Breast Disorders - Exam 2 Flashcards
What layer of embryonic tissue do the breast come from? What binds the lobes together?
Arises from the ectoderm
stroma (fibrous tissue)
How many lobes does a normal breast contain? What is considered the breast base? What is considered the breast apex?
12-20 lobes
base is closest to the ribs
apex: contains major excretory duct for the lobe
What does each breast lobe contain? How many visible opening are usually present in the nipple?
group of lobules that have several ducts which unite to form the major duct for the lobe
Usually only 6-8 openings visible on nipple surface
Areola also contains _______ which may be visible as punctate prominences. What type are they? What is there job?
Montgomery glands
sebaceous glands
function to secrete oil to help a breastfeeding mother’s nipple stay well lubricated
What is 80-85% of normal breast tissue composed of? How does the breast consistency change comparing Nonpregnant, nonlactating breast vs pregnant vs lactating breasts
adipose tissue
Nonpregnant, nonlactating - small, tightly packed alveoli
Pregnant - alveoli hypertrophy and lining cells proliferate
Lactation - alveolar cells secrete lipids and proteins (milk)
_______ is on the deep surface of breast to support the breast in upright position
cooper’s ligaments
**Where does the majority of the breast lymphatics drain to? **Why is this important clinically? **Which ones specifically?
**axillary lymph nodes
most common site of breast cancer metastases
sentinel nodes
fetal breasts arise from the _____. What happens to the prepubertal breast?
basal layer of epidermis
rudimentary bud with few branching ducts
In the prepubertal breast, ducts are capped with ______, ______ or _______.
alveolar buds, end buds or small lobules
What happens to the breast around puberty? What age? What cell types specifically?
estrogen/progesterone affect breast tissue
Communication between epithelial and mesenchymal cells resulting in extensive branching of ductal system and lobule development
age 10-13
Overall, what factors contribute to breast growth? What happens to the nipple/areola during puberty?
increased acinar tissue, ductal size and branching, and deposits of adipose
Nipple and areola enlarge during puberty, smooth muscle fibers surround the base of the nipple and nipple sensitivity to touch increases
What is happening in premenstrual breast changes? What phase? What hormones?
breast epithelial cells proliferate during the luteal phase when estrogen and progesterone are increased
premenstrual breast changes _____ cells increase in number and size. ______ widen. What happens as a result?
acinar cells increase in number and size
ductal lumen widens
Overall increased breast size, turgor/fullness, and tenderness
What happens to breast tissue postmenstrual?
breast epithelial cells undergo programmed cell death at the end of the luteal phase when estrogen and progesterone levels decline
DECREASED size and turgor, reduced number and size of breast acini, decreased diameter of ducts
**When does final breast differentiation occur? What 2 hormones influence it?
FINAL is completed during the FIRST full-term pregnancy
progesterone and prolactin
How does the breast tissue change during late pregnancy?
fatty tissues are almost completely replaced by cellular breast parenchyma
What will estrogen and progesterone level do postpartum? What triggers the onset of milk production? What hormone regulates milk production?
Rapid drop in estrogen and progesterone postpartum
Drop in progesterone triggers onset of milk production
Prolactin is main regulator of milk production
What can cause the breast to rapidly return to pre-pregnancy state?
stopping nursing
giving estrogens
causes the breast to increase in adipose tissue aka back to pre-pregnancy breasts
How does the breast change during menopause? What elements are lost?
the decrease in estrogen and progesterone cause the breast to atrophy and involute, become less elastic, glands and ducts decrease
parenchymal elements (the functional tissue of the mammary gland, primarily consisting of the milk ducts and the glandular tissue responsible for milk production)
Is some nipple discharge normal? What will it look like?
