Breast disease Flashcards
Woman’s lifetime chance of developing invasive breast cancer over lifetime?
1/8
Breast parenchyma
mammary glands with 20-40 lobules that drain into lactiferous ducts which go to the nipple
Major blood supply to breast
Internal mammary (off internal thoracic) and lateral thoracic
Node drainage
97% axillary 3% internal mammary
Breast innervation
intercostobrachial nerve- sensation of upper medial arm
Long thoracic nerve- serratus anterior
Thoracodorsal
Lateral pectoral
Hormones that promote breast development?
Estrogen- ductal development and fat deposition
Progesterone- promotes lobular-alveolar (stromal) development that makes LACTATION possible
Prolactin- milk production
Oxytocin- milk letdown
Average risk woman screening guidelines?
Clinical breast evaluation 1-3 yrs above age 20.
Annually after age 40.
Screening mammography starting at age 40. No upper limit.
High risk woman screening guidelines?
Clinical breast exam every 6-12 months
Annual mammography starting at age 25 or 5-10 yrs before the age of the youngest cancer diagnosis in the family.
Interval breast MRIs along with their annual mammogram.
When is ultrasound used for breast evaluation?
- For uncertain mammographic findings
- Premenopausal women (and under 40)
- Women with dense breast tissue
- Guiding needle for breast biopsy
- DISTINGUISHING CYST VS. SOLID MASS
What is digital mammography better than film mammography for?
Women with dense breasts
Women younger than 50
Premenopausal or perimenopausal
Mastalgia associations
Premenstrual symptom
HRT
Pregnancy
Fibrocystic change
What do you use to evaluate focal lesions in areas of trauma?
Ultrasound
If at high risk of cancer you should do mammography for breast pain.
FDA approved medication for mastalgia?
Danazol ONLY. Many side effects.
NSAIDs, supportive bra, warm and cool compresses.
MCC bloody nipple discharge?
Intraductal papilloma
Worrisome cause of bloody nipple discharge?
Invasive papillary carcinoma
Galactorrhea causes?
Pregnancy, pituitary adenoma, hypothyroidism, stress, meds like OCPs, antihypertensives, PSYCH DRUGS.
TRH causes TSH and prolactin release. TRH is elevated in hypothyroidism (trying to get TSH to stim the thyroid) so there’s also too much prolactin release.
What do you do with bloody nipple discharge?
Test on guaiac card
Send for cytologic eval
Serous discharge cause?
Normal menses, OCPs, fibrocystic change, early pregnancy
Yellow-tinged discharge cause?
Fibrocystic change or galactocele
Green, sticky discharge cause?
Duct ectasia
lactiferous duct becomes blocked or clogged.
Signs of duct ectasia can include nipple retraction, inversion, pain,[5] and sometimes bloody discharge.
What percent of nipple discharge is associated with underlying malignancy?
5%
The most concerning associated sx with nipple discharge?
Happens spontaneously, bloody or serosanguinous, unilateral, persistent, single duct involvement, associated with a mass
Purulent discharge cause?
Superficial or central breast abcess
Treatment of nipple discharge?
Most is benign and requires no treatment
How often does mammography pick up a new breast cancer?
Misses it 10-15% of the time!
MC breast masses?
Fibroadenomas and breast cysts
What should you always do first for abnormal breast masses?
Radiographic evaluation
U/s for 30 yo
Findings on radiology most suggestive of malignancy?
Spiculated mass Architectural distortion with retraction Assymetric localized fibrosis Microcalcifications with linear/branched patterns Increased vascularity Altered subareolar duct pattern
The radiology is worrisome for malignancy. What next?
Biopsy with the least invasive sampling possible
Biopsy for cyst?
In what case should a cyst be excised?
Needle aspiration.
Excise if fluid is bloody, if cyst persists after fluid is removed with TWICE with needle aspiration, or if the fluid reaccumulates in 2 wks
Biopsy for palpable solid mass in a woman less than 30?
What do you do if the FNA yields no fluid or tissue?
Fine needle aspiration (multiple passes through the mass from different angles while aspirating the syringe).
If FNA fails, do an excisional biopsy.
Biopsy for palpable solid mass in a woman over age 30?
Core needle biopsy
What do you do about a non palpable lesion found on mammography? Why this?
Excisional biopsy under needle or wire guidance. You want to excise a 1 cm rim of normal tissue around the abnormal tissue to avoid needing to go back for a lumpectomy if it ended up being malignant.
How often are tumors malignant by age group?
2/3 benign in reproductive-age
1/2 benign in perimenopausal
Most malignant in postmenopausal
Fibrocystic change cause?
Exaggerated stromal response to hormones and growth factors
Presentation of fibrocystic change?
Often multiple and bilateral
Painful breast masses, swelling, tenderness
NO CANCER RISK
Age of fibrocystic change?
30-40 yo peak incidence
Treatment of fibrocystic change?
Reducing caffeine, tea, chocolate.
Avoiding trauma, wearing supportive bra.
Evening primrose oil, vitamins E and B6, danazol, progestins, bromocriptine, tamoxifen (though off label).
Fibroadenoma age, characteristics?
- Women 25-35. More common than breast cysts in women younger than 25 yo.
