Breast Disorders Flashcards
What are the 3 components of the breast?
Skin
Subcutaneous tissue
Breast tissue (epithelial elements and stromal elements)
Ideally, when should you perform a breast exam? What are the 2 components of the breast exam?
7-9 days after onset of menses
inspection & palpitation
What are some abnormalities that may be seen on breast inspection?
Asymmetry Skin changes Nipple asymmetry Nipple inversion or retraction Nipple discharge or crusting
When should you order a mammogram?
for screening
dx- initial study for new, palpable breast mass
What is evaluated in BI-RADS for mammogram?
Shape Margin Orientation Echogenicity Homogeneity Attenuation
BI-RADS scoring?
0: incomplete
1: negative
2: benign
3: probably benign
4: suspicious A-C
5: highly suggestive or malignancy
6: known biopsy proven malignancy
FU for pts with BI-RADS 1 or 2?
routine FU annual screening if 40 or older
FU for pts with BI-RADS score or 3?
probably benign
FU in 6 months for repeat mammogram
FU for pts with BI-RADS score of 4/5
biopsy to determine further work up
What is the initial study for young, low risk women with suspected fibroadenoma? Wha can be used for screening in high risk women?
US
MRI
What is a targeted US?
Palpable mass evaluation
Concurrent with diagnostic mammogram
Solid vs. cystic vs. mixed
What other diagnostic studies may be used to evaluated breast tissue?
breast tomosyntesis: 3D xray
Molecular breast imaging
What kind of breast biopsies can you perform?
skin punch biopsy
FNA > simple cysts
core needle biopsy > complex masses
surgical biopsy
Which pts are fibroadenomas usually seen in?
Young women
More frequent in black women
Usually a solitary mass
Presentation for fibroadenoma?
Round or ovoid, 1-5 cm
Rubbery
Discrete
Movable
Non-tender
How can you dx a fibroadenoma?
core needle biopsy
Tx for fibroadenoma?
Excision
Conservative treatment with monitoring
What is a phyllodes tumor?
Large fibroadenoma that grows rapidly
can be benign, borderline or malignant
Tx for phyllodes tumor
excision required
What is the MC breast lesion?
fibrocystic changes
Fibrocystic changes are most commonly seen in women…. y/o
30-50
increased risk with alcohol use
Fibrocystic changes are…dependent
estrogen
Clinical presentation for fibrocystic changes?
Painful, Multiple, usually bilateral
Rapid changes in size and appearance
Nodular breast tissue
Mobile
Tender
How can you dx fibrocystic changes?
mammogram and/or US
FNA
Tx for fibrocystic changes
breast support
+/- evening primrose oil, low fat diet, avoid caffeine, Vit E
will subside with menopause
Risk factors for breast CA?
BRCA1/BRCA2 genes
Personal and/or family history ovarian, peritoneal or breast cancer
Radiotherapy to chest b/t age 10-30
Others: age, white race, postmenopausal obesity, tall stature, high estrogen levels, nulliparity, higher bone density, alcohol, smoking, DES exposure
Protective factors for breast CA?
Breastfeeding Higher parity Physical activity Oophorectomy ≤ 35 y/o Aspirin use
What screening tool can you use to determine risk of breast CA for average risk women?
Gail model
if higher than 1.67 considered higher risk
USPSTF guidelines for mammogram in average risk women?
Age 40-49, individualize (grade C)
Every 2 years, age 50-74 (grade B)
ACOG guidelines for mammogram in average risk women?
Age 40-49, shared decision making
Recommend at age 50-74
Every 1-2 years
≥ age 75, shared decision making
screening guidelines for higher risk pts?
annual mammogram starting at 25 (or 5-10 yrs before dx of relative)
supplemental breast MRI -6 months apart
Genetic testing in breast CA?
refer to genetic counselor if possible
BRCA mutation carriers
(Blood, saliva, buccal mucosa samples)
BRCA1: 65% risk of breast cancer by age 70
BRCA2: 45% risk of breast cancer by age 70
other genes: ATM, CHEK2, PALB2
Who should undergo genetic testing for breast CA?
Any relative with BRCA 1 or 2 mutation
Breast CA before age 50
Bilateral breast cancer
Breast & ovarian CA in same woman or same family
Multiple breast CA in same family
2+ primary types of BRCA 1 or 2 related cancers in single family member
Male breast cancer
Ashkenazi Jewish ethnicity
What is ductal carcinoma in situ?
Neoplastic lesions confined to breast ducts and lobules
What stage is DCIS?
always stage 0!
confined within ducts
Px of DCIS?
excellent!
3% 20 yr mortality
What is the MC type of breast CA?
infiltrating ductal carcinoma?
Infiltrating ductal carcinoma arises from?
epithelial lining of the large or intermediate-sized ducts
Infiltrating lobular carcinoma arises from?
epithelium of the terminal ducts of the lobules
What are the molecular subtype of breast cancers?
Luminal A/B
HER2-enriched
Basal “triple negative)
-ER/PE/HER2 neg
breast CA presentation
most due to abn. mammogram
breast/axillary mass
+/- skin changes
-erythema, thickening, dimpling
with metastasis
-back/leg pain, abn pain, nausea, jaundice, SOB
Work up for breast CA?
Mammogram
-spiculated soft tissue mass**
US
-solid v. cystic, vascular supply
MRI
Bx
Liver enzymes
What imaging should you order to eval for metastasis?
