Breast Lump Flashcards
Breast mass
Lesion that persists throughout menstrual cycle, differs from surrounding breast tissue and corresponding area on contralateral breast
Milk (mammary) lines
Anatomic precursors to mammary glands and nipples
. Ventral epidermal ridges appearing by 6th week of gestation
Polythelia
. Supernumerary nipples
. Presence of 2+ nipples on individual
Mastodynia (Mastalgia)
Breast pain
Skin dimpling
Retraction of skin causing the appearance of a pit below general skin contour
. May be secondary to underlying mass
Nipple eversion
Outwardly positioned nipple
Nipple inversion/retraction
Inwardly positioned nipple
Pedunculated
Having peduncle/elongated stalk
Montgomery glands/tubercles of nipple
Sebaceous glands that appear as small bumps around dark area surrounding nipple papilla
Pager disease of nipple
Uncommon form of breast cancer that starts as scaly, eczema-like lesion on the nipple that may weep, crust, or erode
Peau d’ orange
Giving appearance as skin of orange assoc. w/ some forms of breast cancer
Abscess
Local accumulation of puss w/in body tissue
Pus
Thick, opaque/yellowish liquid produced in affected tissue consisting of white blood cells, bacteria, serum, and tissue debri
Breast lump differential factors to consider
Age variation, biological sex, genetics, external influences
Breast cancer
Malignant proliferation of epithelial cells lining ducts/lobules of breast
Breast cancer signs and symptoms
. Weight loss, firm . Non tender breast mass . Non-mobile mass . Nipple discharge . Skin dimpling . Nipple retraction . Corresponding lymph node enlargement
Fibroadenoma of breast
. Common benign neoplasm occurring most frequently in young women w/in 20 years of puberty
Fibroadenoma signs and symptoms
. Usually discovered accidentally
. Typical lesion is round, firm, discrete, very mobile, non-tender mass 1-2 cm in diameter
. Skin dimpling or retraction absent
Breast abscess
Painful collection of pus that forms in breast usually appearing as lump under skin
Breast abscess signs and symptoms
Usually patient present w/ fever, skin, erythema, warmth, swelling/induration and pain/tenderness
Mastitis
Inflammation of mammary glands w/in breast, usually bacterial in origin
Mastitis signs and symptoms
Presents w/ breast pain, swelling, tenderness, skin erythema, and warmth
Fibrocystic disease of breast
. Not actually disease, classified as process
. Benign often painful bilateral inflammatory breast condition due to monthly hormonal fluctuations in women
Fibrocystic disease of breast signs and symptoms
Painful lumps appearing in one or both breasts
. Vary daily/monthly in size and tenderness
. Occur in premenopausal women
Breast boundaries
. Against ant. Thoracic wall . Extends from clavicle and 2nd rib down to 6th rib . From sternum across midaxillary line . Surface area rectangular . Overlies pec major and serratus ant.
