breast disorders/breast cancer Flashcards
usual age of breast development?
10-12 years
lobule development in the breasts evident when ?
1-2 years after menses
tanner stages 1-5
- no glandular tissue, flat areola
- breast bud, wider areola
- breast fills, widens beyond areola
- increased size, areola& papilla form second mound (elevated)
- final adult size, areola flattens again against breast, projecting central papilla
what is “witch’s milk”?
Neonatal production of milk
First 2 hours to 2 days of life
Due to influence of maternal hormones
self breast exams useful? what does ACOG recommend?
low sensitivity and detectability BUT Despite this, breast self exam has potential to detect palpable breast cancer
ACOG encourages “breast self-awareness” for women ages 20 and older.
if youre going to do it, when should self breast exam be performed? why?
5-9 days after menses, when estrogen is lowest (follicular phase) . B/c in luteal phase, ducts are engorged and it may be harder to feel a lump
ACOG recommends clinical breast exams when?
every 3 years age 20-39, every year age 40+
clinical breast exam: If mass palpated, what should you tell the pt to do? why?
pt should put hands on her hips to help determine fixation
inspect breasts in ___ and ___ position
upright and supine
Breast CA most often found in what quadrant?
upper outer quadrant
mastitis: what is it? cause?
Usually breast-feeding
Sudden onset of pain and symptoms of inflammation and infection (induration, tenderness, warmth)
txt for mastitis
Antibiotics, warm compresses and
KEEP BREASTFEEDING!
Abx: depends on if its MRSA or not..
Abx for Postpartum mastitis and NO MRSA or abscess
Dicloxacillin 500 mg QID or Cephalexin 500 mg QID
Abx for postpartum mastitis and POSITIVE MRSA
Bactrim DS 1-2 tabs PO BID or Clindamycin 300 mg TID
what is mastalgia/mastodynia (breast pain): likely cause?
Usually not cancer
- Common- fibrocystic changes
- Hormonal changes: if cyclic pain
- just large, pendulous breasts not appropriately supported
txt for breast pain (mastalgia/mastodynia)
supportive bras (avoid underwire), decrease caffeine, can try evening primrose oil or Vit E
what is galactorrhea? what can cause this? (5)
milk production when not breast feeding
idiopathic, chronic breast stimulation, steroids, metabolic/hormonal, pituitary tumor
galactorrhea evaluation (3)
- Analyze the milky discharge checking for fat droplets
- B-HCG, prolactin levels, and TSH
- Mammogram, US, MRI as indicated
to evaluate for a pituitary tumor (20% of cases)
those with galactorrhea from a pituitary tumor may have amenorrhea why?
highest serum prolactin levels
what is abnormal nipple discharge normally from?
- Usually solitary papilloma; can be DCIS (ductal caricinoma in situ)
- fibrocystic changes
- papillomatosis (benign growths)
- breast cancer or duct ectasia
bilateral discharge, is it worrisome?
NO, as long as theres no blood
lots of bloody discharge from nipple, what do you need to do?
sent for cytology
what is the likely cause of each?
- Straw-colored, clear
- Grossly bloody
- Staining of the bra, without discharge
- Straw-colored, clear- usually papilloma
- Grossly bloody- lesion in the duct- DCIS, fibrocystic change or papilloma
- Staining of the bra, without discharge- Paget’s disease
intraductal papilloma: who most commonly gets these? symptoms?palpable? what do you need to do to rule out cancer?
- growth in the duct
- Most common around perimenopause
- Rarely palpable, but can cause bloody, serous or turbid d/c
- Excision of the duct should be done to help differentiate from cancer
what is mammary duct ectasia ?
AKA comedomastitis or plasma cell mastitis
- Blockage of a duct with chronic inflammation. (gets clogged with thick, cheesy, material and dilated)
- may be palpable and have nipple retraction
dx of mammary duct ectasia ?
need excision to rule out cancer
who usually gets mammary duct ectasia?
peri-menopausal women (45-50)
what is polythelia?
accessory nipple or supernumerary nipple condition
Can vary from just a hairy patch to full-blown breast development with glandular tissue
are fibrocystic changes normal?
mostly yes! 60% of premenopausal women have them . can be cysts or just increased stromal tissue
when do fibrocystic changes become worrisome?
Can be a “disease” when it occurs with severe pain, nipple discharge or degree of “lumpiness” to cause suspicion of cancer
most common finding in fibrocystic changes and what causes this?
hyperplasia - decrease in progesterone or increase in estrogen (worse premenstrually when progesterone drops)
txt for fibrocystic changes (3)
- Breast pain alleviated by thiazide diuretic or aspiration of a cyst
- Diet and lifestyle- low fat, no caffeine or nicotine
- Vit E and Evening primrose oil
fibrocystic changes txt: if behavior, lifestyle and dietary changes dont help… 3 medical options
- tamoxifen (anti-estrogen)
- danazol (androgenic steroid)
- GnRH agonist
what is the most common benign tumor of the breast?
fibroadenoma
what is a fibroadenoma like?
sharply circumscribed, freely mobile, “rubbery”
where in the world is breast cancer highest and lowest?
