Breast Disorders

Question 1

What are the normal changes in the breast during the mid 20s?

Answer 1

Lobules and stroma in breast respond to hormonal stimuli in an exaggerated fashion
Development of single and multiple palpable fibroadenomas

Question 2

What are the normal changes in the breast during the mid 30s-40s?

Answer 2

Enhanced normal lobular tissue – “adenosis” The degree of palpable nodularity increases

Question 3

What are the normal changes in the breast during menopause?

Answer 3

Glandular tissue undergoes further hypertrophy in assoc. with increased stromal tissue

Higher prevalence of cyst formation in late menopause.

Question 4

Describe the three types of breast pain:

Answer 4

Cyclic:
Occurs during late menstrual cycle, may accompany PMS
Resolves at onset of menses

Noncyclic:
Pain unrelated to menstrual cycle
Focal tenderness helpful – suggests tender cyst or tender area of modularity

Nonbreast Pain
Pain arises from chest wall mistakenly attributed to breast
Localized or diffuse chest wall pain
Radicular pain from cervical arthritis
Costochondritis

Question 5

What is the first line treatment for breast pain/chest wall pain?

Answer 5

NSAIDS

Question 6

What should be considered pathologic for nipple discharge:

Answer 6

Considered pathologic if discharge is spontaneous, arises from single duct, persistent, contains gross blood

Question 7

What is the most important factor in malignancy?

Answer 7

Age is important factor in malignancy

Question 8

what are some causes of nipple discharge:

Answer 8

-Benign intraductal papilloma 
Medications:
-Tricyclic antidepressants
-Cimetidine (Tagamet)
-Verapamil
-Metoclopramide
Endocrine:
-Prolactin level

Question 9

How are benign diseases separated?

Answer 9

Subdivided into proliferative and nonproliferative lesions

Question 10

Are proliferative/non-proliferative cancerous?

Answer 10

-Nonproliferative had no increased risk of breast cancer in studies

-Proliferative lesions have risk of malignancy
Risk depended upon specific proliferative lesion
Ranged from minimal to almost 6 fold increase

Question 11

What should you look for on physical exam of the breast?

Answer 11

Symmetry on inspection
Skin or nipple retraction, nipple inversion
Discoloration or edema (peau d’orange)
Nipple discharge
Palpation – masses, nodules
Do NOT forget to check axillary and supraclavicular areas for nodes

Question 12

What should always be down before imaging and biopsy?

Answer 12

BREAST EXAM

Question 13

If someone has a palpable breast mass and they are premenopausal what should you do? what about post-menopausal?

Answer 13

Premenopausal:
OK to follow over one menstrual cycle and re-evaluate

Postmenopausal:
Start work-up upon discovering mass

Question 14

What constitutes a suspicious mass?

Answer 14

Suspicious mass
Hard
Nontender
Irregular
High-risk patient

Question 15

Does a negative mammogram mean there is no cancer?

Answer 15

Not necessarily. 10-15% of mammograms miss breast cancer

Question 16

What is fibrocystic change?

Answer 16

Benign changes – microcystic formation leads to nodularity
Breasts feel “lumpy” and possibly tender on exam
Breast tenderness usually cyclical
BILATERAL

Question 17

What contributes to fibrocystic breast disease?

Answer 17

HRT in postmenopausal women
Most common in menstruating women
High caffeine intake (controversial)
Genetic disposition
Larger breasts
Dietary fat intake (being studied)

Question 18

What is mastoplasia?

Answer 18

Mastoplasia – “ropy” thickening of tissue common in 25-55 yo

Question 19

What are the symptoms associated with breast cysts?

Answer 19

Mass is tender and may fluctuate in size with menstrual cycle
On physical exam
Smooth and mobile

Question 20

What will U/S show with breast cysts?

Answer 20

Anechoic (fluid filled)
Round or oval
Well-circumscribed
Posterior enhancement
If ALL above are present, almost 100% benign simple cyst
Can drain cyst if symptomatic

***some can appear “complex” and these need a workup

Question 21

What is Mastitis? What are the two types?

Answer 21

inflammation of the ducts

lactational and non-lactational

Question 22

Describe lactational mastitis:

Answer 22

Lactational:
Reflux of bacteria into breast during breast-feeding
Patient will notice extreme tenderness
On exam erythema, warmth, tender to touch and possibly induration
Need to treat with antibiotics – usually for gram-positive cocci
Woman can continue to nurse and continue to pump milk
May be painful, but will help prevent engorgement
Be sure to follow-up with patient

Question 23

What is non-lactational?

Answer 23

Secondary to milk ducts become congested with secretions and debris – “duct ectasia”
Periductal inflammation
On exam, may have green nipple discharge or retraction, significant tenderness, erythema and warmth
Broad spectrum antibiotic to cover gram-positive cocci and skin anaerobes

Question 24

What are some proliferative disorders of the breast?

Answer 24

Proliferative Lesions:

Fibroadenoma
Microglandular adenosis
Sclerosing adenosis
Papilloma
Atypical ductal hyperplasia
Atypical lobular hyperplasia

Question 25

describe fibroadenomas:

Answer 25

Benign tumors most commonly found in young women (21-25 yo peak), but can be found in older women
Specific types include:
-Juvenile adenoma
-Giant adenoma
Do NOT increase chance of breast cancer

Question 26

How would a fibroadenoma present on exam?

Answer 26

Well-circumscribed
“rubbery”
Mobile
Not usually tender

Question 27

What is a juvenile fibroadenoma?

Answer 27

Adolescence
Can be large – 5 cm or more
Characteristics on exam similar to previous slide, but commonly larger
May need surgical excision to prevent asymmetry of breasts

Question 28

What is giant fibroadenomas?

Answer 28

Usually pregnancy or in nursing mothers
Large in size (similar to juvenile fibroadenoma)
May need surgical excision due to size
May regress on their own after delivery or stopping lactation

Question 29

Descibe a papilloma:

Answer 29

Lesions occurring in peripheral ducts
Minimally increase risk of breast cancer
On exam, usually present as a mass – not usually well-circumscribed, may be difficult to palpate
Nipple discharge may be present – may be the presenting symptom

Question 30

What is sclerosing adenosis?

Answer 30

Proliferation of stromal tissue
Minimal increased cancer risk
On exam, may not be any specific findings
Usually found on mammogram
Noted as “microcalfications” or “adenosis tumor”
“Tubular carcinoma” has similar appearance
Diagnosis will be dependent on pathology interpretation
Complete surgical excision may be necessary

Question 31

What proliferative breast disease has a high risk of becoming cancerous?

Answer 31

Atypical Ductal and Lobular Hyperplasia

tx: surgical excisions