breast Flashcards
who should be screened with mammography
free for all women over 40
for screening to be useful and effective, you need to be obtaining a diagnosis that will allow for a likelihood of survival of at least 10 years (since expected mortality is age 85, stop screening at 75)
what views are used in screening mammography
2 views
medial/lateral/oblique to include axial tail and cranial-caudal
are screening and diagnostic mammography the same thing?
no
screening is two views
diagnostic is done after an abnormality is detected (i.e palpable lump or abnormal screening mammogram)–> has several views including lateral and magnification/cone views
describe the elements of a breast history
- lump–> duration, tenderness, change with menses
- nipple discharge–> color, spontaneous, unilateral or bilateral
- nipple inversion or scaling
- breast dimpling, ulceration, erythema, edema
- symptoms of distant mets disease
- gyne history–> age of menarche, menopaus; parity; age at first pregancy; breast feeding; use of OCPs or hormone replacement therapy
- PMHx–> previous history of breast disease, recent breast trauma, prior radiation, family history
what elements make up a complete breast exam
both breasts
both axillae and supraclavicular fossae
lungs and liver and vertebral percussion tenderness (if indicated
what is the most common cancer for women
breast
DDx of a breast mass
Vascular–> hematoma, AVM
Inflammatory–> mastitis, abscess
Neoplasm–> benign (fibroadenoma) or malignant (breast or non breast) primary or secondary
Degenerative/deficiency/drugs
Idiopathic, intox
Congenital–> breast bud
Autoimmune/allergic–> non infectious mastitis
Traumatic–> fat necrosis
Endocrine–> fibrocystic change, cysts, gynecomastia
screening for ages 50-74 with no family history
every 2 years
screening for ages 50-74 with family history
annually
screening for ages 40-49 with no family history
discuss with MD
how much does screening reduce mortality from breast cancer
30% reduction
screening for ages 40-49 with family history
offered every 2 years
screening for ages above 74
discuss with MD
how does the accuracy of mammograms change with age
more accurate as you get older because breast less dense
30% less accurate under age 40
screening for ages below 40
not recommended unless high risk requires referral
major risk factors for breast cancer
- being female
- family history of breast cancer in 1st degree relative especially if premenopausal or bilateral or ovarian cancer in 1st degree relative (most women who are dx have no family history)
- known BRCA1/2 mutation carrier
- personal history of lobular carcinoma in situ (LCIS)
- atypical hyperplasia
- previous chest wall irradiation to developing breast
- mammographic density greater than 75% of the breast volume
what is the most common abnormality found on mammography
micro calcifications (not palpable)
worry about calcifications that are irregular and clumped together (more than 10 in one area)
moderate risk factors for breast cancer
older age
personal history of breast cancer
north american/european descent
hyperplasia without atypia
some mammographic density
lesser risk factors for breast cancer
family history of post menopausal breast cancer
nulliparity
later age at menopause or early age at menarche
post menopausal obesity
alcohol consumption and diet
what factor might make you consider a breast lump to be malignant
taller than wide in breast tissue
how do breast cysts present
likely due to estrogen stimulation, common between ages 40-60/premenopausal
may be multiple or solitary, fluctuate in size and degree of tenderness and the menstrual cycle
are mobile, may be ill defined, usually round, not always fluctuant
may recur after aspiration so reassess in 6 weeks
how do you investigate a breast mass
- imaging (U/S, mammogram)
- clinically guided FNA, aspiration (can be done as family doc without local) for immediate diagnosis and treatment
- core biopsy gets architecture to tell you if a cancer is invasive or not
how do you do an FNA in clinic
22 gauge needle, 10 cc syringe, alcohol swab and bandaid, urine specimen container
only gathers cells but can say whether benign or malignant
fluid enters if its at least partially a cyst–> examine the fluid and re-examine the breast
- -green tinged or straw colored fluid/clear cloudy is normal
- -re-examine the breast to be sure the mass is gone
- -if the fluid is normal and the mass is gone, discard the sample
- -old blood or persistence of the mass, send fluid for cytology and arrange breast imaging
describe what fibrocystic breast changes are in the breast
common manifestation of normal breast physiological changes related to the menstrual hormone cycle that occurs in almost all women–> usually lumpiness (no discrete lump) with pain and fluctuates with cycle
microscopic cysts embedded in dense fibrous tissue of the breast gives a “lumpy” or nodular quality without a discrete mass –> imaging is normal
management of breast fibrocystic changes
reassurance–> no increased risk of malignancy
manage pain and diet–> reduce salt, caffeine intake, dietary fat intake
severe mastalgia responds to hormonal manipulation (sometimes over OCPs, danazole, tamoxifen)
if 50% of your relatives have breast cancer, what is your lifetime risk?