YES! about 80% of women will experience it at some point in their reproductive years
Usually multi-duct with a milky white, dark green, brown discharge
What is green nipple discharge related to?
related to cholesterol diepoxides
**Describe the presentation of physiologic nipple discharge? What if it is bloody?
Multiduct nonbloody discharge elicited following manual pressure
If bloody and pregnant, no worries
bloody and not pregnant = problem
**What are the 5 red flags for abnormal nipple discharge?
Spontaneous
Bloody
Unilateral and/or uniductal
Pt > 40
Associated breast mass
aka 1 pinpoint bead of fluid = concerning
What is the MC cause of pathologic nipple discharge?
intraductal papillomas
What are some important questions to ask regarding abnormal nipple discharge?
Unilateral or bilateral
Single or multiple ducts
Spontaneous or must be expressed
Constant or intermittent
Elicited by pressure at a single site or general pressure
Timing in relation to menstrual cycle
Pre- or post-menopausal
History of hormone use (contraception, HRT)
There are many causes of galactorrhea, what are the 3 highlighted ones from lecture?
antipsychotics because they mess with the dopamine -> prolactin relationship
pituitary adenomas
chest wall irritation or stimulation (think nipple piercing)
What is the classic presentation of galactorrhea?
bilateral multiductal milky discharge in nonlactating patient
What tests would you want to order in a pt presenting with galactorrhea?
pregnancy test, prolactin, renal function, thyroid then ENDO consult!!
What is the classic pathologic discharge presentation? Does a mass have to be felt?
unilateral, spontaneous serous or serosanguineous discharge from single duct
do NOT have to have a mass to be cancerous
_____ discharge is more suggestive of cancer but usually due to _____
bloody discharge
benign papilloma
**What are the 2 first line tests when working up a pt for pathologic nipple discharge? Which one is preferred for which patients?
mammogram or breast US
younger than 40 = US
older than 40 = mammogram
also okay to order both!!
**What is the definitive dx for pathologic discharge?
subareolar duct excision (microductectomy)
What 5 types of medications/essential oils are high offenders for causing gynecomastia?
androgens
anabolic steroids
methadone
lavender oil
tea tree oil
How can you tell the difference between true gynecomastia and pseudogynecomastia? How is it graded?
Gynecomastia: true glandular enlargement - CENTRAL, may be tender
pseudogynecomastia: Fatty tissue - diffuse, nontender
Grade findings according to severity
Higher number = more severe
What will pubertal gynecomastia present like?
tender 2-3 cm discoid enlargement of glandular tissue beneath areola
What are s/s of gynecomastia that are highly suggestive of cancer?
Asymmetry
Enlargement not beneath areola
Unusual firmness
Nipple retraction
Bleeding or discharge
What 5 labs would you want to order in a pt presenting with gynecomastia?
- Serum prolactin
- beta-hCG
- Serum free testosterone
- LH
- Serum estradiol
When would a hCG be positive in males? When would it be mildly elevated?
+ beta-hCG usually 2o testicular tumor or other CA (i.e., lung or liver)
may see mildly elevated hCG in pts with primary hypogonadism and high LH
What does a low testosterone and high LH in the presence of gynecomastia indicate?
primary hypogonadism
What does a high testosterone and high LH in the presence of gynecomastia indicate?
androgen resistance
What does an increased serum estradiol indicate in the presence of gynecomastia?
Increased - testicular tumors, elevated hCG, liver disease, obesity, adrenal tumor, hermaphroditism, aromatase gene mutations
When does pubertal gynecomastia tend to resolve?
usually resolves spontaneously in 1-2 years
What is the tx for painful or persistent gynecomastia?
raloxifine or tamoxifen (SERM)
anastrozole (Aromatase inhibitor)
testosterone therapy for low T
sx
What is the caution for Aromatase inhibitors? What is the name of the drug?
NOT recommended in use in teenagers because of the risk of osteoporosis and delayed epiphyseal fusion
anastrozole (Arimidex)
What can anastrozole (Arimidex) do to estradiol and testosterone levels?
Causes decreased serum estradiol and increased testosterone
When is radiation therapy recommended in gynecomastia?
Prophylactic - men with prostate CA receiving antiandrogen tx
What are the 2 MC pathogens in mastitis?
