Breast Disorders Flashcards
1
Q
Adult female breast is actually a modified what? Histologically what is it composed of?
A
- modified sebaceous gland, located within superficial fascia of chest wall
- histologically primarily composed of:
lobules or glands
milk ducts
CT
fat
2
Q
Younger breasts are predominately made up of what? What is this replaced by?
- How does this help in detecting cancer?
A
- younger breasts predominately glandular tissue
- glands are replaced by fat, this process accelerates with menopause
- differences in palpable consistency and in radiographic density b/t glands and fat are key components of breast cancer detection programs
3
Q
Breast make up?
A
- organized into 15-25 lobules, with disproportionate amt of glandular or lobular tissue present in upper outer quadrants of each breast (MC area for cancer)
- lobules consist of clusters of secretory cells arranged in an alveolar pattern and surrounded by myoepithelial cells
- glands drain into series of collecting milk ducts that course through the breast
- come together into approx 5-10 collectung ducts that lead to and drain at the nipple
4
Q
What can occur to diff areas of breast tissue?
A
-CT:
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
Blood supply and lymphatic system of breast?
A
- rich blood supply: blood supply from internal mammary artery, lateral thoracic artery, thoracodorsal artery, thoracocramial artery, intercostal perforating arteries
- huge lymphatic system: superficial and deep nodal chains throughout the trunk and neck, including those located in axilla, deep into pectoralis muscles, and caudal to diaphragm
- support milk production and overall breast health
6
Q
Breast tissue in response to hormonal changes?
A
- breast tissue is very sensitive to hormonal changes, especially glandular cells - circulating levels of estrogen and progesterone
- tissue responsiveness to circulating hormones is also responsible for the changes that occur during the normal menstrual cycle and for sxs often reported by pts receiving hormones in pharm doses
7
Q
What occurs to breast tissue during menstrual cycle?
A
- breast tissue tends to swell from changes in body’s levels of estrogen and progesterone, the milk glands and ducts enlarge, and in turn, the breasts retain water. During menstruation, breasts may temporarily feel swollen, painful, tender or lumpy
8
Q
When should we recommned SBEs to pt?
A
- week following menstruation when breasts are least tender
9
Q
How common is breast cancer?
A
- MC malignancy in women
- accounts for approx 30% of cancers in women
- 15% are dx in women younger than 40
- by time woman is 80 - 1/10 probability of developing breast cancer
10
Q
RF for breast cancer - how is age RF?
A
- age is most sig. RF after gender
- breast cancer is rare in women younger than 25, about 2% occur b/f age 20
- incidence increases with age, with a plateau in women aged 50-55
11
Q
How are family hx and genetics RFs for breast cancer?
A
- 1st degree relative sig increases risk (sister, mom)
- 2 or more relatives with breast or ovarian cancer
- breast cancer occurring in an affected relative younger than 50
- relatives with both breast and ovarian cancer
- one or more relatives with 2 cancers (breast and ovarian or 2 independent breast cancers)
- male relatives with breast cancer
- genetics - BRCA1 and BRCA2
12
Q
How is race a RF for breast cancer?
A
caucasian more likely, although incidence in black women is increasing
- individuals of Ashkenazi Jewish descent have 2x greater risk
13
Q
What about menarche and menopause increases risk of breast cancer?
A
- early menarche (under 12)
- late menopause (after 50)
14
Q
How does increased estrogen increase risk for breast cancer?
A
- increased exposure to estrogen: obesity, persistent anovulation (PCOS)
- use of estrogen therapy: BSO b/f age of 35 with HRT
postmenopausal tx with HRT, esp high doses of estrogen and use of progesterone
15
Q
What are other RFs for breast cancer?
A
- nulligravid state
- first preg after 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
16
Q
What are BRCA1 and BRCA2? Mutation?
