Breast Disorders Flashcards
1
Q
- Adult female breast is actually a what?
- Histologically primarily composed of:
4
A
- modified sebaceous gland, located within the superficial fascia of the chest wall.
- Lobules or glands
- Milk ducts
- Connective tissue
- Fat
2
Q
- Younger breasts are predominately made of what tissue?
- Glands are replaced by ______. This process accelerates with ________?
- What are key components of breast cancer detection programs? 2
A
- glandular tissue.
- fat, menopause.
- Differences in palpable consistency and
- in radiographic density between the glands and fat are
3
Q
- Organized into 15 to 25 lobules, with a disproportionate amount of the glandular or lobular tissue present in the _______ _______ quadrants of each breast.
- Lobules consist of clusters of _____________ arranged in an alveolar pattern and surrounded by _______________?
- Glands drain into a series of collecting _________ that course through the breast.
- Come together into approximately _______ collecting ducts that lead to and drain at the nipple.
A
- upper outer
- secretory cells, myoepithelial cells.
- milk ducts
- five to ten
4
Q
- What can go wrong with connective tissue? 2
- Fat tissue problems?
- Duct system issues? 3
A
- Connective tissue
- Fibrocystic changes
- Fibroadenomas - Fat tissue
- Necrosis from trauma or may harbor lipomas - Duct system
- May become dilated
- Contain papillary neoplasms
- Undergo malignant transformations
5
Q
Rich blood supply
1. Blood supply from where? 5
- Huge lymphatic system
Superficial and deep nodal chains throughout the trunk and neck, including those located in the what? 3
(Support _________ and overall breast health)
A
- internal mammary artery,
- lateral thoracic artery,
- thoracodorsal artery,
- thoracocramial artery,
- intercostal perforating arteries
- -axilla,
-deep to the pectoralis muscles
-and caudal to the diaphragm
(milk production)
6
Q
- Breast tissue is very sensitive to hormonal changes, especially the glandular cells.
- Circulating levels of what? 2 - What is also responsible for the changes that occur during the normal menstrual cycle and for symptoms often reported by patients receiving hormones in pharmacologic doses?
A
- estrogen and progesterone
2. Tissue responsiveness to circulating hormones
7
Q
- During each menstrual cycle, breast tissue tends to _____ from changes in the body’s levels of estrogen and progesterone.
- The milk glands and ducts enlarge, and in turn, the breasts __________.
- During menstruation, breasts may temporarily feel what? 4
- We recommend that women practice monthly breast self exams when?
A
- swell
- retain water
- swollen,
- painful,
- tender, or
- lumpy.
- the week following menstruation when the breasts are least tender.
8
Q
Risk factors for breast cancer?
A
- Age (most significant)
- Family history
- Race
- Genetics
- Early menarche
- Late menopause
- Increased exposure to estrogen
- Use of estrogen
- Nulligravid state
- First pregnancy after age 35
- Fibrocystic conditions, when accompanied by proliferative changes.
- Cancer in one breast
- Endometrial Cancer
- Not breastfeeding
- Hx of epithelial hyperplasia with atypia
- Exposure to ionizing radiation or to other carcinogens.
- Certain dietary factors (fat, ETOH)
9
Q
Where are most breast cancers found?
A
Upper outer quadrant
lots of lymphdrainage there
10
Q
What patients with family history are at risk for breast cancer?
6
A
- 1st degree relative significantly increases risk (sister, mother)
- Two or more relatives with breast or ovarian cancer
- Breast cancer occurring in an affected relative younger than 50 years
- Relatives with both breast cancer and ovarian cancer
- One or more relative with 2 cancers (breast and ovarian cancer or two independent breast cancers)
- Male relatives with breast cancer
11
Q
- Race: Who is more likely to get breast cancer?
2. What nationality would have the highest risk?
A
- Caucasian more likely, although incidence in black women is increasing.
- Individuals of Ashkenazi Jewish descent have a 2-times greater risk.
12
Q
- Early menarche is a risk factor: before what age?
2. Late menopause: after age what?
A
- under age 12
2. After age 50
13
Q
- Increased exposure to estrogen is a risk factor: What would cause this? 2
- Use of estrogen therapy is a risk factor: What specifically would make you at risk? 2
A
- Increased exposure to estrogen
- Obesity
- Persistent anovulation - Use of estrogen therapy
- BSO before age 35 with HRT
- Postmenopausal tx with HRT, especially high doses of estrogen and use of progesterone.
14
Q
- BRCA 1 and BRCA 2 are what kind of genes?
- Function? 2
- Directly involved in repair in what?
