Breast Med Flashcards
When milk production is not necessary, ______ is inhibited by ______ (from the ______)
Prolactin
Dopamine
Hypothalamus
Other hormones that influence the milk secretory system include…
Progesterone Insulin Cortisol Thyroxine Oxytocin
Breast Masses
Simple Cyst
Fibrocystic condition
Fibroadenomas
Cancer
Nipple discharge; causes:
Carcinoma
Intraductal papilloma
Galactorrhea
“Cig”
Breast Infections
Mastitis
Abscess
Mastodynia/Mastalgia
Cyclic and non-cyclic
Generally, abnormal breast masses are eval by sono in women _____ and by _____ in women ______
30 years and younger,
mammo in women 30 plus
Cysts are benign developments in _______ women
middle aged women
Cyst PE
palpable, unilateral soft to firm, round, mobile mass that is often tender.
Cyst dx requires
radiograph
Cyst tx
aspirate, but monitoring without aspiration is sometimes acceptable
what do you do with bloody or turbid aspirated fluid from a cyst?
cytology, some are excised
When do you excise a cyst?
bloody fluid, palpable mass after aspiration, fluid reaccumulates in two weeks, or cyst recurs even after 2 aspirations
a condition where cysts of microscopic or larger size develop in the breasts and surrounding tissue becomes thickened, bumpy, and fibrous.
Fibrocystic Breast Disease/Hyperplasia without atypia…..Glandular and ductal tissue may also change.
Fibrocystic condition rarely develops in ______ ____
postmenopausal women
In Fibrocystic Breasts, breasts can change ______ and masses can _______
size
disappear and reappear cyclically
______ discharge may be normal with changes premenstrually in Fibrocystic Breasts
Serous
What is the plan of action with a patient with possible Fibrocystic Breasts?
either confirm radiographically, or have pt return next time they are in the premenstrual area and evaluate then.
Plan if dx remains uncertain after US/Mammo, or if pt’s age or family hx causes concern—
Aspirate for bx
Fibroadenomas are?
benign tumors of unknown etiology
Age typical of Fibroadenomas?
Usually women < 30, including adolescents
Physical Exam may reveal unilateral, round, smooth, mobile, firm/rubbery mass usually 1 cm or larger and non-tender
Fibroadenoma
Physical Exam may reveal bilateral, clumpy, mobile, symmetrical masses, and possibly multiple masses
Fibrocystic Breast Disease
Physical exam reveals a palpable, unilateral, soft to firm, round, mobile mass that is often tender
Cysts
Fibroadenomas do not require further tx beyond routine clinical eval if…
confirmed radiographically + pt is <30yoa + no family hx of breast ca
Fine needle aspiration(FNA) should be done on Fibroadenomas if…
Sono or mammo leave doubt
3 tx routes of Fibroadenomas
(if confirmed by bx!)
left alone
tx with cryoablation
excised if large
bx of solid breast masses on imaging are _____ if less than 30yoa, and _____ if older than 30yoa
fine-needle-aspiration
core-needle biopsy
In any solid mass bx where results are nondiagnostic then _______
an excisional bx is required!
The most common presenting sx of pt’s with breast ca is…
a mass
Breast ca masses may first be detected through
self-exam
clinical exam
screening mammo
Other initial detections of breast ca could include ____ ______, _____ in breast shape, or ____ changes
nipple discharge
change in breast shape
skin changes
Progression of breast ca may present with sx/signs like …..
weight loss, anorexia, night sweats, and fatigue
Breast ca may metastasize to
bone, liver, lung, pleura, brain, or lymph nodes
Physical Exam may reveal a firm to hard, usually non-tender mass that is difficult to distinguish from surrounding tissue, non-mobile, usually unilateral
Breast CA masses
Most common Breast CA
Infiltrating ductal carcinoma (IDC)
Least common types of Breast CA
Invasive lobular carcinoma(ILC)
Ductal carcinoma in situ(DCIS)
Lobular carcinoma in situ (LCIS)
Paget Disease of the Nipple is where….
the epidermis of the nipple is affected.
is a form of ductal carcinoma.
Examination of pagets reveals
crusting, scaling, erosion around the nipple. discharge is common.