Staph aureus
Group B strep
______ increases risk for mastitis. When is it commonly seen
smoking
2-3rd week after birth, UNCOMMON in non-nursing pts
What is the classic presentation of mastitis?
painful erythematous lobule in outer quadrant of breast noted during 2nd or 3rd week of puerperium
may have signs of systemic infections
What is the tx for mastitis?
Continue breastfeeding or use breast pump!!!
warm or cold compresses
supportive care: rest, fluids, NSAIDs, acetaminophen
abx: Dicloxacillin or cephalexin (500 mg QID)
alt: clinda or bactrim
T/F: Mothers with mastitis should pump and dump until infection has resolved
FALSE!!
babies can still drink the milk from the infected breast
What is the severe IV abx tx for mastitis?
Vancomycin + ceftriaxone OR
piperacillin-tazobactam
What should you do if mastitis is NOT improving after 48-72 hours
Evaluate for abscess
Consider biopsy/inflammatory breast CA
What am I? What does it usually arise from?
breast abscess
pre-existing mastitis
What is the tx for peripheral breast abscess?
I&D
abx: Dicloxacillin or cephalexin
alt: clinda or bactrim
What is the tx for subareolar breast abscess? What is the underlying cause?
usually requires subareolar duct excision and complete removal of sinus tracts because normal I&D has a 40% recurrence rate
also want to bx abscess wall to r/o breast CA
due to keratin-plugged milk ducts behind nipple
fat necrosis breast masses are usually accompanied by _____ or ______. +/- ____ and _____. Should order _____ or ____ to help with dx
skin or nipple retraction
+/- ecchymosis, tenderness
US or mammo to help with dx
if you leave a fat necrosis mass untreated, what will happen? If it does not, what should you do next?
mass gradually disappears
If no resolution after several weeks - bx
What is a galactocele? What causes it?
Milk retention cyst
Caused by obstructed duct in lactating or galactorrhea patient
Are US or mammo better at dx galactocele? What is the best way to dx?
US is better at distinguishing fluid from mass
but can order either or both
aspiration of cyst!! will yield a milky substance
Which masses do NOT increase risk of subsequent breast cance?
Fat necrosis
Galactocele
single, nonproliferative lesions in fibrocystic breast changes
fibroadenoma
______ are the MC cause of cyclic breast pain in reproductive age women. What is the age range? What is it due to? _____ increases you risk
Fibrocystic Breast Changes
age 30-50
benign changes in breast epithelium due to ESTROGEN levels
alcohol
Pain or tenderness associated with a mass
Fluctuations in size
Multiplicity of lesions
+/- Nonbloody green or brown nipple discharge
What am I?
**What is the highlighted s/s from lecture?
What makes it worse?
Fibrocystic Breast
fluctuations in size
caffeine
How do you dx fibrocystic breast changes?
US or mammo
aspiration to determine cystic vs solid
bx dominant mass
premenopausal breast tissue is (dense/fatty) and post menopausal breast is (dense/fatty)
premenopause = dense = hard to read on mammo
postmenopause = fatty = easier to read on mammo
What is the tx for fibrocystic breast changes? When can you expect s/s to resolve?
reassurance!!!
avoid trauma, good bra, weight loss, no caffeine, coffee, chocolate, low fat diets, increase in fresh fruits and veggies
CAM: evening primose oil or vit E
Symptoms usually resolve following menopause
________ or _____ have been used in severe pain cases caused by fibrocystic breast changes. ______ is severe refractory cases
danazol or tamoxifen
sx
_____ is the MC benign tumor in the breast. What age range?
Fibroadenoma
young women age 15-35
What is the classic presentation of fibroadenoma? What is the definitive dx?
round, firm, discrete, relatively mobile, nontender mass about 1-5 cm in diameter
core biopsy or mass excision
What will the US report show on a fibroadenoma?
well-defined solid mass with benign features
What is a Phyllodes tumor? What is the tx?
a fibroepithelial tumor that clinically resembles fibroadenomas and has a small chance of becoming malignant
tx with excision with wide local margins
If the fibroadenomas contains ____ or ______ should be more concerning. What should you do next?
calcifications or scarring (anything making it more complex)
excision of the mass
What is the tx for an unclear diagnosis or rapid growth of a fibroadenoma?
sx with good margins of normal tissue!
