Breast Diseases Flashcards
what is the most common cause of benign breast disorders?
fibrocystic breast changes
what are fibrocystic breast disease influenced by?
hormones
fibrocystic breast disease sx’s worse when?
sx’s worse prior and during menstrual cycle b/c relates to the hormones
pathogenesis of fibrocystic breast disease?
hormone induced breast changes
what is created in fibrocystic breast disease?
estrogen-ductal elements -> cause discomfort and hyperplasia
is fibrocystic breast changes a disease?
no, it’s a normal variation in breast histology
risks for fibrocystic breast disease?
nulliparity, late menopause, estrogen replacement therapy
what is the clinical presentation of fibrocystic breast disease?
tender bilateral breast w/palpable nodule that blends into the surrounding breast tissue
lumpiness fluctuates with the menstrual cycle (increase and decrease in size)
what is the nodule like in fibrocystic breast disease?
smooth well-defined edges
freely moving (not hard)
is there usually a mass present in fibrocystic breast disease? if there is?
no there usually isn’t, but if there is then do US +/- FNA
when do you follow up for fibrocystic breast disease if equivocal or non-suspicious on exam?
re-examine in 2-4 weeks (follicular phase of menstrual cycle, days 5-7 best)
what is the best dx imaging for fibrocystic breast disease? what does it distinguish?
US
Distinguishes cystic from solid mass
US for fibrocystic breast disease is done before what? can use US to do what for FNA?
before a FNA - can use US to do needle guided FNA
what does it mean when fluid from cyst comes back clear? if mass is solid?
if clear = cyst
if solid = mammogram
when is mammogram used for fibrocystic breast disease?
Further evaluation of clinically suspicious masses
Further evaluation of solid masses
dx procedures for fibrocystic breast disease?
FNA or Core Needle Bx
when is FNA best done for fibrocystic breast disease?
after US to distinguish b/w a solid and cystic mass
if no aspiration or bloody aspiration from FNA of fibrocystic breast disease, what is the next step?
Core Needle Bx
can FNA be therapeutic for fibrocystic breast disease?
YES! can take off some fluid to decrease pain
what is the difference b/w FNA and Core Needle Bx?
FNA = cytology
Core Needle Bx = histology
Core bx used for what?
uncertain FNA findings
what can core needle bx show that FNA can’t?
epithelial hyperplasia/malignancy b/c does histology
what is the method of choice for histologic dx?
core needle bx
tx for fibrocystic breast disease?
reassurance to pt, avoid impact sports, wear bra
APAP, NSAIDs
Aspiration of cyst (if isolated mass noted)
if pt is in significant discomfort with fibrocystic breast disease, what is the tx?
Tamoxifen (off-label use)
-hormone receptor drug
Danazol (FDA approved)
when does pt with fibrocystic breast disease need followup if isiolated mass noted with aspiration of cyst?
4-6 weeks later to re-assess, then few times/year
sx’s of fibrocystic breast disease will recur until when?
onset of menopause
fibroadenoma common in who?
young women (10-30 y/o)
if mass is detected in >30 y/o what must you rule out?
fibrocystic changes or cancer
when does fibroadenoma NOT occur after?
does not occur after menopause
sx’s of fibroadenoma?
have tumor-like findings
increase in size with pregnancy
regress after menopause
***painless/non-tender
***rubbery
is size of fibroadenoma related to menses?
NO!!!, but size can still change d/t hormones
etiology of fibroadenoma?
benign glandular tumor
dx of fibroadenoma?
US, mammogram, core bx
when do you excise fibroadenoma?
- Painful/Uncomfortable
- Becomes larger
- There’s malignancy on core biopsy
- If the patient is worried about not removing mass
how do you monitor fibroadenoma?
serial breast exams (clinical breast exam and self)
mammogram/US
ddx for fibroadenomas
fibrocystic
breast cancer
breast fat necrosis
breast mastitis
what can breast fat necrosis cause? difficult to distinguish from what?
a mass with nipple or skin retraction
difficult to distinguish from breast cancer
what is breast fat necrosis due to?
trauma including surgery, radiation therapy
dx and tx of breast fast necrosis?
dx = core bx
tx = excision is sometimes needed when dx is not clear
who does breast mastitis occur in?
BREAST FEEDING MOTHERS
offending organism in breast mastitis?
S. aureus
sx’s of breast mastitis?
Unilateral inflammation, erythema, mastalgia, sore nipple, engorged breast
Systemic symptoms (fever, chills)
tx of breast mastitis? abx?
Regular emptying of the breast - breast feeding or mechanical suction (KEEP BREAST FEEDING!!!)
Abx: dicloxacillin
complication of breast mastitis?
Abscess - will need to be aspirated or excised if present
etiology of nipple discharge?
- Normal lactation
- Benign physiologic nipple discharge
- Pathologic nipple discharge
what are benign physiologic nipple discharge causes? colors of discharge?
