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06 - absite > Chapter 24: Breast > Flashcards

Chapter 24: Breast Flashcards

1
Q

Embryology: breast

A

Formed from the ectoderm milk streak

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2
Q

Hormones that cause..

  1. Duct development (double layer of columnar cells)
  2. Lobular development
  3. Synergizes estrogen and progesterone
A
  1. Estrogen: duct development (double layer of columnar cells)
  2. Progesterone: lobular development
  3. Prolactin: synergizes estrogen and progesterone
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3
Q

Cyclic change: increases breast swelling, growth of glandular tissue

A

Estrogen

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4
Q

Cyclic change: increase maturation of glandular tissue; withdrawal causes menses

A

Progesterone

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5
Q

Cyclic change: cause ovum release

A

FSH, LH surge

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6
Q

What causes atrophy of breast tissue after menopause?

A

After menopause, lack of estrogen and progesterone results in atrophy of breast tissue.

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7
Q

Innervates serratus anterior, injury results in winged scapula

A

Long thoracic nerve

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8
Q

Artery: supplies serratus anterior

A

Lateral thoracic artery

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9
Q

Innervates latissmus dorsi; injury results in weak arm pull-ups and adduction

A

Thoracodorsal nerve

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10
Q

Artery: supplies latissimus dorsi

A

Thoracodorsal artery

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11
Q

Innervates pectoralis major and pectorals minor

A

Medial pectoral nerve

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12
Q

Nerve: pectorals major only

A

Lacteral pectoral nerve

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13
Q

Lateral cutaneous branch of the 2nd intercostal nerve; provides sensation to medial arm and axilla; encountered just below axillary vein when performing axillary dissection. Can transect without serious consequences.

A

Intercostobrachial nerve

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14
Q

Arteries that supply the breast

A

Internal thoracic artery, intercostal arteries, thoracoacromial artery, and lateral thoracic artery

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15
Q

Valveless vein plexus that allows direct hematogenous metastasis of breast CA to spine

A

Batson’s plexus

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16
Q

Lymphatic drainage of the breast

A
  • 97% to axillary nodes
  • 2% to internal mamillary nodes
  • Any quadrant can drain to the internal mammary nodes.
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17
Q

Considered N3 disease

A

Mets to supraclavicular nodes

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18
Q

Dx: primary axillary adenopathy

A

1 is lymphoma

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19
Q

Suspensory ligaments of the breast. Divide breast into segments.

A

Cooper’s ligaments

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20
Q

What does skin dimpling of the breast suggest?

A

Breast CA involving Cooper’s ligaments dimpling the skin.

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21
Q

What are breast abscesses usually caused by?

MCC?

A

Usually a/w breast feeding.

MCC: Staph aureus

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22
Q

TX: breast abscess

A

Percutaneous or incision and drainage; discontinue breastfeeding; breast pump; antibiotics.

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23
Q

MCC infectious mastitis in nonlactating women

A

S. aureus MC in non lactating women can be due to chronic inflammatory diseases (e.g., actinomyces) or autoimmune disease (e.g., SLE) -> may need to r/o necrotic cancer (need incisional biopsy including the skin)

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24
Q

What is infectious mastitis usually associated with?

A

Breastfeeding

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25
Q

Mammary duct ectasia or plasma cell mastitis

A

Periductal mastitis

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26
Q

S/S: noncyclical mastodynia, erythema, nipple retraction, creamy discharge from nipple; can have sterile or infected subareolar abscess

A

Periductal mastitis

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27
Q

Risk factors: periductal mastitis

A

Smoking, nipple piercings

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28
Q

Biopsy: Periductal mastitis

A

Dilated mammary ducts, inspissated secretions, marked periductal inflammation

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29
Q

Tx: periductal mastitis

A

If typical creamy discharge is present that is not bloody and not associated with nipple retraction, give antibiotics and reassure; if not or it recurs, need to r/o inflammatory CA (incisional biopsy including the skin)

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30
Q

Breast cysts filled with milk; occurs with breastfeeding

Tx: ranges from aspiration to incision and drainage.

A

Galactocele

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31
Q

Can be caused by increased prolactin (pituitary prolactinoma), OCPs, TCAs, phenothiazines, metoclopramide, alpha-methyl dopa, reserpine.
- Is often a/w amenorrhea

A

Galactorrhea

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32
Q

2-cm pinch of breast tissue.

Tx: will likely regress; may need to resect if cosmetically deforming or causing social problems.

A

Gynecomastia

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33
Q

What is gynecomastia associated with?

A

Cimetidine. Spironolactone. Marijuana. Idiopathic in most.

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34
Q

Due to circulating maternal estrogens; will regress.

A

Neonatal breast enlargement.

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35
Q

MC location of polythelia (accessory breast tissue)

A

Axilla

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36
Q

MC breast anomaly.

Location?

A

Accessory nipples

- Found form axilla to groin

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37
Q

What is compromised with breast reduction?

A

Ability to lactate frequently compromised.

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38
Q

Hypoplasia of chest wall.
Amastia.
Hypoplastic shoulder.
No pectoralis muscle.

A

Poland’s Syndrome

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39
Q

Pain in breast; rarely represents breast cancer.

Dx: history, breast exam, BL mammogram.

A

Mastodynia

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40
Q

Tx: Mastodynia

A 
Danazol.
OCPs
NSAIDs.
Evening primrose oil.
Bromocriptine.
D/C: caffeine, nicotine, methylxanthines.
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41
Q

Pain before menstrual period, most commonly represents acute or subacute.

A

Cyclic mastodynia.

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42
Q

Continuous pain. MC’ly represents acute or subacute infection; continuous mastodynia is more refractory to treatment than cyclic mastodynia.

A

Continuous mastodynia.

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43
Q

Superficial vein thrombophlebitis of breast, feels cordlike, can be painful.

A

Mondor’s disease

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44
Q

What is Mondor’s disease associated with?

Def: superficial vein thrombophlebitis of breast

A
  • Associated with trauma and strenuous exercise.

- Usually occurs in lower outer quadrant.

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45
Q

Tx: Mondor’s disease

A

NSAIDs

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46
Q

Dx: breast pain, nipple discharge (usually yellow to brown), lumpy breast tissue that varies with hormonal cycle.

A

Fibrocystic change.

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47
Q

Types of fibrocystic change.

A

Papillomatosis. Sclerosing adenosis. Apocrine metaplasia. Duct adenosis. Epithelial hyperplasia. Ductal hyperplasia. Lobular hyperplasia.

