Chapter 24 - Breast Flashcards
Estrogen leads to what part of breast development?
Duct (double layer of columnar cells)
Progesterone leads to what part of breast development?
Lobular (glandular) development
Prolactin has what effect on breast development?
Synergizes estrogen and progesterone
Estrogen causes what cyclic change in the breast?
Increased breast swelling, growth of glandular tissue
Progesterone causes what cyclic change in the breast?
Increased maturation of glandular tissue; withdrawal causes menses.
What cyclic change is caused by LH, FSH surge?
Causes ovum release
Long thoracic nerve innervates what? Injury results in what?
Serratus anterior; winged scapula
Thoracodorsal nerve innervates what? Injury causes what?
Latissimus dorsi; weak arm pull-ups and adduction
What artery goes to the serratus anterior?
Lateral thoracic artery (same name as nerve)
What artery goes to latissimus dorsi?
Thoracodorsal artery (same name as nerve)
Medial pectoral nerve innervates what?
Pectoralis major and minor
Lateral pectoral nerve innervates what?
Pectoralis major only
Intercostobrachial nerve comes from where? Innervates what?
From lateral cutaneous branch of the 2nd intercostal nerve; sensation to medial arm and axilla
Branches of what arteries supply the breast?
Internal thoracic artery, intercostal arteries, thoracoacromial artery, lateral thoracic artery
Batson’s plexus allows what to happen in breast cancer?
Valveless vein plexus that allows direct hematogenous mets to spine
What disease does primary axillary adenopathy most likely indicate?
1 lymphoma
Positive supraclavicular nodes indicate what stage disease?
M1
Most common bacteria in breast abscess?
S. aureus, strep; associated with breast feeding
Treatment for abscesses?
- I&D; ice, heat
- drain milk - pump or breastfeed
- if MRSA suspected - PO Bactrim or clindamycin
- if no MRSA risk - dicloxacillin or cephalexin okay
- if unstable or systemic illness - IV Vancomycin
- leukocytosis, fever, tachycardia
Most common bacteria in infectious mastitis?
S. aureus; in nonlactating women can be due to chronic inflammatory diseases (actinomyces, TB, syphilis)
Workup for infectious mastitis?
Need to rule out necrotic cancer. If suspected, can do incisional biopsy including skin.
If purulent nipple discharge, gram stain and culture +/- I&D or needle aspiration.
Repeat episodes warrant duct excision.
What is periductal mastitis?
Inflammation of the subareolar ducts.
Mammary duct ectasia or plasma cell mastitis; dilated mammary ducts, inspissated secretions, marked periductal inflammation
Symptoms of periductal mastitis?
Noncyclical mastodynia, nipple retraction, creamy discharge from nipple; can have sterile subareolar abscess; pts with difficulty breastfeeding.
Treatment for periductal mastitis?
Reassure if discharge is creamy, non bloody and not associated with nipple retraction; otherwise r/o cancer.
What is a galactocele?
Breast cysts filled with milk usually 2/2 obstruction; occurs with breastfeeding.
Imaging shows fat-fluid level or indeterminate mass.
Treatment for galactocele?
Can aspirate - milky substance
Excision unnecessary - no malignant risk
What is galactorrhea caused by?
High prolactin (pituitary prolactinoma), OCPs, TCAs, phenothiazines, metoclopramide, alpha-methyl dopa, reserpine… either prolactinoma or meds.
What is gynecomastia? Caused by?
- cimetidine, spironolactone, marijuana, idiopathic
- cirrhosis, malnutrition
- testicular tumors
What is the cause of neonatal breast enlargement?
Due to circulating maternal estrogens; will regress
Most common location for accessory breast tissue?
Axilla
What is the most common breast abnormality?
Accessory nipples
What is Poland’s syndrome?
Hypoplasia of chest wall, amastia, hypoplastic shoulder, no pectoralis muscle.
Workup for mastodynia?
Pain in breast; rarely represents breast CA. Workup is minimal unless concerning signs on H&P.
Treatment for mastodynia?
- OCPs, tylenol, NSAIDs
- Can try caffeine avoidance, primrose oil
- Bromocriptine no longer used
- Danazol - effective, but androgenic sfx
What is cyclic mastodynia most commonly caused by?
Fibrocystic disease
What is continuous mastodynia caused by?
Most commonly acute or subacute infection
What is Mondor’s disease?
Superficial vein thrombophlebitis of breast; cordlike, can be painful.
