Breast Disorders Flashcards
1
Q
breast examination
A
- Clinical breast exam
- American Cancer Society: evidence unclear, no recommendations; “be familiar”
- NCCN recommends CBE every 1-3 years age 25-39 and yearly at age 40
- US Preventive Services Task Force: not enough evidence
- Self breast exam
- Good to have self-awareness
- May discover lumps earlier than screening
- May not be reliable and can lead to additional tests and biopsies
- Clinical cancers may not be seen with screening
- Physical exam includes: chest, neck, axilla, breast
- Part of your physical exam but self breast exam not recommended anymore.
- The US Preventive Services Task Force concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination beyond screening . They recommend against clinicians teaching women how to perform breast self- examination. mammography in women 40 years and older= what does this mean? Recommend breast exams to younger and older women (who are not screened with mammo)
- Encourage “breast self awareness”
2
Q
breast disorders
A
- Fibrocystic breast changes
- Hormonal changes
- Lumpiness, cysts, pain, nipple secretions
- Tx: support, minimize caffeine & salt, daily exercise, low fat diet, Vit E 100 IUs daily or Vit B6 100 mg daily, Evening primrose oil capsules 1000-3000 mg qd or other omega-3s, NSAIDs, moist heat
- Accessory breast tissue
- Fibrocystic changes is not a disease. Just a description of breast changes that can cause pain, lumps, swelling , cysts.
- If a symptomatic simple breast cyst recurs several times after aspiration, another mammogram and ultrasound should be performed to evaluate the area again. Excision is reserved for suspicious lesions or for patients who no longer desire repeat aspirations.
- Complicated cysts are rarely malignant, but should be aspirated to confirm diagnosis or followed with imaging and examination every six months for two years to document stability. Image-guided FNA or biopsy is indicated if the lesion increases in size or changes in characteristics on repeat imaging.
- Complex cysts should be biopsied, particularly those with thickened cyst walls and/or septa, and solid components.
- Surgical intervention is indicated for complex cysts that are not amenable to core needle biopsy and when pathology results from a core biopsy are discordant, atypical, indeterminate, or reveal a malignancy.
3
Q
benign breast lumps
A
- A fibroadenoma is a firm, noncancerous tumor of a gland, often found in the breast during a breast self-exam. It is round, painless, feels firm and rubbery, and can be easily moved around.
- Fibroadenomas may occur as one lump or multiple lumps in the breast. They are most common in women in their late teens and early 20s. Fibroadenomas can be stimulated by estrogen and progesterone. Breast imaging can suggest a fibroadenoma however diagnosis must be done by biopsy since they can resemble cancer. Once diagnosed, removal is not necessary. Sometimes they stop growing or shrink on their own without treatment.
- Breast cyst:
- A smooth, easily movable round or oval breast lump with distinct edges. Usually found in one breast, but can affect both breasts at the same time
- Breast pain or tenderness in the area of the breast lump
- Increase in breast lump size and breast tenderness just before your period
- Decrease in breast lump size and resolution of other signs and symptoms after your period
- Having one or many simple breast cysts doesn’t increase your risk of breast cancer. But having cysts may interfere with your ability to detect new breast lumps or other abnormal changes. Diagnosis can by done by mammogram or ultrasound, aspiration can be done for diagnosis and treatment. Recurrence is common
- Vit E, B6 can relieve pain associated with cysts. Caffeine reduction can reduce prevalence.
4
Q
biopsies
A
- Fine needle aspiration: cellular sample
- Core biopsy: tissue sample
- Excisional biopsy: larger sample
5
Q
nipple discharge - benign
A
- Very common
- Physiologic (benign) vs pathologic
- Benign nipple discharge is usually bilateral, multi-ductal, and occurs with breast manipulation.
- Risk of cancer is higher when the discharge is spontaneous, bloody or guaiac positive, unilateral/uni-ductal associated with a breast mass, or occurs in a woman over 40 years of age
- One of the most commonly encountered breast complaints- mostly benign in origin
- Up to 50-80% of women in their reproductive years can express one or more drops of fluid
- Benign nipple discharge is usually bilateral, multi-ductal, and occurs with breast manipulation.
- Risk of cancer is higher when the discharge is spontaneous, bloody or guaiac positive, unilateral/uni-ductal associated with a breast mass, or occurs in a woman over 40 years of age.
6
Q
physical exam of nipple discharge
A
- Physiologic (benign) vs pathologic
- Intraductal carcinoma
- Papilloma
- FBC/duct ectasia
- Prolactinoma
- Pregnancy
- Hypothyroid
- Medications
-
Complete medical history:
- Medication
- Lactation status
- Appearance of the discharge
- Spontaneous or provoked by manipulation of the breast
- Unilateral or bilateral
- bilateral nipple discharge is usually due to an endocrinologic or physiologic process, although bilateral synchronous cancers can occur.
-
Recent trauma
- Mammographic imaging with compression as well as vigorous manipulation of the nipple by the patient or her partner.
-
Recent onset of amenorrhea or other symptoms of hypo-gonadism
- Hot flashes, vaginal dryness, etc.
- consider hyper-prolactinemia
-
Exam
- Try to elicit discharge from a nipple and identify the involved duct or ducts
- Pressure in a clockwise fashion around the areola can identify a specific site or duct
- If unclear if blood in discharge, can use sterile white gauze or can send discharge down to path on a dry slide.