If the fibroadenoma is asymptomatic and you choose to monitor it, what are the monitor requirements?
Core needle biopsy to confirm dx OR repeat US and breast exam in 3-6 months
What is the average age of breast cancer? What is the lifetime risk of developing breast cancer in female pts?
60-61
**1 in 8
breast cancer is the main cause of death in women _____. Breast cancer is the ____ MC cause of cancer death in women
40-59
2nd death (1st is lung cancer)
_____ 2x increases risk of breast CA
______ 3x increases risk of breast CA
______ puts you at higher risk for developing breast CA
1 first degree relative (mother/sister) - 2x risk
2 first degree relatives - nearly 3x risk
Younger age of family at dx = higher risk
What percent of pts with breast CA report a positive family hx? What genes? How are they inherited?
15-20%
BRCA1 and BRCA 2 - autosomal dominant
What are the 6 breast cancer risk factors? **What is the greatest risk factor?
Nulliparity OR first full term pregnancy age 30 or later
increased number of periods (early menarche or late menopause)
combination HRT
hx of uterine CA
hx of breast mass
**personal hx of breast cancer
How are most breast cancers dx?
after abnormal mammogram
What is the usually presentation of breast cancer? What quadrant is the most common?
painless breast mass
Usually hard, fixed, irregular margins, nonmobile
Most breast cancers are in the upper outer quadrant!
What are concerning PE findings that would point towards breast cancer?
Change in breast size/contour
Nipple or skin retraction
Edema or erythema
What lymph nodes should you palpate if concerned for breast cancer? What would increase your suspicion for breast cancer?
axillary, pectoral, supraclavicular, infraclavicular, subscapular, epitrochlear and lateral chain
Firm nodes or nodes >5 mm or matted/fixed axillary lymph nodes
What 2 lymph nodes strongly indicate possibility of distant metastases?
+ supraclavicular or infraclavicular nodes
What is the characteristic finding of Paget’s carcinoma? What is it mistaken for?
may only see small (1-2 mm) nipple erosions
Eczematoid eruption and ulceration
dermatits or infection of the nipple
If you see edema of ipsilateral arm, what should that make you think?
advanced breast cancer
If a palpable mass is associated with paget’s disease, what does that mean? non-palpable mass?
Palpable mass - 50% (if present, 95% are invasive cancer, usually infiltrating ductal)
no palpable mass: noninvasive cancer or ductal carcinoma in situ present in 75% of cases
What is the usual presentation of Paget’s disease? How do you dx? What is the tx?
pain, itching or burning of breast along with superficial erosion or ulceration
May see bloody nipple discharge, retracted nipple
full-thickness biopsy of lesion
Mastectomy is traditional therapy
What am I?
Paget’s disease
**What is the characteristic finding for Inflammatory Breast Carcinoma (IBC)?
“Peau d’orange” (orange peel skin) may be seen
Diffuse, brawny edema of skin with erysipeloid border with usually NO palpable underlying mass
can present like mastitis that doesnt get better
What is the tx for Inflammatory Breast Carcinoma (IBC)?
Tx - multiple rounds of chemo, followed by surgery and radiation
_____ is the breast imaging modality of choice. How accurate is it?
mammo
correct in about 90% of cases
Up to ____ of cancers detected on CBE not seen on mammogram. What should you do next?
15%
Biopsy should still be done if dominant or suspicious mass
What kind of biospy is needed to definitively define breast cancer?
core needle bx
What is the general consensus for mammogram screening?
at least once every 2 years among women 50-74
What is the ACS breast cancer screening recommendation? When should you STOP screening for breast cancer?