What is Mondor’s associated with? Treatment?
Trauma and strenuous exercise; NSAIDs. Abx usually not necessary unless severe or systemic. Surgery last line.
Symptoms of fibrocystic disease?
Breast pain, nipple discharge (uncommon, yellow to brown), masses, lumpy breast tissue that varies with hormonal cycle.
How can sclerosing adenosis present?
Cluster of calcifications on mammogram without mass or pain
How is sclerosing adenosis differentiated from breast CA pathologically?
By regularity of nuclei and absence of mitoses
Most common cause of bloody discharge from nipple?
Intraductal papilloma
Malignancy risk with intraductal papilloma?
NOT premalignant
Treatment of intraductal papilloma?
Resection (subareolar resection curative)
What is the most common breast lesion in adolescents and young women?
Fibroadenoma
Characteristics of fibroadenoma?
Painless, slow growing, well cicumscribed, firm and rubbery; change size in pregnancy; grows to several cm in size then stops
Pathology of fibroadenoma? Mammography findings?
Prominent fibrous tissue compressing epithelial cells; popcorn lesions (large, coarse calcifications)
Work up of nipple discharge?
- H&P: nonbloody and multiductal vs persistent, uniductal, unilateral, spontaneous
- If suspicious: ultrasound and bilateral mammogram
- Pathological nipple discharge requires excision of the duct.
What is green discharge due to? What is the treatment?
Fibrocystic disease; if cyclical and nonspontaneous, reassure patient
What is bloody discharge due to? Treatment?
Most commonly intraductal papilloma, occasionally ductal CA; galactogram and excision of that ductal area
What is serous discharge due to? Treatment?
- Usually d/t papilloma, but worrisome for cancer.
- If unitaleral and spontaneous, will require full workup and excisional biopsy of that ductal area.
What is spontaneous discharge due to? Treatment?
Worrisome for cancer no matter what color or consistency; biopsy in area of duct
What is nonspontaneous discharge due to? Treatment
Pressure, tight garments, exercise; not as worrisome
Characteristics of diffuse papillomatosis? Risk of cancer?
Multiple ducts of both breasts, larger when solitary, serous discharge; increased risk of cancer (40%)
Mammogram findings of diffuse papillomatosis?
Swiss cheese appearance
Definition of ductal carcinoma in situ?
Malignant cells of ductal epithelium without invasion of the basement membrane
% risk of cancer with DCIS?
50-60% get cancer if not resected; 5-10% will get cancer in contralateral breast.
Mammogram findings with DCIS?
Usually not palpable; cluster of calcifications on mammography
Margins needed with excision of DCIS?
2-3mm
Patterns of DCIS?
Solid, cribriform, papillary, comedo
What is the most aggressive subtype of DCIS?
Comedo pattern; with necrotic areas; high risk for multicentricity, microinvasion, recurrence
What characteristics increase the recurrence risk following excision of DCIS?
Comedo type, lesions >2.5cm
Treatment for DCIS?
- Lumpectomy and XRT, +/-tamoxifen
- Simple mastectomy for high grade, if large tumor not amenable to lumpectomy, or not able to get good margins
- NO ALND
Cancer risk with lobular carcinoma in situ?
40% get cancer (either breast)
Is LCIS premalignant?
NO, considered a marker for the development of breast CA; do NOT need negative margins
What type of breast CA do patients with LCIS develop?
More likely to develop ductal CA (70%)
% risk of having synchronous breast CA at the time of diagnosis of LCIS?
5%
Treatment for LCIS?
- If dx by CNB - surgical excision
- If dx surgical excision - done
- pleomorphic LCIS requires excision to negative margins
Lifetime risk of breast cancer?
1 in 8 women (12%); 4-5% in women with no risk factors
What % will screening decrease mortality of breast cancer by?
25%
Median survival of untreated breast cancer?
2-3y
Clinical features of breast CA?
Distortion of normal breast architecture, skin/nipple distortion or retraction, hard, tethered, indistinct borders
Workup for symptomatic breast mass in pt <30y?
US: if solid - FNA; excisional biopsy if FNA is nondiagnostic
Workup of symptomatic breast mass in patient 30-50y?
Bilateral mammograms and FNA; excisional biopsy if FNA nondiagnostic (discordant findings).
Workup of symptomatic breast mass in pt >50y?
Bilateral mammograms and excisional or core needle biopsy.
Workup for a breast cyst?
