Breast Disorders Flashcards
1
Q
Diagnostic testing for breast
A
Mammography (MMG)
US
MRI
FNA vs. Core-needle biopsy
Others: Stereotactic core needle biopsy Vacuum-assisted core biopsy MRI guided biopsy Surgical biopsy Incisional biopsy vs. excisional biopsy
2
Q
Screening MMG views
A
two craniocaudal (CC) two mediolateral oblique (MLO)
3
Q
Diagnostic MMG views
A
CC
MLO
+ more views (spot compression, cleavage view)
4
Q
MMG w/ implants
A
notify mammographer
implant pushed back to allow for visualization of breast tissue
5
Q
Breast density
A
fat vs. breast tissue (more dense)
6
Q
US use
A
inconclusive MMG results breasts of young women dense breast tissue better differentiation between a solid and cystic mass guiding tissue core-needle biopsies
7
Q
MRI use
A
Detecting breast cancer in high-risk women
Staging disease in women with breast cancer
Not recommended to evaluate breast mass
8
Q
Dye used in MRI of breast
A
IV gadolinium (check BUN/Cr)
9
Q
Test for mass w/ low pretest probability of CA
A
FNA
10
Q
FNA
A
determines if palpable lump is a simple cyst
11
Q
Core-needle bx
A
obtain samples from larger, solid breast masses
12
Q
BI-RAD scores
A
want to see 1-2
0 - need more imaging
13
Q
Determines solid vs. cystic mass
A
US
14
Q
Breast diseases
A
MASTALGIA MASTITIS/BREAST ABSCESS BREAST CYST FIBROADENOMA
15
Q
Mastalgia sx
A
“breast pain”
Cyclic pain: luteal phase, bilateral, diffuse (fibrocystic changes)
Noncyclic pain: unilateral/focal, may be due to meds (hormonal contraceptives, HRT, SSRI’s, spironolactone); large, pendulous breast may cause ligamentous pain
16
Q
Drugs leading to noncyclic mastalgia
A
Hormonal contraceptives
HRT
SSRI
SPironolactone
17
Q
Most common in lactating women
A
mastitis
18
Q
Presentation of mastitis
A
hard, red, tender, swollen area of one breast + fever
19
Q
Most common cause of mastitis
A
Staph aureus
20
Q
Ddx of mastitits
A
galactocele
abscess
INFLAMMATORY BREAST CANCER
21
Q
Tx for mastitis
A
Dicloxicillin or
Cephalexin
Pt edu: continue breastfeeding!
22
Q
Tx of breast abscess
A
I&D
23
Q
No mass palpated, focal pain, <30
A
US
24
Q
no mass palpated, focal pain, >30 YO
A
US and MMG!
25
Benign breast mass character
```
Discrete margins
No skin changes
Smooth
Soft to firm
Mobile
```
26
Malignant breast mass character
```
Poorly defined margins
May have skin changes
Hard
Immobile
Fixed
```
27
Peak incidence of breast cyst
35-50 YO; influenced by hormonal fluctuation
28
Features of breast cyst
Smooth, mobile mass, +/- tender
May be firm due to being tense with fluid
Often well defined on palpation
- Cluster of cysts may palpate as an ill-defined mass
May not be palpable
29
Tx for breast cyst
simple cyst: no intervention (FNA if symptomatic, if recurs: repeat imagin)
Complicated cyst (<1% . malignancy): FNA or f/u imaging q 6 mo x 2 yrs
Complex cyst (1-23% risk of malignancy): bx, possible surgical excision
30
Fibroadenoma: what is it?
benign, SOLID tumors containing glandular and fibrous tissu
31
Peak age for fibroadenoma
15-35 YO
32
Features of fibroadenoma
well defined, mobile mass
firm and nontender
can increase in size during pregnancy and w/ estrogen use
33
Tx of fibroadenoma
Core needle bx (confirm dx)
OR if benign features on US, 3-6 mo repeat CBE and US
+/- surgical excision or cryoablation
If increases in size: excision mandated to r/o malignant change (rapid growth, consider phyllodes tumor)
34
Rapid growth of fibroadenoma
Phyllodes tumor (grows VERY fast)
35
Signs of pathological d/c
spontaneous, unilateral, single duct
| Blood, serous, clear or associated w/ mass
36
Possible causes of patho d/c
intraductal papilloma!!!
duct ectasia (usually + pain)
carcinoma
infection
37
Physiologic d'c
bilateral, multiple ducts, w/ stimulation
38
Possible causes of physiological d/c
meds
neurogenic stimulation
galactorrhea (prolactinoma)
39
Most common cause of patho d/c
intraductal papilloma (55%): benign but can harbor carcinoma
40
Duct ectasia: what is it?
