Breast Disorders

Question 1

Acute Mastitis

Answer 1

• Definition: infx of the breast ducts; Most common in lactating women secondary to nipple trauma (esp. primigravida)
• Etiology:
  
  • staphylococcus aureus, streptococcus**, candida albicans
• Non-puerperal: consider inflammatory breast cancer, possible ruptured cyst, or period s of breast tissue enlargement in peds (<2 months & 8-17 yo)
• S/sxs:
  
  • unilateral localized breast pain, tenderness, warmth, swelling, induration & skin redness
  • purulent nipple discharge, cracked or fissured
  • systemic sxs: fever, chills, myalgias
• PE: see image
• Dx:
  
  • clinical
    
    • but can cx breast milk
    • imaging saved for cases not responding to empiric tx
• tx:
  
  • Supportive: warm compresses, analgesics, breast pump
  • Antibiotics: anti-staphylococcal (Dicloxacillin 500 mg PO q 6H x 10 days or clindamycin 300 mg PO TID x 10 days)
  • Mothers encouraged to continue breastfeeding: feed baby on affected side first (heaviest emptying)

Question 2

Congestive Mastitis

Answer 2

• Definition: bilateral breast enlargement 2-3 days postpartum due to milk stasis
• S/sxs:
  
  • BILATERAL breast pain & swelling
• Tx:
  
  • breast drainage: manually or breast pump

Question 3

Breast Abscess

Answer 3

• Definition: collection of pus in the breast tissue. Rare complication of acute mastitis
• Etiology:
  
  • staphylococcus aureus, streptococcus, candida albicans
• S/sxs:
  
  • unilateral LOCALIZEd breast pain, tenderness, warmth, swelling, & skin redness
  • Visible induration & fluctuance (d/t pus)
  • purulent nipple discharge
• Dx:
  
  • Clinical diagnosis
  • Can use U/s to differentiate cellulitis vs abscess (ill-defined mass with septations)
• Tx:
  
  • Drainage: needle aspiration or I&D
  • Abx: dicloxacillin, cephalexin, clindamycin
  • Mothers encouraged to continue breastfeeding: Milk drainage critical for resolution of infection

Question 4

Fibroadenoma

Answer 4

• Definition:
  
  • benign solid tumor composed of glandular & fibrous tissue
• Epidemiology:
  
  • 2nd most common benign breast mass, increased in AAs
• S/sxs:
  
  • Non-tender breast mass: gradually grows over time, gets bigger in pregnancy, does not change with the menstrual cycle
• PE:
  
  • Firm, nontender, rubbery, well-circumscribed, avascular, MOBILE, ~2-3cm
  • No axillary involvement
• Dx:
  
  • US: solid, well-circumscribed avascular mass
  • Fine needle aspiration: fibrous tissue & collagen in a swirl
• Tx:
  
  • conservative: observation, reassurance & repeat u/s in 3-6 months
  • excision: if getting bigger after repeating U/s
  • Cryoablation: alternative to surgery if < 4cm

Question 5

Fibrocystic Changes

Answer 5

• Definition: noncancerous, bilateral fluid-filled breast cysts due to exaggerated response to hormones (cyclical)
• Epidemiology:
  
  • most common benign breast disorder in reproductive age women
  • often regress after menopause
• S/sxs:
  
  • multiple, painful/painless breast masses
    
    • may change in size with menstrual hormonal changes
    • -→ often worse before menstruation
• PE:
  
  • mobile, smooth, round lumps in both breasts of varying sizes
  • sometimes tender axillary nodes but no clavicular. nodes
  • usually upper outer section of breasts
• Dx:
  
  • US = initial test
  • Fine needle aspiration: straw-colored or green fluid
• Tx:
  
  • supportive care: observation, supportive bra, warm or cool compresses, analgesics, vitamin E supplements, fish oil
  • Low dose oral contraceptives: reduce sxs
  • Diet: decrease caffeine & stimulants, decrease salt, low fat

Question 6

Galactorrhea

Answer 6

• Definition: milky nipple discharge unrelated to the normal milk production of breast-feeding. Not a disease but a sign of underlying problem
• Etiology:
  
  • pituitary adenoma, hypothyroidism, meds ( tranquilizers, antidepressants, HTN drugs), herbal supplements, excessive breast stimulation (sex & self-exam), infx
• S/sxs:
  