- US and FNA…
- bloody: cyst excisional biopsy
- clear + recurs: rpt US FNA
- if recur x3: US, mammo, MRI
- if suspicious: excisional bx
- complex: FNA, CNBx, or cyst excisional bx
What is the sensitivity/specificity of mammography?
90%; sensitivity increases with age as the dense parenchymal tissue is replaced with fat
Size of tumor that is able to be detected by mammography?
>5mm
General screening guidelines?
- USPSTF: After 50, every 2 yrs; 40-50 if wanted
- ACS: yearly 45-54; every other year thereafter
- High-risk: mammograms starting 10y prior to age of BrCa dx in 1st-degree relative
- Mammography is the only breast imaging modality proven to reduce mortality from breast cancer in multiple RCTs.
What are the node levels of the breast?
- I: lateral to pec minor
- II: beneath pec minor
- III: medial to pec minor
- Rotter’s nodes - between the pec major and minor
What level node needs to be sampled?
Level I
What is the most important prognostic factor in breast cancer?
Nodal status; also tumor size, grade, progesterone/estrogen receptor status
5-year survival if 0 positive nodes?
75%
% of nonpalpable nodes that are positive at surgery?
30%
5 year survival if 1-3 nodes are positive?
60%
5 year survival if 4-10 nodes are positive?
40%
What is the most common location of distant mets in breast cancer?
Bone
What characteristics of tumor have increased multicentricity?
Central and subareolar tumors
T staging for breast cancer?
T1: 5cm, T4: skin or chest wall involvement, peau du’orange, inflammatory cancer
N staging for breast cancer?
- N1: ipsilateral axillary nodes
- N2: fixed ipsilateral axillary nodes
- N3: ipsilateral internal mammary nodes
Factors that will greatly increase breast cancer risk?
- BRCA gene
- >2 primary relatives w/ BL/premenopausal br ca
- DCIS and LCIS
- fibrocystic disease with atypical hyperplasia
Factors that will moderately increase risk of breast cancer?
- FH of breast cancer
- early menarche
- late menopause
- nulliparity
- radiation
- previous breast CA
- environmental risk factor (high-fat diet, obesity)
How much does a 1st degree relative with bilateral, premenopausal breast cancer increase breast cancer risk?
50%
Other cancers associated with BRCA I?
- ovarian (50%)
- endometrial CA
- consider TAH, bilateral oophorectomies
Other cancer associated with BRCA II?
Male breast cancer
Requisites for prophylactic mastectomy?
- FH + BRCA gene
- LCIS, plus one of the following: anxiety, poor access to follow up exams, difficult lesion to follow, patient preference
Receptor positive tumors lead to what prognosis?
Better response to hormones, chemo, surgery, and better overall prognosis
Which receptor-positive tumors have best prognosis?
- Progesterone > estrogen
- Both positive with best prognosis
What % of breast cancers are negative for both receptors?
10%
What type of cancer do males usually have?
Ductal
Male breast cancer is associated with what?
Steroid use, previous XRT, FH, Klinefelter’s syndrome, prolonged hyperestrogenic state
Treatment of male breast cancer?
Modified radical mastectomy
What % of breast CAs are ductal?
85%
What are the subtypes of ductal CA?
Medullary, tubular, mucinous, scirrhotic
Characteristics of medullary breast CA?
Smooth borders, high lymphocytes, ductal type cancer with bizarre cells; majority E+/P+, more favorable prognosis.
Characteristics of tubular CA?
Small tubule formations, nodes + in 10%, more favorable prognosis.
Characteristics of mucinous CA?
Colloid, produces an abundance of mucin, more favorable prognosis
Characteristics of scirrhotic CA?
Worse prognosis
Treatment for ductal CA?
MRM or lumpectomy with ALND (or SNLB); post op XRT
What % of breast cancers are lobular?
10%
Characteristics of lobular CA?
Does not form calcifications, infiltrative, inc. bilateral, multifocal and multicentric
Lobular cancer with signet ring cells have what prognosis?
Worse
Treatment for lobular CA?
MRM or lumpectomy with ALND (or SLNB); postop XRT
Treatment for inflammatory cancer?
May need chemo and XRT 1st, then mastectomy
Stage of inflammatory cancer?
Considered T4
Median survival of inflammatory cancer?
Very aggressive; 36mo
What causes the peau d’orange lymphedema of inflammatory cancer?