Tail of Spence
Axillary tail of breast tissue extends to ant. Axillary fold
Glandular tissue in breast
. Milk-secreting tubuloalveolar glands and ductules form 15-20 septated lobes radiating around nipple
. Each lobe contains smaller lobules
. Each lobule drains into larger collecting ducts and lactiferous sinuses leading to 5-10 porous openings on surface of areola and nipple
Fibrous CT in breast
. Form fibrous bands/suspensions ligaments (Cooper ligaments) connected to skin and underlying fascia
Factors that affect proportion of fibrous CT and adipose tissue
. Age . Nutritional status . Pregnancy . Exogenous hormone use . After menopause atrophy of glandular tissue and dec. lobules
Breast feeding physiology
. Nipple and areola have smooth muscle that contracts to express milk from ductal system
. Rich sensory innervation triggers “milk letdown” following neurohormonal stimulation from infant sucking
. Tactile stimulation makes nipple smaller, firmer, more erect while areola puckers and wrinkles
Male breast tissue
. Small nipple and areola overlying thin disc of breast tissue consisting of ducts
. Ductal branching and development of lobules are minimal w/ no estrogen and progesterone stimulation
. Firm button of breast tissue 2 cm+ in diameter in 1 out of 3 men
Central nodes
. Palpable most frequently
. Lie along chest wall
. High in axilla and midway btw ant. And post. Axillary folds
Pectoral nodes
. Anterior
. Lower border of pec major inside the ant. Axillary fold
. Nodes drain ant. Chest wall and much of the breast
Subscapular nodes
. Posterior
. Located along lat. border of scapula
. Palpated deep in post. Axillary fold
. Drain post. Chest wall and portion of the arm
Lateral nodes
Located along upper humerus
. Drain most of arm
Lymphatics clinical significance in breast
. Cancer cells tend to spread along lymph passages
. Typical spread sup/lat. to axillary lymph nodes
. More than 75% of drainage via axillary lymph nodes
. Most remaining drainage med. to parasternal nodes
. Unilateral lymph blockage can occur
. Lymph can then drain to opposite side
T/F All lymph of breast drains to axilla
F, can go to infraclavicular nodes or into mammary chain of lymph nodes w/in chest
Cyclic breast discomfort qualities
Onset w/ menses
Bilateral
Lasts for several days and varies in intensity
When is mastitis most common?
Breastfeeding women
What percent of palpable breast masses are benign?
90% or more
What is a crucial step is assessment of breast mass?
Excluding breast cancer
Family history related to breast cancer
. Pattern of breast/overran cancer in maternal or paternal family members
. Include men
. Suspicious for autosomal dominant genetic mutations
Gail Model breast cancer risk assessment tool and when to and to not use
. Calculates risk of developing breast cancer w/in 5 yrs and w/in lifetime
. best use for people over 50, no family history of breast cancer or one affected first-degree relative and have screening mammograms
. Don’t use for women w/ history of breast cancer or radiation or are 35 yrs old or younger
What 5 year risk percent or higher is high risk?
1.67
7 risk factors for breast cancer
. Age . Age at 1st menstrual period . Age at time of birth of 1st child . Family history of breast cancer . # past breast biopsies . # biopsies showing atypical hyperplasia . Race/ethnicity
Mammography w/ self-reported palpable masses miss ___percent of invasive cancers
13%
concerning findings in clinical breast exam
. Changes in contour (puckering/swelling)
. Skin changes (dimpling of skin over breasts/inflammation)
. Discharge from nipple (color/spontaneous)
Common breast lesion and characteristics in 15-25 yr olds
. Fibroadenoma
. Smooth, rubbery, round, mobile, nontender
Common breast lesions and characteristics in 25-50 yr olds
. Cysts (Usually soft to firm, round, mobile, often tender)
. Fibrocystic changes (modular, rope like)
. Cancer (irregular firm, mobile or fixed)
Common lesion in breast in people over 50
Cancer until proven otherwise
Common breast lesion during pregnancy/lactation
. lactating adenomas, cysts, mastitis, and cancer
Malignant features in breast
. Hard consistency . Non-mobile . Irregular shelf . Dimpling . Assoc. retraction of nipple . Non-tender . Bloody discharge . Palpable lymph nodes
Features of benign breast
. Cyclical . No skin changes . No bloody discharge . Well circumscribed . Tenderness
Lactational infection/inflammation causes, signs and symptoms
. Fullness or mass w/ erythema and tenderness . Cellulitis . Abscess . Serous or bloody nipple discharge . Fever
Cellulitis treatment
. Oral ABX covering gram+ cocci, apply warm packs, keep breast emptied
Abscess treatment
Surgical drainage
Non-lactational infection/inflammation causes
. Peripheral
. Assoc. w/ DM, RA. Steroids, or trauma
Triple assessment for breast mass
. Exam
. Imaging (mammography, ultrasound, MRI)
. Tissue/cytology sampling (fine needle aspirate, core needle biopsy, excisional biopsy)
Guidelines for diagnostic imaging evaluation for breast mass for people under 30 w/ no risk factors
. Ultrasound to determine cyst, tumor, or abscess
. Ultrasound better dur to high density of breast tissue
. Confirm w/ cytology/tissue sampling
Simple cyst evaluation w/ ultrasound
Likely benign if it has symmetry, round borders, no internal echoes
Complex cyst evaluation w/ ultrasound
. Septation/internal echoes
. Send for referral
Solid tumor evaluation in ultrasound
. Fibroadenoma
. Benign if symmetric. Round borders w/ no internal echoes
Diagnostic evaluation for people over 30
. Diagnostic mammography
. Ultrasound after mammogram may guide FNA or biopsy
. If high index of suspicion and have normal imagine still refer for biopsy
If suspicious mass palpated what is protocol?