- Mutations that occur with BRCAs to cause cancer? 3
- What do the mutations result in? 2
A
- Tumor suppressor genes.
- Prevent cells from growing and dividing too rapidly or in an uncontrolled way.
- Inhibits the growth of cells that line the milk ducts in the breast.
- Directly involved in the repair of damaged DNA.
- Mutations is these:
- disrupt protein production, resulting in an abnormally small, nonfunctional version of the BRCA2 protein.
- change one of the protein building blocks (amino acids) used to make the BRCA proteins.
- defective BRCA protein is unable to help fix damaged DNA.
- Results in the build up of mutations.
- Causes cells to divide in an uncontrolled way and form a tumor.
15
Q
- Harmful BRCA1 mutations may also increase a woman’s risk of developing the following cancers (in addition to breast ca)? 4
- Harmful BRCA2 mutations may also increase the risks of? 4
A
- cervical
- uterine
- pancreatic
- colon cancer
- pancreatic CA
- stomach CA
- gallbladder and bile duct cancer
- melanoma
16
Q
- Men with harmful _______ mutations also have an increased risk of breast cancer and, possibly, of pancreatic cancer, testicular cancer, and early-onset prostate cancer.
- However, male breast cancer, pancreatic cancer, and prostate cancer appear to be more strongly associated with ________ gene mutations .
A
- BRCA1
2. BRCA2
17
Q
Breast Cancer mass characteristics
7
A
- Solitary nodule
- Non-tender
- Firm to hard
- Ill defined margins
- Not mobile
- Skin nipple retractions
- Axillary lymphadenopathy
Remember, a good number of breast masses are found by mammogram with no palpable mass.
18
Q
Breast Care Guidelines from the ACS
1. Women ages _______ should have the choice to start annual breast cancer screening with mammograms (x-rays of the breast) if they wish to do so.
- Women age _______ should get mammograms every year.
- Women ________ should switch to mammograms every 2 years, or can continue yearly screening.
- Screening should continue as long as a woman is in good health and is expected to live how long?
A
- 40 to 44
- 45 to 54
- 55 and older
- 10 more years or longer.
19
Q
What is the most frequent lesion of the breast?
A
Fibrocystic change
20
Q
- Fibrocystic change represents what?
- Common ages?
- Rare in who?
- How will the mass present?
- Exacerbated by what?
A
- Represents an exaggerated physiologic response to a changing hormonal environment.
- Common in women 30-50 years old.
- Rare in postmenopausal women who are NOT taking HRT.
- Painful mass which often exacerbates or increases in size during the premenstrual phase of the cycle.
- Exacerbated by ETOH
21
Q
Physical presentation of fibrocystic conditions?
5
A
- Often multiple, usually bilateral masses
- Rapid fluctuation in size is common
- Painful and tender
- Pain occurs or increases during the premenstrual phase of the cycle
- Size increases during the premenstrual phase of the cycle.
22
Q
Specific diagnostics and treatments: Fibrocystic changes?
8
A
- Reexamine patient at intervals
(Negative cyst that does not resolve over several months may need to be excised.) - Reassure patient that discomfort is not a sign of cancer
- Symptoms usually improve with the cyclical decrease in hormonal stimulation
- Use support bra
- Vitamin E supplements
- Avoid chocolate, alcohol, and caffeinated beverages.
- Teach and encourage monthly BSE.
- May need to be biopsied.
23
Q
Fibroadenoma:
- What is it?
- Can occur in what pattern and which is indicitive of cancer?
- Occurs most frequently in who?
- Tends to occur early in what population?
- Women over ____, need to distinguish from fibrocystic change or cancer.
A
- Benign neoplasm made from an overgrowth of glandular and fibrous breast tissue.
- Can occur alone, in groups or as complex. Complex fibroadenomas can raise risk of breast cancer slightly
- Occurs most frequently in young women, usually within 20 years after puberty. Clinical diagnosis is not difficult.
- Tends to occur at an earlier age in black women.
- 30
24
Q
Physical presentation
Fibroadenoma?
7
A
Fibroadenoma
- Round or ovoid
- Non tender
- Smooth margins
- Rubbery
- Discrete
- Relatively movable
- 1-5cm in diameter
25
Q
Fibroadenomas: Specific diagnostics 3
Rx?
4
A
Fibroadenomas
- Ultrasound can distinguish cystic. Fibroadenomas show up well on ultrasound.
- FNB can confirm cytology.
- Teach and encourage BSE.
- Since fibroadenomas are benign, treatment will vary depending on the diagnosis.
- If it is small, painless, remains the same size, and a biopsy shows no problems, further treatment not needed but likely follow-up ultrasounds.