Dermal lymphatic invasion; erythematous and warm
Preoperative studies needed before breast surgery?
- CXR
- bilateral mammograms
- CBC, LFTs
- abdominal CT if LFTs elevated
- head CT if headaches
- bone scan if bone pain or inc ALP
Subcutaneous (simple) mastectomy indications?
- DCIS, LCIS
- NOT indicated for breast CA; leaves 1-2% of breast tissue, preserves the nipple
Margins necessary with simple mastectomy?
1cm; with SLNB
Indications for SLNB?
Malignant tumors >1cm; NOT indicated for pts with clinically positive nodes.
Complications of lymphazurin blue?
Type I hypersensitivity reactions
What next if no SLN found during SLND?
Formal ALND
The sentinel node is found in what % of the time?
95%
Contraindications to SLNB?
Pregnancy, multicenteric disease, neoadjuvant, clinically positive nodes, prior axillary surgery, inflammatory or locally advanced disease
Modified radical mastectomy includes what?
- all breast tissue
- includes the nipple areolar complex
- axillary node dissection (level I)
Radical mastectomy includes what?
- MRM and overlyting skin
- pectoralis major and minor
- level I, II, III lymph nodes
Complications of axillary lymph node dissection?
Infection, lymphedema, lymphangiosarcoma, axillary vein thrombosis, lympatic fibrosis, intercostal brachiocutaneous nerve injury
Signs of axillary vein thrombosis?
Sudden, early, postop swelling
Most commonly injured nerve after mastecomy?
Intercostal brachiocutaneous nerve; hypersthesia of inner arm and lateral chest wall
Radiotherapy dose for breast cancer?
5000 rad for lumpectomy and XRT
Complications of XRT?
Edema, erythema, rib fractures, pneumonitis, ulceration, sarcoma, contralateral breast CA
Contraindications of XRT?
Scleroderma, previous XRT, SLE, active RA
What is the chance of recurrence following lumpectomy with XRT?
10%; usually within first 2 years
Treatment with local recurrence?
Salvage MRM
Which patients get chemo?
Positive nodes (except postmenopausal women with positive estrogen receptors (tamoxifen), >1cm and negative nodes
By what percent does tamoxifen decrease short-term risk of breast cancer by?
50-60%
What is the risk of blood clots on tamoxifen?
1%
What is the risk of endometrial cancer in patients that are on tamoxifen?
0.1%
What are the symptoms of a metastatic flare? What is the treatment?
Pain, swelling, erythema in metastatic areas; XRT
What is occult breast cancer?
Breast-cancer that presents as axillary metastases with unknown primary
What percent of occult breast-cancer are found to have breast cancer at mastectomy?
70%
What are benign conditions that mimic breast cancer?
Radial scar, fibromatosis, granular cell tumors, fat necrosis
Which malignant tumors have a benign appearance; smooth rounded masses?
Mucinous cancer, medullary cancer, cystosarcoma phyllodes
How does Paget’s disease present? What is the treatment?
Presents with scaly skin lesion on nipple; biopsy shows Paget’s cells. Need modified radical mastectomy if cancer present, otherwise simple mastectomy
What percent of cystosarcoma phyllodes are malignant? How is the diagnosis made?
10%; based on mitoses per high-power field, resemble giant fibroadenoma, has stromal and epithelial elements
What is the treatment for cystosarcoma phyllodes?
Wide local excision with negative margins, no ALND
What is Stuart-Treves syndrome?
Lymphangiosarcoma from chronic lymphedema following axillary dissection, presents with dark purple nodule on the arm 5 to 10 years after surgery
What is the prognosis for a mass that presents during pregnancy?
Worse prognosis because it tends to present late
Treatment for breast cancer that presents during pregnancy?
First trimester: MRM; second trimester: MRM; third trimester: MRM or if late can perform lumpectomy with ALND and postpartum XRT; no chemo or radiation while pregnant, no breast-feeding after delivery
Surgical evaluation is indicated if there is what associated with nipple discharge?
- breast mass
- spontaneous
- uniductal
- bloody
In patients with nipple discharge, if physical examination is otherwise normal, imaging is negative, and the discharge is multiductal and nonbloody, what does the patient need?
laboratory tests, medical evaluation, and galactorrhea workup.
What to do with BI-RADS 1 or 2?
continue annual mammography
What to do with BI-RADS 3?
short-term follow-up - ipsilateral mammogram at 6 months, bilateral mammograms at 12 and 24 months
What to do with BI-RADS 0?
