breast disorders Flashcards
The 3 components of the breast are
Skin
SubQ tissue
breast tissue (epithelial and stromal elements)
What are milk lines
they run from mammary glands and nipples inferiorly, developed in embryo
congenital supernumery nipples can occur along the milk lines (polythelia)
How do you perform a breast exam
inspection and palpation 7-9 days BEFORE menses
Include neck, chest wall, and b/l breasts and axillae
Inspect in 2 positions; sitting up, and supine
When inspecting the breast, look for these abnormalities
significant asymmetry skin changes (dimpling) Nipple asymmetry, inversion, retraction, discharge, or crusting
When palpating the breast, go over all these areas
tail of spence
lymph nodes
entire breast, upright and supine
What is the initial study for a new, palpable breast mass
Mammogram!
What is BI-RADS
mammogram reporting system. Includes:
shape, margin, orientation, echogenicity, homogeneity, and attenuation
How is the BI-RADS scoring system
0: incomplete (not enough info, bad view)
1: Negative (routine f/u)
2: Benign (routine f/u)
3: Probs benign (short-term f/u in 6 mo.)
4a: low suspicion for malignancy
4b: mod suspicion
4c: high suspicion
5: Highly suggestive of malignancy
6: Biopsy proven malignancy
At what stages of a BI-RADS score do you involve a surgeon
4 and 5
If the mass is palpable, do a core Bx or FNA.
If not palpable, do image guided biopsy
Other breast Dx studies include
US: young, low risk woman w/ suspected fibroadenoma
MRI w/ con: high false + rate
Breast tomosynthesis (3D mammogram)
Molecular breast imaging (nuclear imaging)
When would you get a targeted US
evaluate palpable mass
along with diagnostic mammogram
evaluate solid vs cystic vs mixed
Molecular breast imaging is used for
investigation! for dense breast tissue
Breast biopsies include
Skin punch biopsy- eval skin findings
FNA (palpation or US guided)- eval simple cysts
Core (w/ and w/o vacuum)- MC w/ image guidance
Surgical biopsy
What is a fibroadenoma
solitary BENIGN mass, more common in young women and african american women
Fibroadenoma clinical presentation
round/ovoid 1-5cm rubbery discrete moveable non-tender
How do you diagnose and treat a fibroadenoma
CORE needle Bx
Excision, or monitor for conservative Tx
What is a phyllodes tumor
a large, fast growing fibroadenoma
can be benign, borderline, or malignant
MUST excise
What are fibrocystic changes
MC breast lesion, typically in 30-50 y/o
Estrogen dependent, subside with menopause
Increased risk with alcohol use
Fibrocystic changes clinical presentation
painful multiple bilateral rapid change in size and appearance Nodular breast tissue mobile (but not AS mobile as fibroadenoma) TENDER!
How do you diagnose fibrocystic changes
Mammogram, US, or FNA
Treatment for fibrocystic changes includes
Breast support- wear bra day and night Evening primrose oil low fat diet avoid caffeine (chocolate, and tea) vitamin E (400 IU)
RF for breast cancer include
**BRCA 1/2 genes
**PMHx or FHx ovarian, peritoneal, or breast CA
**Radiotherapy to chest @ 10-30 y/o
age
white
post-menopause obesity
tall stature
high estrogen levels (early menarche, late menopause, on HRT or OCP)
nulliparity
first pregnancy 35+ y/o
PROTECTIVE factors against breast cancer include
breastfeeding higher parity physical activity oopherectomy <35 y/o ASA use
What breast cancer screening tools are available for women
Avg risk: GAIL model* High risk (have any of the ** RFs): ontario, manchester, referral tool, pedigree, FHx
USPSTF guidelines for mammograms
40-49: individualize
50-74: q2 years
ACOG guidelines for mammograms
40-49: shared decision making
50-74: q1-2 years
75+: shared decision making
High risk screening guidelines are
Mammogram q 1 year starting at 25, or 5-10 years before age of Dx of affected family member
Supplemental MRI screen at 6 months
Genetic counselors can help identify
BRCA mutation carriers (blood, saliva, buccal mucosa) BRCA1= 65% risk of breast cancer by 70
BRCA2= 45% risk of breast cancer by 70
Who should you refer for BRCA testing (2/2 increased risk of having BRCA gene mutations)
If a relative has BRCA 1 or 2 breast CA before 50 b/l breast cancer breast and ovarian cancer in the same family multiple breast CA in the same family male with breast cancer Ashkenazi jewish
What is Ductal Carcinoma In Situ (DCIS)
Neoplastic lesion CONFINED to ducts and lobules (aka Stage 0)
Great prognosis, 3% 20 year mortality, 6% 20 year recurrence
DDx for DCIS include
DCIS w/ microinvasion (1mm or less)
Atypical ductal hyperplasia
Lobar carcinoma in situ
What are the types of infiltrative breast cancer
Infiltrating ductal (MC): arise from epithelial lining of large ducts
Infiltrating lobar: arise from epithelium of terminal ducts of lobules
Mixed
Molecular subtypes of infiltrative breast cancers include
Luminal A/B (MC): Estrogen positive
HER2: estrogen and progesterone negative
Basal (triple negative): estrogen, progesterone, and HER2 negative breast cancer
How is breast cancer usually found
*abnormal mammogram
breast/axillary mass (hard, fixed, solitary, irregular borders)
skin changes (erythema, thickening, dimpling)
signs of mets (back/leg pain, abd pain, nausea, jaundice, SOB, cough)
This is a BAD finding to se on mammogram
Spiculated soft tissue mass***
How can you diagnose breast cancer
