Breast d/o Flashcards
NCCN recommends CBE every
1-3 years age 25-39 and yearly at age 40
American Cancer Society on CBE
evidence unclear, no recommendations; “be familiar
US Preventive Services Task Force CBE
not enough evidence
the idea is that if you are not consistently doing these exams then you can’t recognize the normal
the main recommendation around SBE
just to create awareness of what they normally feel like
how to document a lump or mass
cms from the nipple in a clock distribution
2cm mass at three o clock 4 cm from the nipple
fibrocystic breast tissue changes vs cysts
responds to hormonal changes a week leading up to your period
can get swollen or heavy
cyts are fluid filled pockets that also come and go with hormones
how to minimize fibrocystic breast tissue
support, minimize caffeine & salt, daily exercise, low fat diet Vit E 100 IUs daily or Vit B6 100 mg daily Evening primrose oil capsules 1000-3000 mg qd or other omega-3s NSAIDs moist heat
accessory breast tissue in the axilla is seen commonly in this population
seen more with pregnancy
also seen commonly in overweight pts
firbroadenoma-what is it
benign tumor made up of glandular breast tissue and stromal (connective) tissue
15-25yo
can change with periods and get bigger with pregnancy or breast feeding
what do fibroadenoma looks like on ULS
hyperechoic oval or lobulated lump
really good through transmission without dark shawdoing
no angular borders and usually wider than it is tall
fallow for 6 mos to make sure it doesn’t change in size
can biopsy
ddx for fibroadenoma
what are we worried about
phyllodes tumor which is typically benign but can get really big really fast
need to look out for this
lactating adenoma is also possible with breast feeding
when are cysts found
what do you do to tx
pockets of fluid that respond to hormones and fluctuate more than a fibroandenoma
30-40 and stopping with menopause
smooth round and oval marble to egg sized
fluctuate
can go for a cm in size to 5 cm in size
do come back a lot so removing is not recommend but can aspirate
treat with ibuprofen and minimize caffeine
ddx of cysts
galactoceles -milk filled cysts in women who are usually recently breastfeeding
RED FLAGS for cysts
aspiration with blood
not good
can be a hematoma and need to send to cytology
could be a lesion that is bleeding in
also if the cysts comes back over night after asperation
with rough edges of internal echos a aspiration or biopsy is recommended
what do cysts look like on ultrasound and MRI
dark round fluid followed by a really hyperechoic shadow
on mammogram a round white marble
sebaceous cysts
can become painful and can be excised to lower the risk of infection
lipoma - how to differentiate from a cyst
feel rubbery and fatty
smooth mobile and round
on ULS it will be isoechoic (same as surroudning tissue (
types of biopsies
Fine needle aspiration
Core biopsy
Excisional biopsy
fibroadenoma biopsy most likely would use
fine needly aspiration
or core biopsy if that doesn’t work
tissue sample that is minimally invasive and
allows for tumor markers
Core biopsy
larger sample would need a ____
when would you need a larger sample
numb the skin entirely
Excision biopsy- especially if core biopsy did not make sense
Excise the lump itself or a piece of the lump
you get a pretty big incidence of infection
how does a core biopsy work
palpation guided or US guided
Reduces time in the OR for other biopsies
tiny little scare
use steri strips
can give you tumor markers -estrogen progesterone and HER2
types of discharge and how to differentiate
Physiologic (benign)-will be b/l white green clear or gray. will be multi ductal and stimulation to the breast
vs pathologic-issue causing it. single sided uniductal typically bloody or serous and happening on it’s own (no after stimulation)
for physiological discharge (
need a prolactin level -maybe an MRI
pregnancy test-HCG quant
thyroid
once in a while renal function
pregnancy
need to ask about medication
infection
MCC of pathological discharge
ii. Papilloma
1. Benign lump in nature; sits in ducts 2. Sometimes do hang out with atypical cells 3. Often removed
if there is nothing abnormal about them they can stay
medications that can cause nipple d/c
antidepressants, antipsychotics, htn meds, Opioid analgesics
what do you want to do for pathologic d/c
Ductography, breast MRI (sensitive but not specific), magnetic resonance ductography, and ductoscopy can be helpful in selected women but are not routinely necessary
Mastalgia
breast pain
need to get a good history to figure out if it’s related to diet, weight changes, hormonal contraception, often times will need a pattern and pain diary
can use OCP to help regulate cycles.
when would you get an ULS of MRI of mastalgia
if less than one quadrant can get a mammogram or uls to rule out cyst or mass that could be causing the pain
Mastitis
Breast infection, often as a result from breastfeeding/clogged ducts.