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48
Q

What type of fibrocystic disease is associated with risk of CA?

A

Atypical ductal or lobular hyperplasia.

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49
Q

Tx: atypical ductal / lobular hyperplasia subtypes of fibrocystic change?

A

Resect.
- Do not need to get negative margins with atypical hyperplasia; just remove all suspicious areas (i.e., calcifications that appear on mammogram).

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50
Q

MCC bloody nipple discharge

A

Intraductal papilloma

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51
Q
  • Usually small, non palpable, close to nipple.

- Not premalignant

A

Intraductal papilloma

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52
Q

Intraductal papilloma

  • Dx?
  • Tx?
A

Dx: contrast ductogram to find papilloma, then needle localization
Tx: Subareolar resection of the involved duct and papilloma.

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53
Q

MC breast lesion in adolescents and young women; 10% multiple.

  • Usually painless, slow growing, well circumscribed, firm, and rubbery.
  • Often grows to several cm in size and then stops.
  • Can change in size with menstrual cycle. Can enlarge in pregnancy.
A

Fibroadenoma

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54
Q

Path: fibroadenoma

A

prominent fibrous tissue compressing epithelial cells

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55
Q

Mammography: fibroadenoma

A

Large, coarse calcifications (popcorn lesions) from degeneration.

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56
Q

Criteria for observation of fibroadenoma.

A

In patients less than 40 years old:

  1. Mass needs to feel clinically benign (firm, rubbery, rolls, not fixed).
  2. US or mammogram needs to be consistent with fibroadenoma.
  3. Need FNA or core needle biopsy to show fibroadenoma.
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57
Q

Tx: enlarging fibroadenoma

A

Excisional biopsy

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58
Q

Why avoid resection of fibroadenoma in teenagers / younger children?

A

Resection can affect breast development.

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59
Q

Fibroadenoma: pts > 40

A

Excisional biopsy to ensure dx

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60
Q

Tx: fibroadenoma

A
  • Pts Observe. No?ex bx.

- Pts > 40: Ex bx to ensure diagnosis

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61
Q

Most nipple discharge is…

A

Benign

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62
Q

Dx: nipple discharge

A

History, breast exam, BL mammogram. Try to find the trigger point on exam.

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63
Q

Nipple discharge: green

Tx?

A

Usually due to fibrocystic disease.

Tx: if cyclical and non spontaneous, reassure pt.

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64
Q

Nipple discharge: bloody

Tx?

A

MC intraductal papilloma; occasionally ductal CA.

Tx: Need ductogram and excision of that ductal area.

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65
Q

Nipple: serous discharge

A

Worrisome for cancer. Especially if coming form only 1 duct or spontaneous.
Tx: Excisional biopsy of that ductal area

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66
Q

Nipple: spontaneous discharge

A

No matter what the color or consistency is, this is for worrisome for CA -> all these patients need excisional biopsy of duct area causing the discharge.

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67
Q

Discharge:

  • Occurs only with pressure, tight garments, exercise, etc.
  • Not as worrisome but may still need excisional biopsy (e.g., if bloody)
A

Nonspontaneous discharge

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68
Q

Sx: nipple discharge

A

May have to do a complete subareolar resection if the area above cannot be properly identified (no trigger point or mass felt).

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69
Q

Malignant cell of the ductal epithelium without invasion of basement membrane

A

Ductal carcinoma in situ.

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70
Q

DCIS Risk Ca:
Ipsilateral Breast
Contralateral Breast

A

Ipsilateral breast: 50%

Contralateral breast: 5%

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71
Q

DCIS: premalignant lesion

A

Yes.

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72
Q
  • Usually not palpable and presents as a cluster of calcifications on mammography.
  • Can have solid, cribriform, papillary, comedy patterns
A

DCIS

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73
Q

Most aggressive subtype DCIS
- Necrotic areas
- High risk for multi centricity, micro invasion, recurrence.
Tx?

A

Comedo pattern DCIS

- Tx: simple mastectomy.

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74
Q

Increased risk of cancer in DCIS?

A

Comedo type and lesions > 2.5cm

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75
Q

Tx: DICS (not high grade)

A

Lumpectomy and XRT.
Need 1cm margins.
No ALND or SLNB.
Possibly tamoxifen.

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76
Q

Tx: High grade DCIS

A

Simple mastectomy if high grade (e.g., comedo type, multi centric, multifocal), if a large tumor not amenable to lumpectomy, or if not able to get good margins. No ALND.

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77
Q

Considered a marker for the development of breast CA, not premalignant itself.

  • 40% get cancer (either breast)
  • No calcifications, is not palpable.
  • Primarily found in premenopausal women.
A

Lobular carcionma in situ - LCIS.

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78
Q

Patient who develop breast CA are more likely to develop a..

A

Ductal CA (70%)

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79
Q

Possibility of synchronous breast cancer at time of LCIS diagnosis?

A

5% (most likely ductal CA)

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80
Q

Do you need negative margins for LCIS?

A

No.

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81
Q

Treatment for LCIS

A

Nothing. Tamoxifen. BL subcutaneous mastectomy (no ALND).

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82
Q

Indications for Surgical Biopsy after core biopsy

A 
Atypical ductal hyperplasia. 
Atypical lobular hyperplasia.
Radial scar.
LCIS
Columnar cell hyperplasia with atypia.
Papillary lesion.
Lack of concordance between appearance of mammography lesion and histologic diagnosis.
Nondiagnostic specimen.
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83
Q

Country: lowest risk of breast CA worldwide

A

Japan

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84
Q

United States breast cancer risk

A

1 in 8 women (12%); 5% in women with no risk factors.

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85
Q

Breast cancer screening decreases mortality by..

A

25%

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86
Q

Years survival: untreated breast cancer

A

2-3 years

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87
Q

%: Beast CA with negative mammogram and negative ultrasound

A

10%

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88
Q

Clinical features of breast CA

A

Distortion of normal architecture.
Skin / nipple distortion or retraction.
Hard.
Tethered. Indistinct borders.

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89
Q

Symptomatic breast mass work up

A

Ultrasound & Core needle biopsy. (consider FNA).

- Need mammo in pts

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90
Q

Symptomatic breast mass work up > 40 years old

A

Need bilateral mammograms.
Ultrasound.
Core needle biopsy.

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91
Q

If core needle biopsy or FNA is indeterminate, non-diagnostic, non-concordant with exam findings / imaging studies..

A

Will need excisional biopsy.

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92
Q

Clinically indeterminate or suspect solid masses will eventually need..

