Breast Disorders Flashcards
where do supernumerary nipples commonly found?
along the milk line
How do you approach a male patient wih gynecomastic?
breast and axillary exam, check the testicles as well
If a patient between the ages 13-early adulthood has gynecomastia, what treatment should they receive?
observation
what can cause gynecomastia in males over 50?
drop in testosterone
What are some meds that can cause gynecomastia?
digoxin, thiazides, estrogens, theophylline, atypical antipsychotics
Medical conditions that can cause gynecomastia
hepatic cirrhosis, renal failure, malnutrition
inflammation at the stie of two closely opposed skin surfaces often due to moisture and maceration
intertrigo
treatments for intertrigo
hairdryer to the area, antifungal, corticosteroid (if needed)
Most frequent, benign condition of the breast
fibrocystic breast disorder
when may a fibrocystic breast mass be the most painful? Why?
during premenstrual phase, due to estrogen
this type of mass is most commonly seen in 30-50 year olds and may fluctuate in size → often multiple and bilateral
fibrocystic breast disorder
45 year old patient presents with tender mass that is only painful right before starting her menstrual cycle, she says sometimes she will have multiple masses but they fluctuate in size and may even disappear, she notes occasional serous discharge with the masses
fibrocystic breast disorder
Treatment for Fibrocystic Breast Disorder
avoid trauma, wear supportive bra, use needle for aspiration to alleviate pain, stop HRT in postmenopausal, primrose oil for pain, decrease intake of dietary fat/caffeine/chocolate
This drug may be used in patients with severe fibrocystic breast disorder but only rarely due to virilizing SE
Danazol
condition where a female develops characteristics associated with male hormones (Androgens)
virilization
most common benign neoplasm of the breast
fibroadenoma of the breast
Patient population most commonly seen with fibroadenomas
young women withing 20 years of puberty, may be younger age in black women
Patient in mid 20s presents with round, mobile, rubbery, non-tender breast lesion measuring less than 5 cm
fibroadenoma
How can you differentiate fibroadenoma from a cyst?
US and aspiration
Treatment for fibroadenoma
none necessary → reassurance
if you have fibroadenoma larger than 3-4 cm it should be excised to rule out
Phyllodes tumor
fibroadenoma like tumor with cellular stroma that grows rapidly → can be benign or malignant
Phyllodes tumor
Treatment for malignant Phyllodes tumor
large excition with clear borders
do you need to perform lymph node resection with a a malignant phyllodes tumor
no → lesion metastasizes to the lungs and not the lymph nodes
milk retention cyst caused by an obstructed milk duct
galactocele
New mother who just stopped breast feeding presents with soft, cystic, mobile mass
galactocele
what is the best method to diagnose galactocele?
clinical history and aspiration
Treatment for galactocele
let it be → won’t need excision
How likely is a galactocele to become cancer?
no risk
organism that most likely causes mastitis
Staphylococcus aureus
risk factors for breast abscess/mastitis
breast conservation treatment, prior breast infection, breast surgery within 30 days, lactation, trauma (bite, piercing, tattoo), lesions (eczema, intertrigo), implants, smoking, poor hygeince, diabetes, autoimmune disorder
If you see infection in non-lactating breast or an abscess does not respond to antibiotic and drainage you must always consider
inflammatory carcinoma
In high risk patient, what would you order after they recover from mastitis?
mammogram
Treatment for mastitis
NSAID, cool compress, Dicloxacillin or Cephalexin PO, Clindamycin
If you are concerned your patient with mastitis has MRSA what would you prescribe them?
PO clindamycin, timethoprim-sulfamethazole or linezolid
IV vancoymcin
what is Paget Disease?
cutaneous sign of underlying breast malignancy
60 year old patient presents with weeping, red, crusty skin condition of the breast, especially the nipple → states she has severe nipple itchiness
Paget Disease
How do you diagnose Paget Disease?
needle biopsy
Paget Disease occurs in ____ patients with breast cancer and ____ of patients with Paget Disease have cancer
1-4%
50%
Common misdiagnosis of Paget Disease
dermatitis or bacterial infection
what is considered normal nipple discharge?
clear, milky, green-tinged
Patient presents with bloody nipple discharge, what do you do?
