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Summer FDTN Exam 3 > breast disorders > Flashcards

breast disorders Flashcards

1
Q

The 3 components of the breast are

A

Skin
SubQ tissue
breast tissue (epithelial and stromal elements)

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2
Q

What are milk lines

A

they run from mammary glands and nipples inferiorly, developed in embryo
congenital supernumery nipples can occur along the milk lines (polythelia)

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3
Q

How do you perform a breast exam

A

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

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4
Q

When inspecting the breast, look for these abnormalities

A 
significant asymmetry 
skin changes (dimpling) 
Nipple asymmetry, inversion, retraction, discharge, or crusting
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5
Q

When palpating the breast, go over all these areas

A

tail of spence
lymph nodes
entire breast, upright and supine

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6
Q

What is the initial study for a new, palpable breast mass

A

Mammogram!

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7
Q

What is BI-RADS

A

mammogram reporting system. Includes:

shape, margin, orientation, echogenicity, homogeneity, and attenuation

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8
Q

How is the BI-RADS scoring system

A

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

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9
Q

At what stages of a BI-RADS score do you involve a surgeon

A

4 and 5
If the mass is palpable, do a core Bx or FNA.
If not palpable, do image guided biopsy

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10
Q

Other breast Dx studies include

A

US: young, low risk woman w/ suspected fibroadenoma
MRI w/ con: high false + rate
Breast tomosynthesis (3D mammogram)
Molecular breast imaging (nuclear imaging)

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11
Q

When would you get a targeted US

A

evaluate palpable mass
along with diagnostic mammogram
evaluate solid vs cystic vs mixed

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12
Q

Molecular breast imaging is used for

A

investigation! for dense breast tissue

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13
Q

Breast biopsies include

A

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

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14
Q

What is a fibroadenoma

A

solitary BENIGN mass, more common in young women and african american women

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15
Q

Fibroadenoma clinical presentation

A 
round/ovoid 
1-5cm 
rubbery
discrete
moveable
non-tender
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16
Q

How do you diagnose and treat a fibroadenoma

A

CORE needle Bx

Excision, or monitor for conservative Tx

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17
Q

What is a phyllodes tumor

A

a large, fast growing fibroadenoma
can be benign, borderline, or malignant
MUST excise

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18
Q

What are fibrocystic changes

A

MC breast lesion, typically in 30-50 y/o
Estrogen dependent, subside with menopause
Increased risk with alcohol use

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19
Q

Fibrocystic changes clinical presentation

A 
painful 
multiple 
bilateral 
rapid change in size and appearance 
Nodular breast tissue 
mobile (but not AS mobile as fibroadenoma) 
TENDER!
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20
Q

How do you diagnose fibrocystic changes

A

Mammogram, US, or FNA

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21
Q

Treatment for fibrocystic changes includes

A 
Breast support- wear bra day and night 
Evening primrose oil 
low fat diet 
avoid caffeine (chocolate, and tea) 
vitamin E (400 IU)
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22
Q

RF for breast cancer include

A

**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

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23
Q

PROTECTIVE factors against breast cancer include

A 
breastfeeding 
higher parity 
physical activity 
oopherectomy <35 y/o 
ASA use
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24
Q

What breast cancer screening tools are available for women

A 
Avg risk: GAIL model* 
High risk (have any of the ** RFs): ontario, manchester, referral tool, pedigree, FHx
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25
Q

USPSTF guidelines for mammograms

A

40-49: individualize

50-74: q2 years

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26
Q

ACOG guidelines for mammograms

A

40-49: shared decision making
50-74: q1-2 years
75+: shared decision making

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27
Q

High risk screening guidelines are

A

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

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28
Q

Genetic counselors can help identify

A

BRCA mutation carriers (blood, saliva, buccal mucosa) BRCA1= 65% risk of breast cancer by 70
BRCA2= 45% risk of breast cancer by 70

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29
Q

Who should you refer for BRCA testing (2/2 increased risk of having BRCA gene mutations)

A 
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
30
Q

What is Ductal Carcinoma In Situ (DCIS)

A

Neoplastic lesion CONFINED to ducts and lobules (aka Stage 0)
Great prognosis, 3% 20 year mortality, 6% 20 year recurrence

31
Q

DDx for DCIS include

A

DCIS w/ microinvasion (1mm or less)
Atypical ductal hyperplasia
Lobar carcinoma in situ

32
Q

What are the types of infiltrative breast cancer

A

Infiltrating ductal (MC): arise from epithelial lining of large ducts
Infiltrating lobar: arise from epithelium of terminal ducts of lobules
Mixed

33
Q

Molecular subtypes of infiltrative breast cancers include

A

Luminal A/B (MC): Estrogen positive
HER2: estrogen and progesterone negative
Basal (triple negative): estrogen, progesterone, and HER2 negative breast cancer

34
Q

How is breast cancer usually found

A

*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)

35
Q

This is a BAD finding to se on mammogram

A

Spiculated soft tissue mass***

36
Q

How can you diagnose breast cancer

A

US: solid/cystic, sharp/ill defined border, vascular supply
MRI
Biopsy
Liver enzymes (alk phos)