Spontaneous cases too, especially in smokers; can be chronic
Mastitis anbx
antibiotics (Keflex, Duricef, dicloxacillin )
(breastfeeding Bactrim, Clindamycin)
no absess–> dicloxacillian
if absess serial aspirations NO I and D
breast feeding technique, hot compresses,
I & D/aspiration for abscesses, rarely surgery
dx tests for mastitis
No imaging necessary if clinically suspect
Infection and complete resolution
ii. Systemic symptoms feels like the flu
1. Red, hot swollen breast +/- abscess
Imaging +/- biopsy if no improvement maybe a core biopsy or punch biopsy
a. Fungal of the breast tx with
nystatin
Infected Sebaceous Cyst tx
Infected Sebaceous Cyst – need I&D
Hidradenitis
younger women, obese, chronic infections/abscesses that can happen in under arm areas, under breast areas.
Hidradenitis
They need multiple I&Ds
doxycyxline
smoking cessation
weight loss
when would you biopsy a cyst
Complex cysts should be biopsied, particularly those with thickened cyst walls and/or septa, and solid components.
when do you see gynecomastia
Common during puberty if estrogen spikes before testosterone
rubbery, mobile, tender breast bud
Typically outgrow this
what is the cause of gynecomastia
d. Caused by an increase in the ratio of estrogen to androgen activity
Causes: drugs, medications (heroin, etoh can increase hormonal activity), hyperthyroidism, liver or kidney disease, hypogonadism, testicular tumors, aging
dx of gynecomastia
g. Diagnosed on exam as a palpable mass of tissue at least 0.5 cm in diameter (usually underlying the nipple)
does feel like a breast bud
breast cancer will be outside of the nipple and will be a firmed fixed hard mass
labs for gynecomastia
estradiol, testosterone, LH, FSH, prolactin, TSH, HCG (even in men)
-hyperthryoidism can cause it
tx for gynecomastia
Plastic surgery if significant/bothersome
ii. Lifestyle modifications
HCG for gynecomastia -why?
testicular mass screening
seen more in younger men
ddx of gynecomastia
lipoma
pseudogynecomastia-fat
cancer
meds that can cause gynecomastia
antidipressants
viagra
rogaine
cardio meds
how common is breast cancer
a. 1 in 8 women will develop breast cancer in their lives
b. Average lifetime risk 12%;
what ages do we typically see breast cancer
i. Early 40s to mid 80s is when it’s typically found
ii. Early stage is mostly where we catch them
lifestyle modifications to minimize breast cancer
exercise
weight management -obesity increasing estrogen
limiting alcohol -4 glasses or less a week
breast feeding
having children before 35
RF for breast cancer
- Radiation exposure
- Obesity (postmenopausal)
- Early menarche, late menopause
- Late or no pregnancy
- Smoking
- Alcohol
- HRT/OCPs
- Family history/genetic mutations (BRCA, CHEK2) –> can increase your risk for other cancers including ovarian cancer
- Previous breast cancer or high risk lesions
- ADH, ALH, LCIS
- Protective: breast feeding, multiple parity
the most important factor in breast cancer
ii. Estrogen is important factor in breast cancer and can increase tumors. So adipose tissue in the breast tissue is another source of estrogen so keeping a healthy BMI is important
iii. Breast tumors that grow with estrogen are also linked with ETOH
American cancer society recommends annual mammogram starting at age
45-55
every two years
can start at age 40
The USPSTF recommends against routine screening mammography in women
40-49
The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take into account patient risk factors (fhx of breast cancer, history of breast biopsy etc)
a lot of time they end up needing biopsies that aren’t necessary Kaiser says 50
Digital better for dense breasts and women
<50 yo
Tomosynthesis -what is it and when would we use it
Tomosynthesis similar to a CT scan takes several xrays through the breast creating a “3D” picture. Combined with standard mammogram can increase detection rates and decrease false positive. Not reimbursed by most insurances, expensive, higher radiation exposure. May be a good adjuvant for very dense breast tissue.
