Breast Disorders Flashcards
Mammographic abnormalities to follow
- masses
- Asymmetric densities
- Microcalcifications
If abnoramlities are found on screening mammogram
Additional imaging is necessary with spot magnification
Causes of asymmetric densities
- Operative procedures
- Previous radiation tx
- Previous infxn
- normal variation
- Local processes
radiographic imaging wihout palpable abnormalities
- Perform ADDITIONAL magnification mammography
- Stereotactic guided core needle biopsy
- Localization and open surgical biopsy
FNA vs. core needle biopsy
Core needle is diagnostic while FNA is nondiagnositc
Lesion that his highly suspicious for malignancy on mammogram
Open surgical biopsy should be performed which may in fact be sufficient therapy via complete excision of the lesion
DCIS
- Incidental microcalcification on mammography
- +/- breast mass
- Req’s surgery
- +/- infiltrative component at excision
- If left not completely resected then there is a 30% chance of development of invasive CA at 10yrs
DCIS histologic patterns
- comedo (30% malignant potential)
- Micropapillary
- Cribiform
Tx of DCIS
- Diffuse/multicentric DCIS = simple mastectomy +/- reconstruction
- Smaller lesions = wide excision with path-free margins and radiotherapy
- Nodal sampling may be reqd in the comedo variant ONLY since there may be spread to axillary nodes
LobularCIS findings
- Rarely p/w mass
- If adjacent to benign mass then surveillance is necessary. If no mass then close observation w/mammography q6mo is necessary
- Core bx may show calcification in which case needle localization and excision is necessary
- No risk for axillary mets
- 15-20% chance of developing invasive CA in the breast
Sclerosing adenosis
- Clusetered microcalcifications
- Simialr to invasive tubular CA
- Follow up on sclerosing adenosis
Atypical ductal hyperplasia
- Atypical hyperplasia in ducts/lobules
- 4-5x higher CA risk
- Reqs needle localization and excision
- Tx = complete excision and close observation
Workup for breast carcinoma
- Mammogram
- US of mass if it feels cystic or hx of cysts
- Aspiration indicated if mass is painful or enlarging
- Biopsy if the mass feels solid
35-60yo women with palpable breast mass
cancerous until proven otherwise
28yo women with palpable breast mass
Higher incidence of benign lesions and higher risk of radiation from mammography. 98% of solid lesions in this age group are solif fibroadenomas. if lumps appear physiologic then observation for 1-2 menstrual cycles is appropriate in low risk pts.
Fibrocystic change
- Uncommon before adolescence or after menopause
- Lumpy breasts (usually B/L)
- Premenstrual tenderness
- Estrogen responsive and responsive to decreased progresterone
Tx of fibrocystic change
- Eliminate caffeine from diet
- Supplement Vit E
- Cyst aspiration
Firm, rubbery, nontender, freely movable breast mass w/o involvement of opposite breast/LN’s
Fibroadenoma = most common in AA’s. Dx based on biopsy or FNA
Large, bulky, breast mass of variable malignant potential and occasional ulceration of overlying skin
Phyllodes tumor. Malignancy depends on: tumor behavior and number of mitoses per HPF
Bloody nipple discharge. Hx of multiple pregnancies.
NONmilky nipple discharge in a NONlactating women warrants investigation
Workup for nipple discharge
- Uni/Bilateral
- Contains blood
- Involves single/multiple ducts
Most common cause of bloody nipple discharge. Workup
Intraductal papilloma. Requires surgical biopsy. Small risk for carcinoma and thus patients should undergo mammography to r/o other breast abnormalities and close exam to ID a single duct that is the source of bloody discharge
Staging infiltrating ductal carcinoma
- Determine extent of dz (regional LN’s, distant mets
2. Mammography to r/o other lesions and lesions in other breast
Prognosis for infiltrating ductal carcinoma
Worse prognosis when axillary LNs contain mets, large primary tumor, distant mets
Workup for pt with infiltrating ductal carcinoma
- CXR to r/o lung/bone mets
- Bone scan in case of bone pain
- Skull CT in case of neuro s/s
- LFT’s to r/o liver mets (alk phos, bilirubin)
Ulcerated breast lesion w/underlying mass, Extensive breast edema (also seen w/cellulitis/abscess of breast). Cancer cells invading dermal lymphatics and vessels.
