Breast disorders

Question 1

a benign condition with clinical and radiographic findings similar to that of breast cancer, including firm/fixed, non-tender mass, skin or nipple retraction, and calcifications on mammography.

Biopsy will reveal fat globules and foamy histiocytes

Answer 1

Fat necrosis of the breast

No further work-up is indicated for excised lesions.

Question 2

Diagnosis

Solitary, well-circumscribed & mobile mass
± Tenderness

Benign

Answer 2

Breast Cyst

Question 3

Diagnosis

Multiple, diffuse nodulocystic masses
Cyclic premenstrual tenderness

Benign

Answer 3

Fibrocystic Changes

Question 4

Diagnosis

Solitary, firm, well-circumscribed & mobile mass
Cyclic premenstrual tenderness

Benign

Answer 4

Fibroadenoma

usually young women/teens

Question 5

Diagnosis

Unilateral, firm, well-circumscribed & mobile mass
±Upper Outer quadrant
Cyclic premenstrual tenderness (eg, premenstrual breast tenderness, size change)

Benign

Answer 5

Fibroadenoma

usually young women/teens

Observation & repeat examination in adolescents
Ultrasound in adults (<30) or patients with persistent mass

Question 6

Diagnosis

After trauma/surgery
Firm, irregular mass
± Ecchymosis, skin/nipple retraction

Benign

Answer 6

Fat Necrosis

of breast tissue

Question 7

Trastuzumab is used for the treatment of patients with **HER2-positive **breast carcinoma and is associated with a risk of what?

Answer 7

cardiotoxicity

Cardiac function should be assessed with ECHO at baseline and at regular intervals

Question 8

What medication is used in the treatment of estrogen receptor-positive breast cancer and increases the risk of venous thromboembolism?

Pts w/ factor V Leiden mutation are at ↑ risk of venous thromboembolism

testing for the mutation is sometimes indicated prior to initiation of medication

Answer 8

Tamoxifen

Question 9

What medication is used in the treatment of postmenopausal estrogen receptor-positive breast cancer and increase the risk of osteoporosis?

Answer 9

Aromatase inhibitors (eg, anastrozole, letrozole)

Baseline bone density scans should be obtained prior to treatment.

Question 10

Diagnosis

Engorgement & inadequate milk drainage in breastfeeding patients
Presents with Fever ± Myalgia, chills, malaise
Firm, red, tender, swollen quadrant of unilateral breast

Answer 10

Lactational Mastitis

Tx: Antibiotics & Frequent breastfeeding or pumping

Antibiotic therapy against MSSA (dicloxacillin, cephalexin), analgesics, and continued breastfeeding.

Question 11

If pre-menopausal pt with hx of breast cancer s/p partial masectomy has negative axillary sentinel LN, but a positive lateral margin on pathology what is the next best step in management.

path reveals ER,PR, HER-2 negative tissue

Answer 11

Continue Breast conserving therapy (consisting of partial mastectomy, axillary sentinel LN biopsy, & whole breast radiation therapy) and reexcise the lateral margins.

Adequate surgical excision of the cancer requires negative margins.

Question 12

Next Best Step In Management:

Bilateral non-bloody nipple discharge with a normal breast exam

no masses, skin changes, or lymphadenopathy

Answer 12

Obtain:
* HCG (r/o pregnancy)
* TSH
* Prolactin

Question 13

Next Best Step In Management:

Unilateral non-bloody nipple discharge with a normal breast exam

no masses, skin changes, or lymphadenopathy

Answer 13

<30: Ultrasound
≥30: Mammography (+u/s, if negative)

Question 14

Diagnosis

Unilateral bloody nipple discharge with a normal breast exam

no masses, skin changes, or lymphadenopathy

Answer 14

Intraductal papilloma

Benign

Question 15

Diagnosis

Unilateral bloody nipple exam with an abnormal breast exam

+ breast mass, + overlying skin changes or + lymphadenopathy

Answer 15

Invasive Ductal Carcinoma

Cancerous

Question 16

Diagnosis

Pt presents with green-brown (nonbloody/nonmilky) nipple discharge
with a palpable subareolar (under nipple) breast mass
no overlying skin changes noted

Answer 16

Mammary duct ectasia

subareolar ductal dilation, inflammation, and fibrosis

Question 17

Diagnosis & NBSIM

Teenage boy presents with a small (<4 cm) firm, unilateral or bilateral, subareolar mass
No pathologic features (nipple discharge, axillary lymphadenopathy, systemic illness)

may be tender to palpation or feel glandular

Answer 17

Pubertal gynecomastia

Reassurance and observation

resolves in a year

Question 18

Diagnosis and NBSIM:

Young woman presents with a painful, mobile and well-circumscribed breast mass
Ultrasound reveals a thin-walled, anechoic (ie, fluid-filled), and without echogenic debris or solid components.

Answer 18

Simple Breast Cyst

if no sxs observe

NBSIM: Fine-needle aspiration bc symptomatic (painful)

Patients with nonbloody fluid on aspiration and complete resolution of both the mass and symptoms require no additional management.
Recurrent mass or bloody aspirate require a biopsy.

Question 19

A breast mass that is complex-appearing (thick-walled, septated, solid and cystic components) are suspicious for cancer and automatically require what intervention?

Answer 19

core needle biopsy

Question 20

Patients with lactational mastitis who do not improve with antibiotic therapy require ____ to evaluate for breast abscess.

Answer 20

breast ultrasound

Tx: abscess drainage (via ultrasound-guided needle aspiration)

Question 21

Inflammatory breast carcinoma (IBC) is an aggressive breast cancer that classically have symptoms of mastitis that do not improve (or only initially improve) with antibiotics. Features include unilateral breast pain, erythema, and swelling. It may also present with a puritic rash or skin thickening and dimpling (peau d’orange appearance).
What is necessary for diagnosis?

Metastatic disease (axillary lymphadenopathy) is common on initial presentation.

Answer 21

Core needle breast biopsy and full-thickness skin punch biopsy

Due to high rates of metastasis, treatment for IBC is typically aggressive (eg, chemotherapy, mastectomy, radiation).
Presents just like** breast abscess **however, in IBC peau d’orange skin thickening and a solid (rather than fluctuant) mass.

Question 22

The greatest risk of breast cancer in women is what?

Answer 22

Age
(thus routine screening mammography is age based at ≥50 years)

other risk factors: Family History or Increased estrogen exposure (nulliparity, early menarche, and late menopause)

Question 23

Selective estrogen receptor modulators (Mixed agonist/antagonist action)
Which one is an adjuvant treatment of breast cancer and which one helps with postmenopausal osteoporosis?

Answer 23

Tamoxifen: adjuvant treatment of breast cancer
Raloxifene: postmenopausal osteoporosis

Question 24

Which selective estrogen receptor modulator carries increased risk for Endometrial hyperplasia/carcinoma & Uterine Sarcoma?

Answer 24

Tamoxifen

other side effects: Hot flashes (most common), VTE, endometrial polyps

Question 25

Diagnosis:

Presents with unilateral bloody nipple discharge and eczematous nipple or skin changes (flaking, crusting skin).

Answer 25

Mammary Paget disease

Due to intraductal tumor growth or necrosis