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Gen Med: Surgery > Breast Disorders > Flashcards

Breast Disorders Flashcards

1
Q

What is included in the breast anatomy?

A

Adipose tissue, glandular tissue, lactation ducts & suspensory ligaments

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2
Q

What info is included in breast hx?

A
  1. Change in general appearance of breast (size, symmetry)
  2. New or persistent skin changes
  3. New nipple inversion
  4. Breast pain (cyclic vs. noncyclic, duration, location)
  5. Breast mass (how it was discovered, duration, change in size, location)
  6. Relationship of mass to menstrual cycles
  7. Nipple discharge (unilateral vs. bilateral, color)
  8. Medications (hormones)
  9. Risk factors for breast cancer
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3
Q

What are the risk factors for breast cancer?

A
  1. BRCA1 & BRCA2 gene mutation
  2. first degreerelative w/ breast or ovarian CA
  3. Personal hx of breast dz
  4. age over 70
  5. age at menarche
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4
Q

What are the protective factors for breast cancer?

A
  1. Breastfeeding
  2. Parity
  3. Recreational exercise
  4. Postmenopausal BMI less than 23
  5. Oophorectomy at less than 35 yrs
  6. ASA use
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5
Q

What is included in the inspection portion of the breast exam?

A
  1. Inspect (arms raised, hands on hips)
    A. Breast symmetry
    B. Skin changes (dimpling, edema, ulceration)
    C. Nipples (symmetry, inversion/retraction, discharge)
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6
Q

What is included in the palpation portion of the breast exam?

A
  1. breasts, axillae, entire chest wall
    A. Pain
    B. Masses
    C. Regional lymph nodes (Axillary & Supraclavicular)
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7
Q

What is included in the documentation portion of the breast exam?

A
  1. “Clock” system
  2. Location of concern & abnormality
  3. Distance from areola
  4. Size of mass
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8
Q

What may be found on exam?

A
  1. Lump, hard knot, or thickening muscle inside the breast or underarm
  2. Dimpling or puckering of the skin
  3. Nipple discharge that starts suddenly
  4. Swelling, warmth, redness or darkening of the breast
  5. Itchy, scaly sore or rash on the nipple
  6. Change in the size or shape of the breast
  7. Pulling in of the nipple or other parts of the breast
  8. New pain in one spot that does not go away
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9
Q

What are the “more in depth” characteristics of a benign tumor?

A
  1. Morphology/differentiation: well differentiated appearance, structure similar to tissue origin, little or no anaplasia
  2. Rate/pattern of growth: SLow, progressive expansion, rare mitotic figures, normal appearing mitotic figures
  3. Local invasion: no invasion, cohesive and expansive growth, capsule often present
  4. Metastasis: no metastasis
  5. Damage to human body: relatively smaller
  6. Prognosis: Good
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10
Q

What are the “more in depth” characteristics of a malignant tumor?

A
  1. Morphology/differentiation: lack of differentiated appearance, structure atypical, variable degree of anaplasia
  2. Rate/pattern of growth: SLow to rapid expansion, mitotic figures numerous, sometimes abnormal appearing mitotic figures
  3. Local invasion: local invasion, infiltrative growth, capsule not present
  4. Metastasis: frequent metastasis
  5. Damage to human body: relatively bigger
  6. Prognosis: poor
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11
Q

What are the characteristics of benign breast masses?

A
  1. Multiple lesions
  2. “Rubbery”
  3. Mobile
  4. Well circumscribed border
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12
Q

What are the characteristics of malignant breast masses?

A
  1. Single lesion
  2. Hard
  3. Immovable
  4. Irregular borders
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13
Q

What are the characteristics of benign nipple discharge?

A
  1. Bilateral
  2. Multiductal
  3. Milky
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14
Q

What are the characteristics of malignant nipple discharge?

A
  1. Unilateral
  2. Uniductal
  3. Bloody, Clear, or Colored
  4. Spontaneous
  5. Persistent
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15
Q

What are the characteristics of benign skin changes?

A
  1. None

2. *Induration

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16
Q

What are the characteristics of malignant skin changes?

