Breasts

Question 1

Concerning symptoms on breast examination?

Answer 1

breast lumps or mass
breast pain or discomfort
nipple discharge

Question 2

What are breast cancer risk factors?

Answer 2

Female
> 40
Genetic mutations BRCA1 and or BRCA2
First degree relatives with early age dx of breast cancer
PMH of breast cancer
High breast tissue density
High dose radiation to chest
High bone density (postmenopausal)
Late age of first pregnancy >30
Early menarche 55
No full term pregnancy
Never breast fed a child
Recent oral contraception use
Recent and long term use of hormonal replacement therapy
PMH of endometrial, ovarian or colon cancer
Ashkenazi Jewish ancestry

Question 3

How and when to screen for breast cancer?

Answer 3

Mammogram

• Women 50-74 years, bienially
• Women under 40- shared decision making, if high risk factors
• Women over 75- on an individual basis

Question 4

Who should get an adjunct MRI?

Answer 4

A BRCA1 or BRCA2 mutation

• A first-degree relative (parent, sibling, child) with a BRCA1 or BRCA2 mutation, even if they have yet to be tested themselves
• A lifetime risk of breast cancer that has been scored at 20 - 25% or greater
• Had radiation to the chest between ages 10 - 30
• Has high genetic syndrome or first degree relative with high risk syndrome such as; Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba
• Extremely dense breast or unevenly dense breast on mammogram

Question 5

What 4 positions are needed to inspect the breasts?

Answer 5

1. sitting arms to the side
2. sitting arms above the head
3. sitting arms pressed against hips
4. sitting arms pressed against hips leaning forward

Question 6

Peau d’orange

Answer 6

• literally means orange peel skin
• hair follicles look like little dimples, texture is similar to an orange
• Caused by cutaneous lymphatic edema
• Seen with inflammatory breast cancer

Question 7

What needs to be inspected on the nipple?

Answer 7

• size
• shape
• direction
• rashes
• discharge or ulceration
• inspect for inversion
• inspect for asymmetry of direction

Question 8

How will breast tissue finding differ based on age group?

Answer 8

Young: dense
Middle: glandular, nodular,
Older: fat

Question 9

If any lumps are present, what should you note?

Answer 9

• Location- by clock and cm from nipple
• Size- in cm
• Shape- round, disk-like, irregular in contour
• Consistency- soft, firm, hard
• Delimitation- well circumscribed or not, can you feel the edges?
• Mobility- in relationship to the skin and chest wall, fixed usually means cancer
• Tenderness
• Lymphadenopathy

Question 10

What are the common lesions for breast masses in 15-25 year olds? What are the characteristics?

Answer 10

Fibroadenoma

- smooth, rubbery, round, mobile, non-tender

Question 11

What are the common lesions for breast masses in 25-50 year olds? What are the characteristics?

Answer 11

Cysts- soft to firm, round, mobile, tender
Fibrocystic changes- nodular ropelike
Cancer- irregular, firm, maybe mobile or fixed to surrounding tissue

Question 12

What are the common lesions for breast masses over 50 year old? What are the characteristics?

Answer 12

Cancer until proven otherwise

irregular, firm, maybe mobile or fixed to surrounding tissue

Question 13

What are the common breast masses in pregnant/lactating women?

Answer 13

Lactating adenomas, cysts, mastitis and cancer

Question 14

Glactorrhea: definition and causes

Answer 14

nipple discharge

• White/milky- less concerning
• Spontaneous/bloody/pus/unilateral- associated with a mass
• Causes- meds (haldol, anti-depressants) or over stimulation

Question 15

Where are the central nodes?

Answer 15

high in middle of axilla, receives from other nodes

Question 16

Where is the pectoral (anterior) node?

Answer 16

along the lateral edge of the pectoralis major muscle, just inside the axillary fold

Question 17

Where is the subscapular node?

Answer 17

along the lateral edge of the scapula, deep in the posterior axillary fold

Question 18

Where is the lateral node?

Answer 18

along the humerus bone, inside the upper arm

Question 19

Paget’s disease of the nipple

Answer 19

Uncommon form of breast cancer

• Starts as a scaly, eczema-like lesion
• may crust, weep or erode
• may have breast mass
• suspect Paget’s disease if dermatitis persists

Question 20

Mastitis

Answer 20

inflammation of the breast tissue/gland

• common when breast feeding
• warm, tender, painful breasts
• tx: antibiotics

Question 21

Gynecomastia

Answer 21

• Proliferation of breast glandular tissue in men due to increase ratio of estrogen to androgen activity
• Normal if: resolves after puberty, monitor it
• Causes include:
  Persistent pubertal
  Drugs
  Idiopathic
  Hypogonadism
  Hyperthyroidism
  Testicular tumor

Question 22

Monilial Intertrigo

Answer 22

• Candida infection
• Occurs between the fold of the breast and other skin. Often seen in older obese women.
• Can be related to an underlying condition such as diabetes or pregnancy.

Question 23

Fibrocystic Breast Disease

Answer 23

• Age 30-50, regress after menopause except with estrogen therapy
• Single or multiple
• Round
• Soft to firm, usually elastic
• Well delineated
• Mobile
• Often tender
• Fluctuate with menses

Question 24

Fibroadenomas

Answer 24

• Age 15-25
• Usually puberty and young adulthood, but up to age 55
• Usually single, may be multiple
• Round, disc-like, or lobular
• May be soft, usually firm
• Well delineated
• Very mobile
• Usually non-tender

Question 25

Breast Cancer

Answer 25

• Age 30 and older, most common over 50
• Usually single, although may coexist with other nodules
• Irregular or stellate
• Firm or hard
• Not clearly delineated form surrounding tissues
• May be fixed to skin or underlying tissues
• Usually non-tender except in inflammatory breast cancer