A

Excisional biopsy unless CA diagnosis is made prior to that.

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93
Q

Tx: cyst fluid

A

Bloody: cyst excisional biopsy
Clear/recurs: excisional biopsy.
Complex: excisional biopsy

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94
Q

Test: gives architecture

A

CNBx

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95
Q

Test: Gives cytology (just the cells)

A

FNA

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96
Q

Mgmt: malignant breast mass (FNA/CNBx)

A

Definitive therapy

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97
Q

Mgmt: suspicious breast mass (FNA/CNBx)

A

Surgical biopsy

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98
Q

Mgmt: atypia breast mass (FNA/CNBx)

A

Surgical biopsy

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99
Q

Mgmt: non diagnostic breast mass (FNA/CNBx)

A

Repeated FNA/CNBx or surgical biopsy

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100
Q

Mgmt: benign breast mass (FNA/CNBx)

A

Possible observation - exam and imaging studies need to concordant with benign disease, otherwise need excisional biopsy.

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101
Q

Sensitivity / specificity: mammography

A

90%

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102
Q

How does mammography increase with age?

A

Sensitivity increases with age as the dense parenchymal tissue is replaced with fat.

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103
Q

Size breast mass to be detected by mammography

A

> 5 mm

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104
Q

Mammography: suggestive of Cancer

A

Irregular borders. Speculated. Multiple clustered. Small. Thin. Linear. Crushed-like and/or branching calcifications. Ductal asymmetry. Distortion of architecture.

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105
Q

BI-RAD 1.

A

Negative

Tx: Routine screening

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106
Q

BI-RADs 2

A

Benign finding

Tx: Routine screening

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107
Q

BI-RADs 3

A

Probably benign finding

Tx: Routine screening

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108
Q

BI-RADs 4

A 
Suspicious abnormality (eg, indeterminate calcifications or architecture)
Tx: definite probability of CA; get CNBx
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109
Q

BI-RADs 5

A

Highly suggestive of CA (suspicious calcifications or architecture)
Tx: high probability of CA; get CNBx.

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110
Q

Tx: BI-RADs 4 lesion CNBx

  • Malignancy?
  • Non-determinate?
  • Benign and concordant with mammogram?
A
  • Malignancy: follow appropriate treatment
  • Non-diagnostic, interdeterminate, or benign and non-concordant with mammogram -> need needle localization excisional biopsy
  • Benign and concordant with mammogram -> 6 month follow-up
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111
Q

Tx: BI-RADs 5 lesion CNBx shows

  • Malignancy?
  • Any other finding?
A
  • Malignancy: follow appropriate tx

- Any other finding (non diagnostic, indeterminate, or benign) -> all need needle localization excisional biopsy.

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112
Q

What allows appropriate staging with SLNBx (mass is still present) and one-step surgery for patients diagnosed with breast cancer?

A

CNBx without excisional biopsy.

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113
Q

Recommendations: mammogram screening?

A

Q 2-3 years after age 40, then yearly after 50.

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114
Q

Recommendations: high-risk mammogram screening

A

10 years before the youngest age of diagnosis of breast CA in first-degree relative.

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115
Q

Why aren’t mammograms generally recommended in patients

A

Hard to interpret because of dense parenchyma.

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116
Q

How does mammogram radiation dose change in younger patients?

A

Dose decreases

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117
Q

Node levels:
I?
II?
III?

A

I: lateral to pectoralis minor muscle
II: beneath pectoralis minor muscle.
III: medial to pectorlis minor muscle

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118
Q

LN: between the pectoralis major and pectoralis minor muscles.

A

Rotter’s nodes

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119
Q

What nodes do you generally take?

A

Level I and II. Take level III nodes only if grossly involved.

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120
Q

Most important prognostic staging factor

A

Nodes

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121
Q

Factors including in prognostic staging

A

Nodes (most important). Size. Grade. Progesterone / Estrogen receptor status.

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122
Q

What is survival directly related to in breast cancer?

A

Number of positive nodes.

  • 0: 75% 5-year survival
  • 1-3: 60% 5-year survival
  • 4-10: 04% 5-year survival
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123
Q

Most common site for distant metastasis

A

Bone

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124
Q

Time: Single malignant cell to 1-cm tumor.

A

Approximately 5-7 years

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125
Q

Location: increased risk of multicentricity

A

Central and subareolar tumors

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126
Q

Breast CA: greatly increased risk (relative risk > 4)

A
  • BRCA gene in pt with +fam hx
  • > 2 primary relatives with BL or premenopausal breast CA
  • DCIS (ipsilateral breast at risk) and LCIS (both breasts have same high risk)
  • Fibrocystic disease with atypical hyperplasia.
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127
Q

Breast CA: moderately increased risk (relative risk 2-4)

A
  • Prior breast cancer
  • Radiation exposure
  • First degree relative with breast cancer
  • Age > 35 first birth
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128
Q

Breast CA: lower increased risk (relative risk

A
  • Early menarche / late menopause
  • Nulliparity
  • Proliferative benign disease
  • Obesity, alcohol, hormone replacement therapy.
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129
Q

BRCA I Cancer Risk

  • Female breast CA
  • Ovarian CA
  • Male breast CA
A

Lifetime risk..

  • Female breast: 60%
  • Ovarian: 40%
  • Male breast: 1%
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130
Q

BRCA II Cancer Risk

  • Female breast CA
  • Ovarian CA
  • Male breast CA
A

Lifetime risk..

  • Female breast: 60%
  • Ovarian: 10%
  • Male breast: 10%
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131
Q

Sx Considerations: BRCA families with history of breast cancer

A

Total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO)

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132
Q

Breast Cancer risk: first degree relative with bilateral, premenopausal breast cancer

A

50%

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133
Q

Considerations for prophylactic mastectomy

A
  • Family history + BRCA gene
  • LCIS
  • Also need one of the following: high patient anxiety, poor patient access for follow-up exams and mammograms, difficult lesion to follow on exam or with mammograms, or patient with preference for mastectomy
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134
Q

Why are positive receptors good?

A

Better response to hormones, chemotherapy, surgery, and better overall prognosis.

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135
Q

Receptor-positive tumors are more common in…

A

Postmenopausal women

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136
Q

What receptor do you want positive: estrogen or progesterone?

A

Progesterone receptor-positive tumors have better prognosis than estrogen receptor-positive tumors.

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137
Q

What happens with positive estrogen AND progesterone receptors?

A

Both positive? Has the best prognosis.