A
- tumor suppressor genes
- preven cells from growing and dividing too rapidly, or in uncontrolled way, inhibitrs growth of cells that line milk ducts in breast. Directly involved in repair of damaged DNA
- mutations in these:
disrupt protein production, resulting in abnorm. small, nonfxnl version of BRCA2 protein - change one of protein binding blocks used to mae BRCA proteins: defective BRCA protein is unable to help fix damaged DNA, results in build up of mutations, causes cells to divide in an uncontrolled way and form tumor
17
Q
Harmful BRCA1 mutations may also increase a woman’s risk of developing what types of cancer in addition to breast CA?
A
- cervical
- uterine
- pancreatic
- colon cancer
18
Q
Harmful BRCA2 mutations may also increase risks of what cancers?
A
- pancreatic
- stomach
- gallbladder and bile duct
- melanoma
19
Q
Do BRCA mutations affect men?
A
- yes, men with harmful BRCA1 mutations have increased risk of breast cancer and possible of pancreatic cancer, testicular cancer, and early onset prostate cancer. However male breast cancer, pancreatic cancer, and prostate cancer appear to be more strongly assoc with BRCA2 gene mutations
20
Q
Presentation of breast cancer mass?
A
- solitary nodule
- non-tender
- firm to hard
- ill defined margins
- not mobile
- skin nipple retractions
- axillary lymphadenopathy
- a good number of breast masses are found by mammogram with no palpable mass
- 90% of Breast cancer masses found by patients
21
Q
Breast cancer screening guidelines?
A
- women 40-44: should have choice to start annual breast cancer screening with mammograms if they wish to do so
- 45-54: should get mammograms q yr
- 55 and older: should switch to mammograms q 2 yrs or can continue yearly screening
- screening should continue as long as woman is in good health and is expected to live 10 more years or longer
22
Q
MC areas for breast cancer?
A
- upper outer quadrant: 50%
- nipple and areola: 18%
- upper inner qaudrant: 15%
23
Q
What is a fibrocystic change? Common in which women?
A
- used to be referred to as fibrocystic condition
- represents an exaggerated physiologic response to a changing hormonal enviro
- most frequent lesion of the breast: most women experience some degree of fibrocystic change
- common in women 30-50
- rare in postmenopausal women who aren’t taking HRT
- painful mass which often exacerbates or increases in size during premenstrual phase of cycle
- exacerbated by ETOH
- most prominent in luteal phase (progesterone)
24
Q
Physical presentation of fibrocystic condition?
A
- often multiple, usually bilateral masses
- rapid fluctuation in size is common
- painful and tender
- pain occurs or increases during premenstrual phase of cycle
- size increases during premenstrual phase of cycle
25
Q
Specific dx and tx for fibrocystic changes?
A
- reexamine pt at intervals (negative cyst that doesn’t resolve over several months may need to be excised)
- reassure pt that discomfort isn’t a sign of cancer
- sxs usually improve with cyclical decrease in hormonal stimulation
- OCPs offer no benefit
- use support bra (w/o wire)
- vitamen E supp
- primrose oil
- avoid chocolate, alcohol, caffeinated beverages
- teach and encourage SBE
- may need to be bx
- NSAIDs, cool or warm compresses
26
Q
What is a fibroadenoma? Occurs in what pop?
A
- benign neoplasm made from an overgrowth of glandular and fibrous breast tissue
- can occur alone, in groups or as a complex - complex fibroadenomas can raise risk of breast cancer slightly
- occurs most freq in young women, usually w/in 20 yrs after puberty, clinical dx isn’t difficult.
- tends to occur at earlier age in black women
- mult tumors are found in 10-15% of pts
- women over 30, need to distinguish from fibrocystic change or cancer
27
Q
Physical presentation of fibroadenoma?
A
- round or oval
- non tender
- smooth margins
- rubbery
- discrete
- relatively movable
- 1-5 cm in diameter
28
Q
Dx and tx for fibroadenomas?