- If it is large (more than 3cm), painful, growing, or a biopsy results in atypical cells, the tumor can be removed.
- It is recommended that fibroadenomas be removed in women over age 40.
26
Q
If rapidly growing need to rule out what?
A
phyllodes
27
Q
Two key differences between fibroadenomas and phyllodes tumors are?
A
- phyllodes tumors tend to grow more quickly and
- develop about 10 years later in life — in the 40s as opposed to the 30s. These differences can help doctors distinguish phyllodes tumors from fibroadenomas.
28
Q
History we need for patient with a breast lump?
8
A
- Age of patient (already have)
- Disease History
- Family History
- Medication History
- Onset of menarche
- LMP
- Where are you in your cycle?
- Onset of Menopause
29
Q
- What on social history would be pertinant info for a breast mass? 2
- Ingestion habits? 2
- Previous pregnancies? 4
- Have you had a mammogram? 1
- Exams? 2
A
- Social habits
- ETOH
- Smoking - Ingestion habits
- Caffeine
- High fat - Previous pregnancies
- How old were you with your first pregnancy?
- Was it term?
- Abortions?
- Did you breastfeed? - Have you ever had a mammogram?
0When was the last time you had a mammogram? - Exams
- How often do you do breast self exam?
- When was the last time you had an exam by a provider?
30
Q
HPI questions to ask about a lump?
6
A
- When did you discover this lump?
- Is it only in one breast?
- Where is it located?
- Is there any pain or tenderness associated with this lump?
- Is there any correlation between the mass and your menstrual cycle?
- Any discharge from the nipple?
How does it feel?
31
Q
- What characteristics suggests a benign process? 3
- Finding what kind of mass if breast cancer until proven otherwise?
- What can of women have difficult breasts to examine? 2
- When is the ideal time for a breast exam?
A
- Easy mobility within the breast,
- regular borders and a
- soft or cystic feel all suggest a benign process, although this is not totally reliable.
- Finding of a DOMINANT mass is considered cancer until proven otherwise.
- Young women with
- multiple nodules and
- diffuse thickening consistent with fibrocystic change have difficult breasts to evaluate. - The ideal time for the breast examination is seven to nine days after a period.
32
Q
Who is US imaging the preferred examination for? 3
A
Ultrasonography is preferred if a 1. palpable mass is found, 2. if a patient is younger than 30 years, or 3. if the patient is pregnant.
33
Q
- US can differentiate between what types of masses?
- Why is this important?
- US is also used for what?
A
- Can differentiate a cystic from a solid palpable mass.
- This distinction is important because cysts are usually not treated, but a solid lump must be biopsied to rule out cancer. In a breast biopsy, a piece of the lump is taken out and tested for cancer.
- US is also used for guidance for needle localization if mass is not palpable, but found on mammogram.
34
Q
- Who is mammography the preferred method of imaging for? 3
- Sensitivity is much reduced in who?
- Usually follow-up with ___ if determination between cystic and solid mass is needed.
A
- Mammography -
- if the patient has a palpable mass, is
- older than 30-35 years, and is
- not pregnant. - Sensitivity is much reduced in
- younger or denser breasts; therefore, mammography is considered inappropriate in patients younger than 35 years. - US
35
Q
What are the kind of biopsies for breast masses?
3
A
- Fine Needle Aspiration
- Core Needle Aspiration
- Excisional Biopsy
36
Q
Fine Needle Aspiration
1. Uses what kind of needle?
Core needle aspiration
2. What needle?
- What is the only definitive dx of breast cancer?
A
- Uses small gauge needle (21-25) to make multiple passes of solid and cystic masses with cytologic exam of material aspirated.
- Uses large gauge needle (14-18) to obtain tissue
- Excisional Bx
- Only definitive diagnosis of breast cancer
- Often therapeutic without additional surgery.
37
Q
A 24y/o female complains of sore nipple with redness and tenderness on her left breast. This is her first baby and she is worried about this condition. She says she is having a hard time nursing from that breast due to the discomfort.
What do you think the dx is?
A
Mastitis
38
Q
Symptoms of Mastitis?
6
A
- Breast tenderness or warmth to the touch
- Generally feeling ill (malaise)
- Swelling of the breast
- Pain or a burning sensation continuously or while breast-feeding
- Skin redness, often in a wedge-shaped pattern
- Fever of 101 F (38.3 C) or greater
39
Q
Mastitis Presentation
4
A
- Unilateral
- Most frequently begins within 3 months after delivery
- May start as a sore or fissured nipple.
