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Breast d/o Flashcards

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1
Q

NCCN recommends CBE every

A

1-3 years age 25-39 and yearly at age 40

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2
Q

American Cancer Society on CBE

A

evidence unclear, no recommendations; “be familiar

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3
Q

US Preventive Services Task Force CBE

A

not enough evidence

the idea is that if you are not consistently doing these exams then you can’t recognize the normal

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4
Q

the main recommendation around SBE

A

just to create awareness of what they normally feel like

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5
Q

how to document a lump or mass

A

cms from the nipple in a clock distribution

2cm mass at three o clock 4 cm from the nipple

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6
Q

fibrocystic breast tissue changes vs cysts

A

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

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7
Q

how to minimize fibrocystic breast tissue

A 
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
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8
Q

accessory breast tissue in the axilla is seen commonly in this population

A

seen more with pregnancy

also seen commonly in overweight pts

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9
Q

firbroadenoma-what is it

A

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

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10
Q

what do fibroadenoma looks like on ULS

A

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

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11
Q

ddx for fibroadenoma

what are we worried about

A

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

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12
Q

when are cysts found

what do you do to tx

A

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

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13
Q

ddx of cysts

A

galactoceles -milk filled cysts in women who are usually recently breastfeeding

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14
Q

RED FLAGS for cysts

A

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

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15
Q

what do cysts look like on ultrasound and MRI

A

dark round fluid followed by a really hyperechoic shadow

on mammogram a round white marble

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16
Q

sebaceous cysts

A

can become painful and can be excised to lower the risk of infection

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17
Q

lipoma - how to differentiate from a cyst

A

feel rubbery and fatty
smooth mobile and round

on ULS it will be isoechoic (same as surroudning tissue (

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18
Q

types of biopsies

A

Fine needle aspiration
Core biopsy
Excisional biopsy

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19
Q

fibroadenoma biopsy most likely would use

A

fine needly aspiration

or core biopsy if that doesn’t work

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20
Q

tissue sample that is minimally invasive and

allows for tumor markers

A

Core biopsy

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21
Q

larger sample would need a ____

when would you need a larger sample

A

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

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22
Q

how does a core biopsy work

A

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

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23
Q

types of discharge and how to differentiate

A

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)

