BREAST DISORDERS Flashcards
Adult female breast is actually a modified _____________, located within the superficial fascia of the chest wall.
sebaceous gland
- the breast is histologically primarily composed of
⦁ lobules or glands
⦁ milk ducts
⦁ connective tissues
⦁ fat
Younger breasts are predominately ____________
The glands are replaced by _____ with aging. This process accelerates with menopause.
glandular tissue.
fat
The differences in palpable consistency and in radiographic density between the glands and fat are key components of breast cancer detection programs
connect breast tissue, holds breast tissue up
Cooper’s ligaments
Each breast = 15 - 25 lobules, with a disproportionate amount of the glandular or lobular tissue present in the ___________ quadrants of each breast.
upper outer quadrants
COMPLICATIONS THAT CAN OCCUR
- CT
- fat
- duct system
o Connective tissue
⦁ fibrocystic changes
⦁ fibroadenomas
o Fat tissue
⦁ necrosis from trauma
⦁ lipomas
o Duct system
⦁ may become dilated
⦁ may contain papillary neoplasms
⦁ may undergo malignant transformations
Breast tissue is very sensitive to ___________, especially the glandular cells.
hormonal changes
breast exams are recommended at what timeline of the menstrual cycle
1 week following menstruation
- During each menstrual cycle, breast tissue tends to swell from changes in the 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
menstruation = not the best time to evaluate the breasts; bring them back for exam during a time when they’re not tender/swollen/lumpy - recommend a week following menstruation
most common malignancy in women
breast cancer
risk factors for breast cancer
⦁ age ⦁ family hx ⦁ race ⦁ genetics ⦁ early menarche ⦁ late menopause ⦁ increased exposure to estrogen ⦁ use of estrogen therapy ⦁ nulligravid state ⦁ first pregnancy after age 35 ⦁ fibrocystic conditions ⦁ cancer in one breast ⦁ endometrial cancer ⦁ not breastfeeding ⦁ hx of epithelial hyperplasia with atypia ⦁ exposure to ionizing radiation or other carcinogens ⦁ certain dietary factors (fat, alcohol)
most significant risk factor for breast cancer after gender
age
age & breast cancer
- Age is the most significant risk factor after gender
- Breast cancer is rare in women < 25 years, about 2% occur before age 30
- Incidence increases with age, with a plateau in women aged 50-55 years.
family hx & breast cancer
- 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 relatives with 2 cancers (breast and ovarian cancer or two independent breast cancers)
- Male relatives with breast cancer
race & breast cancer
- Caucasian more likely, although incidence in black women is increasing.
- Individuals of Ashkenazi Jewish descent have a 2-times greater risk.
_________ MENARCHE & _________MENOPAUSE
are risk factors for breast cancer
EARLY MENARCHE
LATE MENOPAUSE
= increased estrogen exposure
increased exposure to estrogen risk factor
obesity (fat cells release estrogen)
persistent anovulation
BRCA 1 & BRCA 2 are ________ ________ genes
tumor suppressor genes
BRCA 1 & BRCA 2 GENES: their role
- these are tumor suppressor genes; they prevent cells from growing/dividing too rapidly or in an uncontrolled way
- these genes inhibit the growth of cells that line the milk ducts in the breast
- these genes are directly involved in the repair of damaged DNA
When these genes are mutated:
⦁ disrupts 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
In addition to breast cancer, harmful BRCA 1 mutations may also increase a woman’s risk of the following cancers, in addition to breast cancer
⦁ cervical
⦁ uterine
⦁ pancreatic
⦁ colon
“C CUP” = cervical, colon, uterine, pancreatic
In addition to breast cancer, harmful BRCA 2 mutations may also increase a woman’s risk of the following cancers, in addition to breast cancer
⦁ pancreatic
⦁ stomach
⦁ gallbladder & bile duct
⦁ melanoma
BRCA2 = think GI & melanoma
MALE BRCA1 & BRCA 2 MUTATIONS
- men with harmful BRCA1 mutations also have an increased risk of breast cancer, and also possibly pancreatic, testicular, and prostate cancer
- male breast cancer, pancreatic cancer, and prostate cancer = more strongly associated with BRCA 2 mutations
- male breast cancer, pancreatic cancer, and prostate cancer = more strongly associated with _________ mutations
BRCA 2
location - most breast cancers located in _______________ quadrant
outer upper
presentation of breast cancer mass
- solitary nodule
- non-tender
- firm / 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
breast care guidelines from ACS
women aged 40-44 should have the choice to start annual breast cancer screening with mammograms if they wish to do so
women aged 45-54 = annual mammograms
women aged _______ should get annual mammograms
45-54
breast cancer screening guidelines for 55+
Women aged 55 years and older should switch to mammograms every 2 years, or have the choice to continue yearly screening.