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138
Q

%: Breast cancer negative for both receptors.

A

10%

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139
Q

-

A

Male breast cancer

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140
Q

What is male breast cancer associated with?

A

Steroid use.
Previous XRT.
Family history.
Klinefelter’s syndrome

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141
Q

Tx: male breast cancer

A

Tx: Modified Radical Mastectomy (MRM)

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142
Q
  • 85% of all breast cancer.

Tx?

A

Ductal CA

Tx: MRM or BCT (breast conserving therapy) with post XRT

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143
Q

Ductal CA: Subtypes

A

Medullary.
Tubular.
Mucinous.
Scirrhotic.

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144
Q

Ductal CA: smooth borders, increased lymphocytes, bizarre cells, more favorable prognosis.

A

Medullary ductal CA

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145
Q

Ductal CA: small tubule formations, more favorable prognosis.

A

Tubular ductal CA

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146
Q

Ductal CA: produces an abdundance of mucin, more favorable prognosis

A

Mucinous (colloid) ductal CA

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147
Q

Ductal CA: worse prognosis

A

Schirrhotic

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148
Q
  • 10% of all breast CA
  • Does not form calcifications, extensively infiltrative, increased bilateral, multifocal and multi centric disease.
  • signet ring cells confer worse prognosis
A

Lobular cancer

149
Q

Tx: lobular cancer

A

MRM or BCT with post op XRT

150
Q

Path: confers worse prognosis in lobular CA

A

Signet ring cells

151
Q
  • Considered T4 disease
  • Very aggressive -> median survival of 36 months
  • Has dermal lymphatic invasion, which causes peau d’orange lymphedema appearance on breast, erythematous and warm
A

Inflammatory breast cancer

152
Q

Tx: inflammatory breast CA

A

Neoadjuvant chemo, then MRM, then adjuvant chemo-XRT (most common method)

153
Q
  • Leaves 1%-2% of breast tissue, preserves the nipple
  • Not indicated for breast CA treatment
  • Used for DCIS and LCIS
A

Subcutaneous mastectomy

simple mastectomy

154
Q
  • Removes all breast tissue, including the nipple areolar complex
  • Includes axillary node dissection (level 1 nodes)
A

Modified radical mastectomy

155
Q

Surgical options for breast cancer

A 
Subcutaneous mastectomy.
Breast-conserving therapy.
Modified radical mastectomy. 
SLNB.
ALND.
156
Q

Combined with postop XRT; need 1cm margin

A

Breast-conserving therapy.

157
Q

Absolute contraindications to Breast-Conserving Therapy in invasive CA

A
  • Two or more primary tumors in separate quadrants of the breast.
  • Persistant + margins after reasonable surgical attempts
  • Pregnancy: BCT with radiation after delivery.
  • h/o prior therapeutic radiation to breast region that would result in re-treatment with excessively high radiation dose.
  • Diffuse malignant appearing microcalcifications
158
Q

Relative contraindications to breast-conserving therapy in invasive carcinoma

A
  • h/o scleroderma or active SLE
  • Large tumor in a small breast that would result in cosmoses unacceptable to pt.
  • Very large of pendulous breasts if reproducibility of patient setup and adequate dose homogeneity cannot be ensured.
159
Q
  • Indicated only for malignant tumors > 1cm

- Not indicated in pts with clinically positive nodes (need ALND).

A

Sentinel lymph node biopsy (SLB)

160
Q

When is accuracy best for sentinel lymph node biopsy?

A

When primary tumor is present (finds the right lymphatic channels)

161
Q

Dye used for sentinel lymph node biopsy

A

Lymphazurin blue dye or radio tracer is injected directly into the tumor area.

162
Q

What to do: no radio tracer dye is found during sentinel lymph node biopsy

A

Do a formal ALND

163
Q

Contraindications: SLNB (sentinel lymph node biopsy)

A 
Pregnancy.
Multi centric disease.
Neoadjuvant therapy.
Clinically positive nodes.
Prior axillary surgery.
Inflammatory or locally advanced disease.
164
Q

When level nodes do you take for axillary lymph node dissection?

A

Level 1 and 2 nodes

165
Q

Complications of MRM

A

Infection.
Flap necrosis.
Seromas.

166
Q

Complications of ALND

A
  • Infection, lymphedema, lymphangiosarcoma.
  • Axillary vein thrombosis (sudden early post swelling)
  • Lymphatic fibrosis (slow swelling over 18 months)
  • Intercostal brachiocutaneous nerve injury
167
Q

ALND: sudden, early, post op swelling

A

Axillary vein thrombosis

168
Q

ALND: slow swelling over 18 months

A

Lymphatic fibrosis

169
Q

ALND: hypesthesia of inner arm and lateral chest wall; most commonly injured nerve after mastectomy, no significant sequelae

A

Intercostal brachiocutaneous nerve injury

170
Q

MC’ly injured nerve after mastectomy

A

Intercostal brachiocutaneous nerve injury.

171
Q

How long do you leave in drains after ALND?

172
Q

Radiation dose of radiotherapy

A

5,000 rad for BCT and XRT

173
Q

Complications: XRT

A

Edema. Erythema. Rib fratures. Pneumonitis. Ulceration. Sarcoma. Contralateral breast CA.

174
Q

Contraindications: XRT

A

Scleroderma (results in severe fibrosis and necrosis). Previous XRT and would exceed recommended dose. SLE (relative). Active rheumatoid arthritis (relative).

175
Q

Indications for XRT after mastectomy.

A
  • > 4 nodes
  • Skin or chest wall involvement
  • Positive margins
  • Tumor > 5 cm (T3)
  • Extracapsular nodal invasion.
  • Inflammatory CA
  • Fixed axillary nodes (N2) or internal mammary nodes (N3)
176
Q

When can you start XRT after BCT?

A

When you have 1cm negative margins following BCT

177
Q

%: Chance of local recurrence after BCT with XRT

A

10%

  • Usually within 2 years of first operation.
  • Need to re-stage with recurrence.
  • Need salvage MRM for local recurrence.
178
Q

Chemotherapy regimen

A

TAC

taxanes, Adriamycin, cyclophosphamide for 6-12 weeks

179
Q

Who gets chemotherapy with positive nodes?