enlargement of duct
41
Breast CA in #1 cause of CA death in
Hispanics (2nd most in everyone else)
42
% of women w/ breast CA over lifetime
1 in 8 (12%)
43
Strongest risk factors for breast CA
Female gender
| Age (65+)
44
Genetics behind breast CA
BRCA 1 and BRCA2 (tumor suppressor genes -- mutations in these genes linked to breast and ovarian CA)
45
BRCA (+)
increased surveillance
chemoprevention (tamoxifen in females >35 YO)
surgical prevention
Negative BRCA does not r/o breast CA
46
Gene w/ larger risk of breast and ovarian cancer
BRCA1
47
Greater risk of male breast cancer
BRCA2 (7-8%)
48
Screening for breast CA
"breast awareness" (formerly SBEs -- alot of false +)
Clinical breast exams (CBE)
- best time = follicular phase of menstrual cycle
Screening MMG
49
Recommendations for MMG
consider 40-49 YO
Screen everyone 50+ YO
Stop screening @ 75YO
Frequency: q 1-2 Years
50
Presentation of breast CA
Nonpalpable suspicious lesion on mammogram
Palpable mass (most common)
Skin Changes (dimpling, nipple retraction or inversion, erythema, edema, peau d ’orange)
Nipple Discharge
Metastatic spread (i.e. to lungs, bone, brain, liver and lymph nodes
51
Most common sx of breast CA
palpable mass
52
Noninvasive (in situ) carcinoma
Lesions with malignant cells that have not penetrated the basement membrane of the mammary ducts or lobules
53
Types of noninvasive in situ
Locular (LCIS)
| Ductal (DCIS)
54
DCIS
Treated as a malignancy because DCIS has potential to develop into invasive cancer
55
PE of DCIS
MMG: clustered pleomorphic calcifications
PE: WNL (occasional palpable mass, most non-palpable)
Multifocal or multi-centric
56
does NOT become invasive CA
LCIS (incidental finding)
57
increased risk of invasive carcinoma in opposite breast
LCIS
58
DCIS tx
Breast-conserving surgery (BCT) with radiation vs. mastectomy
+/- sentinel lymph node biopsy
Adjuvant (hormone) therapy if estrogen (ER) and progesterone (PR) positive
- Tamoxifen, Arimidex
59
LCIS Tx
```
Not a true cancer; no tx rec’d in most women
Lifelong close surveillance
Chemoprevention
- Tamoxifen, Arimidex
Bilateral prophylactic mastectomy
```
60
Most common invasive breast carcinoma
infiltrating DUCTAL carcinoma (80%)
61
Presentation of ductal carcinoma
palpable mass
| MMG abnormality
62
More likely bilateral invasive breast carcinoma
infiltrating lobular carcinoma
63
Hormone positive invasive CA
lobular
64
Features of Paget Disease of the Breast (PDB)
Scaly, raw, vesicular or ulcerated lesion that begins on the nipple and spreads to the areola
- +/- bloody discharge
- Usually unilateral
- Pain, burning, &/or pruritis may present before clinically apparent disease
65
Inflammatory Breast Cancer (IBC) sx
VERY AGGRESSIVE
Pain, tender, firm, enlarged
skin is warm, thick, peau d'orange, erythema
almost all w/ lymph node invovement; 1/3 distant metastasis
66
Spread of Breast CA
lymphatic spread: axillary, supraclavicular, internal mammary nodes
Hematogenous: lung, liver first; bone, ovaries, brain
67
Most common lymph spread of breast CA
axillary lymph nodes
68
Tx of breast CA
surgery (breast conserving surgery (BCS): lumpectomy); or mastectomy)
Radiation
Chemo
Endocrine therapy
69
Surgical management of breast CA
```
Based on multiple components:
Tumor size
Lymph node involvement
Metastases
Estrogen (ER+/-) and progesterone (PR+/-) status HER2 status
Oncotype recurrence score
Oncotype dx test is used in ER + and LN - patients
BRCA status
```
70
Lumpectomy
Part of the breast containing the cancer is removed
With or without selective sampling of axillary nodes (axillary sentinel lymph node biopsy)
Multiple clinical trials have shown that BCS with post- operative radiation therapy is the appropriate treatment for Stage I or II breast carcinoma
Decreased morbidity
Comparable survival & recurrence rates to more invasive procedures
71
Masectomy types
simple (total): entire breast including nipple/areola
Modified radical: above + axillary lymph nodes
Radical: breast, lymph nodes, pectoralix mm. (rarely performed)
72
Radiation types
```
external beam (5-7 weeks)
brachytherapy = seeds or wires placed in or near the tumor for shorter time frame
```
73
Palliative for metastatic disease
Radiation
74
When is chemo used?
primary and metastatic breast CA and in almost all patient w/ (+) lymph nodes!
75
When to give chemo?
before or after surgery:
Neoadjuvant: before surgery to shrink size of tumor; may allow for conservation surgery
Adjuvant: after surgery, kills CA cells left behind
76
HT for breast CA
SERM: Tamoxifen x 5 years
Aromotase inhibitors: arimidex
Supplement to chemo + radiation
77
HER2/neu
human epidermal growth factor receptor 2
- growth promoting protein
- 1 in 5 w/ breast cancer
- CA cells have increased HER2/neu
- Herceptin targets HER2/neu
- effective in early stage CA, metastatic disease
- herceptin + chemo
78
used in early stage, metastatic disease
Herceptin (HER2)
79
Who should get breast cancer prevention
asymptomatic 35+ w/ prior dx of breast CA who are at increased risk for disease
80
Who should get breast cancer prevention
asymptomatic 35+ w/ prior dx of breast CA who are at increased risk for disease
81
Prevention meds
Tamoxifen
| Arimidex, Raloxifene