A
  1. Retraction
  2. Dimpling
  3. Thickening
  4. Eczema appearing
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17
Q

What are the nonproliferative benign breast dz?

A
  1. Fibrocystic changes
  2. Simple cysts
  3. Lactational adenoma
  4. Fibroadenoma
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18
Q

What are the benign hyperplasia w/out atypica dz?

A
  1. Epithelial hyperplasia
  2. Sclerosing adenosis
  3. Intraductal papillomas
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19
Q

What are the hyperplasia w/ atypica dz?

A

DCIS
LCIS
May become malignant

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20
Q

What are the malignant types of breast cancer?

A
  1. Ductal CA
  2. Lobular CA
  3. Tubular CA
  4. Mucinous CA
  5. Micropapillary CA
  6. Metaplastic CA
  7. Inflammatory CA
  8. Paget’s Dz
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21
Q

What are the ddx for mastalgia?

A 
1. Cyclic
A. Cyclic mastalgia
B. Fibrocystic disease
2. Non-cyclic
A. Large pendulous breasts
B. Diet, lifestyle
C. Mastitis
D. HRT
E. Inflammatory breast CA
3. Extramammary (non-breast) pain
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22
Q

What hx needs to be obtained regarding mastalgia?

A
  1. Unilateral vs. bilateral
  2. Cyclic vs. noncyclic
  3. Systemic or local symptoms (e.g. erythema, fever)
  4. History of trauma
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23
Q

What imaging needs to be obtained regarding mastalgia?

A
  1. Ultrasound

2. Mammogram

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24
Q

What is cyclic mastalgia?

A
  1. Normal hormonal changes

2. Usually luteal phase of menstrual cycle

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25
Q

What is fibrocystic dz?

A

Increased fibrous or cystic tissue

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26
Q

What causes pendulous breasts?

A

Stretching of Cooper’s ligaments

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27
Q

Who is at risk for fibrocystic dz?

A

Premenopausal women

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28
Q

What is included in fibrocystic dz?

A
  1. Premenstrual breast swelling/tenderness

2. Nodules/masses/lumps related to dense breast tissue or cysts

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29
Q

How is fibrocystic dz managed?

A 
1. Lifestyle
A. Eliminate caffeine
B. Low fat diet
2. Symptomatic
A. Support garments (well-fitting, supportive bra, sports bra)
B. Compresses
3. NSAID’s
A. OCP’s  (Progestogens)
B. Rarely:
-Danazol
-Tamoxifen - IF severe mastalgia
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30
Q

What is the presentation for mastitis?

A
  1. Usually seen in breastfeeding mothers
  2. Unilateral, swollen, wedge-shaped area of breast
  3. Pain, redness, induration (hardening)
  4. Systemic symptoms (high fever, malaise, chills)
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31
Q

What is the treatment for mastitis?

A
  1. Rest, fluids, MH
  2. Dicloxicllin 500mg QID x 10-14d
  3. Continue frequent breast feeding
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32
Q

What is inflammatory breast cancer?

A
  1. Peau d’orange-dimpling of involved skin due to retraction caused by lymphatic involvement & obstruction
  2. Associated erythema, pain
  3. Cellulitis may mimic inflammatory CA
33
Q

How does Paget’s dz present?

A
  1. Presents as skin changes resembling eczema

2. Redness, discoloration, or mild flaking nipple skin

34
Q

How does advanced paget’s dz present?

A
  1. Tingling, itching, ↑ sensitivity, burning, & pain
  2. +/- nipple discharge
  3. ≈ 50% also have a breast lump
35
Q

True/false: More than 90% of palpable breast masses in women in their 20’s to early 50’s are benign. What are the ddx?

A

True

  1. Fibrocystic changes
  2. Fibroadenoma
  3. Fat necrosis
  4. Phyllodes tumor
  5. Intraductal papilloma
  6. Breast cancer
36
Q

What is included in the hx of a breast mass?

A
  1. How it was discovered
  2. Duration
  3. Change in size
  4. Location
  5. Relationship of mass to menstrual cycles
37
Q

What is a fibroadenoma?