Highest rates in N. America and northern Europe, lowest in Asia and Africa
what women have higher mortality despite having lower incidence? why?
African American, more advanced stage at diagnosis and higher stage-specific mortality
MOST breast cancer still occurs in women with ….
NO KNOWN RISK FACTORS
what 3 things could increase risk for a man having breast cancer ? (likely weeds)
genetic: kleinfelters syndrome (XXY)
testes: injury/disease/undescended
liver: cirrhosis and alcohol use
general risk modifications for breast cancer (7)
Decrease postmenopausal hormones Have kids early in life Breastfeed at least 6 months Lose adult weight and then maintain Limit alcohol consumption Get regular physical activity Get early detection
4 types of breast cancer
Ductal (DCIS) – 80-85% (most are non-specific infiltrating)
Lobular - 10% (LCIS)
Paget’s
Inflammatory
BRCA 1 or 2 most likely asscociated with breast cancer?
BRCA1
3 primary mammographic signs of breast cancer
- mass (a spiculated / star shaped one)
- calcifications (1mm or less, sandlike)
- developing density
secondary mammographic signs of breast cancer (6)
Architectural distortion Skin thickening or retraction Nipple and areolar thickening Abnormal ductal patterns Lymphadenopathy Asymmetry of the breast tissue
inflammatory breast cancer, what kind of cancer is it ? what are the signs?
Form of ductal cancer
Peau d’orange from blockage of lymphatics
paget’s disease (breast cancer): how does it present?
Scaly, eczematous lesion of areola and nipple
- Underlying breast mass or abnormal mammogram
- Mammary adenocarcinoma (usually ductal)
what causes nipple retraction?
tumor extension to the skin or ductal involvement
breast cancer: if lymph nodes are negative for cancer, what is the survival rate?
high! 85%
what pts do you do an oncotype Dx assay on?
for estrogen receptor positive, lymph node negative pts
what is an oncotype Dx assay?
assay that quantifies the risk of disease recurrence and assesses the likely benefit from certain types of chemo
based on histology; analyzes a panel of 21 genes to determine a recurrence score
what can sentinel node mapping cause? (adverse effect)
Axillary lymph node dissection can cause arm edema and damage to nerves, vessels
what is a sentinel node biopsy?
inject tumor with blue dye, see what lymph it travels to (to see where else the tumor is spreading). remove lymphs
what breast cancer pts get a mastectomy for treatment?
Mastectomy for those with 2 or more tumors, large masses, previous radiation, connective tissue dz or inavailability of radiation
when would breast cancer pts get radiation therapy?
initial therapy for small tumors with intent to remove via lumpectomy, followed by more radiation
after removal of large tumors with unsure surgical margins
success of chemo treatment depends on what factors? what age patients do better with it?
depends on tumor characteristics, lymph node status, age and health of patient younger women (<65 yo) do better
adjuvant systemic therapy for cancer treatment is best for what patients?
most benefit for those with positive lymph nodes
what is included in adjuvant system therapy for cancer? (4)
- SERMs
- Aromatase inhibitors
- immunotherapy
- targeted therapy for gene-specific breast cancers (HER2, BRCA, hormone-receptor)
if there is a hormone-receptor positive tumor, what do you do to txt it?
remove the hormones! SERMs and aromatase inhibitors are good for this
what do SERMs do? what is the main drug?
Binds competitively to estrogen receptor to inhibit estrogen’s effects
(tamoxifen)
tamoxifen is good to txt ____ cancer but can cause ____ cancer
good for breast
bad for uterine (endomedtrium)
what do aromatase inhibitors do and what is our main drug?
lowers estrogen levels (prevents conversion of androgens to estrogens)
- letrozole
recurrence rate for cancer for lumpectomy vs mastectomy?
lower for mastectomy
which cancer has high correlation with HER2 ? (weeds)
pagets
what is carcinoma in-situ and what are the two types?
confinement of the cells to the ducts or lobules
LCIS: lobular carcinoma in situ
DCIS: ductal carcinoma in situ
Two genes, ____ and ____, are tumor suppressor genes whose LACK has been previously associated with breast cancer progression
(maybe weeds)
RB and PTEN
When both genes (RB and PTEN) were inactive, patients were_____ times more likely to have their ____ tumor progress to full blown invasive breast cancer.
five times
DCIS