Inflammatory breast carcinoma is very aggressive and is described as….(dismal prognosis)
the skin will be erythmatous, warm and have peau d’orange. Axillary lymph nodes are palpable, but no detectable mass.
Nipples may become inverted.
Dx of inflammatory breast carcinoma by
punch bx when suspicion is a reasonable step.
A new-onset breast mass in a women >50 years old…
is considered cancer until proven otherwise
What if a palpable mass is not detected on mammo?
get sono
BRCA 1 &2 are what and cause what
tumor suppressor genes.
a mutation here leads to uncontrolled cell growth
“increased risks” categories for breast ca prevention tx such as tamoxifen or raloxifene or aromatase inhibitors are..
age, family hx, personal hx, or assessment tool value of 3% or higher
___% of women with breast cancer do not have an obvious risk factor other than age
75%!!!
__-__% of breast cancers are a result of BRCA 1 and 2 mutations
5-10%
Uses of Tamoxifen (Soltamox)
- SERM- Breast ca prevention/treatment.
- post and pre menopausal women.
Raloxifene
- SERM- Breast ca prevention.(only in Postmenopausal women)
- Osteoporosis tx (but no longer highly recommended)
Contraindications of Tamoxifen and Raloxifene
hx of clots.
pregnancy.
Aromatase inhibitors are…
used for breast ca prevention in postmenopausal women only
Clinical Breast Exams may occur every…
1-3 years in pt’s that are 25-39 years, and annually from 40 years.
USPSTF recommends mammos every__ in pt’s ____-____years
2 years
50-74 years old
ACOG recommends mammos annually at age ___
40
When do you start screening a pt with a first degree relative with pre-menopausal breast cancer?
10 years earlier than the cancer was first detected in the relative
When do you start screening a pt who has tested positive for a BRCA mutation?
Start screening mammos or MRI at age 25
USPSTF states perform a risk assessment for an inheritable syndrome using a tool IF a pt has….
a family hx of breast, ovarian, tubal or peritoneal ca, OR if Ashkenazi Jewish ancestry.
Risks from Gina:
Family hx of b,o,t,p, ca before age 50, bilat breast ca, both breast and ovarian ca(or two types of BRCA-related ca), breast ca in a male, multiple cases of breast ca in the fam, Ashkenazi Jewish ethnicity
_____ all pt’s with abnormal sonogram or mammo for bx
refer
Bx will include 1. 2. 3.
- histological analysis
- whether or not the cells are estrogen/progesterone-receptor-positive
- if there is ERBB2(HER2/neu) over-expression
If analysis is neg for both estrogen and progesterone receptors and for ERBB2, it is called “triple-negative” breast cancer
ERBB2 is an
acquired mutation found in 25% of breast ca’s; it stimulates cell growth and can be a more aggressive ca than other cancers without this mutation.
TNM (and stages)
Tumor
Node
Metastasis
stages include: 0, I, IIA, IIB, IIIA, IIIB, IIIC, IV
Most reliable predictor for survival is…
the stage of breast cancer at the time of dx
____ ____ ____ and ___ ____ _____ are major prognostic factors of breast cancer.
Lymph node status
Hormone receptor status
If cancer has spread to the lymph nodes it is…
2x more likely to metastasize
If cancer is hormone receptor positive, it has a…
lower recurrence rate and is therefore a favorable prognosis
Tx of breast cancer will be guided by…
and could include….
histological analysis and staging, and could include lumpectomy, mastectomy, axillary lymph node dissection, radiation (in most pt’s), hormonal therapy (SERMS and/or AIs), tissue-targeted therapy and chemotherapy.
Induction (preoperative) chemotherapies may be used to…
shrink tumor to allow for breast conserving surgery in nonmetastatic cases.
Chemo, Hormonal and TTTs may be started before…
Surgery
Breast conservation surgery can only be given to pt’s who can
receive adjuvant radiation.
Avoid prescribing these if a pt comes to you on Tamoxifen.
Why?
Paroxetine Fluoxetine Bupropion Duloxetine will lower effectiveness
Hormonal therapy in hormone receptor positive cancer includes _____ and/or ___ for how long?