50%
send this women for BRCA mutation testing
if your mother has breast cancer, what is your lifetime risk?
30%
BRCA positive women have what risk for breast cancer
85% or greater risk
curable with mastectomies
what is lobular carcinoma in situ and how is it detected
detected by doing biopsy for other reasons i.e fibroadenoma
LCIS implies a greater personal risk (1% a year) of developing breast cancer in either breast
not a mass–> it is an insidious pathological finding
is a tissue confirmation necessary if radiology says a breast lump is consistent with a fibroadenoma?
not always if very young or very typical physical exam and imaging
yes if older patient, solid and cystic components, atypical features on physical and imaging (irregular margins, lobulation etc)
what kind of tissue diagnosis is needed for a fibroadenoma
FNA biopsy showing benign cells is enough if not worried
if concerned you can get a core biopsy
what is the natural history of a breast fibroadenoma
if less than 3cm in diameter–> 1/3 get smaller, 1/3 remain stable, 1/3 enlarge
may enlarge during pregnancy
risk of malignancy in adenoma is less than the chance of cancer in the rest of the breast
remove if enlarging, symptomatic or at patient request
generally follow with U/S imaging for growth
what is the “triple test” for breast lump
clinical assessment
imaging
cytology
if all three are benign, lesion is probably benign (98%) and can be followed
if any aspect of the triple test is inconclusive or suspicious, needs further workup
what is lactational mastitis
secondary infection due to obstructed milk ducts
management of lactational mastitis
directed massage to facilitate emptying, continued nursing, abx to cover staph aureus
may progress to an asbcess, requiring serial aspirations and continued abx
how do you manage a breast abscess
typically requires drainage with serial aspirations or incisions
may need IV abx if systemically unwell
culture fluid to guide abx
can continue nursing
how do you manage simple breast cysts
leave them alone and follow
dont need to do anything
what is non lactational mastitis
much less common and associated with smoking
tends to be recurrent ad associated with draining sinuses at the areolar margin
typically has periareolar mastitis and abscess formation
treat recurrent disease with surgical resection of involved ducts
what causes gynecomastia
imbalance of estrogen and testosterone, may be unilateral or bilateral
what is the etiology of gynecomastia
- natural increases in estrogen due to puberty, aging etc or extra causes of increased estrogen i.e obesity
- meds–> antiandrogens, anti ulcer meds, anxiolytics, tricyclics, digoxin, CCBs, some abx
- drugs–> alcohol, anabolic steroids, marijuana, amphetamines, heroin, methadone
- disease–> hypogonadism, hormone producing tumours, hyperthyroidism, renal or liver failure
how do you investigate gynecomastia
U/S anf mammogram looking for breast tissue
how do you manage gynecomastia
reassurance if developmental
otherwise treat underlying disease or stop drug use
not associated with increased cancer risk
symptom control
surgical resection of requested
what abx to use for mastitis/breast abscess
keflex
what is the most common cause of spontaneous, unilateral, uniductal serious or bloody nipple discharge with normal mammogram?
intraductal papilloma (98%)
what is intraductal papilloma
benign growth in the duct
how do you investigate intraductal papilloma
U/S and mammogram to exclude underlying cancer–> do mammogram with all bloody discharge
galactogram is optional (mammogram study with contrast to look at ductal system)
cytology of discharge doesnt change management so not necessary
treatment of intraductal papilloma
surgical excision of the involved duct (also helps exclude intraductal papillary cancer)
what is bilateral milky discharge?