37
Q

Imaging to consider for mets includes

A

bone scan/MRI
CT abdomen
abdominal MRI, US, or PET-CT
chest CT/CXR

38
Q

Surgical options for breast cancer include

A

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)

39
Q

What surgical approach is no longer really used

A

Radical mastectomy: take all breast tissue, nipple areolar complex, nodes, AND pec major/minor

40
Q

Medical breast cancer treatment includes

A

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)

41
Q

ADE of Trastuzumab (herceptin) include

A

HF
respiratory problems
life threatening allergic reaction

42
Q

Breast cancer follow up should include

A

F/u q 3-6 months x 2 years, then q 1 year

Annual mammogram and CBE indefinitely

43
Q

most breast cancer recurrences are

A

within 5 years

44
Q

Chemo / prophylactic surgery for BRCA 1/2 carrier without a PMHx of cancer

A

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

45
Q

What is inflammatory breast cancer (IBC)

A

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

46
Q

IBC is characterized by

A 
**diffuse dermatologic erythema and edema (peau d/orange) 
breast pain, tenderness 
firm enlarged breast 
PRURITIS 
node involvement 
\+/- mass
47
Q

Pathology behind IBC is

A

Lymphedema caused by tumor emboli w/in the dermal lymphatics

48
Q

How do you diagnose IBC

A

Diagnostic mammogram on ipsilateral side
screening mammogram on contralateral side
Breast/regional node US
Final Dx: Full thickness skin biopsy

49
Q

Full thickness skin biopsy of IBC reveals

A

dermal lymphatic invasion by tumor cells

50
Q

How do you treat IBC

A

Chemo followed by mastectomy w/ axillary node dissection and post-mastectomy radiation

51
Q

What is Paget’s Disease of Breast (PDB)

A

rare
MC in 50-60 y/o
Malignant intraepithelial adenocarcinoma cells occur w/in epidermis of the nipple

52
Q

PDB is characterized by

A

scaly, raw vesicular or ulcerated lesions

start at the nipple and spread to areola

53
Q

PDB presents as

A

Unilateral
Occasionally bloody discharge
Pain, burning, pruritis to skin PRIOR to actual skin findings

54
Q

How do you diagnose PDB

A 
Full thickness wedge or punch Bx of nipple 
bilateral mammogram (MUST if there is a mass)
55
Q

How do you treat PDB

A

Mastectomy or BCT followed by radiation

56
Q

What is the prognosis of PDB

A

W/ palpable mass: 5 year survival is 20-60%

w/o palpable mass: 5 year survival is 75-100%

57
Q

Worrisome nipple discharge findings include

A

Spontaneous discahrge
bloody
Unilateral or Uniductal
Associated with a mass

58
Q

How do you evaluate nipple discharge

A

Focused US, mammogram if 30+
MRI
+/- labs (hCG, PRL, renal function, thyroid function)

59
Q

How do you treat nipple discharge

A

If med related, reassure patient
Terminal duct excision
Malignancy: appropriate cancer surgery

60
Q

What is mastitis

A

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)

61
Q

How does mastitis present clinically

A

Fever (usually high)
swelling
painful, erythematous lobule in outer breast quadrant
+/- systemic Sx and axillary LAD

62
Q

How do you treat mastitis

A 
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
63
Q

What is a breast abscess

A

localized collection of pus in breast tissue
2/2 untreated or refractory mastitis/cellulitis
*Staph Aureus
0.1% incidence in breast feeding

64
Q

RF for a breast abscess include

A

30+
primiparity
>41 weeks gestation
tobacco use

65
Q

How does a breast abscess present

A

Local, painful inflammation
Fluctuant, tender, palpable mass
fever, malaise

66
Q

How can you diagnose a breast abscess

A

clinically!
US
breast milk cultures

67
Q

How do you treat a breast abscess

A

Drain and give Abx
US guided needle aspiration
-follow up in 1-2 days to make sure you dont need gen surg

68
Q

What is gynecomastia

A

benign proliferation of glandular breast tissue in men
Symmetric, bilateral
can be tender initially, but subsides after a few months

69
Q

What causes gynecomastia

A 
Drugs- spironalactone, estrogens, cimetidine, ketoconazole, GH, gonadotropins, antiandrogena, 5ARI  
Hypogonadism 
Tumors 
CKD, chronic liver disease 
hyperthyroid 
androgen resistance 
congenital adrenal hyperplasia
70
Q

How does gynecomastia present

A

mass or lump BEHIND nipple, 4cm or less
tender for 6 months
(on PE, eval thyroid, abdomen, and genitalia)

71
Q

Pathologic diagnosis of gynecomastia includes

A

hCG, estradiol, testosterone, LH, and DHES levels

Pediatric endocrinologist

72
Q

How do you treat gynecomastia

A

70& regress spontaneously in 1 year
If occurrence is after 17 y/o, or lasts >1 year, regression is rare
Consider psychotherapy and surgery

Summer FDTN Exam 3 (25 decks)

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