Bone scan / MRI
CT abdomen
Abdominal MRI or U/S or PET-CT
Chest CT / CXR
Tx for Breast CA?
Surg:
- Lumpectomy + radiation therapy (breast conservation)
- Mastectomy
- Modified radical mastectomy
- breast reconstruction
Medical therapy options for breast CA?
chemo + estrogen antagonists
- Tamoxifen or Raloxifine for ER + cancers (take 5 yrs post surg)
- Aromatase inhibitors
- Trastuzumab: for HER-2 cancers
Follow up after breast CA tx?
Every 3-6 months x 2 years, then annually
Annual mammogram and CBE indefinitely
Most recurrences are within 5 years
Prophylactic options for BRCA 1 or 2 carriers without personal hx of CA?
BSO btwn 35-40 and done childbearing
intensive screening
chemoprevention with
Tamoxifen
Which pts are most likely to get inflammatory breast CA (IBC) ?
black women
rare invasive breast CA, highly aggressive
Presentation of IBC?
diffuse dermatologic erythema and edema (peau d’orange)
rapid presentation \+/- mass Breast pain Tender, firm, or enlarged breast Itching of the breast Lymph node involvement 1/3 have distant metastasis
Pathology of IBC?
lymphedema caused by tumor emboli within the dermal lymphatics
Dx of IBC?
**Full-thickness skin punch biopsy: Dermal lymphatic invasion by tumor cells
mammogram, lymph node US, core needle biopsy
Tx for IBC?
chemo followed by mastectomy with axillary node dissection and post mastectomy radiation
poor px
Peak incidence of Paget disease of the breast (PDB)?
50-60 y/o
Presentation of PDB?
usually unilateral, occasional bloody DC, pain/burning and or pruritus
scaly, raw, vesicular or ulcerated lesion that begins on the nipple and spreads to the areola
Pathology of PDB?
malignant, intraepithelial adenocarcinoma cells (Paget cells) occurring singly or in small groups within the epidermis of the nipple
Dx of PDB?
Full thickness wedge or punch biopsy of the nipple
Bilateral mammogram
tx of PDB?
Mastectomy or BCT followed by radiation
px with mass: 5 yr 20-60%
w/out mass: 5 yr 75-100%
causes of nipple DC?
Usually benign
Early endocrine dysfunction – hyperprolactinemia, hypothyroidism
Meds – OCPs, tricyclics, antipsychotics
Cancer – 5-15%
Nipple DC seen with fibrocystic changes of ductal ectasia?
Non-spontaneous
Non-bloody
Bilateral
Green, yellow, or brown; sticky
Nipple DC seen with endocrine/meds?
Milky, bilateral, multiple ducts
Nipple DC seen with infectious cause?
purulent
What should make you worried about nipple DC?
Spontaneous
Bloody
Unilateral, uniductal
Associated with a mass
Work up for nipple DC?
US, mammogram if >30
ductography
MRI, MR ductography
labs: HCG, PRL, renal tests, thyroid tests
Tx for nipple DC?
If medication related, reassurance
Terminal ductal excision
If malignancy, appropriate cancer surgery
Who is mastitis usually seen in?
primiparous nursing patient
Organism seen in mastitis? Causes?
s. aureus
Can be hospital acquired infection
Disrupted flow of milk causing engorgement
Infection of the infant
Can mastitis occur in pt who is not lactating?
YES
Periductal mastitis
Idiopathic granulomatous mastitis
Presentation of mastitis?
Fever, Swelling, Painful, erythematous lobule in outer breast quadrant
+/- other systemic symptoms
+/- axillary lymphadenopathy
Dx for mastitis?
clinical!
if refractory tx –> US
Tx for mastitis?
Continue breastfeeding or use breast pump
Local heat
Breast support
Abx
Monitor for abscess
What abx can you use for tx of mastitis?
Dicloxacillin 500 mg po QID
Cephalexin 500 mg po QID
Alternatively, clindamycin 300 mg po TID
Describe a breast abscess. What causes this?
Localized collection of pus in the breast tissue
Secondary to untreated or refractory to treatment mastitis or cellulitis
Risk factors for breast abscess?
age > 30 years
primiparity
gestational age ≥ 41 weeks
tobacco use
Presentation of breast abscess?
Localized, painful inflammation
Fluctuant, tender, palpable mass
Fever, malaise
Dx of breast abscess?
clinical findings & US
breast milk US
+/- blood cx
Tx of breast abscess?
I&D
abx
What is physiologic gynecomastia?
Benign proliferation of glandular breast tissue in males
Symmetrically distributed around areolar-nipple complex
can be tender, usually bilateral
What can cause pathologic gynecosmatia?
drugs-exogenous estrogen
hypogonadism
tumors
What drugs are assoc. with gynecomastia?
Estrogens Spironolactone Cimetidine Ketoconazole Growth hormone Gonadotropins Antiandrogen therapies 5-alpha-reductase inhibitors
lots more!
Presentation of gynecomastia?
Mass or lump behind nipple
Gradual enlargement
≤ 4 cm diameter
Tender for about 6 months then gradually resolves
What should be included in PE for gynecomastia?
thyroid, abdomen, and genitalia at a minimum
dx of gynecomastia
usually clinical
if pathologic: +/- HCG, testosertone, LH, DHEA, peds endo
Tx fo physiologic gynceomastia?
regress spontaneously in >70%
+/- psychotherapy, surg
Tx for pathologic gynecomastia?
depends on etiology
