Breast Disease & Breast Cancer Flashcards
Nerves around the breast / injuries
Intercostobrachial nerve → through axilla; sensory to upper medial arm
Long thoracic nerve (C5-7) → serratus anterior (“winged scapula”)
Thoracodorsal nerve → latissimus dorsi
Timing of breast exams
SBE: monthly 5d after menses
CBE: yearly
Mammograms:
Should have yearly mammogram starting at age 40; continue as long as the woman is in good health
No upper age limit!
If strong FHx breast cancer (mother or sister), mammogram screening 5 yrs earlier than youngest family member’s diagnosis or 10 years if family member was premenopausal.
Breast pain (mastalgia / mastdynia)
If cyclic, can be 2/2 PMS, normal hormonal fluctuations, fibrocystic change
If no signs of malignancy and really low risk, reassure → NSAIDs, support bra, warm compresses
Consider U/S if hx trauma or mammogram if higher risk for cancer
Nipple discharge:
Mostly normal physiologic
Worrisome: spontaneous, bloody / SS, unilateral, persistent, from single duct, a/w mass
Bloody Nipple discharge:
Think intraductal papilloma / invasive papillary cancer
Galactorrhea:
Think pregnancy, pituitary adenomas, hypothyorid, stress, OCPs/antiHTN/antipsychotics
Serous nipple discharge
Think normal menses, OCPs, fibrocystic change, early pregnancy
Yellow-tinged nipple discharge
Think fibrocystic change, galactocele
Green, sticky nipple discharge
Think duct ectasia
Purulent nipple discharge
Think breast abscess
Breast masses
Never dismiss a mass just because mammogram is negative
Think malignant if firm, nontender, poorly circumscribed, immobile
Breast mass work up
Get U/S for women < 30, mammogram for women >30
If concerning on imaging or exam, get tissue
Cystic → aspirate ; excise cyst if bloody fluid or persistent
Solid → fine needle aspiration if < 30 → excisional bx if FNA fails, or nondiagnostic
Core needle biopsy if > 30
Nonpalpable → excisional bx under needle / wire guidance
Benign breast disease: Fibrocystic change
Painful breast masses that are multiple / bilateral, hormonal response, fluctuates in cycle
Peak incidence in women 30-40 years old
Treat with less caffeine, tea, chocolate (controversial), avoiding trauma, using support bra
Not associated with increased cancer risk
Benign breast disease: Fibroadenoma
Benign tumor with glandular / stromal component
Usually solitary but can be bilateral; rubbery / nontender, can change during cycle
Peak incidence in women 20-35 years old
Classic fibroadenoma in a woman < 30 may be only solid breast mass not requiring tissue dx
Follow clinically if stable!
If concerned, get FNA for cytology to r/o cancer or phyllodes tumor, or excise if large/bothersome
Benign breast disease: Cystosarcoma phylloides
Rare variant of fibroadenoma
Any age but mostly premenopausal women
Large, bulky, mobile mass, smooth, well circumscribed, grows quickly
Most benign but may degenerate; need to make pathologic dx after wide local excision with 1cm margin; if really big → simple mastectomy
Benign breast disease: Intraductal papilloma
Benign solitary lesion from epithelial lining of lactiferous ducts; rarely degenerate into malignancy #1 cause of bloody nipple discharge in absence of mass But send S/S discharge for cytology to r/o invasive papillary carcinoma Tx: excise involved ducts.
Benign breast disease: Mammary duct ectasia
Subacute inflammation of ducts → dilation → inflammation
Usually at or after menopause
Nipple discharge, noncyclic breast pain, nipple retraction, often bilateral
Get mammogram / excisional bx to r/o carcinoma
Risks for malignant breast disease
Increasing age is big one, also personal hx, first degree family hx, esp higher if family member premenopausal or male, BRCA ½, ionizing radiation at young age (Hodgkin lymphoma), atypical ductal o rlobular hyperplasia on bx.
Diagnosis of malignant breast disease
Often SBE / CBE / mammmo; masses / skin change / dimpling; bloody discharge should be ruled out
50% of tumors in upper outer quadrant. Mets: to bone, liver, lung, pleura, brain, LNs
Noninvasive disease: Lobular carcinoma in situ (LCIS)
Neoplastic epithelial cells in breast lobules without invasion of stroma
Multicentric & bilateral; often picked up incidentally on bx for another finding (can’t see on mammograms and can’t palpate on PE)
Premalignant lesion - 25-30% risk of invasive breast cancer w/in 15 yrs in either/both breasts
Treatment of Lobular carcinoma in situ (LCIS)
Observe only; may consider SERM to decrease risk - otherwise close followup
Noninvasive disease: Ductal carcinoma in situ (DCIS)
Malignant epithelial cells in mammary ducts, not stroma
Higher capacity to progress to outright invasive ductal cancer in same site
Mammogram → clustered microcalcs +/- palpable mass
Dx: needal localization bx or excisional bx if palpable
Treatment of ductal carcinoma in situ
Surgical excision of all microcalcifications with wide margins
May need simple mastectomy if extensive only
Invasive breast disease types
Infiltrating ductal carcinoma (70%)
Invasive lobular carcionoma (10-20%)
Paget disease of nipple (1-3%)
Inflammatory breast carcinoma (1-4%)
Infiltrating ductal carcinoma (70%)
From ductal epithelium, usually unilateral
Invasive lobular carcionoma (10-20%)
From lobular epithelium, often bilateral
Paget disease of nipple (1-3%)
Often with DCIS / invasive carcinoma in subareolar area
Malignant cells invade nipple epidermis → eczematous changes w/ scaling, erosion, etc.
Inflammatory breast carcinoma (1-4%)
Really aggressive, poorly differentiated
Dermal lymphatic invasion → peau d’orange
Treatment of invasive breast disease
Modified radical mastectomy or [lumpectomy + radiation] but need to be able to get rads
Get sentinel LN biopsy
Breast reconstruction afterwards
Hormone status of invasive breast disease
ER/PR+ = better prog
HER2/neu = worse prognosis
If ER+, usually use tamoxifen x 5 yrs; letrozole / anstrozole (aromatase inhibitors) even better if postmenopausal (most estrogen coming from fat!)
Remember tamoxifen predisposes to endometrial cancer!
If HER2/neu+, may try trastuzumab (mAb vs HER2/neu)
Metastatic / recurrent
ER-: combo chemo
ER+: consider oophorectomy / GnRH antagonists if premenopausal,
consider tamoxifen / aromatase inhibitors if postmenopausal
Systemic adjuvant chemo along with hormonal therapy if indicated often used
Prognosis of invasive breast disease
Stage is #1 predictor, also ER/PR status and lymph node status
Follow up of invasive breast disease
PE q3-6mo x 3y, then space to q6mo x 2y, then q12mo
Mammogram @ 6mo, then annually
Avoid HRT
Low transverse incision risk:
Can damage the iliohypogastric or ilioinguinal nerves (both pass through psoas and then go through transversus abdominus to anterior abdominal wall, where they run between internal and external oblique.
At risk if low transverse incision extended beyond lateral border of rectus
Iliohypogastric nerve
Provides cutaneous sensation to the groin and the skin overlying the pubis
Ilioinguinal nerve
Provides cutaneous sensation to the groin, symphysis, labium and upper inner thigh.