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24
Q

for physiological discharge (

A

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

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25
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
26
medications that can cause nipple d/c
antidepressants, antipsychotics, htn meds, Opioid analgesics
27
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
28
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.
29
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
30
Mastitis
Breast infection, often as a result from breastfeeding/clogged ducts. Spontaneous cases too, especially in smokers; can be chronic
31
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
32
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
33
a. Fungal of the breast tx with
nystatin
34
Infected Sebaceous Cyst tx
Infected Sebaceous Cyst – need I&D
35
Hidradenitis
younger women, obese, chronic infections/abscesses that can happen in under arm areas, under breast areas.
36
Hidradenitis
They need multiple I&Ds doxycyxline smoking cessation weight loss
37
when would you biopsy a cyst
Complex cysts should be biopsied, particularly those with thickened cyst walls and/or septa, and solid components.
38
when do you see gynecomastia
Common during puberty if estrogen spikes before testosterone rubbery, mobile, tender breast bud Typically outgrow this
39
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
40
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
41
labs for gynecomastia
estradiol, testosterone, LH, FSH, prolactin, TSH, HCG (even in men) -hyperthryoidism can cause it
42
tx for gynecomastia
Plastic surgery if significant/bothersome | ii. Lifestyle modifications
43
HCG for gynecomastia -why?
testicular mass screening | seen more in younger men
44
ddx of gynecomastia
lipoma pseudogynecomastia-fat cancer
45
meds that can cause gynecomastia
antidipressants viagra rogaine cardio meds
46
how common is breast cancer
a. 1 in 8 women will develop breast cancer in their lives | b. Average lifetime risk 12%;
47
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
48
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
49
RF for breast cancer
1. Radiation exposure 2. Obesity (postmenopausal) 3. Early menarche, late menopause 4. Late or no pregnancy 5. Smoking 6. Alcohol 7. HRT/OCPs 8. Family history/genetic mutations (BRCA, CHEK2) --> can increase your risk for other cancers including ovarian cancer 9. Previous breast cancer or high risk lesions 10. ADH, ALH, LCIS 11. Protective: breast feeding, multiple parity
50
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
51
American cancer society recommends annual mammogram starting at age
45-55 every two years can start at age 40
52
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
53
Digital better for dense breasts and women
<50 yo
54
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.
55
BI-RADA 2
benign managment is routine screening and likelihood of CA is 0%
56
BIRAD 4
suspicious tissue diagnosis is management and the can be low moderate or high risk of suspicion
57
typically want to start mammograms for pt with a familial risk at
10 years younger than the earliest diagnosis in your family
58
BIRADS 3
probably benign and need short interval follow up
59
6 is a
known biopsy proven CA with surgical excision
60
5 is a
high suggestive of malignancy and needs tissue diagnosis
61
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
62
can we use breast uLS for surveillance?
- used for diagnostic workup in combination with mammogram. Not used for surveillance.
63
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
64
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
65
how do we determine lifetime risk of breast cancer >20%
The American Cancer Society's recommendations for MRI screening:
66
in-situ cancer is contained
In-situ cancer is contained within the ducts or lobules. ducts more common
67
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?
68
what is in-situ is it palpable?
1. Precursor to invasive cancer in half of cases. 2. Higher detection 3. Pleomorphic microcalcifications seen on mammogram; not usually palpable
69
inflammatory CA
cancer cells are blocking the lymphatic vessels 1. Edematous, squishy, red 2. Rare but advanced type of breast cancer 3. Typically over 1/3rd of breast
70
ddx of inflammatory CA
mastitis. If not able to treat with abx, then get mammogram
71
cancer typically of the nipple
Paget’s disease
72
TYPICAL AREAS OF METS
. BONE, LUNG, BRAIN, LIVER – TYPICAL AREAS OF METS
73
younger women typically have these types of tumors
3. Younger women typically tend to have more aggressive tumors
74
what is the best type of tumor
4. ER and PR status -->best tumor is ER and PR positive and HER2 negative
75
what targets HER2
a. HER2 = more aggressive | i. Herceptin targets these tumors
76
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
77
i. Chemotherapy done as tx for
– Neo-adjuvant or Adjuvant | 1. Neoadjuvant – done in case of inflammatory cancer
78
Endocrine therapy is used for
ER+ tumors only 1. Meds that reduce estrogen in the body a. Taken for 5-10 years – menopausal like symptoms can be present
79
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
80
b. Lymph node dissection is done for
biopsy proven cancer in the lymph nodes.
81
treatment schedule for chemo
d. Treatment is usually 5 days a week for 5 weeks, starts 1 month after surgery or chemotherapy
82
phyllodes tumor
like a fribroadenoma but changes really fast this is what we are worried about with firboadenomas usually benign but can be malignant
83
Mastitis imaging
don't normally need it if you think there is an infection
84
if you think there is an abssess
bactrim if you
85
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.
86
Occasionally, noncyclic pain may be caused by a
fibroadenoma or a cyst.
87
BIRADS 1-3
MRI or ductogram
88
bi-rads3-4
GET A TISSUE BIOPSY if benign then duct exicison
89
density classifications
1- almost entirely fat 2 scattered -most of the population 3- heterogeneously dense -40% 4- extremely dense
90
DCIS
this is stage 0 ductal carcinoma insitu Precursor to invasive cancer in half of cases.
91
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,
92
eczema os the nipple that doesn't improve with steroids want to think about
pagets disease
93
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:
94
surgery would not be helpful in which pts with CA
METS
95
lumpectomy is conducted with
radiation
96
anti-estrogen therapy
tomoxifen
97
herceptin is used for people that are
HER 2 positive

GYN (13 decks)

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