Chapter 32 Benign Breast Disease and Breast Cancer Flashcards
breast cancer is the most common malignancy in women in the US (except for skin cancers), representing approximately ___ of female cancers
30%
a woman has 1 in 8 chance 12% of developing invasive breast cancer over her lifetime. despite its incidence, the cause of breast cancer is unknown
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in addition to breast cancer, 50% of women will have benign breast lesions over their lifetime
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prolactin - involved in milk production
oxytocin from the posterior pitutiary causes
milk letdown
most organizations support routine clinical breast evaluation every 1-3 years for all women above age 20.
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after age 40, clinical brast evaluation should be done__
annually
breast self-awareness
encourages women to become familiar with their breasts and to report any changes from baseline.
current mammogram screening guidelines by the ACS include mammogram every year starting at age 40 continuing for as long as a woman is in good heatlh. there is no agreed upon consensus of an upper age limit at which mammogram screening can be stopped
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BRCA1 or BRCA2 gene mutation, a first degree relative (mother, sister, dauther) with either mutation and those deemed to be at high risk based on a validated risk assessment tool )Gail/Claus model)
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or who have a hereditary syndrome associated with multiple cancer diagnoses (Li Fraumeni, LynchII syndrome)
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moderate risk: personal hx of breast cancer or its precursor lesions, or those who have dense breast tissue on mammogram
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mammogram starting 5-10 years before the age of the youngest cancer diagnosis in the family
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women at highest risk for breast cancer might also have interval breast MRIs along with the annual screening mammogram
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breast pain (mastalgia, mastodynia) common complaint 65%. cyclic 67% or noncyclic 33%
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breast pain can be normal physiologic response to
hormone fluctiations. or it can be pathologic response to trauma or malignancy.
only 1-7% of women with breast pain will have underlying malignancy
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vast majority of breast pain is benign and can be treated with oral and topical Nsaids , a supportive bra/sports bra, diet and lifestyle changes (decrase caffeine intake and smoking), and use of warm and cool compresses and massage.
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many women will require a decreased dose or discontinuation of OCP and HRT in order to relieve their breast pain
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danazol is the only medication approved by FDA to treat mastalgia
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as many as 50-80% of women will have nipple discharge. vast majority of nipple discharge is due to normal physiology or benign processes, and only 5% is associated with underlying malignancy
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most concerning discharge is
spontaneous bloody or serosanguineous, unilateral, persistent, from a single duct, and associated with a mass.
bilateral, nonbloody, multiductal secretion is usually benign regardless of color.
most common cause of bloody nipple discharge is an
intraductal papilloma
galactorrhea is associated with
pregnancy, ptiutiary adenomas, hypothyroidism, ,stress, and medications such as ocps, antihypertensives, and psychotropic drugs
women with associated masses should have ultrasound <30, mammogram >30
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up to 10-15% of new breast cancers are not sen or detected via mammography. a suspicious mass should never be dismissed just because the mammogram is negative. the most common causes of breast masses are fibroadenomas and breast cysts.
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malignant masses are classically
single, firm, nontender, and immobile with irregular borders.
lumph nodes are worrisome if larger than 1cm, fixed, irregular, firm , or multiple.
any palpable mass/ abnormality seen on radiologic imaging should be evaluated with mammography and biopsied to obtain a pathologic diagnosis.
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if a palpable cystic mass is found on examination and confirmed on ultrasound, it can be drained and sampled for diagnosis using needle aspiration
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the cyst should be exicsed if bloody
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when a palpable solid mass is found on exam and confirmed with ultrasound or mammogram, a tissue sample should be obtained for diagnosis.
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when a palpable solid mass is found on exam and confirmed with ultrasound or mammogram, a tissue sample should be obtained for diagnosis.