- Glandular and stromal components.
- Rubbery, nonetender, well-circumscribed, firm, MOBILE
- Usually solitary
- Bilateral only 25% of the time
If woman is less than 30 years old and has classic finding, this is the ONLY TIME you wouldn’t need a biopsy for tissue diagnosis.
Follow clinically if stable.
What seems like fibroadenoma but is scarier?
Cystosarcoma phyllodes, a rare variant of fibroadenoma.
LARGE, bulky, mobile mass that’s painless (like fibroadeoma). RAPID GROWTH.
Low-grade malignancy. 10% contain malignant cells.
Diagnosis of cystosarcoma phyllodes? Treatment?
Core-needle biopsy. Do wide local excision with 1 cm margin. If needed…may have to do mastectomy.
Intraductal papilloma characteristics?
Diagnosis and treatment?
Epithelial lining of lactiferous ducts
MCC bloody nipple discharge (r/o invasive papillary carcinoma)
Excision of the involved ducts.
Rarely undergo malignant transformation
Mammary duct ectasia (Plasma cell mastitis)?
Age? Presentation? Treatment
CAUSES DILATED MAMMARY DUCTS
Plasma cells infiltrate
Periductal inflammation
At or after menopause, but can also occur in adolescents.
Nipple discharge, noncyclic breast pain, nipple retraction, subareolar masses, OFTEN BILATERAL.
Usually improves with NO TREATMENT.
Local excision of inflamed area if not.
Epidemiology and risk factors of malignant breast disease
- INCREASING AGE is key risk factor.
- Black women have a lower incidence, but a higher mortality
- Previous hx of breast cancer inc risk of developing it in the CONTRALATERAL breast
- BRCA1/2
- Ionizing radiation to the chest from ages 10-30
- Atypical ductal or lobular hyperplasia
- Lifetime estrogen exposure
- HRT for more than 5 years
Prevention
Tamoxifen (also for rx)
LCIS?
Malignant epithelial cells
Mid-40s and premenopausal
NOT PALPABLE AND NOT SEEN ON MAMMOGRAMS…but risk of invasive breast cancer is low at 25-30% in 15 years
Options for LCIS treatment?
1) Observation
2) SERMs
3) Bilateral mastectomy
DCIS?
Malignant epithelial cells (like LCIS)
HIGHER POTENTIAL FOR PROGRESSION TO INVASIVE CARCINOMA THAN LCIS.
Mid-50s
Diagnosis via mammograms revealing clustered microcalcifications. Only 10% have palpable mass.
DCIS treatment options? Local recurrence risk?
1) Excision of all micro calcifications with wide margins. If this isn’t achieved, do radiation.
2) Simple mastectomy
5% local recurrence per year. 1/2 is DCIS again but 1/2 is invasive carcinoma.
MC breast malignancy?
Infiltrating ductal carcinoma
Invasive lobular carcinoma frequency?
8% of malignant breast cancers. Tends to be bilateral.
Paget’s disease of nipple
MALIGNANT (paget’s of VULVA is BENIGN)
Epidermis of nipple with eczematous changes.
Often concomitant DCIS or invasive carcinoma.
Inflammatory breast carcinoma
EXTREMELY AGGRESSIVE.
Poorly differentiated. Dermal lymphatic invasion. Peau d’orange.
Treatment- surgery?
BCT (breast conserving therapy) with lumpectomy and radiation.
Size and histology, palpable lymph nodes. 60-75% of women would qualify for it.
Treatment- axillary node status?
Outcome predictor.
Past: axillary LN dissection
Currently: Sentinel LN biopsy (SLNB). Intradermal injection of dye before surgery around the primary tumor to ID the sentinel lymph nodes so you can sample them before or after resection.
Treatment- radiation therapy?
For all patients who undergo conservative therapy due to risk of recurrence.
High risk of recurrence?
> 4 positive lymph nodes
Large primary tumor
Positive resection margins
Tumor receptor status/prognosis/drug
ER PR + give tamoxifen for premenopausal, aromatase inhibitors or fulvestrantfor postmenopausal.
HER2/neu more aggressive give trastuzumab.
ER negative- combo chemo with doxorubicin and vincristine in addition to CMF (cyclophosphamide, methotrexate, fluorouracil)
What would you give an ER positive patient who has metastatic or recurrent disease?
Hormonal therapy is better than chemo for them.
Prognosis
Stage is key.
Follow up after treatment?
Physical exam every 3-6 months x 3 years
Every 6-12 months x 2 years.
Annually thereafter.
Mastectomy as treatment should have yearly mammograms on remaining breast.
Advise women on tamoxifen to be wary of endometrial cancer signs.
Can a woman still be ok to get pregnant after breast cancer?
YES ITS FINE. No difference in survival rates. Doesn’t stimulate dormant cells and whatnot.
Can be on OCPs too.
SHOULD NOT use HRT or ERT ever.
FNA vs core needle biopsy
Fine-needle aspiration biopsy. Your doctor inserts a thin needle into a lump and removes a sample of cells or fluid.
Core needle biopsy. Your doctor inserts a needle with a special tip and removes a sample of breast tissue about the size of a grain of rice.