Some women – because of their family history, a genetic tendency, or certain other factors – should be screened with _____ along with mammograms. (The number of women who fall into this category is very small.)
MRIs
Z-method for breast cancer & quadrant
Outer upper > nipple > inner upper > outer lower > inner lower
% risk for breast cancer decreased down the Z line, except for the nipple.
Outer upper quadrant = highest % chance, then nipple, then back to Z formation
1cm = pea; 2cm = peanut; 4cm = walnut; 5cm = keylime
most frequent lesion of the breast**
Fibrocystic change
fibrocystic change = represents an exaggerated physiologic response to a _____________________
changing hormonal environment
- a painful mass which often exacerbates or increases in size during premenstrual phase
fibrocystic change
- exacerbated by alcohol
fibrocystic change
FIBROCYSTIC CHANGE
- used to be referred to as fibrocystic condition
- represents an exaggerated physiologic response to a changing hormonal environment
MOST FREQUENT LESION OF THE BREAST
⦁ most women experience some degree of fibrocystic change
- common in women aged 30-50
- rare in postmenopausal women who are NOT taking HRT
- a painful mass which often exacerbates or increases in size during premenstrual phase
- exacerbated by alcohol
signs/symptoms of fibrocystic changes
- often multiple, usually bilateral masses**
- rapid fluctuation in size = common
- painful & tender**
- pain occurs or increases during premenstrual phase of the cycle
- size also increases during premenstrual phase of the cycle
pain & size increase during ________________ of the cycle
premenstrual phase
which is why you don’t do breast exams before or during menstrual cycle - do 1 week after
SPECIFIC DIAGNOSTICS & TREATMENT FOR FIBROCYSTIC CHANGES
- reexamine the pt at intervals - a cyst that doesn’t resolve over several months may need to be excised
- reassure pt that discomfort is not a sign of cancer
- symptoms usually improve with the cyclical decrease in hormone stimulation
- OCPs offer no benefit
- use support bra
- vitamin E supplements
- avoid chocolate, alcohol, caffeinated beverages
- teach and encourage monthly BSE
- may need to be biopsied
Fibroadenomas occur most frequently in
young women
usually within 20 years after puberty
fibroadenomas tend to occur at an earlier age in
black women
Benign neoplasm made from an overgrowth of glandular and fibrous breast tissue
fibroadenoma
CLINICAL PRESENTATION OF FIBROADENOMAS
- round or ovoid
- non-tender**
- smooth margins
- rubbery
- discrete - only 1 present*
- relatively movable
- can be 1-5cm in diameter
DIAGNOSTICS & TREATMENT FOR FIBROADENOMA
- ultrasound can distinguish cysts - fibroadenomas show up well on ultrasound
- can do FNB to confirm cytology
Since fibradenomas are benign, treatment will vary depending on the diagnosis
- if it is small, painless, remains the same size, and biopsy shows no problems, then further treatment is not needed, but should continue to do follow-up ultrasounds
- if it is large (> 3cm), painful, growing, or biopsy shows atypical cells = remove it
It is recommended that fibroadenomas be removed in women
> 40
If fibroadenoma is rapidly growing need to rule out
phyllodes tumor
⦁ Phyllodes tumor doesn’t metastasize through lymph nodes..it goes directly to the
lungs
phyllodes tumors can be __________ or _______
benign or malignant
Two key differences between fibroadenomas and phyllodes tumors
1) phyllodes tumors tend to grow more quickly
2) phyllodes tumors 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
imaging: - a patient’s _____ determines the preferred imaging method
age
when is an ultrasound preferred for imaging?
