Clinical Approach To Breast Disease Flashcards
What is the prevalence of cancer among women who present with breast symptoms
<10%
- masses are more likely to be cancerous than pain symptoms (although both have low odds regardless)
50% of women will experience a non-cancerous breast lump at some point in their life
Malignant breast diseases odds start to increase in the 30s and increase with age
**breast cancer is the most common malignancy in women and is high on the death rates of cancer as well
Most common presenting breast symtpoms
Palpable masses
Pain
Swelling/erythema/infection
Gynecomastia
Nipple discharge
Medical history elements that are required in women
All women
- age of menarche (1st period)
- number of pregnancies
- number of live births and age of first birth
- any history of breast imaging and/or biopsies and/or histological results
- smoking history
- family history of breast cancer (if yes, what type and bilateral or unilateral )
- medications
Premenopausal women
- date of last menstral cycle
- cycle length and regularity
- any use of oral contraceptives
Post menopausal women
- date/age of menopause
- use of HRT (hormone replacement. Therapy)
What questions to ask pertaining to breast symptoms?
Mass
- onset
- location
- painful Or not
- mobile or fixed
Pain
- onset
- provocation
- palliative factor
- quality
- region/radiation
- related symptoms
- severity
- time of any characteristics of pain
Nipple discharge
- unilateral vs bilateral
- provoked vs continuous
- color and consistency
Infection/skin changes
- fever/chills
- dimpling
- redness
- swelling
- pain associated
Physical exam of the breast
Inspection
- symmetry
- nipple inversion
- skin changes
- alterations in breast contour
- retraction
- erythema
- dimpling
Palpation of lymph nodes
- central posterior and anterior lymph nodes
Palpation of breast
- usually done circular from outer -> inner or along a zigzag pattern from outer -> inner*
- size
- consistency
- mobility
- distance from areolar edge
- circumferential position on the breast
What physical exam breast findings are concerning of breast cancer
Firm/hard breast tissue
Irregular surface of breast tissue
Fixed or tethered mobility of a mass
Painless mass
Age >50 yrs
Positive for lymphadenopathy
Sampling, retraction or nipple discharge
DDX for breast mass
1) Benign nodule
- most common in younger patients (<50)
2) Fibroadenoma
- common in 15-35 and is the most common benign tumor
- are single solid and rubbery with no tenderness and no lymphadenopathy.
- also doesnt grow fast. If it growing fast think phyllodes tumor first
- arise in terminal duct lobular unit and comprised of stroma and epithelial cells. Unknown cause but is believed to hormonal (since it increases in size during pregnancy but regresses after menopause)
- treatment = US and mammogram (if cystic = FNA and your good, if solid = biopsy and remove if patient wants)
3) Simple Cysts
- common in 30-50s
- non-proliferative breast changes with a fluid filled round/oval mass that is due to terminal duct obstruction
- usually is tender, smooth firm and discrete
* *physical exam alone cannot distinguish between benign cyst and malignancy so you need to get imaging (US is first line)**
- treatment = FNA with US (if fluid is bloody = send for culture and cytology). Otherwise that should be it unless it recurs then biopsy it
4) Fat necrosis
- benign condition due to trauma or surgery (may be no inciting event)
- typically is self resolving (but if persists = get imaging and biopsy since it could be underlying malignancy
5) Phyllodes tumor
- fibroepithelial breast tumor that can be malignant (20-30%)
- they fell just like fibroadenoma but grow really fast and large. Also 20% have axillary lymphadenopathy
- treatment = excision with wide margins
Breast cancer physical exam findings
Physical exam findings:
- typical single mass
- non-tender
- firm/hard
- irregular
- fixed skin or chest wall
Associated findings that are very increased suspension
- skin or nipple retraction
- axillary or supraclavicular lymphadenopathy
- peau d’orange shape
- breast enlargement
- redness or edema
- ulceration
What is the triple assessment or triple
Do the following:
- History and clinical breast exam
- ultrasound or mammogram
- tissue sampling
Needs to be done for every breast mass
BI-RADS assessment categories
Is done in-conjunction with imaging of breast masses
Category scores
0 = incomplete = obtain additional imaging
1 = negative findings = no additional imaging needed except high clinical suspicion
2 = benign findings = resume routine screening
3 = Probably by benign findings = Follow up and consider more imaging
4 = suspicious abnormalities = biopsy
5 = malignancy = biopsy and urgent referral to subspecialist
6 = biopsy-proven malignancy
Breast pain facts
Also called “mastalgia or mastodynia”
2nd most common symptom leading to evaluation in primary care setting
Only 7% of breast cancers have mastalgia so not a common sign (need more)
Two subtypes:
1) cyclical mastalgia
- 66% of all breast pain cases
- most common age 20-30s
- bilateral
- diffuse or poorly localized pain
- associated with menses
2) non-cyclical mastalgia
- most common age 30-40s
- bilateral or unilateral
- focal or diffuse
- sharp/burning
- no association w/ menses
Extramammary pain (non-breast pain)
Non-breast pain that occurs along the chest wall
Causes
- chest wall trauma
- rib fracture
- shingles
- fibromyalgia
- angina
Fibrocystic breast changes
Proliferation of glandular tissue thought to be due to excess estrogen or progesterone
- estrogen = ductal hyperplasia
- progesterone = stoma hyperplasia
Cystic changes occur in scarring and inflammation that leads to fibrotic changes
believed to have caffeine and iodine deficiency play a role also
Clinical findings of fibrocystic breast changes
Cyclical pain or tenderness during the luteal phase of cycle
- pain improves with menstration
Unilateral, bilateral or focal pain
Often multiple and mobile masses
The pain is usually upper outer quadrant and easily palpated
Also may show non-bloody green or brown discharge from nipple
cyclical features and multiplicity of lesions distinguish this from fibroadenoma or malignancy
dominant mass is present = evaluated further
Medications that cause non-cyclic mastalgia
Oral contraceptives
Hormone therapy
Psychotropic agents
SSRIs
Digoxin and spironolactone
