Breast Flashcards
Most common cause of breast masses in adolescents and young women?
Fibroadenoma (proliferative breast disorder without atypia)
Tumors arise from the epithelium and stroma of the terminal duct-lobular unit. The typical palpable characteristic of a fibroadenomas is a small (1–2 cm), firm, well- circumscribed, mobile mass. Can be lobulated. Slippery
Average age 20 on presentation
Often doubles in size in first year
Red flags for malignancy concerns (patients must be evaluated within 2 weeks at breast center)
- All patients presenting with a discrete, hard lump with fixation—with or without skin tethering.
- Women aged 30 years or more who have a discrete lump that persists after the next period, or those who present after menopause.
- Women under 30 years with an enlarging lump or a fixed, hard, or tethered lump, or a worrying family history.
- All patients who have previously had histologically confirmed breast cancer, who present with a further lump or suspicious symptoms.
- Unilateral eczematous skin that does not respond to topical treatment.
- Nipple distortion or dimpling of the skin (peau d’orange).
- Unilateral bloody nipple discharge
What causes mastalgia?
Endocrine abnormalities (prolactin, estrogen) Psychoneurendocrine factors: stress affects serotonin and endogenous opioids, and causes inadequate dopaminergic tone. Water retention (breast swelling and pain in the pre-menopausal woman)
How do you evaluate mastalgia?
R/O pathology, mammogram > age 30 physical exam
R/O pregnancy
How do you treat mastalgia?
Adjust hormonal supplement (estrogen dose or birth control pills)
Consider Vitamin E
Non-steroidal anti-inflammatory medications
Bromocriptine (especially for cyclical pain)
Danazol: side effects of amenorrhea, weight gain, acne and hirsutism.
Tamoxifen: studied to be effective in Italy, not FDA approved for this indication in US
Components of breast history:
Nipple discharge (bloody and single duct*)
Pain (rarely meaningful for cancer risk)
Lumps (the most frequent presentation of cancer other than mammographic findings)
Change in shape or size of breast
Changes in the skin
Distinguish physiologic nipple discharge from pathologic nipple discharge
Physiologic discharge:
* Often with compression, multi-duct, often bilateral * Clear, yellow, white or dark green in color
Pathologic discharge:
* Spontaneous, bloody or associated with a mass * Usually confined to a single milk duct * Milky, bilateral and associated with amenorrhea with Prolactinomas
Causes of physiologic nipple discharge?
- Mechanical Stimulation
- Puberty
- Menopause
- Post-lactational
- Stress
- Drugs: Phenothiazines, methyldopa, haloperidol, etc
Causes of pathologic nipple discharge?
- Intraductal papillomas
- Infection
- Trauma
- Cancer
- Prolactin secreting tumors (bilateral galactorrhea associated w/ amenorrhea)
Evaluation of pathologic nipple discharge?
- Breast examination and Mammogram/Ultrasound
- Send fluid for cytological examination
- If blood, atypia or associated mass, surgery is
indicated- nipple duct excision under local anesthesia
- ??? Unknown role for ductography
Eczema of the areola
Early eczema: the inflammation usually begins on the areolar skin and is associated with itching
Scaly eczema: changes usually spare the nipple
Pagets disease must involve the nipple
Does accessory (ectopic) breast tissue have an increased risk for breast cancer?
No
What is polythelia?
Supranumery nipples
What is Mondor’s disease?
Thrombophlebitis of the superficial veins of the breast.
Symptoms: pain and palpation of a cord like structure.
Self limited, requiring essentially no treatment.
Breast mass management
Mammogram for age > 30, Ultrasound if age < 30
Needle aspiration (solid v. cyst)
* if fluid is aspirated, observe, reassure
* bloody aspiration, or if mass persists - biopsy
Solid masses
if discrete mass, refer for excisional biopsy