- is preferred if a palpable mass is found
- is preferred if patient is < 30
- is preferred if patient is pregnant
- Ultrasounds can differentiate cystic from a solid palpable mass - this is important because cysts are usually not treated, but a solid lump must be biopsied to rule out cancer
- US is also used for guidance for needle localization is a mass is not palpable, but is found on a mammogram
when to do mammography
- if the patient has a palpable mass
- is > 30-35
- is not pregnant
- sensitivity is much more reduced in younger / denser breasts, therefore mammography is considered inappropriate in patients < 35
Usually follow up with ultrasounds if determination between cystic & solid mass is needed
when to refer
- refer to surgeon for further investigation
- Biopsy - if the diagnosis depends ultimately upon examination of tissue/cells from biopsy
types of biopsies
⦁ FNA
⦁ core needle aspiration
⦁ excisional biopsy
only definitive diagnosis of breast cancer
excisional biopsy
MASTITIS SYMPTOMS
fever (101 +)
malaise - ill feeling
breast tenderness , warm to the touch
- swelling of the breast
- pain or burning sensation continuously or while breast-feeding
- skin redness, often in a wedge-shaped pattern
most common bug of mastitis
staph aureus
most commonly affected group for mastitis
newly breastfeeding women (first baby)
presentation of mastitis
- unilateral
- most frequently begins within 3 months after delivery
- may start out as a sore or fissured nipple
- may have a lump if starting to form an abscess
abx treatment for mastitis
dicloxacillin or cephalosporin (Keflex) x 5-7 days
TREATMENT FOR MASTITIS
- staph aureus = culprit
- Antibiotics for PCN-resistant staph = Dicloxacillin or Cephalosporin (Keflex) x 5-7 days
- regular emptying of the breast by nursing followed by expression of any remaining milk by hand or which mechanical suction device
- warm compresses to the breast
- failure to respond within 3 days with ABX = should prompt consideration of MRSA
- pt may need to be admitted for IV therapy
- any delay in treatment could result in breast abscess
MASTITIS PREVENTION
- breastfeed equally from both breasts
- empty breasts completely to prevent engorgement & blocked ducts
- use good breastfeeding techniques to prevent sore, cracked nipples
- avoid dehydration - drink plenty of fluids
- practice careful hygiene = handwashing, clean nipples, keep baby clean
breast abscess
- area of redness, tenderness & induration on breast during nursing or otherwise
- most likely culprit = Staph Aureus
- the early stages of infection can be treated while nursing from that breast, but if the infection is not controlled within 24 hrs, an abscess may form
- Treatment = surgical drainage & nursing is discontinued; pt likely admitted for IV therapy & I&D
MOST COMMON CAUSE OF SPONTANEOUS NIPPLE DISCHARGE FROM A SINGLE DUCT
intraductal papilloma
benign growth in single milk duct
intraductal papilloma
INTRADUCTAL PAPILLOMA
- tiny wart-like growth in breast tissue that sometimes punctures a duct
- little benign tumors that grow inside milk ducts and can cause benign nipple discharge
- most commonly occurs in women aged 35-55
- causes & risk factors = unknown
- MOST COMMON CAUSE OF SPONTANEOUS NIPPLE DISCHARGE FROM A SINGLE DUCT
⦁ discharge can be serous, bloody or cloudy - mass may not be palpable; unilateral. serous or serosanguinous dripping from single duct
= 1 lump, usually near a nipple, causes nipple discharge
solitary intraductal papilloma
groups of lumps, farther away from the nipple. Usually don’t cause discharge, and can’t be felt
multiple papillomas
very small groups of cells inside the ducts. a type of hyperplasia, and are more scattered than multiple papillomas
papillomatosis
other tests for intraductal papilloma
- breast biopsy to rule out cancer
- examination of discharge to see if cells are cancerous
- x-ray with contrast is injected into the affected duct (ductogram)
treatment of intraductal papilloma
- the involved duct is surgically removed, and the cells are checked for cancer
CAUSES OF NIPPLE DISCHARGE
⦁ Papilloma ⦁ premenopausal women - spontaneous ⦁ prolactinoma ⦁ oral contraceptive agents ⦁ abscess ⦁ medications (anti-psychotics) ⦁ hypothyroidism
- check prolactin levels, check for pituitary tumor, check TSH / T3/T4
SUSPICIOUS VS NOT SUSPICIOUS NIPPLE DISCHARGE
O SUSPICIOUS NIPPLE DISCHARGE
- 1 breast
- 1 duct
- associated with a lump
- leaks out on its own
- occurs most days of the month
- discharge is watery or bloody (red, brown or black)
- a lot of discharge
O NOT SUSPICIOUS DISCHARGE
- both breasts
- several ducts
- squeezing brings it on
- occasional
- different colors (green, yellow, white)
- a little
evaluation of breast tenderness
Breast examination checking for: ⦁ areas of tenderness ⦁ mass ⦁ trauma (bruising) ⦁ nipple discharge US/Mammogram, if necessary
breast tenderness is
- May be unilateral or bilateral
- usually not related to trauma to the breast
- usually related to fibrocystic changes
- may be associated with breast cancer
- may be related to dietary habits (caffeine, chocolate, salt)
treatment of breast tenderness
- NSAIDS
- eliminate caffeine, chocolate, salt
- monthly SBE
- RTC if symptoms don’t resolve within 1-2 months