A
- US can distinguish cystic, fibroadenomas show up well on US
- FNB can confirm cytology
- teach and encourage SBE
- since fibroadenomas are benign, tx will vary depending on dx
- if it is small, painless, remains same size, and bx shows no problems, further tx not needed but likely f/u US
- if it is large (more than 3 cm), painful, growing, or a bx results in atypical cells, tumor can be removed
- it is recommended that fibroadenomas be removed in women all 40 (malignant transformation more likely)
29
Q
If there is a rapidly gorwing mass what needs to be ruled out? diff b/t this and fibroadenomas?
A
- phyllodes tumor
- 2 key diff: phyllodes tend to grow more quickly and develop about 10 yrs later in life - 40s compared to 30s. These diff can help doctors distinguish phyllodes tumors from fibroadenomas
30
Q
What is more concerning - 35 yo female presenting with a mass in breast or 51 yr presenting with a mass?
A
- 51 yr old esp with family hx of breast cancer, smokes, drinks, had child after 35
31
Q
What is impt hx info to have for pt presenting with a breast mass?
A
- age of pt
- disease hx
- family hx
- med hx
- onset of menarche: LMP, where are you in cycle?
- onset of menopause?
- social habits: drinking, smoking
- ingestion: caffeine, high fat
- previous pregnancies: how old at first preg, was it term, abortions? breastfeed?
- have you ever had a mammogram?
- how often do you do SBE?
- when was last time you had exam by provider?
32
Q
HPI - for pt with breast mass?
A
- when did you discover this lump?
- is it only in one breast?
- where is it located?
- is there any pain or tenderness assoc with this lump?
- is there any correlation b/t mass and your menstrual cycle
- any d/c from the nipple
- how does it feel?
33
Q
Physical findings on breast exam that don’t support cancer? That don’t support cancer?
A
- easy mobility within the breast, regular borders and a soft or cystic feel all suggest a benign process, although this isn’t totally reliable
- finding of dominant mass is considered cancer until proven otherwise
34
Q
What women have diff breasts to eval? What can be done?
A
- young women with multiple nodules and diffuse thickening consistent with fibrocystic change have difficult breasts to eval
- re-exam at diff times in menstrual cycle is often informative and reassuring when no dominant nodule emerges
- the ideal time for breast exam is 7-9 days after period
35
Q
Preferred exam is based off of?
A
- pts age determines preferred imaging method
36
Q
When is US preferred for imaging?
A
- if palpable mass is found, if pt is younger than 30, or if pt is pregnant
- can diff a cystic from a solid palpable mass. This distinction is impt b/c cysts are usually not tx, but solid lump must be bx to rule out cancer, in breast bx a piece of lump is taken out and tested for cancer
- US is also used for guidance for needle localizaiton if mass isn’t palpable but found on mammogram
37
Q
When is mammography preferred method of imaging?
A
- if pt has palpable mass, older than 30-35 and isn’t pregnant: sensitivity is much reduced in younger or denser breasts, therefore mammography is considered inappropriate in pts younger than 35
- usually f/u with US if determination b/t cystic and solid mass is needed
38
Q
When should you refer pt on? What does dx ultimately depend on?
A
- refer on to surgeon for further investigation if suspected mass
- bx: dx depends ultimately upon exam of tissues or cells removed by bx
39
Q
Diff types of biopsies?
A
- FNA
- core needle aspiration
- excisional bx
40
Q
How is a FNA done?
A
- use small gauge needle (21-25) to make multiple passes of solid and cystic masses with cytologic exam of material aspirated
- must obtain adequate specimen
- sensitivity 92-98%
- specificty exceeds 99%
41
Q
How is Core needle aspiration done?
A
- uses large gauge needle (14-18) to obtain tissue
- must obtain adequate specimen
- sensitivity 92-98%
- specificity exceeds 99%
42
Q
How is excisional bx done?
A
- mass and surrounding tissue are excised for histological exam
- only definitive dx of breast cancer
- often therapeutic w/o additional surgery
43
Q
What is mastitis?