US: solid/cystic, sharp/ill defined border, vascular supply
MRI
Biopsy
Liver enzymes (alk phos)
Imaging to consider for mets includes
bone scan/MRI
CT abdomen
abdominal MRI, US, or PET-CT
chest CT/CXR
Surgical options for breast cancer include
Lumpectomy + radiation (breast conservation)
Mastectomy (all breast tissue, nipple areolar complex, preserve pec major and minor)
Modified radical mastectomy (also take out nodes)
Breast reconstruction (can start w/ mastectomy)
What surgical approach is no longer really used
Radical mastectomy: take all breast tissue, nipple areolar complex, nodes, AND pec major/minor
Medical breast cancer treatment includes
Chemo + Estrogen antagonists;
ER+ (luminal A/B): Tamoxifen or Raloxifen
Prevent E production: Aromatase inhibitors (+ tamoxifen to prevent recurrence) extended survival w/ mets
HER2: Trastuzumab (herceptin)
ADE of Trastuzumab (herceptin) include
HF
respiratory problems
life threatening allergic reaction
Breast cancer follow up should include
F/u q 3-6 months x 2 years, then q 1 year
Annual mammogram and CBE indefinitely
most breast cancer recurrences are
within 5 years
Chemo / prophylactic surgery for BRCA 1/2 carrier without a PMHx of cancer
BSO at 35-40 y/o (childbearing is complete)
Intensive screening for breast CA
Consider hormonal risk reduction (breast CA)
Chemoprevention + Tamoxifen instead of prophylactic mastectomy
-if you are a BRCA carrier WITH a PMHx of cancer, more complicated prophylaxis
What is inflammatory breast cancer (IBC)
rare, aggressive, invasive breast cancer
Onset is weeks to months!!
MC in young women and african american women
Poor prognosis 2/2 high risk of early recurrnce
IBC is characterized by
**diffuse dermatologic erythema and edema (peau d/orange) breast pain, tenderness firm enlarged breast PRURITIS node involvement \+/- mass
Pathology behind IBC is
Lymphedema caused by tumor emboli w/in the dermal lymphatics
How do you diagnose IBC
Diagnostic mammogram on ipsilateral side
screening mammogram on contralateral side
Breast/regional node US
Final Dx: Full thickness skin biopsy
Full thickness skin biopsy of IBC reveals
dermal lymphatic invasion by tumor cells
How do you treat IBC
Chemo followed by mastectomy w/ axillary node dissection and post-mastectomy radiation
What is Paget’s Disease of Breast (PDB)
rare
MC in 50-60 y/o
Malignant intraepithelial adenocarcinoma cells occur w/in epidermis of the nipple
PDB is characterized by
scaly, raw vesicular or ulcerated lesions
start at the nipple and spread to areola
PDB presents as
Unilateral
Occasionally bloody discharge
Pain, burning, pruritis to skin PRIOR to actual skin findings
How do you diagnose PDB
Full thickness wedge or punch Bx of nipple bilateral mammogram (MUST if there is a mass)
How do you treat PDB
Mastectomy or BCT followed by radiation
What is the prognosis of PDB
W/ palpable mass: 5 year survival is 20-60%
w/o palpable mass: 5 year survival is 75-100%
Worrisome nipple discharge findings include
Spontaneous discahrge
bloody
Unilateral or Uniductal
Associated with a mass
How do you evaluate nipple discharge
Focused US, mammogram if 30+
MRI
+/- labs (hCG, PRL, renal function, thyroid function)
How do you treat nipple discharge
If med related, reassure patient
Terminal duct excision
Malignancy: appropriate cancer surgery
What is mastitis
Infection of a duct, commonly while breast feeding (Staph Aureus); flow of milk is disrupted causing engorgement
can also be non-lactating (periductal mastitis, idiopathic granulomatous mastitis)
How does mastitis present clinically
Fever (usually high)
swelling
painful, erythematous lobule in outer breast quadrant
+/- systemic Sx and axillary LAD
How do you treat mastitis
Continue breast feeding!! or use a pump, try to get milk flowing (wont transfer to baby) local heat breast support Dicloxacillin or Cephalexin Monitor for abscess formation -should see improvement in 1-2 days
What is a breast abscess
localized collection of pus in breast tissue
2/2 untreated or refractory mastitis/cellulitis
*Staph Aureus
0.1% incidence in breast feeding
RF for a breast abscess include
30+
primiparity
>41 weeks gestation
tobacco use
How does a breast abscess present
Local, painful inflammation
Fluctuant, tender, palpable mass
fever, malaise
How can you diagnose a breast abscess
clinically!
US
breast milk cultures
How do you treat a breast abscess
Drain and give Abx
US guided needle aspiration
-follow up in 1-2 days to make sure you dont need gen surg
What is gynecomastia
benign proliferation of glandular breast tissue in men
Symmetric, bilateral
can be tender initially, but subsides after a few months
What causes gynecomastia
Drugs- spironalactone, estrogens, cimetidine, ketoconazole, GH, gonadotropins, antiandrogena, 5ARI Hypogonadism Tumors CKD, chronic liver disease hyperthyroid androgen resistance congenital adrenal hyperplasia
How does gynecomastia present
mass or lump BEHIND nipple, 4cm or less
tender for 6 months
(on PE, eval thyroid, abdomen, and genitalia)
Pathologic diagnosis of gynecomastia includes
hCG, estradiol, testosterone, LH, and DHES levels
Pediatric endocrinologist
How do you treat gynecomastia
70& regress spontaneously in 1 year
If occurrence is after 17 y/o, or lasts >1 year, regression is rare
Consider psychotherapy and surgery