think cancer → mammogram or surgical evaluation
If patient presents complaining of nipple discharge that stains the inside of her bra, what is your first thought?
galactorrhea → evaluate thyroid and pituitary gland
If there is no mass and the nipple discharge is not bloody, what is your treatment of choice?
reexamine every 3-4 months for 1 year → mammogram or US
You have a nonpregnant patient who is not breast feeding and has milky discharge
galactorrhea
If you have a patient with bilateral galactorrhea what do you think is the most likely cause?
hormone
causes of galactorrhea
breast stimulation, trauma, stoping oral contraceptive, oophorectomy, miscarriage, abortion, some meds, increased prolactin secretion
Lab values you want to order if patient presents with galactorrhea
serum prolactin, TSH, B-HCG, FSH (if also has amenorrhea), MRI of pituitary
benign solitary lesion that grows in the epithelial linging of the breast ducts
intraductal papilloma
Most common cause of bloody nipple discharge in the absence of a mass
intraductal papilloma
Patient presents with intermittent discharge from one nipple, the discharge is sometimes serous, watery, or bloody
intraductal papilloma
where do 75% of intraductal papillomas present? How do they feel and size?
beneath aerola
small and soft
< 3 cm
Most common age range for intraductal papilloma
30-50 yo
Treatment for intraductal papilloma
excisional biopsy of the duct and small amount of surrounding tissue
If an intraductal papilloma is not excised how often do you need to check the lesion? Why?
every 3-4 months
twofold increase in developing subsequent cancer
this is seens most commonly in premenopausal women and believed to be caused by local response to stagnant secretions and calcifications may be common
mammary duct ectasia
Patient presents with nipple discharge (multicolored, sticky), non-cyclic breast pain, nipple retraction, or subaereolar mass
mammary duct ectasia
Diagnostic test of choice in patient with mammary duct ectasia
mammogram and US
Treatment for mammary duct ectasia
spontaneously resolves, excision if persistent/recurrent
what percentage of new breast cancers are not seen on mammogram?
10-15%
which diagnostic testing method is most reliable for detecting breat cancer before a mass can be palpated?
mammogram
What type of mammogram will you order for a young woman with dense breast tissue?
digital
indications for mammogram
screening at risk women at regular intervals, eveluate each breast after curable breast cancer diagnosis is made, eveluate suspicious breast mass, search occult breast cancer in women with metastic disease in the axillary nodes, screening before cosmetic procedures, monitor breast cancer treatment, guide for diagnostic procedures
Ordered for asymptomatic women in the hope of detecting a cancer not clinically apparent
screening mammogram
what is the American Cancer Societ recommendation for breast cancer screening?
annually from 45 - 55 → every other year after 55
what is ACOG recommendations for screening for breast cancer?
should begin by age 50 and screen every 1-2 years → stop screening by 75
how are mammogram results reported?
BI RADS (breast imaging reporting and date system)
two most important mammogram findings suspicious for breast malignancy
masses and microcalcifications
What is the recommended test for determining if a breast mass is solid or cystic?
US and aspiration
Is US a good screening method for breast cancer?
no → primary diagnostic tool
Patient felt a lesion herself on self breast exam, what test do you want to order first?
US
This breat exam has high sensitivity but low specificity → leading to more unnecessary biopsies
MRI
This test is recommened in women at high risk for breast cancer, axillary lymph nodes with no mammogram findings, or a patient with Paget Disease with no mammogram findings?
MRI
what percent of suspected cancer lesions will be benign and what percent of benign looking lesions will be malignant?