A

Everyone EXCEPT postmenopausal women with positive estrogen receptors (they get hormonal therapy only aromatase inhibitor (anastrozole))

180
Q

Tx: postmenopausal, positive nodes, estrogen receptor positive

A

Hormonal therapy only with aromatase inhibitor (anastrozole)

181
Q

Chemo: > 1cm and negative nodes

A

Everyone gets chemo except patients with positive estrogen receptors - > they can get hormonal therapy only with tamoxifen if they are premenopausal or aromatase inhibitor (anastrozole) if they are postmenopausal.

182
Q
A

No chemo.

Hormonal therapy as above if positive estrogen receptors.

183
Q

Tx after chemo: pts positive for estrogen receptors

A

Appropriate hormonal therapy

184
Q

Have been shown to decrease recurrence and improve survival

A

Both chemotherapy and hormonal

185
Q

Taxanes

A

Docetaxel, paclitaxel

186
Q
  • Decreases risk of breast cancer by 50%

- 1% risk of blood clots; 0.1% risk of endometrial cancer

187
Q

What happens to women with breast cancer recurrence?

A

Almost all women with recurrence die of disease.

188
Q

Increased recurrences and metastases occurs with..

A

Positive nodes.
Large tumors.
Negative receptors.
Unfavorable subtype.

189
Q
  • Pain, swelling, erythema is metastatic areas.

Tx?

A

Metastatic flare
- Tx: XRT can help
XRT is good for bone metastasis

190
Q

Breast CA that presents as axillary metastases with unknown primary.
Tx?

A

Occult breast CA

- Tx: MRM (70% are found to have breast CA)

191
Q
  • Scaly skin lesion on nipple
  • Have DCIS or ductal CA in breast
    Tx?
A

Paget’s disease

Tx: need MRM if cancer present; otherwise simple mastectomy (need to include the nipple-areolar complex with Paget’s)

192
Q

Bx: Paget’s disease

A

Paget’s cells

193
Q

Tx: Paget’s disease

A

Need MRM if cancer present; otherwise simple mastectomy (need to include the nipple-areolar complex with Paget’s)

194
Q
  • 10% malignant, based on mitoses per high-power field (>5-10)
  • No nodal metastases, hematogenous spread if any (rare)
  • Resembles giant fibroadenoma; his stromal and epithelial elements (mesencymal tissue)
  • Can often be large tumors
    Tx?
A

Cystosarcoma phyllodes

- Tx: WLE with negative margins; no ALND

195
Q

Tx: Cystosarcoma phyllodes

A

WLE with negative margins; no ALND

196
Q
  • Lymphangiosarcoma from chronic lymphedema following axillary dissection
  • Pts present with dark purple nodule or lesion on arm 5-10 years after surgery
A

Stewart-Treves syndrome

197
Q
  • Tends to present late, leading to worse prognosis.
  • Mammography and US do not work as well during pregnancy.
  • Try to use ultrasound to avoid radiation
A

Pregnancy with mass

198
Q

Tx: pregnant with mass - cyst

A

Drain it and send FNA for cytology

199
Q

Tx: pregnant with mass - solid

A

Perform core needle biopsy or FNA

200
Q

Pregnancy with mass: core needle and FNA equivocal

A

Need to go to excisional biopsy.

201
Q

If breast CA

  • 1st trimester?
  • 2nd trimester?
  • 3rd trimester?
A
  • 1st: MRM
  • 2nd: MRM
  • 3rd: MRM or if late can perform lumpectomy with ALND and postpartum XRT
202
Q

Radiation in pregnancy with breast cancer.

A

No XRT while pregnant, no breastfeeding after delivery.

203
Q

Boundaries of the axilla:

  • Superior
  • Posterior
  • Lateral
  • Medial
A
  • Superior: axillary vein
  • Posterior: long thoracic nerve
  • Lateral: latissimus dorsi
  • Medial: lateral to, deep to, or medial to pectoral minor muscle, depending on the level of nodes taken.
204
Q

What four nerves must the surgeon be aware of during an axillary dissection?

A
  1. Long thoracic nerve
  2. Thoracodorsal nerve
  3. Medial pectoral nerve
  4. Lateral pectoral nerve
205
Q

Courses along lateral chest wall in midaxillary line on serratus anterior muscle; innervates serratus anterior muscle

A

Long thoracic nerve

206
Q

Courses lateral to long thoracic nerve on latissimus doors muscle; innervates latissimus dorsi muscle

A

Thoracodorsal nerve

207
Q

Runs lateral to or through the pectoral minor muscle, actually lateral to the lateral pectoral nerve, innervates the pectoral minor and pectoral major muscles

A

Medial pectoral nerve

208
Q

Runs medial to the medial pectoral nerve (names describe orientation from the brachial plexus!); innervates the pectoral major.

A

Lateral pectoral nerve

209
Q

What is the name of the deformity if you cut the long thoracic nerve in this area?

A

“Winged scapula”

210
Q

What is the name of the cutaneous nerve that crosses the axillary in a transverse fashion?

A

Intercostobrachial nerve

211
Q

What is the name of the large vein that marks the upper limit of the axilla?

A

Axillary vein

212
Q

What is the lymphatic drainage of the breast?

A

Lateral: axillary lymph nodes
Medial: parasternal nodes that run with internal mammary artery.

213
Q

What are the suspensory breast ligaments called?

A

Cooper’s ligaments

214
Q

What is the mammary “milk line”?

A

Embryological line from should to thigh where “supernumerary” breast areolar and / or nipple can be found

215
Q

What is the “tail of Spence”?

A

“Tail” of breast tissue that tapers into the axilla.

216
Q

Which hormone is mainly responsible for breast milk production?

217
Q

What is the incidence of breast cancer?

A

12% lifetime risk

218
Q

What percentage of women with breast cancer have no known risk factor?

219
Q

What percentage of all breast cancers occur in women younger than 30 years?

220
Q

What percentage of all breast cancers occur in women older than 70 years?

221
Q

What are the major breast cancer suspeptibility genes?

222
Q

What option exists to decrease the risk of breast cancer in women with BRCA?

A

Prophylactic bilateral mastectomy

223
Q

What is the most common motivation for medicolwegal cases involving the breast?

A

Failure to diagnose a breast carcinoma.

224
Q

What is the train of error for misdiagnosed breast cancer?

A
  1. Age 75% of cases of misdiagnosed breast cancer have these three characteristics.
225
Q

What are the history risk factors for breast cancer?

A

NAACP

  • Nulliparity
  • Age at menarche (younger than 13 years)
  • Age at menopause (> 55 years)
  • Cancer of the breast (in self or family)
  • Pregnancy with first child (> 30 yrs)
226
Q

What are physical / anatomic risk factors for breast cancer?

