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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
USPSTF guidelines for mammograms
40-49: individualize | 50-74: q2 years
26
ACOG guidelines for mammograms
40-49: shared decision making 50-74: q1-2 years 75+: shared decision making
27
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
28
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
29
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 ```
30
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
31
DDx for DCIS include
DCIS w/ microinvasion (1mm or less) Atypical ductal hyperplasia Lobar carcinoma in situ
32
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
33
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
34
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)
35
This is a BAD finding to se on mammogram
Spiculated soft tissue mass***
36
How can you diagnose breast cancer
US: solid/cystic, sharp/ill defined border, vascular supply MRI Biopsy Liver enzymes (alk phos)
37
Imaging to consider for mets includes
bone scan/MRI CT abdomen abdominal MRI, US, or PET-CT chest CT/CXR
38
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)
39
What surgical approach is no longer really used
Radical mastectomy: take all breast tissue, nipple areolar complex, nodes, AND pec major/minor
40
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)
41
ADE of Trastuzumab (herceptin) include
HF respiratory problems life threatening allergic reaction
42
Breast cancer follow up should include
F/u q 3-6 months x 2 years, then q 1 year | Annual mammogram and CBE indefinitely
43
most breast cancer recurrences are
within 5 years
44
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
45
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
46
IBC is characterized by
``` **diffuse dermatologic erythema and edema (peau d/orange) breast pain, tenderness firm enlarged breast PRURITIS node involvement +/- mass ```
47
Pathology behind IBC is
Lymphedema caused by tumor emboli w/in the dermal lymphatics
48
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
49
Full thickness skin biopsy of IBC reveals
dermal lymphatic invasion by tumor cells
50
How do you treat IBC
Chemo followed by mastectomy w/ axillary node dissection and post-mastectomy radiation
51
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
52
PDB is characterized by
scaly, raw vesicular or ulcerated lesions | start at the nipple and spread to areola
53
PDB presents as
Unilateral Occasionally bloody discharge Pain, burning, pruritis to skin PRIOR to actual skin findings
54
How do you diagnose PDB
``` Full thickness wedge or punch Bx of nipple bilateral mammogram (MUST if there is a mass) ```
55
How do you treat PDB
Mastectomy or BCT followed by radiation
56
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%
57
Worrisome nipple discharge findings include
Spontaneous discahrge bloody Unilateral or Uniductal Associated with a mass
58
How do you evaluate nipple discharge
Focused US, mammogram if 30+ MRI +/- labs (hCG, PRL, renal function, thyroid function)
59
How do you treat nipple discharge
If med related, reassure patient Terminal duct excision Malignancy: appropriate cancer surgery
60
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)
61
How does mastitis present clinically
Fever (usually high) swelling painful, erythematous lobule in outer breast quadrant +/- systemic Sx and axillary LAD
62
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 ```
63
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
64
RF for a breast abscess include
30+ primiparity >41 weeks gestation tobacco use
65
How does a breast abscess present
Local, painful inflammation Fluctuant, tender, palpable mass fever, malaise
66
How can you diagnose a breast abscess
clinically! US breast milk cultures
67
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
68
What is gynecomastia
benign proliferation of glandular breast tissue in men Symmetric, bilateral can be tender initially, but subsides after a few months
69
What causes gynecomastia
``` Drugs- spironalactone, estrogens, cimetidine, ketoconazole, GH, gonadotropins, antiandrogena, 5ARI Hypogonadism Tumors CKD, chronic liver disease hyperthyroid androgen resistance congenital adrenal hyperplasia ```
70
How does gynecomastia present
mass or lump BEHIND nipple, 4cm or less tender for 6 months (on PE, eval thyroid, abdomen, and genitalia)
71
Pathologic diagnosis of gynecomastia includes
hCG, estradiol, testosterone, LH, and DHES levels | Pediatric endocrinologist
72
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

Summer FDTN Exam 3 (25 decks)

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