60%
30%
Diagnostic procedure of choice for a breast lesion
large needle core biopsy
If you are in outpatient setting and feel suspicious lump what test can you do without anesthesia?
fine needle biopsy
If the patient have mammogram or clinical indication of malignancy, does a negative fine needle biopsy indicate there is nothing to worry about?
no
Method of choice in testing breast lesions
core needle biopsy
Women who are considered high risk for developing breast cancer
BRCA 1 or BRCA 2 gene in self or first degree relative, lifetime risk 20-25%, radiation to chest between ages 10-30, Li-Fraumeni syndrome or Cowden syndrome or first defree relative with one of these
Rate of breast cancer in American women
1 in 8
what has lead to the decline of breast cancer in women?
discontinue HRT
most significant risk factor for breast cancer
age
what factors increase exposure to estrogen and thus increased risk of breast cancer?
first full term pregnancy after 30, early menarche, late menopause, combined HRT after meopause
Risk assessment model that evaluates womans risk of developing breast cancer and recommendations
Gail 2
protective factors for breast cancer
breast feeding, physical activity, early surgical or chemical menopause, early pregnancy, don’t drink, healthy diet
two main breast cancer genes
BRCA 1 and BRCA 2
Women with BRCA1 or 2 gene have ___ percent of getting breast cancer
40-85% → 3-7x greater risk than normal women
Women with BRCA1 or 2 gene have ____ percent lifetime risk of ovarian cancer
16-60%
Men with the BRCA2 gene are at increased risk for what two types of cancer
breast and prostate
classic presentation of breast cancer
hard, immovable, single dominant lesion with irregular borders → often painless
Symptoms a patient will complain about with breast cancer
breast pain, nipple discharge, erosion, retraction, enlarged/itching nipple, redness, hardness, enlargement/shrinking of brest, axillary mass,
Late symptoms of breast cancer
back pain, weight loss, bone pain, jaundice
Most common site of breat cancer
outer wing
80% of all breast cancers are
nonspecific infiltrating duct carcinoma
What do you use to describe a breast mass?
size, shape, location, consistency, fixed or not
Describe a classical malignant breast mass
single, firm, nontender, immobile, irregular borders
Describe suspicious lymph nodes
> 1 cm, fixed, irregular, firm, mobile
What is Breast Conseving Therapy?
lumpectomy + radiation
What type of biopsy is done to evaluate axillary lymph nodes?
sentinel lymph node biopsy
what are complications of full axillary node dissection?
full arm edema, seroma formation, loss of sensation, shoulder dysfunction
Categories for staging breast cancer
TNM → Tumor, Lymph Node Status, Metastases
what would indicate poor prognosis for breast cancer?
larger tumor size, more lymph node involvement, metastases
If a high risk patient undergoes radical mastectomy or undergoes conservative breast therapy they should also receive?
radiation
What are some complications of radiation?
arm edema, arm weakenss, radiation pericarditis, soft tissue necrosis
three ways a breast cancer tumor can spread
local infiltration, lymphatic, hematogenous
If a tumor infiltrates locally, where will it most likely go?
breast parenchyma → deep pectoral fascia or overlying skin
where is breast cancer most ilkely to spread lymphatically?
axillary lymph nodes
axillary node involvement is directly related to ____ but not the ____ of the tumor within the breast
size of primary tumor, location
Second place for lymph node metastases
internal mammary node chain
where is breat cancer most likely to hematogenously spread to?
lungs and liver → others are bone, pleura, adrenals, ovaries, brain
Factors to consider that may affect chemotherapy choices
tumor burden, general health, prior treatment and toxicities
Side effects of chemotherapy
nausea/vomiting, infertility/premature ovarian failure
small risk → neutropenia, cardiomyopathy, peripheral neuropathy, leukemia
Standard care for patients with stage I, II, III breast cancer
surgical resection → radiation or systemic therapy
When doing breast augmentation, where is the preferered placement of the implant?
under the pectoralis muscle
capsule contraction or scarring around the breast implants occurs in what percent of patients?
15-25%
what percent of implants rupture in patients?
5-10%
If a patient is getting breast reconstruction after a mastectomy how long should they wait after the surgery to get the implants?
at least 3 month if not done at time of mastectomy
Can a prepubescent girl get breast augmentation - implants or reduction?
no
What are the 4 extra views taken by mammogram on a patient with breast implants called?
implant displacement views
scar tissue that has formed around implants is called ____ and cause you to not be able to perform implant displacement views on mammogram
contractures
Do women who get breast implants have greater risk of cancer?
no but detecting it may be harder
What is the diagnostic test of choice if you suspect your patient has a ruptured bresat implant?
MRI
Difference in saline vs silicone implant ruptures
saline implants will leaky more quickly while silicone implants will leak very slowly (years) → dangerous