Galactorrhea í further workup with endocrine studies
White, clear, yellow, green, brown, gray, blue
what are pathologic nipple discharge causes?
Benign intraductal papillomas (MOST COMMON CAUSE)
Intraductal breast cancer
what drugs can cause galactorrhea and gynecomastia?
antipsychotics
when have pt with nipple discharge what exam should be performed?
complete breast exam of all 4 breast quadrants
also LNs:
- Subareolar area
- Axilla
- Supraclavicular
- Infraclavicular
what else needs to be assessed on PE for nipple discharge besides breast exam and LNs? elicit what?
skin changes for dimpling, edema, erythema, crusting of the nipple
elicit discharge
what LNs need to be assessed for nipple discharge?
- Subareolar area
- Axilla
- Supraclavicular
- Infraclavicular
sx’s of benign nipple discharge?
Provoked, bilateral, multiductal
sx’s of pathologic nipple discharge?
Unprovoked, unilateral, uniductal, blood/blood tinged discharge (sanguineous)
associated with breast mass
what lab to run if unclear sanginous nipple discharge?
Guaiac
labs to run for bilateral/multi-ductal nipple discharge?
- Pregnancy Test
- Prolactin Levels -> can cause galactorrhea
- Thyroid function
primary dx test for nipple discharge?
US, Mammography, Ductography
Surgical excision if imaging is negative
Core needle bx if suspicious lesion
is cytology of discharge useful?
NO!!!! cytology can’t tell you if nipple discharge is worrisome
tx for physiologic nipple discharge?
Reassurance, may change medications if medication induced (ex: if on antipsychotics, may need to change med)
tx for pathologic nipple discharge?
Terminal duct excision (this is when duct has carcinoma)
if determined nipple discharge is breast cancer, proceed to what?
breast CA management
what is the MOST COMMON cancer in women?
Breast Cancer
breast cancer risk rises at what age and peaks at what age?
rises in 60s and peaks in 70s and then declines
what genetic mutations are risk factors for breast cancer?
BRCA 1 and/or BRCA 2 genetic mutation
ASSHKENAZI JEWISH ANCESTRY
what family history is a risk factor for breast cancer?
Breast Cancer in 1st Degree Relatives
- Esp if diagnosed ≤ pre-menopausal
- Bilateral breast cancer
- Risk increases with increased number of 1st degree relatives with breast cancer
what breast characteristics are risk factors for breast cancer?
- High tissue breast density
- Proliferative fibrocystic breast disease
- Ipsilateral breast cancer
what gynecological hx is a risk factor for breast cancer?
- early menarche
- late menopuase
- nulliparous
- never breast fed
- last 1st preg
- recent and long-term estrogen replacement therapy
- post-menopausal obesity
prior what is a risk factor for breast cancer?
prior radiation tx to chest wall d/t prior cancer
what does ACOG recommend about BSEs? if do BSE, when do them?
recommends them for high risk pts
If high risk and do BSE -> should do at the same time every month during menstrual cycle
breast cancer screening methods?
BSEs (only if high risk pt)
Clinical Breast Exam (CBE)
Mammography
when does ACOG recommend to do CBE?
20-39 y/o q2-3 years, annually thereafter
screening methods for suspicious lesion on mammography?
US
Stereotactic bx (US guided bx)
Open Excision bx
MRI guided bx
can non-suspicious breast mass be ruled out as benign on exam?
NO!!!
what must you remember to exam on PE for breast cancer?
breast “tail” and axillary LNs, sternal border
what is the Breast cancer screening METHOD OF CHOICE for asymptomatic women?
Mammogram
what’s so good about Mammogram screening for breast cancer?
detects early cancer before symptom onset
detects cancer before LN spread in 80% of cases
detects cancer 2 years BEFORE a palpable mass is felt
what are findings on mammogram that are suggestive of breast cancer?
Clusters of 5-8 microcalcifications in a linear distribution usually in one area of the breast
Soft tissue masses - e.g. speculated lesion, ill-defined lesions
at what age is mammogram most sensitive?
> 50 d/t less dense, fibrotic and greater fatty breast tissue
when do you start screening for breast cancer with mammogram?
age 40
when do you stop screening for breast cancer?
75 y/o
frequency of screening for breast cancer?
q1-2 years
if have abnormal mammogram screening but UNCLEAR IF MALIGNANT, what do you do?
Dx mammogram
-mag views and spot compression views
Targeted US
a non-palpable mass on mammogram is followed by what test?
US - to see if it’s cystic or solid (solid = cancer)
any suspicious mass on mammogram screening whether palpable or non-palpable requires additional what?
additional screening
if have palpable mass on screening, what’s the preferred next step?
core bx - helps determine surgical plan
if have non-palpable mass on screen, what’s the next step?
stereotactic bx
benign lesions of the breast are categorized into what 3 groups?
- Non-proliferative
- Proliferative w/out atypia
- Proliferative with atypia
tx of benign proliferative w/atypia?
excision bx and breast cancer chemoprevention
what are the 2 main types of breast cancer?