Q 1 yr starting 40-45, may transition to Q2 yrs at 55
If 75+ years old, may continue screening as long as the pt has at least estimated 10 years life expectancy
Where are more than 95% of breast cancer are in _____ components of the breast
epithelial component
ductal and lobular
invasive or carcinoma-in-situ (CIS) arise mostly from the _______ and are _____
intermediate ducts
invasive!
aka not a good thing
knowing the presence or absence of _______ is very important in the management of breast cancer. What are the 3 options?
hormone receptor sites!
estrogen, progesterone or HER2 receptors
If the cancer is ER/PR/HER2 +, where is it more likely to metastasize to? What if there are no receptors present?
ER/PR/HER2 + - metastasize to bone, soft tissue, genital organs
No Receptors - metastasize to liver, lung, brain
Are most cancers positive or negative for receptors? Which kind is associated with worse outcomes?
most are positive!
80% - ER + and/or PR +
23% - HER2 + (human epidermal growth factor receptor 2)
13% - no hormone receptors** associated with worse outcomes
What is the difference between radical mastectomy and modified radical mastectomy? Which one is used frequently
Radical Mastectomy - en bloc removal of breast, PECTORAL MUSCLES, axillary lymph nodes
Modified Radical Mastectomy - removal of breast and underlying pectoralis major fascia with evaluation of select axillary nodes
Modified Radical Mastectomy used frequently!!
______ is the excision of tumor mass with negative margin, axillary evaluation and postoperative irradiation. When is it an option?
breast conservation therapy
For stage I and II and certain stage III cancers
What type of breast cancer is hormonal therapy indicated?
If positive for ER/PR/HER2
5 years of tamoxifen (SERMs) tx of choice
or
aromatase inhibitors (anastrozole)
What 2 events does tamoxifen increase your risk for?
Increased risk of endometrial cancer and VTE
What is the adjuvant therapy for hormonal receptor negative breast cancer?
pembrolizumab (Keytruda)
When is systemic chemotherapy used in breast CA?
reduce occult metastases
_____ may be used for chemoprevention of breast CA in some high-risk women
tamoxifen (Nolvadex), raloxifene (Evista)
SERM
What does SERM stand for? what is the MOA?
Selective Estrogen Receptor Modulators
bind to estrogen receptors; block estrogen in some (not all) tissues
How does the MOA differ slightly between tamoxifen and raloxifene?
tamoxifen - blocks estrogen in breasts; mimics estrogen in uterus and bone
aloxifene - blocks estrogen in breasts and uterus; mimics estrogen in bone
Which SERM has a less potent estrogen blockade andsmaller reduction in new cancer but with less estrogenic SE (endometrial CA, VTE)?
Raloxifene
What are the SEs of SERM and aromatase inhibitors? Can you use a SERM and aromatase inhibitor at the same time?
think menopausal symptoms
hot flashes, nausea, muscle aches and cramps, hair thinning, headache, paresthesias
NO!! one or the other
What is the MOA of aromatase inhibitors? How does it compare to tamoxifen?
inhibit aromatase (enzyme that produces estrogen)
May be slightly MORE effective at reducing recurrence of breast CA
May be LESS effective than tamoxifen at initial chemoprevention
______ are contraindicated in pregnant women and may increase serum concentration of _____
Aromatase Inhibitor
methadone
________ MOA attach to and cause destruction of estrogen receptors. What drug class?
Fulvestrant (Faslodex), elacestrant (Orserdu)
SERD
does NOT mimic effects of estrogen
______ are used to reduce release of GnRH and FSH/LH
GnRH agonists/antagonists
What is the follow up recommended for breast cancer pts? What is the median time to recurrence?
PE Q 4 mo x 2 yrs, then Q 6 mo x 3 yrs, then yearly
Mammogram 6 months after radiation, then yearly
Routine laboratory tests
4 years
What type of breast cancer has the higher chance of recurrence? If ________ is present, survival rate decreases
Hormone receptor negative cancers
axillary lymphadenopathy
Consider chemoprophylaxis with _____ or _______ if patient is ≥ 35 years old and has ??????
SERM or aromatase inhibitor
5-year risk of breast cancer ≥ 3%
10-year risk of breast cancer ≥ 5%
consider prophylactic mastectomy if a strong family history
