Breast Diseases Flashcards
What are fibrocystic breast changes
hormone induced breast changes
What are the risks for fibrocystic breast disease
- nulliparity
- late menopause
- estrogen replacement therapy
In fibrocystic breast disease, estrogen affects what? Progesterone?
estrogen: ductal elements
progesterone: stroma
Clinical presentation of fibrocystic breast disease
-painful bilateral breasts
-palpable nodular areas with smooth defined
edges
-freely moving nodules
-+/- nipple discharge
The changes in the breast with firbocystic disease fluctuates with what
the menstrual cycle
Imaging you want to get for fibrocystic breast disease. Why?
US- distinguish cystic mass from a solid mass (done before FNA)
Mammogram- further evaluate suspicious/solid masses
When should you do an FNA
after an ultrasound to distinguish between a solid and a cystic mass
If there is no aspiration or bloody aspiration on FNA what do you do next
refer for core needle biopsy
What does a core biopsy give you
histologic information (epithelial hyperplasia, malignancy)
Besides uncertain FNA findings, when else should a core biopsy be done?
if cytology from FNA is benign but the mass persists for 3-6 months
Treatment for fibrocytic breast changes (mild)
- avoid impact sports
- bra with adequate support
- ? decrease caffeine
- ? vit e and oil of pirmrose
If a patient is experiencing significant discomfort associated with fibrocystic changes what can you prescribe
Tamoxifen, Danazol
Diangosis of fibrocystic breast disease is made based off of what
history and physical
Buzz words for fibrocystic breast disease
pre-menstrual painful, lumpy breasts
Who gets firbocystic breast changes
women between ages 30-50 (increases with age)
Who gets fibroadenomas of the breast
younger women ages 10-30
Characteristic of fibroadenomas
- get bigger with pregnancy
- goes away after menopause
- painless
- round/oval, hard/rubbery, movable nodules
- 1 to 5 cm in diameter but can vary (not related to menses)
When is excision of a fibroadenoma indicated
if diagnosis is uncertain or if very large and uncomfortable
What do you use to monitor fibroadenomas of the breast
- serial breast exams
- mammograms/ultrasound
What is the most common cause of pathogenic nipple discharge
benign intraductal papilloma
What types of things can cause benign physiologic nipple discharge (galactorrhea
- rx induced
- CNS lesions
- pinuitary adenoma
- Cushing’s
- chest wall lesions
- idiopathic
Important history points to obtain for females presenting with nipple discharge
-is there a mass present?
-unilateral or bilateral?
-spontaneous, persistent, intermittent?
relation to menses?
-premenopause of post?
Physical exam findings of a benign nipple discharge
- provoked
- bilateral
- multiductal
- milky, white, clear, yellow, green, brown, gray, blue discharge
Physical exam findings of suspicious of pathologic nipple discharge
- unprovoked
- unilateral
- unidutal
- serous, sanguinous or serosanguinous
- associated with breast mass
- women >40
What labs should you do with bilateral/multiductal discharge
- pregnancy test
- prolactin levels
- thyroid function
Treatment for pathologic nipple discharge
terminal duct excision
Who gets mastitis
breast feeding mothers
What causes mastitis
S aureus
Sx’s of mastitis
- unilateral inflammation, erythema, mastalgia, sore nipple, engorged breast
- systemic sx’s (fever chills)
Treatment of mastitis
- regular emptying of the breast
- dicloaxacillin
Complication of mastitis
abscess
Risk factors for breast cancer
- age (peak 70)
- BRCA1/BRCA2 genetic mutation
- family history of breast/ovarian cancer
Breast characteristics that put a woman at risk for breast cancer
-high tissue breast density
-proliferative firbocystic breast disease
ipsilateral breast cancer
Gynecological history that puts a woman at risk for breast cancer
- early menarche
- late menopause
- nulliparous
- never breastfeeding
- recent and long term estrogen replacement therapy
- post menopausal obesity
Screening methods for breast cancers
- bilateral self breast exam
- clinical breast exam
- mammography
If a suspicious lesion is found on mammography what do you do next?