A

CHAFED LIPS

  • Cancer in the breast (3% synchronous contralateral cancer)
  • Hyperplasia, Atypical hyperplasia, Female, Elderly, DCIS
  • LCIS, Inferited genes, Papilloma, Sclerosing adenosis
227
Q

What is the relative risk of hormone replacement therapy?

228
Q

Is “run of the mill” fibrocystic disease a risk factor for breast cancer?

229
Q

What are the possible symptoms of breast cancer?

A

No symptoms. Mass in the breast. Pain (most painless). Nipple discharge. Local edema. Nipple retraction. Dimple. Nipple rash.

230
Q

Why does the skin retraction occur?

A

Tumor involvement of Cooper’s ligaments and subsequent traction on ligaments pull skin inward.

231
Q

What are the signs of breast cancer?

A

Mass (1 cm is usually the smallest lesion that can be palpated on examination).
Dimple. Nipple rash. Edema. Axillary / supraclavicular nodes.

232
Q

What is the most common site of breast cancer?

A

Approximately one half of cancers develop in the upper outer quadrants.

233
Q

What are the different types of invasive breast cancer?

A 
Infiltrating ductal ca (75%)
Medullary ca (15%)
Infiltrating lobular CA (2%)
Tubular ca (2%)
Mucinous ca (colloid) (1%)
Inflammatory breast ca (1%)
234
Q

What is the MC type of breast cancer?

A

Infiltrating ductal ca

235
Q

What is the differential diagnosis of breast cancer?

A

Fibrocystic disease of the breast. Fibroadenoma. Intraductal papilloma. Duct ectasia. Fat necrosis. Abscess. Radial scar. Simple cyst.

236
Q

Breast exam recommendations?

A

Self-exam of breasts monthly.
Ages 20-40 years: breast exam every 2-3 years by a physician.
> 40 years: annual breast exam by physician.

237
Q

When is the best time for breast self-exam?

A

1 week after menstrual period

238
Q

Why is mammography a more useful diagnostic tool in older women than in younger?

A

Breast tissue undergoes fatty replacement with age; making masses more visible; younger women have more fibrous tissue, which makes mammograms harder to interpret.

239
Q

What are the radiographic tests for breast cancer?

A

Mammography and breast ultrasound, MRI

240
Q

What option is best to evaluate a breast mass in a woman younger than 30 years?

A

Breast ultrasound

241
Q

What are the methods for obtaining tissue for pathologic examination?

A

FNA, core biopsy (larger needle core sample), mammotome sterotactic biopsy, and open biopsy which can be incisional (cutting a piece of the mass) or excisional (cutting out the entire mass)

242
Q

What are the indications for biopsy of breast mass?

A

?Persistent mass after aspiration.
solid Mass. Blood in cyst aspirate. Suspicious lesion by mammo/US/MRI. Ulcer or dermatitis of nipple. Patient’s concern of persistent breast abnormality.

243
Q

What is the process for performing a biopsy when a non palpable mass is seen on mammo?

A

Stereotactic (mammotome) biopsy or needle localization therapy

244
Q

What is needle loc biopsy (NLB)?

A

Needle localization by radiologist, followed by biopsy; removed breast tissue must be checked by mammo to ensure al of the suspicious lesion has been excised.

245
Q

What is a mammotome biopsy?

A

Mammogram-guided computerized stereotactic core biopsies

246
Q

What is obtained first, the mammogram or the biopsy?

A

Mammogram is obtained first; otherwise, tissue extraction (core or open) may alter the mammography findings (FNA may be done prior to the mammo because the fine needle will not affect the mammography findings).

247
Q

What would be suspicious mammographic findings?

A

Mass, microcalcifications, stellate / spiculated mass

248
Q

What is a “radial scar” seen on mammogram?

A

Spiculated mass with central lucency, +/- microcalcifications

249
Q

What tumor is a/w a radial scar?

A

Tubular carcinoma, thus, biopsy is indicated.

250
Q

What is the “workup” for a breast mass?

A
  1. Clinical breast exam
  2. Mammogram on breast ultrasound.
  3. FNA, core biopsy, or open biopsy
251
Q

How do you proceed if the mass appears to be a cyst?

A

Aspirate it with a needle

252
Q

Is the fluid from a breast cyst sent for cytology?

A

Not routinely, bloody fluid should be sent for cytology.

253
Q

When do you proceed to open biopsy for a breast cyst?

A
  1. In the case of a second cyst recurrence.
  2. Bloody fluid in the cyst.
  3. Palpable mass after aspiration.
254
Q

What is the preoperative staging workup in a patient with breast cancer?

A
  1. Bilateral mammo (CA in one breast is a risk for cancer in 2)
  2. CXR (lung mets)
  3. LFT (liver mets)
  4. Serum calcium level, alkaline phosphatase (if these tests indicate bone mets/bone pain, proceed to bone scan)
  5. Other: depending s/s
255
Q

What hormone receptors must be checked for in the biopsy specimen?

A

Estrogen and progesterone receptors

256
Q

What staging system is used for breast cancer?

257
Q

Stage: tumor

258
Q

Stage: tumor

259
Q

Stage: Tumor 2-5 cm in diameter with mobile axillary nodes
- or -
Tumor > 5cm with no nodes

260
Q

Stage: Tumor > 5cm with mobile axillary nodes
- or -
Any size tumor with fixed axillary nodes, no metastases

261
Q

Stage: Peau d’orange (skin edema) or Chest wall invasion / fixation or Inflammatory cancer or breast skin ulceration or breast skin satellite metastases or any tumor and + ipsilateral internal mammary lymph nodes.

262
Q

Stage: Any size tumor, no distant mets.
Positive: supraclavicular, infraclavicular, or internal mammary lymph nodes

263
Q

Stage: distant mets (including ipsilateral supraclavicular nodes)

264
Q

What are the sites of metastases?

A

Lymph nodes (MC). Lung / pleura. Liver. Bones. Brain.

265
Q

What are the major treatments of breast cancer?

A

Modified radical mastectomy.
Lumpectomy and radiation + SLND.
(Both: either +/- post op chemo / tamoxifen)

266
Q

What are the indications for radiation therapy after a modified radical mastectomy?

A

Stage 3A, Stage 3B, Pectoral muscle / fascia invasion.
Positive internal mammary LN.
Positive surgical margins.
> 4 positive axillary LN’s postmenopausal.

267
Q

What breast carcinomas are candidates for lumpectomy and radiation (breast-conserving therapy)?