A
- breast tenderness or warmth to the touch
- generally feeling ill
- swelling of breast
- pain or burning sensation continuously or while breast feeding
- skin redness, often in wedge shaped patern
- fever of 101 F (38.3 C) or greater
- This occurs MC in nursing mothers
- Staph aureus MC bug (unilateral, nursing for first time) - think inflammatory cancer in non nursing pts esp if bilateral
44
Q
Presentation of mastitis?
A
- unilateral
- erythematous, tender, warm to touch
- most freq begins within 3 months after delivery
- may start as a sore or fissured nipple (use lanolin cream)
- may have a lump if starting to form an abscess
- ask:
any fever, when did you deliver your baby? Is other nipple affected?
45
Q
Tx of mastitis?
A
- regular emptying of breast by nursing followed by expression of any remaining milk by hand or with mechanical device
- abx against PCN-resistant staph:
dicloxacillin or keflex for 5-7 days - warm compress
- failure to respond w/in 3 days should prompt consideration of resistant MRSA
- pt may need to be admitted for IV therapy
- delay in tx could result in breast abscess
46
Q
Prevention of mastitis?
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 nipples, keeping baby clean
47
Q
Presentation of breast abscess? Culprit? Tx?
A
- staph aureus likely culprit
- area of redness, tenderness, and induration on breast during nursing or otherwise
- early stages of infection can be tx while nursing from that breast, but if infection not controlled w/in 24 hrs, an abscess may form
- if abscess progresses, surgical drainage is performed and nursing is d/c’d. Pt likely admitted for IV therapy and I and D
48
Q
What is an intraductal papilloma?
A
- tiny wart like growth in breast tissue that sometimes punctures a duct: benign tumors that are composed of fibrous tissue and blood vessesl that grow inside milk ducts and can cause benign nipple d/c
- occurs most often in women 35-55
- causes and RFs unknown
- intraductal papilloma is MC cause of spontaneous nipple D/C from single duct - d/c can be serous, bloody or cloudy
- rule out malignancy by cytology
49
Q
Diff types of intraductal papilloma?
A
2 types and 1 related condition:
- solitary intraductal papillomas: one lump, usually near a nipple, causes nipple d/c
- multiple papillomas: groups of lumps, farther away from a nipple, usually doesn’t cause d/c, and can’t be felt
- papillomatosis: very small groups of cells inside the ducts, a type of hyperplasia, more scattered than multiple papillomas
50
Q
Other tests for dx intraductal papilloma? Tx?
A
- breast bx to rule out cancer
- an exam of d/c to see if cells are cancerous
- an x-ray with contrast dye injected into affected duct (ductogram)
- tx:
involved duct is surgically removed and cells are checked for cancer
51
Q
Diff causes of nipple d/c?
A
- papilloma
- premenopausal women: spontaneous
- prolactinoma
- oral contraceptive agents
- abscess
- meds
- hypothyroidism
52
Q
nipple d/c features that you should be suspicious of?
A
- 1 breast
- 1 duct
- assoc with lump
- leaks out on it’s own
- most days of the month
- watery or bloody (red, brown or black)
- a lot
53
Q
Nipple d/c that isn’t suspicious?
A
- both breasts
- several ducts
- squeezing brings it on
- occasional
- diff colors (green, yellow, white)
- a little
54
Q
Breast tenderness - associations?
A
- may be unilateral or bilateral
- usually not related to trauma to breast
- usually related to fibrocystic changes
- may be assoc with breast cancer
- may be related to dietary habits:
caffeine, chocolate, salt
55
Q
What are you checking for on breast exam if pt presents with tenderness?
A
- areas of tenderness
- mass
- trauma (bruising)
- nipple d/c
- US/mammogram if necessary
56
Q
Tx of breast tenderness?
A
- NSAIDs - esp for fibrocystic change
- eliminate:
caffeine, chocolate, salt - monthly SBE
- return for recheck if sxs don’t resolve w/in 1-2 months
- have F/U in plan!