Non-invasive type:
-ductal carcinoma in situ (DCIS)
Invasive type:
-infiltrating ductal
sx’s of breast cancer?
painless, persistent mass
suspicious sx’s of breast cancer?
bone pain, HA, seizures, double vision
PE for breast cancer?
- Examine all four quadrants of the breast
- Dimpling
- Nipple retraction
Skin changes:
-Erythematous, edema, peau d’orange
- Assess axilla, supra and infraclavicular area
- Assess nipple discharge
what skin change is a sign of breast cancer?
peau d’orange
what is the most useful entry in the pts clinical record for evaluation of breast cancer?
location and size of mass
early sx’s of breast cancer?
Immobile, fixed, ill-defined margins, hard
Painless
early breast cancer mammography abnormalities?
linear calcifications
late sx’s of breast cancer?
fixed mass, nipple retractions, asymmetric breast enlargement or shrinkage, pain, BLOODY DISCHARGE
PEAU D’ORANGE
what is the criteria for normal LNs?
movable, non-tender <5mm are usually normal
LNs that present with what are of concern?
hard, immovable, >1cm may denote mets
axillary LN involvement and/or supra/infraclavicular LNs denote mets
breast cancer staging?
mammogram, bx, TNM staging, biomarkers, alk phos, LFTs, CBC
when do you do PET scan for breast cancer?
stage 3 or greater
what helps determine rate of recurrence of breast cancer?
mammaprint or oncotype diagnostics (genomic health)
what LNs are first targeted by breast cancer tumor invasion and tell you if you need to remove other LNs?
sentinel LNs
if sentinel LNs are positive, what must be removed?
axillary LNs
what tumor biomarkers is breast tissue sampled for?
ER, PR, and HER-2
ER+ and PR+ respond to what tx? has better what then ER/PR - tumors?
hormonal tx
better prognosis
HER-2 positive is worse than survival than?
ER+/PR+
what staging status of breast cancer has a poor response to therapy?
- ER and PR negative
- Over expression of HER-2
- Triple negative breast cancer (negative ER/PR, negative HER)
- Poor general health
- Positive LNs
tx for breast cancer is what type of approach?
multidisciplinary approach
surgery options for breast cancer tx?
lumpectomy, radical mastectomy, modified radical mastectomy, simple masectomy
lumpectomy is C/I when?
> 2 tumors in different quadrants, large tumor, persistently positive margins, diffuse cancer
difference b/w radical mastectomy and modified radical mastectomy?
radical mastectomy removes muscles around mass and LNs
modified radical mastectomy removes breast tissue and LNs but spares musculature
when after surgery do you do radiation therapy for tx of breast cancer? indications?
5-7 weeks after surgery
indications:
- Breast conserving surgery
- Large tumors >5cm
- +LN involvement
what are the indications for hormone tx for breast cancer?
ER/PR+
hormone therapy options for tx of breast cancer?
Tamoxifen (SERM - anti estrogen in the breast)
aromatase inhibitors (anastrozole, exemestane, letrozole)
how long is Tamoxifen given? used in who?
10 years or may do 5 year then switch to aromatase inhibitors
used in pre-menopausal women
adrs of Tamoxifen?
DVT, uterine cancer
what hormone therapy drug is superior to Tamoxifen (SERM)? given for how long?
Aromatase inhibitors
given for 5 years
adrs of aromatase inhibitors? C/I in who?
bone loss, myalgia, and arthalgias
C/I in pre-menopausal women
what are the targeted therapy indications for tx of breast cancer? what is the targeted therapy?
HER+
targeted therapy = Trastuzumab (Herceptin)
Herceptin is given with what?
conventional chemo
who must you be cautious with when giving Herceptin?
cardiac disease pts b/c increases risk of CHF 5x
when is adjuvant chemo offered for tx?
after surgery, before radiation
results of adjuvant chemo is best in what women?
LN positive women (metastatic breast cancer)
indications for adjuvant chemo?
LN positive, ER/PR negative, triple negative, HER-2+
when is neoadjuvant chemo given?
before surgery
if HER2+ what’s the tx? if HER2- what’s the tx?
If HER-2 positive then get chemo and Herceptin, if negative, then only get chemo
what is a common adr of chemo drugs?
peripheral neuropathy
what is the only tx option for triple negative breast cancer pts?
chemotherapy
when should pts be referred for hospice?
when prognosis is <6 months
prognosis of male breast cancer?
poorer prognosis than women b/c present with metastatic disease
sx of male breast cancer?
same as female breast cancer, but includes gynecomastia
tx for male breast cancer?
modified mastectomy followed by radiation therapy
hormonal therapy: tumors are usually ER positive (Tamoxifen)
chemotherapy
most important tx for male breast cancer?
hormonal therapy with Tamoxifen
sx’s of metastatic breast cancer?
seizures, HA’s, back pain, spontaneous bone fractures, dyspnea, cough, hypercalcemia