A

Stage 1 and 2 (tumors

268
Q

What approach may allow a patients with stage 3A cancer to have breast-conserving surgery?

A

Neoadjuvant chemotherapy - if the prep chemo shrinks the tumor.

269
Q

What is the treatment of inflammatory carcinoma of the breast?

A

Chemotherapy first! Then often followed by radiation, mastectomy, or both.

270
Q

What is a “lumpectomy and radiation”?

A

Lumpectomy (segmental mastectomy: removal of a part of the breast); axillary node dissection; and a course of radiation therapy after operation, over a period of several weeks.

271
Q

What is the major absolute contraindication to lumpectomy and radiation?

272
Q

What is a modified radical mastectomy?

A

Breast, axillary nodes (level I and 2) and nipple-areolar complex are removed. Pectoralis major and minor muscles are not removed (Auchincloss modification). Drains are placed to drain lymph fluid.

273
Q

Where are the drains placed with an MRM?

A
  1. Axilla

2. Chest wall (breast bed)

274
Q

When should the drains be removed s/p MRM?

275
Q

What are the potential complications after a modified radical mastectomy?

A

Ipsilateral arm lymphedema. Infection. Injury to nerves, skin flap necrosis, hematoma / serum, phantom breast syndrome.

276
Q

During an axillary dissection, should the patient be paralyzed?

A

No, because the nerves (long thoracic / thoracodorsal) are stimulated with resultant muscle contraction to help identify them.

277
Q

How can the long thoracic and thoracodorsal nerves be identified during an axillary dissection?

A

Nerves can be stimulated with a forceps, which results in contraction of the latissimus dorsi (thoracodorsal nerve) or anterior serratus (long thoracic nerve)

278
Q

When do you remove the drains after an axillary dissection?

A

When there is

279
Q

What is a sentinel node biopsy?

A

Instead of removing all the axillary lymph nodes, the primary draining or “sentinel” lymph node is removed.

280
Q

How is the sentinel lymph node found?

A

Inject blue dye and/or technetium-labeled sulfur colloid (best results with both)

281
Q

What follows a positive sentinel node biopsy?

A

Removal of the rest of the axillary lymph nodes

282
Q

What is now considered the standard of care for lymph node evaluation in women with T1 or T2 tumors (stages 1 and 2A) and clinically negative axillary lymph nodes?

A

Sentinel lymph node dissection

283
Q

What do you do with a mammotome biopsy that returns as “atypical” hyperplasia?

A

Open needle loc biopsy as many will have DCIS or invasive cancer

284
Q

How does tamoxifen work?

A

It binds estrogen receptors

285
Q

What is the treatment for local recurrence in breast after lumpectomy and radiation?

A

“Salvage” mastectomy

286
Q

Can tamoxifen prevent breast cancer?

A

Yes. In the breast cancer prevention trial of 13,000 women at increased risk, tamoxifen reduces risk by ~ 50% across all ages.

287
Q

What are common options for breast reconstruction?

A

TRAM flap, implant, latissimus dorsi flap

288
Q

What is a TRAM flap?

A

Transverse Rectus Abdominis Myocutaneous flap

289
Q

What are the side effects of tamoxifen?

A

Endometrial cancer (2.5 x relative risk), DVT, PE, cataracts, hot flashes, mood swings

290
Q

In high-risk women, is there a way to reduce the risk of developing breast cancer?

A

Yes, tamoxifen for 5 yr will lower the risk ~ 5%, but with an increased risk of endometrial cancer and clots, it must be an individual patient determination

291
Q

What type of chemotherapy is usually used for breast cancer?

A

CMF (cyclophosphamide, methotrexate, 5-fluorouracil) or CAF (cyclophosphamide, adriamycin, 5-fluorouracil)

292
Q

What makes a tumor high risk?

A 
> 1 cm in size
Lymphatic / vascular invasion
Nuclear grade (high)
S phase (high)
ER negative
HER-2/neu overexpression
293
Q

What is DCIS also known as?

A

Intraductal carcinoma.

294
Q

Describe DCIS.

A

Cancer cells in the duct without invasion. (Cells do not penetrate the basement membrane).

295
Q

s/s: DCIS

A

Usually none; usually nonpalpable

296
Q

DCIS: mammographic findings

A

Microcalcifications

297
Q

DX: DCIS

A

Core or open biopsy

298
Q

DCIS: most aggressive subtype

299
Q

Risk: lymph node mets DCIS

300
Q

What is the major risk with DCIS?

A

Subsequent development of infiltrating ductal carcinoma in the same breast

301
Q

Tx: DCIS Tumor

A

Remove with 1 cm margins +/- XRT

302
Q

Tx: DCIS Tumor > 1cm

A

Perform lumpectomy with 1 cm margins and radiation or total mastectomy (no axillary dissection)

303
Q

What is a total (simple) mastectomy?

A

Removal of the breast and nipple without removal of the axillary nodes (always remove nodes with invasive cancer)

304
Q

When must a simple mastectomy be performed for DCIS?

A

Diffuse breast involvement (e.g., diffuse micro calcifications), > 1cm and contraindication to radiation

305
Q

What is the role of axillary node dissection with DCIS?

A

No role in true DCIS (i.e., without micro invasion); some perform a sentinel lymph node dissection for high-grade DCIS

306
Q

What is adjuvant for DCIS?

A
  1. Tamoxifen

2. Postlumpectomy XRT

307
Q

What is the role of tamoxifen in DCIS?

A

Tamoxifen for 5 years will lower the risk up to 50%, but with increased risk of endometrial cancer and clots; it must be an individual patient determination.

308
Q

What is a memory aid for the breast in which DCIS breast cancer arises?

A

Cancer arises in the same breast as DCIS.

309
Q

What is LCIS?

A

Lobular Carcinoma in Situ (Carcinoma cells in the lobules of the breast without invasion)

310
Q

s/s: LCIS

311
Q

Mammographic findings: LCIS

312
Q

Dx: LCIS

A

LCIS is found incidentally on biopsy

313
Q

LCIS: major risk

A

Carcinoma of either breast

314
Q

Which breast is more at risk for developing an invasive carcinoma?

A

Equal risk in both breasts! (think of LCIS as a risk marker for future development of cancer in either breast)

315
Q

What percentage of women with LCIS develop an invasive breast carcinoma?

A

~ 30% in the 20 years after diagnosis of LCIS

316
Q

What type of invasive breast cancer do patients with LCIS develop?