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2/3 of tumors in reproductive age women are benign. whereas 1/2 of palpable masses in perimenopausal women and the majority of lesions in postmenopausal women are malignant
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fibrocystic change of the breast due to exaggerated stromal response to hormones and growth factors. it typically presents as painfulb reast masses that are often multiple and usually bilateral. in the absence of atypical hyperplasia, fibrocystic change is NOT associated with increased cancer risk
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dx of fibrocystic changes
breast welling, pain, tenderness
treatment of fibrocystic disease:
reduction of caffeine, tea, and chocolate. avoiding trauma and wearing a support bra may also help decrease pain associated with fibrocystic change.
breast fibroadenomas are benign tumors with glandular and stromal components. most masses are 1-5cm in diameter. lesions > 5cm are termed giat fibroadenomas. in these cases, __should be ruled out
cytosarcoma phyllodes
fibroadenomas most common benign tumors of the breast. more common than breast cysts in women younger than 25 years. rarely occur and often regress after menopause
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diagnosis of fibroadenomas:
palpated on Physical exam, round, well circumscribed, mobile, firm lesions that are rubbery and nontender. classic fibroadenoma in a woman less than 30 years old may be the only solid breast mass that does not require tissue diagnosis.
cytosarcoma phyllodes - rare variant of fibroadenoma and involve epithelial and stromal proliferation
dx: large, bulky, mobile mass that is painless. mass is large 4-7cm, smooth, and well circumscribed and is characteraized by rapid growth. most lesions are benign; however, some physicians consider cytosarcoma phyllodes a low grade malignancy. few tumors do develop true sarcomatous potential. core needle biopsy is the preferred method for diagnosis but should be strongly correlated with clinical suspicion
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intraductal papilloma: benign, solitary lesion that involes epithelial lining of lactiferous ducts. it is the most common cause of bloody nipple discharge in the absence of a concurrent mass.
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mammary duct ectasia - causes dilated mammary ducts. commonly occurs at or after menopause, but is also a cause of breast mass in adolescents.
dx: nipple discharge, noncyclic breast pain, nipple retraction, subareolar masses. discharge is multicolored, sticky, originating from multiple ducts, and often bilateral pt should have what
mammogram and excisional bx to r/o carcinoma
risk of getting breast cancer increases with
age
4/5 women are with breast cancer and are above age 50
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breast cancer is leading cause of death in US women aged 40-59
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risk factor: increasing age
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having one affected first degree family member increases the patient’s risk by nearly 2 times.
having two first degree family members increase a patient’s risk by nearly 3 times
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prevention fo breast cancer: early pregnancy, prolonged lactation, chemical/surgial sterilization, exercise, abstinence from alcohol, and low fat diet help prevent breast cancer.
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tamoxifen - selective estrogen receptor modulator (SERM) is effective in suppressing the development of breast cancer. by binding to Estrogen receptor, tamoxigen completely inhibits estrogen binding and thereby blocking stimulation of breast cancer cells.
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tamoxifen currently used as adjuvant therapy in pts with early stage, surgically treated, ER positive breast cancer and has been shown to decrease rate of recurrent BCA by 40% and breast cancer mortality by 35%
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breast cancer metastacizes to
bone, liver, lung, pleura, brain, lymph nodes
benign intraductal papilloma is most common cause of __
bloody nipple discharge
dcis (15%) is PREINVASIVE diseasE and is treated with lumpectomy and radiation therapy
LCIS (4%) treated with observation and possible tamoxifen to prevent subsequent invasive breast cancer
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INVASIVE BREAST CANCER:
infiltrating ductal carcinoma (76%) and infiltrating lobular carcinoma (8%) treated with lumpectomy and radiation / modified mastectomy with equal risk of recurrence and survival in properly selected patients
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standard adjuvant treatment for women with positive lymph nodes is combination chemotherapy
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all hormone receptor positive patients should receive hormone therapy aimed at suppressing estrogen, and thereby suppressing stimulation of cancer ells. this is most commonly achieved with tamoxifen (an etrogen agonist/antagonist) or aromatase inhibitors (letrozole, anastrazole), which have antiestrogen activity.
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intraductal papilloma is most cmomon cause of bloody nipple discharge. second most common cause is invasive papillary breast cancer. fibrocystic breast change, fibroadenoma, and cystosarcoma phyllodes typically present as painful and nonpainful breast masses
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radiation therapy is necessary for all patients who undergo conservative therapy. breast reconstruction should be considered when a large mass is removed from the breast as it carries significant psychosocial benefits.
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estrogen/progesterone-receptor positive tumors should be treated with an antiestrogen agent or aromatase inhibitor following surgical resection. postmenopausal women with ER+ and PR+ should be first reated with an aromatase inhibor like letrozole with hormone receptor positive cancers. tamoxifen is first line hormone therapy for premenopausal women. trastuzmab is amonoclonal antibody for adjuvant treatment in tumors that are her2/neu positive
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