SERMS (Tamoxifen for tx and prevention of recurrence, Raloxifene for prevention of recurrence)
AIs
for 5 years following cancer tx (some pts will take a SERM for 5 years followed by an AI for 5 years)
AI MOA
Aromatase Inhibitors are antineoplastic agents for post-menopausal women with receptor-positive cancer. they BLOCK CONVERSION of ANDROGENS to ESTROGEN
Risk of AIs
accelerate bone loss
Chemo is used if ____ _____ test positive or….
lymph nodes
tumor is larger than 1cm, or if bx shows ERBB2 overexpression
The need for chemotherapy in a pt with stage I or II HRP cancer can be determined by….
Oncotype DX test which looks at the genetic likelihood of recurrence or spread
ERBB2(HER2) ________ is an indication for ______ plus a _______/__________
Overexpression
Chemo
Tissue-targeted medication/ERBB2 directed monoclonal antibodies
Second line tx’s for menopausal/vasomotor symptoms
gabapentin or clonidine
Completed care by oncologist(1year)…pt should receive….
thorough H&P with clinical breast exam every 3-6months for 3 years, then every 6-12 months for 2 years, then annually….
Annual _____ mammos should be done on patients who…
Diagnostic…who are breast ca survivors
Serous or yellow-tinged discharge from nipples without any red flags can be normal phys changes associated with…
menses, OCPs, or Fibrocystic changes.
Red flags of discharge
Bloody Unilateral and Persistent Mass is near by or Spontaneous (bUmPs)
SOAP documentation should include:
Color, bilateral or unilateral, spontaneous or expressed, presence or absence of associated mass or lymphadenopathy, any associated skin changes, history of trauma
Most common cause of bloody nipple discharge is?
Intraductal Papilloma
a benign, unilateral lesion
Plan with pt’s suspected of intraductal papillomas
1 send discharge to cytology to rule out invasive carcinoma
2 mammo and subareolar US may help to exclude cancer
Tx: excise the duct
Drugs that can cause Gynecomastia
Ginko Yheroin N Etoh C Omeprazole, Opiods Methyldopa, Marijuana Azole Spironolactone, Saw palmetto, supplements TCAs, Testosterone, Tamoxifen dIaepam fInesteride Amphetamines
Galactorrhea is -
spontaneous flow of milk from the nipple - caused by high levels of prolactin in the blood from pregnancy, a pituitary tumor, hypothyroidism, excessive exercise, renal failure, or a side-effect of certain medications
Meds that lower _____ levels will trigger a rise in prolactin levels such as:
Dopamine.
Antipsychotics, cimetidine(Tagamet), metoclopramide, SSRIs, TCAs, Verapamil, and opiates.
Three steps of ddx for Galactorrhea
1 consider pregnancy and meds.
2 then order prolactin and thyroid levels, if thyroid is normal but prolactin is high then
3 order a MRI of sella turcica to eval for pituitary tumor/adenoma
Mastitis is caused usually by:
Staph aureus
Mastitis Tx:
Dicloxacillin 500mg qid for 10 days.
Hospitalize pt if severe.
Breast Abscess cause and tx.
When would you bx?
usually a collection of pus in a blocked milk duct/galactocele.
Dicloxacillin 500mg qid (Bactrim if MRSA suspected)
Drain the abscess with needle or incision.
Bx if it does not resolve promptly and the pt is not lactating.
Breast tenderness (mastodynia/mastalgia) is usually ____
cyclic
Things that increase pain of cyclic mastalgia
OCP, HRT
Causes of non-cyclic breast pain
OCPs, HRT, SSRIs, Spironolactone and digoxin.
Treatment of Mastalgia
NSAIDs(including topical diclofenac), Vit B6, Tamoxifen, and/or a well-fitted bra
Mastalgia may be a comp from…
breast augmentation - scarring around the implant can result in breast firmness, distorted shape and pain
Imaging of mastalgia is only done when…
pain is focal, and no cause for pain can be identified
Or pt has risk factors
Documentation of a mass includes:
Location, size, shape, unilateral/bilateral, soft/firm, smooth/rough, tender/non-tender, mobile/non-mobile
Documentation of discharge includes:
Color, consistency, presence or absence of blood, unilateral / bilateral, spontaneous