Additional imagin
What is the use of an ultrasound in a breast exam?
to distinguish between solid and cystic, especially in the younger population
When is surgical biopsy appropriate for breast cancer workup?
If percutaneous biopsy is not feasible d/t anatomic considerations. If image-guided biopsy reveals discordant pathology from imaging.
When is MRI appropriate in the setting of breast cancer?
Used for imaging after the diagnosis of breast cancer and for women who have increased risk in breast cancer. There is minimal evidence to support its use for screening in the general population.
Next step for 31yr patient with breast mass?
mammogram and ultrasound
Next step for 29yr patient with breast mass?
ultrasound, +/- mammogram pending findings
How to manage cystic breast masses?
- common in premenopausal women
- US is diagnostic, add mammo if >30
- FNA biopsy/aspiration - do not send clear fluid d/t high likelihood of false positive
- If mass doesn’t completely disappear, get biopsy of solid component
How do you manage mastalgia?
This is often non-cancerous and of unknown etiology. Treat conservatively and reassure. Consider NSAIDs. Consider danazol, tamoxifen. Surgery is not recommended.
How do you manage lumpy or cobblestone breasts with ridges of tissue appreciated on palpation that evolves with the menstrual cycle?
Likely fibrocystic change (not “disease”). This is a normal variant that often occurs in women 30-50, improves with OCPs, and resolves with menopause. Treat symptoms. Unlikely breast cancer if no dominant mass can be found (workup like breast mass if one is found).
What is physiological nipple discharge?
milky and bilateral
Nipple discharge that is nonbloody, but dark green or brown is associated with what?
Ductal ectasia - a result of keratin plugs w/ associated inflammation and secretion causing dilation that can be seen on US.
Workup for pathological nipple discharge?
- US and BL mammography
- tissue diagnosis of masses found
- surgical excision of duct
In a patient with nipple discharge and concern for endocrine disorder, what labs should be ordered?
TSH, prolactin
In a patient with nipple discharge, concern for endocrine disorder, and elevated prolactin, what test should be ordered?
MRI to look for prolactinoma
How do you differentiate a fibroadenoma from a phyllodes tumor?
- Clinical findings are the same
- The clues will be rapid growth and size
- Imaging (mammo) will not always differentiate
- CNB may not differentiate
- surgical excision will definitively tell
If CNB or FNA shows atypia, atypical ductal/lobular hyperplasia, LCIS, radial scar, what should be done?
formal surgical excision
A young patient with a firm irregular breast mass presents and eventually receives a CNB showing saponification, chronic inflammation, lymphocytes, histiocytes. She has a hx of mammoplasty. What is the dx?
fat necrosis
A patient who just gave birth presents with a tender nodule in a breast. Imaging shows well-circumscribed mixed denisty lesion. US shows partially cystic mass. What is the dx and treatment?
galactocele,
A patient presents with a tender and palpable cord in her breast. What is the dx and treatment?
Mondor disease. Treat conservatively with NSAIDs. May require abx and even excision if infected or not responding to treatment.
What is the most common organism identified in mastitis?
S aureus
In a patient with breast pain who gives a history of “cracked nipple” or an abrasion in the breast, what is the first thought for diagnosis?
Mastitis. Will usually also have erythema, swelling, and tenderness of the breast.
Should a breastfeeding patient with mastitis continue breastfeeding?
Yes. Antibiotics chosen should take into account the safety of the infant.
Do atypia and radial scar increase risk of breast cancer?
Yes. 4 fold. That’s why excisional biopsy is recommended.
Is LCIS associated with an increased risk of breast cancer?
Yes. Increased lifetime risk of 20-25%. However it is not pre-malignant, so you don’t need negative margins. But because of the increased chance of associated cancer within the rest of the lesion, an excisional biopsy must follow.
What happens to prolactin levels in most medication induced gynecomastia (men)? How do you treat?
Often elevated. Changing medication will usually cause regression. Aromatise inhibitors or tamoxifen can treat medically if surgery is to be avoided in men.
A male presents with a solitary hard mass in his breast. There is palpable adenopathy and skin changes. What do you do?
Aggressive workup. Mammography and CNB are necessary.
In a patient with nipple excoriation and a presumed dx of dermatitis of the breast, what do you do if there is no recovery after 2 weeks after topical steroids and removal of known offending agents?
Punch biospy. Need to rule out Paget disease.