- US
- stereotactic biopsy
- open excision biopsy
- MRI guided biopsy
Expert opinion on breast self exams
DONT DO IT
Things to remember when doing a breast exam
- examine the “tail”
- examine axillary LNs
- examine sternal border
Screening method of choice for asymptomatic women
mammogram
Mammograms detect cancer ___ before palpable mass is felt
2 years
Findings on mammogram that are suggestive of cancer
- clusters of 5 to 8 microcalcificatins in a linear distribution
- soft tissue masses (spiculated lesion, ill defined lesions)
When should mammograms start? When should you stop? How often do you do iy
> 50 if average risk
stop at 75
get one every 1-2 years
If an abnormality is noted on a screening mammorgram whats the next step
diagnostic memmogram (magnification view and spot compression views)
target ultrasound
What denotes cancer suspicion that you can determine with an ultrasound
mass irregularity
Ultrasound is useful in distinguishing ___ from ___ masses
cystic from solid masses
When is mammogram and ultrasound used as diagnostic techniques
non palpable mass on mammogram—> US
non palpable calcified mass on mammo–> US guided biopsy
mass on mammo w/ dense breasts–> US
If a suspicious malignant mass is found on screening whats next
if palpable–> core biopsy or excisional biopsy
if non palpable–> stereotactic biopsy
What is a stereotactic breast biopsy
procedure in which patient is prone on the mammo table and biopsies are taken with a computer assisted device
Three categories benign breast lesions fall under
- non proliferative
- proliferative without atypia
- proliferative with atypia
Examples of proliferative with typia lesions
- atypical ductal hyperplasia
- atypical lobular hyperplasic
- flat epithelial atypia
- lobular carcinoma in situ
Tx for proflierative lesions with atypia
excisional biopsy and breast cancer chemoprevention
Two types of non invasive breast cancer
- ductal carcinoma in situ
- ductal lobular in situ
Types of invasive breast cancer
- infiltrating ductal (76%)
- invasive lobular
- ductal/lobular
- inflammatory
- mucinous, tubular, medullary, papillary metastatic breast cancer
Suspicious symptoms for breast cancer
- bone pain
- HA
- seizures
- double vision
What types of breast skin changes should you look for in breast cancer
- erythema
- edema
- peau d’prange
Early signs and symptoms of breast cancer
- immobile, fixed, ill defined margins, hard
- painless
Mammographic abnormalities that make you think early breast cancer
linear calcifications
Signs and symptoms of late breast cancer
- fixed mass to skin or chest wall
- skin or nipple retractions
- breast enlargement (asymmetry) or shrinkage
- breast edema, erythema, pain
- bloody nipple diacharge
When assessing lymph nodes with breast cancer what is considered normal
moveable, non tender <5mm
Lymph nodes that present as what are concerning
- matted, hard, firm, immovable
- fixed to skin or deeper tissue
- > 1cm
What would typically denote metastatic breast cancer
axillary lymph node involvement and/or supra/infraclavicular LNs
Stage 0 breast cancer =
carcinoma in situ
Stage I breast cancer
<2cm
neg LNs
Stage IIA breast cancer
<2cm w/ +lymph
OR
2-5cm, - lymph
Stage IIB breast cancer
> 2cm w/ +LNs
OR
5cm w/ -LNs
Stage III breast cancer
> 5cm
+LNs
skin and chest wall infiltration
Stage IV breast cancer
distant metastases
Where does breast cancer like to metastasize to
- brain
- done
- liver
- lungs
What are sentinel LNs
first LNs target by tumor invasion
What do sentinel LNs determine
biopsied to check LN invasion
if neg–> axillary LNs are spared
Prognosis of ER/PR positive tumors
better than ER/PR negative tumors because the respond to hormonal treatment
HER-2 positive. Good prognosis or bad?
bad,high rate of recurrencce
BUT
more responsive to therapy
When is breast conserving surgery contraindicated
- > 2 tumors in different quadrants
- large tumor
- persistently positive margins
- diffuse cancer
Type of surgical approaches to breast cancer treatment
- radical mastectomy
- modified radical mastectomy
- simple mastectomy
- skin sparing mastectomy
- skin and nipple sparing mastectomy
When is radiation therapy done
5-7 weeks after surgery
Indications for radiation therapy for breast cancer tx
- breast conserving surgery
- large tumors >5cm
- lymph node involvement
HER + targeted therapy
trastuzumb (herceptin)
targeted against HER-2 receptor oncogene over-expression
Herceptin is given with what
conventional chemotherapy
How long is herceptin given for
1 year
Herceptin increases a patients risk of what
CHF
What is the goal for chemotherapy with breast cancer
- eliminate micrometastases and recurrence
- stop disease progression
Which population see the best results with chemotherapy
LN positive women
Indications for chemotherapy
- LN positive
- ER/PR negative
- tumor >2cm
- triple negative
What medications given with conventional chemo can increase survival
- paclitaxel
- docetaxel
What are paclitaxel and docetaxel good for?
- Her2 negative
- Stage I,II,III
Hormonal therapy for ER/PR positive patients
- tamoxifen
- aromatase inhibitors
Side effects of tamoxifen
- DVT
- uterine cancer
- vasomotor symptoms
What population are aromatase inhibitors contraindicated in
pre menopausal women
Side effects of aromatase inhibitors
- bone loss
- myalgia
- arthralgia
Only treatment option for triple negative breast cancer
chemo
Possible risk factors for breast cancer in men
- hx of prostate cancer
- men with 1st degree relatives with h/o breat cancer
- BRCA2 gene mutations