7
Q
clear/colored/milky nipple discharge labs and imaging
A
- Labs
- Multiductal discharge and/or symptoms (such as menstrual irregularity, infertility, headaches, visual disturbances, or symptoms of hypothyroidism)
- HCG quant, prolactin, Creatinine/BUN, TSH
- *appropriate endocrinological follow-up if there are abnormal findings
- Uniductual discharge:
- no testing indicated
-
Imaging
- Age appropriate screening if no palpable lesion.
8
Q
causes of clear/colored/milky nipple discharge
A
-
Causes:
- Abscess
- Breast cancer
- Breast infection
- Excessive breast stimulation
- Fibroadenoma
- Fibrocystic breasts
- Ductal carcinoma in situ (DCIS)
- Galactorrhea
- Hormone imbalance
- Injury or trauma to the breast
- Intraductal papilloma
- Mammary duct ectasia
- Medication use
- Paget’s disease of the breast
- Pregnancy
- Prolactinoma
9
Q
causes of galactorrhea
A
- Medications, such as certain sedatives, antidepressants, antipsychotics and high blood pressure drugs
- Cocaine or opioid use
- Herbal supplements, such as fennel, anise or fenugreek seed
- Birth control pills
- Noncancerous pituitary tumor (prolactinoma) or other disorder of the pituitary gland
- Underactive thyroid (hypothyroidism)
- Chronic kidney disease
- Excessive breast stimulation, which may be associated with sexual activity, frequent breast self-exams with nipple manipulation, a skin rash on the chest or prolonged clothing friction
- Idiopathic galactorrhea, may just mean that your breast tissue is particularly sensitive to the milk-producing hormone prolactin in your blood. Increased sensitivity to prolactin, even with normal prolactin levels can lead to galactorrhea.
- Galactorrhea in men
- In males, galactorrhea may be associated with testosterone deficiency (male hypogonadism) and usually occurs with breast enlargement or tenderness (gynecomastia). Erectile dysfunction and a lack of sexual desire also are associated with testosterone deficiency.
- Galactorrhea in newborns
- Galactorrhea sometimes occurs in newborns. High maternal estrogen levels cross the placenta into the baby’s blood. This can cause enlargement of the baby’s breast tissue, which may be associated with a milky nipple discharge.
10
Q
treatment of clear/colored/milky nipple discharge
A
if persists, can consider central duct excision
11
Q
bloody nipple discharge labs and imaging
A
-
Bloody Nipple Discharge
- Grossly bloody nipple discharge simply means that a lesion in the duct is bleeding.
- Differential diagnosis
- Intraductal carcinoma (in-situ or invasive)
- Bleeding papilloma
- Benign fibrocystic changes with an active intraductal component
- eg, plasma cell mastitis, ductal ectasia, intraductal hyperplasia, or papillomatosis
- Pregnancy and lactation (up to 20% of the time)
- hypervascularity of developing breast tissue, benign, requires no treatment
- for bilateral, multiductal persistant secretions, think about endocrine causes
- check serum preg, Prolactin, TSH, Creatinine
-
Imaging
- >35yo diagnostic mammogram including peri-areolar U/S
12
Q
treatment of bloody nipple discharge
A
-
Treatment
- If imaging negative and
- <60yo→ close follow up with exam and imaging vs ctrl duct excision
- >60yo→ central duct excision
- If imaging positive, appropriate management with biopsy/surgical referral.
13
Q
nipple discharge
A
- Labs: Serum prolactin, pregnancy test, TSH, BMP (renal function)
- Imaging: retroareolar ultrasound and mammography
- Ductography, breast MRI, magnetic resonance ductography, and ductoscopy can be helpful in selected women but are not routinely necessary
- Surgical evaluation of pathologic nipple discharge with central duct excision is required for diagnosis and treatment even if the imaging results are negative
- You make a small cut around the nipple and send a biopsy off to pathology
- Treat underlying cause, discontinue offending medication
14
Q
breast pain (mastalgia)
A
- Obtain a good history!
- Cyclical, localized area, trauma/injury, diet/weight changes
- Workup-imaging not typically needed
- Treatment/Counseling: reassurance!
Support garments, NSAIDs/Tylenol, Low fat diet, less caffeine, OCPs - It may come and go with monthly periods (cyclic) or may not follow any pattern (noncyclic).
- Cyclic pain is the most common type of breast pain. It may be caused by the normal monthly changes in hormones. This pain usually occurs in both breasts. It is generally described as a heaviness or soreness that radiates to the armpit and arm. The pain is usually most severe before a menstrual period and is often relieved when a period ends. Cyclic breast pain occurs more often in younger women. Most cyclic pain goes away without treatment and usually disappears at menopause.
- Noncyclic pain is most common in women 30 to 50 years of age. It may occur in only one breast. It is often described as a sharp, burning pain that occurs in one area of a breast. Occasionally, noncyclic pain may be caused by a fibroadenoma or a cyst. If the cause of noncyclic pain can be found, treating the cause may relieve the pain.
- Breast pain can get worse with changes in your hormone levels or changes in the medicines you are taking. Stress can also affect breast pain. You are more likely to have breast pain before menopause than after menopause
15
Q
mastitis
A
- Breast infection, often as a result from breastfeeding/clogged ducts. Spontaneous cases too, especially in smokers; can be chronic
- Systemic symptoms feels like the flu
- Red, hot swollen breast +/- abscess
- No imaging necessary if clinically suspect
- infection and complete resolution
- tx: antibiotics (Keflex, Duricef, dicloxacillin (breastfeeding), Bactrim, Clindamycin), breast feeding technique, hot compresses, I&D/aspiration for abscesses, rarely surgery
- imaging +/- biopsy if no improvement
- For women that are breast feeding, you want to avoid I and Ds because they can get milk fistulas