A
  1. Solitary, firm, rubbery, mobile mass
    A. Firm, tan, lobulated
    B. Well circumscribed mass
    C. Variable size
  2. Women less than 30
  3. Slow growing
38
Q

What is phyllodes tumor?

A
  1. Resembles fibroadenoma

2. Formed w/in the stroma (connective tissue)of the breast

39
Q

How is phylodes tumor staged?

A
  1. Phyllodes tumors are not staged usual sense
    A. Classified on the basis of cytology
    B. Benign, borderline, or malignant
40
Q

What is Intraductal papilloma?

A
  1. Unilateral bloody nipple discharge
  2. Sub-areolar intraductal mass
  3. Benign tumor
41
Q

What is fat necrosis?

A
  1. Caused by trauma

2. Tender, firm mass w/ indistinct borders

42
Q

How is fat necrosis sen on exam?

A
  1. May appear suspicious on exam

2. Benign breast calcification seen on mammo

43
Q

How is fat necrosis evaluated based on age?

A
  1. 30 yr – Diagnostic mammogram
44
Q

How is fat necrosis evaluated based on composition?

A
  1. Simple cyst
    A. Symptomatic – Aspirate
    B. Asymptomatic – Observe for 2-4 months
  2. Complex cyst –
    A. USN-guided needle aspiration/Bx
    B. Solid mass – Core needle biopsy (CNB) or Excision
  3. No specific findings – Re-examine after two cycles
45
Q

What are the physiologic etiologies of nipple discharge?

A
  1. Lactation
  2. Physiologic nipple discharge (Galactorrhea)
    A. Hyperprolactinemia
    B. Hypothyroidism
    C. Medication related
    D. Neurogenic stimulation
46
Q

What are the pathologic etiologies of nipple discharge?

A
  1. Intraductal papilloma
  2. Ductal ectasia
  3. DCIS
47
Q

What is included in nipple discharge hx?

A
  1. Unilateral vs. bilateral
  2. Spontaneous vs. provoked discharge
  3. Appearance of discharge
  4. Medications (e.g. antipsychotics, antidepressants)
  5. History of trauma
  6. History of amenorrhea
  7. History of hypogonadism (e.g. hot flashes, vaginal dryness)
48
Q

What is included in the clinical breast exam for nipple discharge?

A
  1. Attempt to elicit discharge, identify involved duct(s)

2. Evaluate discharge for gross blood or guaiac

49
Q

What is included in the initial evaluation of nipple discharge?

A
  1. Breast USN
  2. Mammogram
    A. If woman > 30 yrs
  3. Multiductal discharge
    A. Prolactin, TSH, urine HCG
50
Q

What is included in the further evaluation of nipple discharge?

A
  1. Ductography
  2. Ductoscopy
  3. MRI
51
Q

How is physiologic nipple discharge managed?

A

Directed at underlying cause

52
Q

How is pathologic nipple discharge managed?

A
  1. Surgery
    A. Terminal duct excision
    B. Intraductal papilloma
    C. Cause in > 50% of cases
53
Q

What are the general characteristics of breast cancer?

A
  1. Poorly differentiated lump or found on mammo/USN
  2. > 80% of breast CA cases discovered by pt
  3. Genetics believed to be cause of 5–10% of cases
  4. Atypical ductal hyperplasia (DCIS & LCIS) found in fibrocystic breasts → ↑ risk
  5. DM may ↑ the risk
54
Q

What are the life style risk factors for breast cancer?

A
  1. Long-term smokers ↑ 35% to 50%

2. Sedentary lifestyle ↑10%

55
Q

What are the common sites of metastasis from breast cancer?

A
  1. Bone
  2. Liver
  3. Lung
  4. Brain
56
Q

Define malignant breast disease?

A
  1. Pathologic finding on FNA, core needle Bx or excision Bx
    A. DCIS/LCIS
    B. Invasive carcinoma
57
Q

What are the treatment modalities for malignant breast dz?

A
  1. Radiation
  2. Chemotherapy
  3. Lumpectomy
  4. Mastectomy
    5 .Hormonal therapy
58
Q

What is included in breast cancer screening?