. No matter what age mammogram
. Can have ultrasound
. Refer for biopsy
Breast MRIs
. Use limited
. May be helpful as adjunct study to guide core biopsy when localization would be difficult w/ conventional imaging
Fine needle aspiration and result evaluation
. Small gauge needle and syringe
. Good for cystic lesions (need experienced person for complex cystic lesions)
. If aspirate non-bloody and mass disappears reexamine 4-6 weeks (if reoccurs reimage consider referral)
. If aspirating does not cause cyst to disappear refer out
. If aspirate is bloody send for cytology and refer out
Core needle biopsy
. Larger hollow needle
. Preferred method for solid/suspicious mass
. Can mark suspicious area for future
. Requires specialist
. Sn. And Sp* approaches excisional biopsy
Excisional biopsy
. Surgical removal of suspicious area
. Core needle biopsy mostly replaced this
. Indications to do it: discordance btw imaging characteristics and core biopsy histology, nondiagnostic specimen from core biopsy, lesion automatically unsuitable for core biopsy
When it is worthwhile to screen for a disease
. When test accurately detects target disease when asymptomatic
. Test high sensitivity and specificity
. Is reproducible
. Safe and acceptable to patients
. Simple and cost effective
. When there is effective treatment and early detection change w/ disease
United States preventative services task force (USPSTF)
. Independent panel of experts in primary care and prevention
. Highly evidence-based guidelines on when and how to screen
BRCA1 and BRCA2
. Human genes that produce tumor suppressor proteins
. Repair damaged DNA
. If mutated, DNA damage ma not be repaired properly
. Cells more likely to develop additional genetic alterations that can lead to cancer
. Autosomal-dominant
Risks if you have mutated BRCA genes
. Inc. risk ovarian cancer (occurs at younger age)
. Inc. risk other organs (male breasts, pancreas, prostate, Fallopian tubes)
Prevalence of BRCA1 and 2
Less than 1% of population but causes 5-10% of female breast cancers
BRCA1 mutations
. Inc. risk by 70 yrs old to 44-78%
BRCA2 mutation risk
31-51% developing cancer
High risk factors for familial breast cancer
. Age 50 or younger breast cancer diagnosis
. Breast cancer in 2+ individuals in Same lineage
. Multiple primary or ovarian tumors in 1 person
. Breast cancer in male relative
. Ashkenazi Jewish ancestry
If no family history is present what are next steps:
.BRCAPRO calculator
. Referral for genetic counseling
. Genetic testing
. Appropriate specialty referrals
BRCA positive patients risk management
. Intensive screening (yearly mammogram/MRI, CBE, chemo prevention
. Surgical forms of risk reduction (mastectomy, bilateral salpingo-oophorectomy btw age 35-50)
Male breast cancer incidence inc. btw ages ___
60 and 70
Risk factors for breast cancer in men
. Higher in African American men . Radiation exposure . BRCA . Klinefelter syndrome . Testicular disorder . Family history of breast cancer . Alcohol use, cirrhosis, and obesity
When to screen trans patients
. Over 50 yrs old
. Had estrogen therapy for over 5 yrs
. Family history
. BMI over 35
How to screen Trans men
. If there are intact breasts routine screening
. Postmastectomy: yearly chest wall and axillary exams
