breast Flashcards
Gynecomastia - ages?
- newborn
- pubertal (but may perists after puberty
- elderly males
causes of pathologic gynecomastia
- cirrhosis
- hypogonadism (eg. Klinefelter)
- testicular tumors
- drugs
drugs that causes gynecomastia
- spironolactone
- Hormones
- cimetidine
- Ketoconazole
Benign breast disease - DDX
- breast cyst –> solitary, well circumscribed, mobile mass, +/- tenderness
- Fibrocystic changes: multiple, diffuse nodulocystic masses, cyclic premenstrual tenderness
- fibroadenoma: solitary, well circumscribed mobile mass, cuclic premensrual tenderness
- Fat necrosis: post-trauma/surgey, firm irregular mass +/- ecchymosis, skn/nipple retraction
Fat necrosis - definition/presentation
Benign, usually painless, lump due to injury to breast tissue
Up to 50% patients may not report trauma
calcification on mammo
Fibroadenoma - epidemology/presentationsituations
MC under 35. Small, well-defined marble-like, mobile mass
increased size with estrogen (pregn, prior to menstr)
Fibrocystic changes - epidemiology/cancer
MC in premenopausal over 35
no risk for cancer
Fibrocystic changes - presentation
premenstrural breast pain or lumps, often bilateral or multifocal
Palpable breast mass - algorithm
A: younger than 30: U/S +/- mammo:
- simple cyst –> aspiration if patient desires
- complex cyst or sold mass –> image-guide core biop
B: 30 or older –> Mammo +/- U/S
- suspicious for malignancy –> core biopsy
MCC of physiologic galactorrhea
hyperprolactinemia
Common problems related to lactation (which of them have fever)
- engorgement
- nipple injury
- plugged duct
- galactocele
- mastitis - fever
- abscess - fever
breast engorgement?
BILATERAL symmetric fullness, tenderness + warmth
common 3-5 days after delivery when colostrum is replaced by milk (or after abrupt stopping of lactation)
production exceeds the release
treatment: NSAID, year supportive bra, avoid nipple stimulation and manipulation, ice packs
plugged duct?
focal tenderness + firmness + or erythema, no fever
galactocele?
subareolar, mobile, well-circumscribed, nontender mass, no fever
mastitis vs abscess in breast
mastitis: tenderness/erythema + fever
abscess all above + FLUCTUANT MASS
Lactational mastitis - clinical presentation
ever
firm red tender, swoellen quardrant of unilateral breast
+/- myalgia, cholld malaise
Lactational mastitis - treatment
analgesia
frequent breastfeeding or pumping
antibiotcs
Lactational mastitis - RF
history of mastitis engorgement + inadequate milk drainage due to - sudden increase in sleep duration replacing nurcsing with formula weaning presure on the duct (prone sleeping, tight clothing cracked or clogged nippl e pore poor latch
Lactational mastitis - pathogenesis
skin flora (S. aureus) enters duct nipple + multiplies in stagnat milk
Phyllodes tumor - definiton/appearance / cancer?
large mass of connective tissue and cysts with leaf-like lobulations (AT STROMA)
- some may becoma malignant
Phyllodes tumor - age
MC in 5th decade (postmenopausal)
Periductal mastitis - definition/epidemiology
- inflammation of subareolar ducts
- in smokers (low vit A –> epithelial become squamous
- -> keratin –> plag –> inflammation behind –> granoulation tissue –> retraction
Periductal mastitis - presentation
subareolar mass with nipple retraction
Sclerosing adenosis? / cancer?
increased number of the acini and their glandsi and stromal fibrosis –> associated with calcification
- 1.5-2x increased risk
Mammary duct ectasia - definition/epidemiolgy/presentation
- inflammation with dilation (ectasia) of subareola ducts
- multiparous postmenopauseal
- -> green brown nipple discharge
Mammary duct ectasia - biopsy
chronic inflammation with plasma cells
benign breast conditions - cancer?
- Fibroadenoma - no
- fibrocystic changes - no
- sclerosing adenonis - 1.5-2 x cancer
- Intraductal papilloma –> 1.5-2 x cancer
- epithelial hyperplasia –> x5 if atypical, x2 if not atypical
- Phylloid tumor –> some may become malignant
- Fat necoris
- Lacational mastitis
- Gynecomastia
- Periductal mastitis
- Mammary duct ectasia
evaluation of nipple discharge
- unilateral or bloody or serous –> breast U/S or mammo if older than 30
- if bilateral, milky, nonbloody –> palpable lump or skin changes?
yes: U/S or mammo
no: pregnancy test, Guaiac test, prolactin, TSH, consider MRI of pituitary
breast Ca RF
modifiable: Hormones, nulliparity, increased age at first live birth, alcohol
non-modifiable: mutation or breast ca in 1st degree relatives, white, age, early menarche or later menopause
Ductal carcinoma in situ of breast - presentation
- often seen early as MICROCALCIFICATIONS in mammography
- usually does not produce mass
when to check somebody for BRCA
breast Ca under 50
ovarian ca in any age
alcohol - breast ca
dose dependent
breast abscess - treatment
needle aspiration + antibiotics
different methods of biopsy in breast cancer (only names)
- fine needle aspiration
- core needle biopsy
- open biopsy
breast cancer - best initial biopsy / characteristics
FNA
- FP rate less than 2%, but because is small sample, FN rate of 10%
breast cancer - core needle biopsy characteristics
larger sample, MORE DEFORMING but you can test for estrogen, progesterone and HER 2/neu receptors.
difficulties include greater deformity and possibility that the needle will miss the lesion
breast cancer - the most accurate biopsy / characteristics
open
allows for frozen section to be done while the patient is in the operating room followed by immediate resection of cancer followed by sentinel node
If a breast biopsy is going to be performed, what is the point in doing a screening test like mammography
5-10% of patients have bilateral disease. In addition, there is huge difference in the management of the patient if there is a single or multiple lesions within the same breast
breast cancer - indications for PET
to determine the content of abnormal lymph nodes or masses that are not easily accessible to biopsy
breast cancer - surgery
lumpectomy with radiation is equal in efficacy to modified radical mastectomy but much less deforming
modified radical mastectomy
mastectomy (removal of the nipple, areola, and breast tissue) as well as removing the majority of lymph nodes from under the arm, referred to as an axillary lymph node dissection (no muscles are removed and only lymph nodes I and II are removed not the III vs radical
breast cancer - radiation after lumpectomy
indispensable in preventing recurrences at the breast
breast cancer - contraindication for lumpectomy
multifocal cancer or contraindication of radiation
breast cancer - when Radical mastectomy
NEVER
aromatase inhibitors vs tamoxifn
slightly superior in efficacy (BETTER –> if both arematase inh are the answer for the most likely to benefit)
aromatase inhibitors are generally for postmenopausal and tamoxifen in premenopausal
hallmark features of inflammatory carcinoma
breast erythema, warm, pain and edema
situations with calcification in mammography
- Ductal in situ and invasive
- sclerosing adenosis
- fat necrosis
intraductal papilloma - clinical features
unilateral bloody nipple discharge
no mass or lymphadenopathy
nothing in mammo
intraductal papilloma - management
mammography + U/S
- biopsy +/- excision
MCC of nipple discharge (serous or body)
Intraductal papilloma
