Chapter 33: Disorders of the Breast

Question 1

How do hormones affect the breast tissue

Answer 1

Hormones: Estrogen is primarily responsible for the growth of adipose tissue and lactiferous ducts. Progesterone leads to lobular growth and alveolar budding.

Question 2

How often does breast pain/breast mass = cancer?

Answer 2

a. History: Breast pain and/or mass. Pay attention to this as the patient’s anxiety can be high. Only about 6% of evaluated breast symptoms are cancer.

Question 3

How helpful is a mammogram at detecting cancer?

Answer 3

i. Mammogram: Breast lesions 2 years before they become palpable. 4 shots, 2 craniocaudal and 2 medio-lateral. Evaluate for calcium, fibrocystic change, and distortion of normal architecture. Easier to detect ductal carcinoma than lobular.

Question 4

Discuss BIRADs

Answer 4

Breast imaging reporting and data system)
a. 0 = need additional imaging due to nondiagnostic lesion
1 = negative
2 = benign
3 = Probably benign = F/u, most likely benign though
4a = Low suspicion = Needs intervention
4b = intermediate suspicion = Possible malignancy
4c = Moderate concern = No classic sign but malignancy expected
5 = highly suggestive
6 = Bx proven malignancy

Question 5

When do we use US vs MRI?

Answer 5

ii. US: Used in younger women with fibrocystic change or those with dense tissue to discern better detail. Less than 40 typically get this more than mammogram.
iii. MRI: Can’t detect microcalcifications and is $$$, but can show good detail otherwise. Good adjunct

Question 6

FNA vs. core biopsy

Answer 6

iv. FNA Bx: Aspirate with 22-24 gauge needle. Fluid = cyst, return in 4-6 months for standard CBE. If reappears, return for diagnostic mammo or US. Bloody fluid needs to go for cytology with imediate diagnostic mammo and US
v. Core needle: Larger bore, 14-16 gauge, for larger solid masses. 3-6 2cm samples taken

Question 7

Three types of mastalgia

Answer 7

1. Cyclic - Begins with luteal phase of menstrual cycle and resolves with onset of menses. Bilateral pain, often the upper quadrants
2. Non cyclic - Not associated with cycle. Tumors, mastitis, cysts, history of breast surgery, medications like hormones, antidepressants, setraline and amitriptyline, antihypertensives, etc.
3. Extramammary - Chest wall trauma, rib fractures, shingles, fibromyalgia. Give NSAIDs, r/o dangerous stuff like heart pthology

Question 8

Three options for treatment of mastalgia

Answer 8

1. Danazol is the only one FDA approved for this use, lots of SEs.
2. SERMs can help, like Tamoxifen. Estrogen antagonist, but increase endometrial hyperplasia and DVT, hot flashes, VB. Only give in severe mastalgia cases not helped by anything else. Raloxifen a bit better, does not stimulate endometrium
3. Some with cyclic mastalgia have decrease in pain with oral contraceptives or the injectable medroxyprogesterone acetate

Question 9

Ductal ectasia and it’s link to nipple discharge

Answer 9

i. Usually benign but can be an early sign for bad stuff. Bilateral non-bloody often associated with fibrocystic change and ductal ectasia (ductal dilation with inflammation and fibrocystic changes). Can also see green, brown, or yellow

Question 10

Milky discharge =

Answer 10

ii. Milky = TCAs, oral contraceptives, lactation, hyperprolactinemia, hypothyroid

Question 11

Bloody discharge and what we can do about it if we’re fancy

Answer 11

iii. Bloody + bilateral = invasive ductal, intraductal papilloma or intraductal carcinoma. Ductography to diagnose with potential excision. Fiberoptic ductoscopy allows visualization and biopsy (not very available)

Question 12

Chances of a nonproliferative breast mass becoming cancer

Answer 12

Nonproliferative: No increased chance of developing invasive carcinoma

Question 13

6 types of nonproliferative change

Answer 13

1. Fibrocystic change - Fibrous change associated with ruptured cysts
2. Cysts - Lobules grow and shrink, can fill with fluid
3. Fibrosis - Firmness of breast
4. Adenosis - Increased glands with growing lobules. No change in architecture of lobules.
5. Lactational adenomas - Secondary to exaggerated hormone response
6. Fibroadenomas - Round, solid, rubbery, mobile. Structural and glandular components. Can enlarge in pregnancy due to hormones and cause pain

Question 14

Proliferative without atypia increases our cancer risk by how much?

Answer 14

1.5 - 2.0x

Question 15

Types of proliferative but not atypical breast changes

Answer 15

Epithelial hyperplasia
Sclerosing adenosis
Complex sclerosing lesions
Pappillomas

Question 16

Epithelial hyperplasia is what exactly?

Answer 16

1. Epithelial hyperplasia - More than the normal two layers of cells (myoepithelial and luminal)

Question 17

Sclerosing adenosis vs complex sclerosing lesions

Answer 17

2. Sclerosing Adenosis - Increasing fibrosis within an expanded lobule that compresses against epithelium
3. Complex sclerosing lesions (radial scar) - Nidus of tubules entrapped in a densely hyalinized stroma surrounded by radiating arms of epithelium. Mimics invasive carcinoma

Question 18

What are papillomas?

Answer 18

4. Papillomas - Intraductal growths composed of abundant stroma lined by both luminal and myoepithelial cells. Can lead to serous or serosanguinous drainage in women aged 30-50 years

Question 19

When we think atypical proliferation, what is happening? How much of an increased chance of cancer is there?