  • milky nipple discharge
• PE:
  
  • should do a visual field exam: to exam for changes secondary to prolactinoma
• Dx:
  
  • hcg
  • serum prolactin
  • TSH
  • MRI or CT of pituitary gland
  • mammogram
• Tx :
  
  • tx underlying cause
  • RED FLAGS: unilateral, palpable mass, blood, nipple retraction → REFER to breast clinic

Question 7

Gynecomastia

Answer 7

• Definition: enlargement of glandular breast tissue & adipose tissue in males due to increased estrogen or decreased androgens
• Etiology:
  
  • Hormonal:
    
    • seen in infants d/t high maternal estrogen, during puberty, and in older males
  • Medications:
    
    • spironolactone, ketoconazole
  • Other
    
    • idiopathic, malignancy, cirrhosis, hyperthyroidism
• S/sxs:
  
  • palpable mass of tissue: at least 0.5cm in diameter, centrally located, symmetrical, bilateral, tender to palpitation
• Dx:
  
  • clinical dx
    
    • but you can order testosterone levels or mammogram if breast cancer is suspected
• Tx:
  
  • d/c offending meds
  • Supportive: observation if early in disease course
  • Tamoxifen: estrogen antagonist in the breast
  • Surgery: if refractory to meds and severe

Question 8

Breast Cancer: Types, Risks, & epidemiology

Answer 8

• Types: “breast cancer is a group of diseases”
  
  • Luminal A (40%): slow growing, ER/PgR
  • Luminal B (15%): fast growing, ER/PgR/HER2
  • Basal (15%): aggressive, no targeted therapies
  • HER2 Enriched (10%): aggressive, HER2
  • Ductal Carcinoma in Situ: non-invasive, surgically removed & cured
• Risks:
  
  • BRCA1 & BRCA2, PALB2, 1st degree relative, radiation therapy to the chest at 10-30 yo , increasing age, increased # of menstrual cycles (late pregnancy, early menarche, late menopause), no breast feeding, long-term hormone replacement , breast density, OCPs, EtOH, tobacco, obesity
• Epidemiology:
  
  • most common non-skin malignancy in women, 2nd most common cause of cancer death in women (after lung), 12% chance of diagnosis (with BRCA ~70% chance)

Question 9

Breast Cancer: S/sxs, PE, Dx, & Tx

Answer 9

• S/sxs:
  
  • painless, hard, fixed, immobile lump
  • unilateral discharge, may be bloody
• PE:
  
  • Mass most common in upper outer quadrant (65%) and areola (18%)
  • Skin changes: asymmetric erythema, discoloration, ulceration, skin retraction, changes in breast size, nipple inversion
  • Axillary lymphadenopathy
  • Metastasizes to bone, lungs, liver, brain
  • Paget disease of the breast: eczematous itchy scaly rash on nipples with yellow discharge
  • Inflammatory breast cancer:peau d’orange (orange peel appearanced/t lymphedema and pulling of carcinoma on skin)
• Dx:
  
  • US: initial modality to evaluate breast masses
  • Mammogram: microcalcifications & spiculated masses, high breast density makes it harder to catch
  • MRI: rapid uptake of contrast, annual for women at high lifetime risk > 30yo
  • Biopsy:
    
    • fine needle aspiration → does not allow receptor testing
    • core biopsy: allows receptor testing but greater deformity
    • open biopsy: most accurate, allows for immediate resection of cancer
    • imaging guided biopsy
    • sentinel lymph node biopsy
• Tx:
  
  • *Based on TNM staging
  • Surgery: mastectomy
  • chemo and/or radiation

Question 10

When to Screen with Mammograms

Answer 10

• *Varying recommendations
• USPSTF: q 2 years for 50-74yo
• American cancer society: annually for women > 40yo until lifespan is <10 years
• Transgender women: q 2 years for > 50 yo WITH 5-10 yrs of feminizing hormones
• Transgender man: same criteria as cis-female

Question 11

When to conduct Genetic BRCA testing

Answer 11

• if 1st degree female relatives with bilateral breast cancer
• 1st degree relative with breast or ovarian cancer
• male relative with breast cancer
• 2+ 1st or 2nd degree female relatives with ovarian cancer
• 2+ 2nd degree relatives on the same side with breast or ovarian cancer
• Ashkenazi jewish heritage