Inflammatory carcinoma (worse prognosis than infiltrating ductal CA)
Skin edema overlying a mass
peau d’orange. Worse if tumor invasion involves local dermal lymphatics
Retraction of skin overlying the mass/retraction of nipple
tumor involvement of breast support structures/lymphatics
Previous fluid aspiration from cystic mass with rapid recurrence of cystic fluid
Must excise to r/o CA
1.5cm mass fixed to deeper tissues
Fixation to chest wall = invasion of structures outside of the breast
Palpable Supraclavicular LN
= stage IV disease d/t LN mets
Hard fixed LN in the ipsilateral axilla
Matted group of nodes with metastasis which give the patient node-positive N2 status
Soft LN in ipsilateral axilla
May be some other inflammatory etiology of the LN
Small nodules on skin of breast
Satellite nodules of CA on the skin
Arm edema
Obstruction of axillary LNs
Paget’s disease of the breast
- 95% have underlying CA (infiltrating ductal CA or DCIS)
- Evaluate any mass w/biopsy
- Chronic eczematoid lesion of nipple
- Benign
- Paget’s cells
Anatomical structure of the breast
- 15-20 radially arranged lobes, each with 20-40 lobules
- Duct converges on the nipple and provides drainage for each lobe
- Internal mammary artery and lateral thoracic arteries provide arterial supply
Breast CA techniques
- Modified radical mastectomy
- Auchincloss modification = spares the pec minor
- Patey modification = transection of pec minor and dissection of level III nodes
- Radiation therapy is indicated for tumors >5cm or involving the pectoral fascia/muscle or involve the resection margin or involvement of supraclavicular nodes
- Radical mastectomy = removal of breast, skin, pec maj/minor, and axillary LN’s (useful for tumors that extend into pec muscle)
- Simple mastectomy = breast, nipple-areolar complex, and skin
- SubQ mastectomy = breast tissue only
- Lumpectomy/semental mastectomy = (good for solitary tumor <5cm) removes primary lesion w/clear margins, axillary node sampling, local radiotherapy to the breast
LN sampling techniques
- Lymph node removal at levels I and II
2. Sentinel node technique
Patients who should have mastectomy over lumpectomy w/radiation
- Small breast + large tumor
- Younger pts d/t higher risk of local recurrence
- Pts w/large breasts d/t increased complications of radiation tx
- Pts with connective tissue dz or prior radiation ot the chest/breast
Contraindications to mastectomy
- Primary lesions involving the chest wall
- Extensive local/regional disease
- Stage III/IV CA
Stage 0 or small 1 CA tx
lumpectomy, axillary sampling, radiation tx. No need for adjuvent therapy
Larger Stage I cancer
Lumpectomy, axillary sampling, post-op radiation tx, adjuvent tx (depends on ER and menopausal status)
Stage II CA
Same as stage I + modified radiacl mastectomy for larger primary lesions or pts w/small breasts in which lumpectomy would yield poor cosmetic results + adjuvant tx (depends on ER and menopausal status)
Adjuvant tx options based on age
Premenopausal pts tolerate CTX better
Postmenopausal pts tolerate hormonal tx better
small 0.5cm nodule in the suture line 5yrs post-op for stage II BCA
Local recurrence until proven otherwise. Must perform surgical vs. core-needle bx. Local excision indicated if bx shows CA and pt has had previous mastectomy but mastectomy should be performed if previous surgery was a lumpectomy.
Unilateral painful breast. Currently breastfeeding. Low grade fever. Very firm, red, tender, indurated breast mass. Tx?
Mastitis secondary to skin breaks in the nipple allowing bacteria to enter. Must eval for s/s of infection, abscess formation. Tx = warm compress + ABx to tx staph/strep infections. Pt may continue breastfeeding or use pump to allow milk let-down
Mastitis + area of fluctuance in the tender inflamed area
Abscess formation requiring open surgical drainage (Needle drainage is INADEQUATE!)
If pt is treated for suspected mastitis w/ABx and does not improve what should you suspect?
Suspect inflammatory carcinoma of the breast.
Tx of BCA in pregnancy
ER/PR status are NOT reliable in pregnancy. Stage I/II may be treated with mastectomy/lumpectomy + rads (may delay rads till postpartum if BCA detected in 3rd tri) with only 1% spontaneous abortion. Certain CTX regimens are safe in 2nd/3rd tri. Stage III/IV require immediate rads + CTX and thus may necessitate abortion
Workup for MALE with 1cm hard nodule beneath the right nipple. Non-painful but fixed to surrounding tissue). Tx?
- B/L mammogram to r/o gynecomastia vs. CA
Tx = mastectomy + post-op rads
Natural hx of males w/BCA
- males present at later stage with fixation, nipple retraction, and ulceration.
Medications a/w gynecomastia in older men
- Diuretics
- Estrogens
- Isoniazid
- Marijuana
- Digoxin
- EtOH abuse