BI-RADA 2
benign managment is routine screening and likelihood of CA is 0%
BIRAD 4
suspicious
tissue diagnosis is management and the can be low moderate or high risk of suspicion
typically want to start mammograms for pt with a familial risk at
10 years younger than the earliest diagnosis in your family
BIRADS 3
probably benign and need short interval follow up
6 is a
known biopsy proven CA with surgical excision
5 is a
high suggestive of malignancy and needs tissue diagnosis
indications for an MRI screening
BRCA 1 or 2 gene mutation
First degree relative with BRCA 1 or 2
Increased lifetime risk
History of mammographicall occult breast cancer
Radiation therapy to the chest wall young age
leads to a lot of false positive
no radiation exposure
can we use breast uLS for surveillance?
- used for diagnostic workup in combination with mammogram. Not used for surveillance.
Thermography- what is and when do we use it
Thermography-measures heat. Procedure is safe but does not detect or provide a diagnosis of any condition.
Currently not endorsed by any reputable medical agency including the american cancer society, national cancer institiute, american college of radiology, american medical association
The American Cancer Society’s recommendations for MRI screening:
. Lifetime risk of breast cancer >20%
OR
. Hx radiation treatment to the chest prior to age 30 yo
how do we determine lifetime risk of breast cancer >20%
The American Cancer Society’s recommendations for MRI screening:
in-situ cancer is contained
In-situ cancer is contained within the ducts or lobules.
ducts more common
management of ductal carcinoma in-sit
is treated so that it does not progress to invasive cancer. Should we call it cancer? Are we over treating people?
what is in-situ
is it palpable?
- Precursor to invasive cancer in half of cases.
- Higher detection
- Pleomorphic microcalcifications seen on mammogram; not usually palpable
inflammatory CA
cancer cells are blocking the lymphatic vessels
- Edematous, squishy, red
- Rare but advanced type of breast cancer
- Typically over 1/3rd of breast
ddx of inflammatory CA
mastitis. If not able to treat with abx, then get mammogram
cancer typically of the nipple
Paget’s disease
TYPICAL AREAS OF METS
. BONE, LUNG, BRAIN, LIVER – TYPICAL AREAS OF METS
younger women typically have these types of tumors
- Younger women typically tend to have more aggressive tumors
what is the best type of tumor
- ER and PR status –>best tumor is ER and PR positive and HER2 negative
what targets HER2
a. HER2 = more aggressive
i. Herceptin targets these tumors
if ER, PR, and HER2 negative
ER, PR, and HER2 negative – no treatments
this is the most aggressive type of tumor
NOT GOOD
treat with chemo but higer incidence of recurrence and spread
i. Chemotherapy done as tx for
– Neo-adjuvant or Adjuvant
1. Neoadjuvant – done in case of inflammatory cancer
Endocrine therapy is used for
ER+ tumors only
- Meds that reduce estrogen in the body
a. Taken for 5-10 years – menopausal like symptoms can be present
Oncotype score –
DNA test on the tumor that tells you how well it will respond to chemo therapy
shows how aggressive and the recurrence risk might be and how effective chemo might be
herceptin targeted with chemo does have higher success rates
b. Lymph node dissection is done for
biopsy proven cancer in the lymph nodes.
treatment schedule for chemo
d. Treatment is usually 5 days a week for 5 weeks, starts 1 month after surgery or chemotherapy
phyllodes tumor
like a fribroadenoma but changes really fast this is what we are worried about with firboadenomas
usually benign but can be malignant
Mastitis imaging
don’t normally need it if you think there is an infection
if you think there is an abssess
bactrim if you
Noncyclic pain is most common in women and is described as
30-50
It is often described as a sharp, burning pain that occurs in one area of a breast.
Occasionally, noncyclic pain may be caused by a
fibroadenoma or a cyst.
BIRADS 1-3
MRI or ductogram
bi-rads3-4
GET A TISSUE BIOPSY if benign then duct exicison
density classifications
1- almost entirely fat
2 scattered -most of the population
3- heterogeneously dense -40%
4- extremely dense
DCIS
this is stage 0
ductal carcinoma insitu
Precursor to invasive cancer in half of cases.
DCIS-what does it look like
Abnormal number and morphology of cells lining the duct, not extending into the breast tissue.
Appears as new pleomorphic calcifications or linear branching. Not usually palpable
Treated like cancer,
eczema os the nipple that doesn’t improve with steroids want to think about
pagets disease
occurs when cancer cells block the lymphatic vessels in skin covering the breast,
inflammatory breast cancer
It is considered a locally advanced cancer — meaning it has spread from its point of origin to nearby tissue and possibly to nearby lymph nodes.
include:
surgery would not be helpful in which pts with CA
METS
lumpectomy is conducted with
radiation
anti-estrogen therapy
tomoxifen
herceptin is used for people that are
HER 2 positive
