Breast Disease & Breast Cancer Flashcards

1
Q

Nerves around the breast / injuries

A

Intercostobrachial nerve → through axilla; sensory to upper medial arm
Long thoracic nerve (C5-7) → serratus anterior (“winged scapula”)
Thoracodorsal nerve → latissimus dorsi

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2
Q

Timing of breast exams

A

SBE: monthly 5d after menses
CBE: yearly

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3
Q

Mammograms:

A

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.

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4
Q

Breast pain (mastalgia / mastdynia)

A

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

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5
Q

Nipple discharge:

A

Mostly normal physiologic

Worrisome: spontaneous, bloody / SS, unilateral, persistent, from single duct, a/w mass

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6
Q

Bloody Nipple discharge:

A

Think intraductal papilloma / invasive papillary cancer

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7
Q

Galactorrhea:

A

Think pregnancy, pituitary adenomas, hypothyorid, stress, OCPs/antiHTN/antipsychotics

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8
Q

Serous nipple discharge

A

Think normal menses, OCPs, fibrocystic change, early pregnancy

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9
Q

Yellow-tinged nipple discharge

A

Think fibrocystic change, galactocele

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10
Q

Green, sticky nipple discharge

A

Think duct ectasia

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11
Q

Purulent nipple discharge

A

Think breast abscess

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12
Q

Breast masses

A

Never dismiss a mass just because mammogram is negative

Think malignant if firm, nontender, poorly circumscribed, immobile

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13
Q

Breast mass work up

A

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

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14
Q

Benign breast disease: Fibrocystic change

A

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

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15
Q

Benign breast disease: Fibroadenoma

A

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

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16
Q

Benign breast disease: Cystosarcoma phylloides

A

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

17
Q

Benign breast disease: Intraductal papilloma

A
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.
18
Q

Benign breast disease: Mammary duct ectasia

A

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

19
Q

Risks for malignant breast disease

A

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.

20
Q

Diagnosis of malignant breast disease

A

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

21
Q

Noninvasive disease: Lobular carcinoma in situ (LCIS)

A

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

22
Q

Treatment of Lobular carcinoma in situ (LCIS)

A

Observe only; may consider SERM to decrease risk - otherwise close followup

23
Q

Noninvasive disease: Ductal carcinoma in situ (DCIS)

A

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

24
Q

Treatment of ductal carcinoma in situ

A

Surgical excision of all microcalcifications with wide margins
May need simple mastectomy if extensive only

25
Q

Invasive breast disease types

A

Infiltrating ductal carcinoma (70%)
Invasive lobular carcionoma (10-20%)
Paget disease of nipple (1-3%)
Inflammatory breast carcinoma (1-4%)

26
Q

Infiltrating ductal carcinoma (70%)

A

From ductal epithelium, usually unilateral

27
Q

Invasive lobular carcionoma (10-20%)

A

From lobular epithelium, often bilateral

28
Q

Paget disease of nipple (1-3%)

A

Often with DCIS / invasive carcinoma in subareolar area

Malignant cells invade nipple epidermis → eczematous changes w/ scaling, erosion, etc.

29
Q

Inflammatory breast carcinoma (1-4%)

A

Really aggressive, poorly differentiated

Dermal lymphatic invasion → peau d’orange

30
Q

Treatment of invasive breast disease

A

Modified radical mastectomy or [lumpectomy + radiation] but need to be able to get rads
Get sentinel LN biopsy
Breast reconstruction afterwards

31
Q

Hormone status of invasive breast disease

A

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

32
Q

Prognosis of invasive breast disease

A

Stage is #1 predictor, also ER/PR status and lymph node status

33
Q

Follow up of invasive breast disease

A

PE q3-6mo x 3y, then space to q6mo x 2y, then q12mo
Mammogram @ 6mo, then annually
Avoid HRT

34
Q

Low transverse incision risk:

A

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

35
Q

Iliohypogastric nerve

A

Provides cutaneous sensation to the groin and the skin overlying the pubis

36
Q

Ilioinguinal nerve

A

Provides cutaneous sensation to the groin, symphysis, labium and upper inner thigh.