galactorrhea–> physiologic, drug related, or pituitary prolactinoma (must do serum prolactin to rule out prolactinoma)
what is bilateral green/yellow multiductal sometimes foul nonspontaneous discharge
dialted retroareolar ducts filled with debris, related to fibrocystic changes
stop smoking and stop squeezing
how would you investigate a 55 year old woman with enlarging mass in right breast over months with indrawing of overlying skin
- bilateral diagnostic mammogram
- U/S of involved breast
- core biopsy–> important! (FNA cant confirm invasive disease)
- then confirm STAGING to exclude mets disease–> bone scan only if patient has lymph node spread
what is the management for breast cancer
- lumpectomy/partial mastectomy with radiation treatment (reduce risk of recurrence)
-or- - mastectomy with or without reconstruction (if multiple cancer sites, cant do radiation etc)
AND - management of axilla
–> sentinel node biopsy if clinically node negative on exam or U/S, axillary dissection if node positive
how do you do a sentinel node biopsy
inject with radioactive technetium and dye that maps nodes and then gamma probe to find the radioactive nodes
what is the adjuvant therapy for breast cancer
treatment given without evidence of cancer to decrease recurrence risk
given after lumpectomy to reduce recurrence risk, to axilla or breast or chest wall after mastectomy with positive nodes or other high risk of recurrence
adjuvant chemo/systemic therapy is given to patients who are at high risk for occult mets (tumour larger than 2cm, grade 2-3, lymphovascular invasion, positive nodes)
adjuvant tumour factors include menopausal status, comorbidities and ability to tolerate treament, tumour ER status, tumour Her 2 status
are lumpectomy and mastectomy equal in cure rates?
only when you do lumpectomy PLUS adjuvant radiation…if you do both its equal and mastectomy
lumpectomy alone isnt the same –> chance of recurrence with lumpectomy alone is about 30% (compared to 5-7% with radiation)
higher risk of complications with mastectomy so usually offer lumpectomy
who can’t get radiation (and thus need mastectomy)
connective tissue disorders (SLE especially…get vasculitis) or previous radiation i.e or lymphoma
how do you stage breast cancer
TNM staging
stage 1–> small with negative nodes
stage 2–> 2-5 cm with or without positive nodes
stage 3–> any tumour with fixed nodes, maybe supraclavicular, maybe fixed in muscle or skin
stage 4–> cancer with distant mets
how do invasive ductal carcinoma and invasive lobular carcinoma differ
ductal–> malignant cells originate from the ductal epithelium
lobular–> malignant cells originate from the lobular cells (higher chance of bilateral malignancy and can be harder to see on mammogram)
who needs chemo?
if there is lymph node involvement–> i.e if sentinel node biopsy shows an active node
also probably hormone treatment
how do you stage cancer
with CXR and liver enzymes –> further investigations if abnormal
bone scan only if patient has lymph node involvement
how common is male breast cancer
less than 1% of breast cancer
usually in older men with major risk factors being BRCA mutation and family history
investigation same as for women (U/S and mammogram)
management of male breast cancer
surgery is mastectomy with SLNB or ALND depending on clinical node status
adjuvant therapy is same as for women
what is ductal carcinoma in situ
malignancy cells in the ducts that have not crossed the basement membrane
if untreated–> progression to invasive cancer (but otherwise survival rate is 98%)
most DCIS is NOT palpable and is diagnosed from an abnormal mammogram–> typical features are pleomorphic, clustered, branched, microcalcifications without a mass
investigations for DCIS
in non palpable lesions–> mammographic core biopsy to get a diagnosis and excision at once
can also use fine wire guided excisional biopsy
how do you manage DCIS
not usually invasive so SLNB not always needed unless high grade, extensive, palpable, suspicious for invasion
surgical excision with clear margins and adjuvant radiation
may need mastectomy and reconstruction if extensive
what is lobular carcinoma in situ
usually incidental finding on core biopsy done for something else
not visible on imaging
associated with increased further risk of breast cancer anywhere in breast–> 20-30% over 15 years
management of LCIS
ongoing screening (most common)
chemoprevention–> i.e tamoxifen (only reduces risk… to about 10-15%
bilateral mastectomies
what is paget’s disease of the nipple
rare (1%) pathologic diagnosis of a typical malignant cell (paget’s cells) in the epidermis of the nipple
presents with unilateral scaling, flaking, crusting or thickening of the nipple or areola
looks like dermatitis or other skin lesions
often accompanied by unilateral redness, tenderness, discharge, maybe nipple inversion
how do you assess paget’s disease of the nipple
biopsy the nipple (scrape, punch, incision etc)
mammogram to exclude underlying breast cancer (most have underlying cancer)
with unilateral nipple skin symptoms, especially if unresponsive to steroids, needs to be biopsied
how do you manage paget’s disease of then nipple
if all imaging is negative, treat with central lumpectomy with or without radiation
underlying cancer is treated like any other cancer with mastectomy and SNLB