A

Most commonly, infiltrating ductal carcinoma with equal distribution in the contralateral and ipsilateral breast

317
Q

What medication may lower the risk of developing breast cancer in LCIS?

A

Tamoxifen for 5 yrs will lower the risk up to 50%, but with an increased risk of endometrial cancer and clots; it must be an individual patient determination.

318
Q

What is the treatment of LCIS?

A

Close follow-up (or bilateral simple mastectomy in high-risk patients)

319
Q

What is the major difference in the subsequent development of invasive breast cancer with DCIS and LCIS?

A

LCIS cancer develops in either breast; DCIS cancer develops in the ipsilateral breast.

320
Q

How do you remember which breast is at risk for invasive cancers in patients with LCIS?

A

LCIS: liberally in either breast

321
Q

MCC bloody nipple discharge in young women

A

Intraductal papilloma

322
Q

MC breast tumor

A

Fibroadenoma

323
Q

What is Paget’s disease of the breast?

A

Scaling rash / dermatitis of the nipple caused by invasion of skin by cells from a ductal carcinoma

324
Q

What are the common options for breast reconstruction after a mastectomy?

A

Saline implant

TRAM flap

325
Q

What is the incidence of breast cancer in men?

326
Q

What is the average age at diagnosis?

A

65 years of age

327
Q

What are the risk factors?

A

Increased estrogen. Radiation. Gynecomastia from increased estrogen. Estrogen therapy. Klinefelter’s syndrome (XXY). BRCA2 carriers.

328
Q

Is benign gynecomastia a risk factor for male breast cancer?

329
Q

What type of breast cancer do men develop?

A

Nearly 100% of cases are ductal carcinoma (men do not usually have breast lobules)

330
Q

S/S: Breast cancer in men

A

Breast mass (most are painless), breast skin changes (ulcers, retraction), and nipple discharge (usually blood or a blood-tinged discharge)

331
Q

MC presentation: breast cancer in main

A

Painless breast mass

332
Q

Dx: breast cancer in men

A

Biopsy and mammogram

333
Q

Tx: breast cancer in men

A
  1. Mastectomy
  2. Sentinel LN dissection of clinically negative axilla
  3. Axillary dissection if clinically positive axillary LN
334
Q

MCC green, straw-colored or brown nipple discharge

A

Fibrocystic disease

335
Q

MCC breast mass after breast trauma

A

Fat necrosis

336
Q

Thrombophlebitis of superficial breast veins

A

Mondor’s disease

337
Q

What must be ruled out with spontaneous galactorrhea (+/- amenorrhea)

A

Prolactinoma (check pregnancy test and prolactin level)

338
Q

Mesenchymal tumor arising from breast lobular tissue; most are benign

A

Cystosarcoma phyllodes

339
Q

Phyllodes tumor: age

A

25-55 years (usually older than pt with fibroadenoma)

340
Q

s/s: phyllodes tumor

A

Mobile, smooth breast mass that resembles a fibroadenoma on exam, mammogram / ultrasound findings

341
Q

Dx: Phyllodes tumor

A

Core biopsy / excision

342
Q

Tx: Phyllodes tumor

A

If benign, wide local excision; if malignant, simple total mastectomy.

343
Q

What is the role of axillary dissection with cystosarcoma phyllodes tumor?

A

Only if clinically palpable axillary nodes, as the malignant form rarely spreads to nodes (MC site of mets is the lung)

344
Q

Is there a role for chemotherapy with cystosarcoma phyllodes?

A

Consider chemotherapy if large tumor > 5 cm and “stromal overgrowth”

345
Q

Benign tumor of the breast consisting of streams overgrowth, collagen arranged in “swirls”

A

Fibroadenoma

346
Q

Solid, mobile, well-circumscribed round breast mass, usually

A

Fibroadenoma

347
Q

Dx: fibroadenoma

A

Negative needle aspiration looking for fluid; ultrasound, core biopsy

348
Q

Tx: fibroadenoma

A

Surgical resection for large or growing lesions; small fibroadenomas can be observed closely.

349
Q

MC breast tumor in women

A

Fibroadenoma

350
Q

Common benign breast condition consisting of fibrous (rubbery) and cystic changes in the breast

A

Fibrocystic disease

351
Q

S/S Breast pain or tenderness that varies with the menstrual cycle; cysts; and fibrous (“nodular”) fullness

A

Fibrocystic disease

352
Q

Dx: fibrocystic disease

A

Breast exam, history, and aspirated cysts (usually straw-colored or green fluid)

353
Q

Tx: fibrocystic disease

A

Stop caffeine.
Pain meds (NSAIDS)
Vitamin E, evening primrose oil (danazol and OCP as last resort)

354
Q

What is done if the patient has a breast cyst?

A

Aspirate s/t needle drainage:

  • Bloody / palpable mass: open bx
  • Straw / green color: follow closely, 2nd? needle aspirate
  • Re-recurrence usually requires open biopsy
355
Q

Superficial infection of the breast (cellulitis)

356
Q

MCC mastitis

A

Breast-feeding

357
Q

MCC mastitis - bacteria

358
Q

Tx: mastitis

A

Stop breast-feeding and use a breast pump instead; apply heat; administer antibiotics

359
Q

Why must the patient with mastitis have close follow-up?

A

To make sure that she does not have inflammatory breast cancer!

360
Q

Causes of breast abscesses

A

Mammary ductal ectasia (stenosis of breast duct) and mastitis

361
Q

Breast abscess: MC bacteria

A

Nursing - S. aureus

Nonlatating: mixed infection

362
Q

Tx: Breast abscess

A

Antibiotics (eg, dicloxacillin)
Needle or open drainage with cultures taken.
Resection of involved ducts if recurrent.
Breast pump if breast-feeding.

363
Q

Infection of the breast during breast feeding - most commonly caused by S. aureus; treat with antibiotics and follow for abscess formation

A

Lactational mastitis

364
Q

What must be ruled out with a breast abscess in a non lactating woman?

A

Breast cancer

365
Q

Enlargement of the male breast

A

Male Gynecomastia

366
Q

Causes of male gynecomastia

A 
Medications.
Illicit drugs (marijuana)
Liver failure
Increased estrogen
Decreased testosterone
367
Q

Major DDX male gynecomastia in the older patient

A

Male breast cancer

368
Q

Tx: male gynecomastia

A

Stop or change medications; correct underlying cause if there is a hormonal imbalance; and perform biopsy or subcutaneous mastectomy (i.e., leave nipple) if refractory to conservative measures and time.

06 - absite (44 decks)

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