- May have a lump if starting to form an abscess
40
Q
Mastitis Treatment
- What bug is the culprit?
- Abx? 2
- Other treatments? 2
- Failure to respond to treatment in 3 days should prompt what?
A
- Staph aureus is the culprit.
- Antibiotics against PCN-resistant staph:
- Dicloxacillin or a
- cephalosporin (Keflex) for 5-7 days. - Regular emptying of the breast by nursing followed by expression of any remaining milk by hand or with a mechanical suction device.
- Warm compresses to breast.
- Failure to respond within 3 days should prompt consideration of resistant staphylococci. (MRSA)
41
Q
- If the Mastitis is MRSA what should you do?
2. Delay in treatment could cause what?
A
- Pt may need to be admitted for IV therapy.
2. Delay in treatment could result in breast abscess.
42
Q
Mastitis Prevention
5
A
- Breastfeed equally from both breasts.
- Empty breasts completely to prevent engorgement and blocked ducts.
- Use good breastfeeding techniques to prevent sore, cracked nipples.
- Avoid dehydration by drinking plenty of fluids.
- Practice careful hygiene:
Handwashing
Cleaning the nipples
Keeping the baby clean.
43
Q
- What is a breast abscess?
- Bug?
- Early stage tx?
- Later? 3
A
- Area of redness, tenderness and induration on breast during nursing or otherwise.
- Staph Aureus is likely the culprit.
- Early stages of infection can be treated while nursing from that breast, but if infection not controlled within 24 hours, an abscess may form
- If abscess progresses,
- surgical drainage is performed and
- nursing is D/C’d.
- Patient likely admitted for IV therapy and I&D.
44
Q
What is the most common cause of spontaneous nipple discharge from a single duct?
A
Intraductal papilloma
45
Q
- What is an intraductal papilloma?
- What can it cause?
- What are they composed of? 2
- What age most commonly?
- What can the discharge look like? 3
A
- An intraductal papilloma is a tiny wart-like growth in breast tissue that sometimes punctures a duct.
- can cause benign nipple discharge.
- Benign tumors that are composed of
- fibrous tissue and
- blood vessels that grow inside milk ducts - Occurs most often in women ages 35 – 55.
- Discharge can be
-serous,
-bloody or
-cloudy
ONE NIPPLE ONLY
46
Q
Intraductal Papilloma
What are the two types?
What is the one related condition?
A
Two types, and one related condition:
- Solitary intraductal papillomas
- Multiple papillomas
- Papillomatosis
47
Q
Intraductal Papilloma
Describe the following:
1. Solitary intraductal papillomas 3
2. Multiple papillomas 4
- Papillomatosis 3
A
- –
- one lump,
- usually near a nipple,
- causes nipple discharge - –
- groups of lumps,
- farther away from a nipple,
- usually doesn’t cause discharge, and
- can’t be felt - –
- very small groups of cells inside the ducts,
- a type of hyperplasia,
- more scattered than multiple papillomas
48
Q
Intraductal papilloma tests?
3
Tx?
A
- A breast biopsy to rule out cancer.
- An examination of the discharge to see if the cells are cancerous.
- An x-ray with contrast dye injected into the affected duct (ductogram)
- The involved duct is surgically removed and the cells are checked for cancer.
49
Q
Causes of nipple discharge
7
A
- Papilloma
- Premenopausal Women- spontaneous
- Prolactinoma
- Oral Contraceptive Agents
- Abscess
- Medications
- Hypothyroidism
50
Q
- What would make nipple discharge suspicious to us? 7
- not suspicious?
6
A
- Suspicious
- 1 breast
- 1 duct
- Associated with a lump
- Leaks out on it’s own
- Most days of the month
- Watery or bloody (red, brown or black)
- A lot - Not Suspicious
- Both breasts
- Several ducts
- Squeezing brings it on
- Occasional
- Different colors (green, yellow, white)
- A little
51
Q
What is breast tenderness usually related to? 1
Could be associated with? 2
A
- Usually related to fibrocystic changes
- May be associated with breast cancer
- May be related to dietary habits
52
Q
What foods may be related to breast tenderness?
3
A
- caffeine
- chocolate
- salt
53
Q
Evaluation of Breast Tenderness
Breast examination checking for? 5
A
- areas of tenderness
- mass
- trauma (bruising)
- nipple discharge
- US/Mammogram, if necessary
54
Q
Treatment of Breast Tenderness
5
When should you recheck if symptoms do not resolve?
A
1. NSAIDS Eliminate: 2. caffeine 3. chocolate 4. salt 5. Monthly SBE
- Return for recheck if symptoms do not resolve within 1-2 months
