Breast & Axillae

Question 1

What are protective factors against breast cancer?

Answer 1

lactation
early menopause
early childbirth

Question 1

What are common risk factors for breast cancer?

Answer 1

Female
Increasing age (>40)
Nulliparity, first pregnancy after 30, menarce <12, menopause >55
Fhx
BRCA mutations
>5 hr HRT use, >10 year OCP use

Question 2

What findings on mammography would indicate higher risk of malignancy?

Answer 2

mass that is poorly defined, spiculated (spiked) border
microcalcifications
architectural distortion
interval mammographic changes

Question 3

What are the screening mammography reccomendations?

Answer 3

every other year from 40-74 for average risk individuals (some organizations reccomend every year)

Question 4

What purpose can US serve in regards to breast masses?

Answer 4

Differentiates between cystic and solid masses

Question 5

What workup should be done to assess for metastasis of breast cancer?

Answer 5

bone scna, abdominal US, chest XR, head CT (if neuro sx are present)

Question 6

What is ductal carcinoma in situ?

Answer 6

non invasive malignancy of ductal epithelial cells completely contained within breast ducts

Question 7

What are signs/sx and workup for ductal carcinoma in situ?

Answer 7

80% of DCIS are non-palpable and are detected by screening mammogram

Question 8

Treatment and prognosis for ductal carcinoma in situ

Answer 8

lumpectomy and radiation
mastectomy if high grade, large area of disease
tamoxifen adjunctively

99% 5 year survival rate

Question 9

What is invasive ductal carcinoma?

Answer 9

most common type of breast cancer
invasive cancer originating from ductal epithelium and infiltrating into thoracic fascia to become fixed to the chest wall

Question 10

signs/sx of invasive ductal carcinoma

Answer 10

may extend into the skin (dimpling, retraction)
may invade cooper ligaments within ducts (nipple retraction)

Question 11

What is inflammatory carcinoma?

Answer 11

invasive ductal carcinoma that invades into dermal lymphatics

most aggresive form of breast cancer

Question 12

What is Paget’s disease of the breast?

Answer 12

ductal carcinoma that invades nipple and presents unilaterally as a dermatitis

Question 13

signs/sx Paget’s disease of the breast

Answer 13

unilateral breast dermatitis appearance
skin of the nipple and areola ulcerated and erythematous
oozing with serosanguineous discharge
can have itching or burning

Question 14

Workup/investigations for Paget’s disease of the breast

Answer 14

scrape cytology (large cells with high nuclear:cytoplasm ratio, occasional acinar formation, intracytoplasmic vacuoles)

punch, wedge, or excisional biopsy

Question 15

RFs for Paget’s disease of the breast?

Answer 15

postmenopausal women

Question 16

Treatment and prognosis for Paget’s disease of the breast

Answer 16

refer to oncology
poor prognosis

Question 17

what are the invasive ductal carcinomas?

Answer 17

invasive ductal carcinoma
Paget’s disease of the breast
inflammatory carcinoma

Question 18

what is lobular carcinoma in situ?

Answer 18

neoplastic cells completely contained within breast lobule

Question 19

signs/sx lobular carcinoma in situ

Answer 19

rubbery and ill-defined, no palpable findings, no mammographic findings (usually found incidentally on breast biopsy for other indication)

Question 20

treatment lobular carcinoma in situ

Answer 20

if dx on core biopsy, excisional biopsy necessary to rule out malignancy
consider chemoprevention - tamoxifen, oncologist

Question 21

what is a fibroadenoma?

Answer 21

a benign glandular breast tumor with dense fibroblastic stroma; RARELY becomes malignant

most common benign breast tumor in women

Question 22

signs/sx fibroadenoma

Answer 22

single movable breast nodule, often in upper outer quadrant
not fixed to skin
non-tender, firm, smooth, rubbery, mobile, well-circumscribed

Question 23

investigations/workup for fibroadenomas

Answer 23

core or excisional biopsy if concerned about malignancy

Question 24

what is fibrocystic breast disease?

Answer 24

benign fibrous and cytstic hyperplasia of breast tissue due to excess estrogens; usually affecting women of reproductive age

Question 25

signs/sx fibrocystic breast disease

Answer 25

generalized premenstrual breast tenderness and lumpiness
often B/L
may have multiple nodules and palpable lumps
increase in breast pain/lumpiness from ovulation to just before menses
may regress during pregnancy and with onset of menses

Question 26

workup/investigations fibrocystic breast disease

Answer 26

dx clinically based on sx and CBE
US can distinguish between fluid-filled cysts and solid masses

Question 27

what is mastitis

Answer 27

inflammation of the ducts of the breasts due to infection, typically caused by staph aureus

Question 28

RF mastitis

Answer 28

lactating women, 2-3 weeks postpartum

Question 29

signs/sx mastitis

Answer 29

unilateral localized breast pain
erythema
malodorous breast milk
pain worse with nursing

Question 30

workup and tx for mastitis

Answer 30

workup: gram stain with culture
tx:
alternating warm and cold compresses
continue nursing
antibiotics

Question 31

what is gynecomastia?

Answer 31

enlargment of male breasts

Question 32

what are physiologic causes of gynecomastia?

Answer 32

puberty
elderly (increased conversion of andorgens to estrogens)
neonatal (maternal estrogens)

Question 33

what are pathological / non-physiologic causes of gynecomastia?

Answer 33

endocrinopathies: primary hypogonadism, hyperthyroidism, hyperprolactinemia, adrenal disease
tumors: pituitary, adrenal, testicular, breast
chronic diseases: liver disease, malnutrition
medication induced: spironolactone, digoxin, chemo
genetic: klinefelter’s syndrome

Question 34

work-up for gynecomastia

Answer 34

labs: serum TSH, PRL, LH/FSH, free testosterone, estradiol, LFTs,B-HCG
imaging: chest XR, CT chest, abdomen and pelvis
testicular US to rule out testicular masses