A
  1. Self Breast Exam monthly
  2. Clinical Breast Exam every 2-3 yr age 20-40; annually > 40
  3. Mammogram Baseline age 35-40; Q 1-2 yr 40-50; Annually > 50
  4. BRCA1, BRCA2- strong FH or gene present
    (Only obtain if it changes your Tx plan)
59
Q

What are the general characteristics of breast CA?

A
  1. 12% lifetime risk
  2. 50% develop in upper outer quadrant (most common site)
  3. Invasive ductal carcinoma is most common (90%)
  4. Staging TMN- tumor/mets/nodes (stages I-IV)
  5. Often found through screening, asymptomatic early
60
Q

What is Stage 0 breast cancer?

A
  1. pre-cancerous or marker condition

2. DCIS or LCIS

61
Q

What is Stage 1-3 breast cancer?

A

w/in the breast or regional lymph nodes

62
Q

What is Stage 4 breast cancer?

A

metastatic cancer that has a less favorable prognosis

63
Q

How is breast cancer diagnosed?

A
  1. Screening measures first- mammogram or ultrasound
  2. FNA, core biopsy, open biopsy
  3. Hormone receptors must be checked (Estrogen & Progesterone)
64
Q

What is included in the pre-op workup for breast cancer?

A
  1. Bilateral mammogram/MRI/US- Cancer in one breast is a risk factor for CA in contralateral breast
  2. R/O metastasis
    A. CXR
    B. CBC
    C. LFT’s
    D. CA+
    E. Alk Phos
    F. Maybe brain CT
65
Q

How is the breast divided?

A

4 quadrants + Tail of Spence

66
Q

What are the nerves in the breast that you need to be aware of in masectomies?

A
  1. Long Thoracic - Lateral chest midaxillary line-> Serratus anterior muscle
  2. Thoracodorsal - Lateral to long thoracic-> Lat dorsi
  3. Medial pectoral- Through pec minor-> Pec minor/major
  4. Lateral pectoral- Medial to medial pectoral-> Pec major
67
Q

What are the boundaries of axillary dissection?

A
  1. Superior boundary-> Axillary vein
  2. Posterior boundary->Long thoracic nerve
  3. Lateral boundary-> Lat dorsi
  4. Medial boundary-> Pec minor muscle
68
Q

What are the types of breast surgery?

A
  1. Mastectomy: Removal of the whole breast
  2. Quadrantectomy: Removal of ¼ of breast
  3. Lumpectomy: Removal of a small part of breast
69
Q

What is included in lumpectomy and radiation?

A
  1. Removal of part of breast w/ axillary node dissection

2. For stage I & II (tumors

70
Q

What is included in modified radical mastectomy?

A
  1. Breast, axillary nodes & nipple are removed

2. Drains left in place to drain fluid

71
Q

How is inflammatory CA managed?

A

always treat w/ Chemo first!

72
Q

What is Adjuvant therapy for breast CA?

A
  1. hormone blocking therapy
  2. Chemotherapy
  3. Monoclonal antibodies
  4. Radiotherapy
73
Q

What is hormone blocking therapy?

A
  1. If estrogen receptors (ER+) &/or progesterone receptors (PR+)
    A. Tamoxifen –blocks estrogen receptors
    B. Aromatase inhibitor – block estrogen production
    -Post-menopausal only (Aromasin, Femara, Arimidex)
74
Q

When is chemotherapy indicated for breast cancer?

A

Stages 2-4

75
Q

What is se of monoclonal antibody therapy?

A

HER2+ tx w/ trastuzumab(Herceptin) – risk of heart damage

76
Q

How does monoclonal antibody therapy work?

A

HER2 causes cellular growth & division)

77
Q

What is radiotherapy?

A
  1. External beam radioTx

2. Brachytherapy (internal w/surgery)

78
Q

What is included in the post-op after a mastectomy?

A
  1. Usually home same day or 1-2 days post- op depending on extent of case
  2. Careful monitoring of drain output-> d/c when
79
Q

What complications may arise from mastectomy?

A
  1. Long thoracic nerve injury “winged scapula” deformity
  2. Arm lymphedema
  3. Hematoma/seroma
  4. Skin flap necrosis

Gen Med: Surgery (6 decks)

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