Answer 19

Proliferative with atypia = 8-10x increased risk. When malignant cells replace the normal epithelium lining the ducts or lobules, the lesion is known as a carcinoma in situ. Basement membrane remains intact.

Question 20

LCIS vs DCIS and what we do about them

Answer 20

1. LCIS - uniform small atypical cells obliterating glandular acini
   a. Excisional biopsy. Preventative therapy with SERMs like Tamoxifen in order to reduce the risk of invasive breast cancer
2. DCIS - Epithelial cell atypical proliferation
   a. Core needle biopsy followed by surgical biopsy or excision. Prevent therapy like with LCIS.

Question 21

How common is breast cancer?

Answer 21

4. Breast Cancer: Second most common malignancy in women, ranking only behind skin cancer. Also second leading cause of death in women cancer related. Lifetime risk is 1/8 (12%) with lifetime risk of dying is 3.6%

Question 22

Most important risk factor for breast cancer?

Answer 22

Age, most over 50

Question 23

6 other important risk factors to know besides age

Answer 23

i. Menarche before age 12
ii. Menopause after 55
iii. > 20cGy radiation (0.3 in a mammogram), takes 5-10 years after high dose exposure
iv. Firmer breasts
v. Overweight after menopause
vi. Women who drink 2-4 alcoholic drinks per week are at 30% greater risk of dying of breast cancer than women who never drink.

Question 24

BRCA1 vs BRCA 2

Answer 24

b. Genetics: BRCA 1 on 17q21. Associated with half of early-onset breast cancers and 90% of hereditary ovarian cancers. BRCA 2 on 13q12-13 has lower incidence of early onset breast cancer and much lower risk of ovarian cancer.

Question 25

What is the gail model and what are the limitations?

Answer 25

i. Gail Model: Calculates risk of getting breast cancer in the next 5 years and lifetime risk. Seven risk factors: History of LCIS or DCIS, age, menarche age, age of first birth, number of first degree relatives with breast cancer, history of breast biopsy, and race/ethnicity.

Falsely increased in women who have had multiple biopsies and less useful for those with second degree contacts. This tool, unlike reality, uses family history as the leading risk factor (recall that age is the leading risk factor).

Question 26

What is a “poor” outcome with the Gail model and what can we do with it?

Answer 26

1. Women at “high risk” (1.7%+ chance in 5 years) referred for prophylactic therapy via SERMs (Tamoxifen, Raloxifene) and prophylactic mastectomy

Question 27

Commonality and behavior of invasive ductal vs invasive lobular

Answer 27

ii. 70-80% are invasive ductal. Cannot lead to lobular. Unilateral, unicentric and only the ipsilateral breast.
iii. 5-15% are invasive lobular, multifocal and bilateral, can spread to become ductal and/or more lobular.

Question 28

To define as a cancer as stage 1 or 2, what are the limits?

Answer 28

Up to 5cm

0-3 nodes involved

NO METS

Question 29

Stage 3 of breast cancer

Answer 29

Locally advanced.

Basically any number of local nodes affected without metastasis, size can be larger than 5cm.

Question 30

Stage 4 of breast cancer

Answer 30

Distant metastasis

Question 31

Surgery options for breast cancer

Answer 31

i. Surgery: Lumpectomy with radiation, mastectomy, modified radical mastectomy (axillary nodes) and don’t forget SLNBx. Tissue expanders and reconstructive therapy great for image.

Question 32

Adjuvant medical therapy for breast cancer

Answer 32

1. Adjuvant systemic therapy for all breast cancer regardless of LN status. Chemo to kill cells and tamoxifen to prevent estrogen acting to cause more cancer (ER+) and for 5 years post-op.

Question 33

Talk about aromatase inhibitors

Answer 33

Aromatase inhibitors - Prevent production of estrogen in women. Extend survival in metastatic women and act as primary adjuvant therapy, in conjunction with tamoxifen to reduce recurrence rate

Question 34

When do we use Trastuzumab?

Answer 34

Trastuzumab against Her2/neu. SE: Heart failure, respiratory problems, life threatening allergic reactions

Question 35

How do we follow women after treatment for breast cancer

Answer 35

Every 3-6 months for first 2 years. Annually after that. Most re-occurrences occur within first 5 years

Question 36

Breast cancer screening review

Answer 36

Screening: Breast self-awareness in low risk patients and breast self exams in high risk.

CBEs every 1-3 years from 20-39, annually thereafter. Mammography annually after 40, or 50 with your decision from 40-50. Nothing after 75.

If Genetic issues, monthly BSEs from 18-20, annual CBEs, screening mammograms after 25 or 5-10 years before the age of diagnosis of affected relative.

Question 37

How do we treat stage 0 cancer?

Answer 37

BCT or mastectomy. No adjuvant therapy needed unless using radiation with BCT

Question 38

How do we treat stage 1 cancer?

Answer 38

BCT or mastectomy. Chemotherapy if >2cm, consider tamoxifen. Consider SLnBx.

Question 39

How do we treat stage 2 cancer?

Answer 39

Modified radical or BCT with axillary LN dissection if indicated. Chemo if greater than 1 cm, again consider tamoxifen as well. Radiation of supraclavicular nodes, consider chest wall, if mastectomy performed and/or 4+ affected LNs

Question 40

Stage 3 treatment

Answer 40

Same as Stage 2 as far as surgery. If inflammatory breast cancer, radiation to breast.

Question 41

Stage 4 treatment

Answer 41

Surgery for local control, chemotherapy, consider hormones