is preferred treatment for hyper-prolactin induced anovulatory infertility
