CM- Evaluation of Breast Disease Flashcards
Describe the proper technique for examination of the breasts.
Inspection:
- patient sitting with arms at their sides
- arms raised over their heads
- hands on their hips
- pay attention to:
- symmetry of size, configuration, ptosis,
- skin appearance [peau d’orange]
- nipple deformity or excoriation
- retractions
Palpation:
- cervical, supraclavicular, axillary nodes with patient sitting
- have patient supine with hand abducted over their head
- with flat palmar surface of the fingers palpate in wedges from outer to nipple or in concentric circles from outer to nipple
What are the 4 ways the breast tissue is characterized with respect to consistency?
- soft or fatty
- rubbery or glandular
- finely nodular or granular
- lumpy or diffusely nodular
If you find a dominant mass during a breast exam, how should you characterize it?
- location [oclock to the nipple]
- size measured with a ruler
- consistency
- borders
- fixed or mobile
How does the 5YSR differ for local breast cancer vs metastatic disease?
Local = 98% survival rate Mets = 25% survival rate
In the patient history, if they document breast pain, what questions should be asked?
- location
- duration
- relationship to the menstrual cycle
- caffeine [FCD]
- trauma to the breast [fat necrosis]
If the patient presents with a history of breast mass, what 5 questions must you ask?
- size and consistency
- how long has it been there?
- has it changed size?
- does it cause pain?
- Associated signs like fever, erythema, focal tenderness?
If a patient presents complaining of nipple discharge, what questions do you need to ask?
- color and consistency?
- unilateral or bilateral
- multi-ductal or uniductal
- spontaneous or induced by manipulation
- Meds? Current illicit drugs?
How does screening mammography differ from diagnostic mammography?
Screening:
- asymptomatic woman
- 2 view of each breast [cranio-caudal and medial/lateral/oblique
- performed without radiologist in attendance
Diagnostic
- woman has a problem to evaluate
- 3 views [same 2 as screening plus medial lateral]
- spot compression and magnification views in the area of concern
- performed with radiologist present
What is the main limitation of mammography?
In women <30, the breast tissue is very dense and can obscure detection of even a large mass that would be palpable by physical exam [false neg in 11-25% of cases]
Predictive value of mammography is much greater for patients over 50yr of age
What is the utility of US in viewing breast masses?
Why is it not a good screening tool?
- differentiates cystic masses from solid masses.
- used instead of mammography for dense glandular breasts of young women or nodular dense fibrotic breasts
- used to evaluate pregnant or lactating women’s breasts
It is not a good SCREENING tool because:
- its accuracy is not good for lesions <1cm
- it cannot identify small clusters of calcifications
What is the utlity of MRI for breast pathology?
- inflammatory lesions suspicious for cancer
- soft tissue masses
- breast implant ruptures
You discover a breast lesion that is smooth, round and lobulated, mobile, discrete and of soft/rubbery consistency. Is it “probably benign” or “probably maligant’?
probably benign
- fibroadenoma
- cyst
- intraductal papilloma
- phyllodes
- sebaceous cyst
- cystosarcoma
7 lipoma
8 metastatic melanoma - primary breast cancer
You discover a breast mass that is irregular in shape, immobile with respect to adjacent breast tissue, skin and chest wall.
It is rock ard in consistency. Is this “probably benign” or “probably malignant’?
What is the DDx?
Probably malignant
- cancer
- fibrocystic changes
- infection
- fat necrosis
What is the clinical presentation of fat necrosis?
How does it occur?
What does it mimic on PE and mammography?
What needs to be done to definitely confirm the diagnosis?
It is a benign condition that can mimic breast cancer on physical exam and mammography [stellate mass with calcifications].
It is common in large breasted women that have experienced breast trauma.
The mass is superficial and often involves skin retraction.
You need to do a SURGICAL BIOPSY NOT FNA because fine needle aspirations will lack breast epithelial cells in the aspirate and be “non-diagnostic’
What are the steps of management in women over 30 when a breast mass is felt on PE?
- mammography +/- ultrasound
- If it is solid–> Core needle biopsy/FNA
If it is benign - excise or observe
If it is malignant or atypical- excise/definitive therapy - If it is cystic–> aspirate
If the cyst disappears –> follow routine
If there is residual mass/blood–> excise or core biopsy
What are the steps of management for a woman under 30 when a breast mass is felt on PE?
- Ultrasound
- if it is solid —> core needle biopsy/FNA
- benign –> excise or observe
- malignant–> GET MAMMOGRAM, excise/definitive therapy - If it is cystic –> aspirate/observe
cyst disappears–> follow routine
residual mass or bloody fluid-> excise or core biopsy
When are 3 situations when a surgical biopsy or core needle biopsy should be considered for cysts?
- if they do not resolve completely
- grossly bloody aspirate
- recur quickly post aspiration
If you take a FNA and the aspiration has a rubbery consistency, what are you thinking it is?
If it is gritty, what are you suspicious of?
Rubbery = fibroadenoma Gritty = cancer
A patient has a normal clinical exam, but is found to have a suspicious lesion on screening mammography. What are the 3 best options for management?
- early mammographic follow up and physical exam in 4-6 months
- needle localized surgical excision breast biopsy
- stereotactic or sonographic guided core needle biopsy or FNA
What is the main advantage of the screening mammography?
What is the main disadvantage?
Advantage = high frequency of non-invasive cancers detected that can be removed before spread
Disadvantage = high frequency of benign biopsys
The mammography is very sensitive for masses but not specific for malignant > benign
In an effort to avoid unnecessary surgical biopsies, what 2 techniques are used? Which is more common?
- Stereotactic guided FNA
- inadequate sampling because only cytologic specimen and not histologic tissue
- requires experienced cytopathologist
Stereotactic core needle biopsy
- specimen is a thin piece of tissue with histologic specimen
What are the pros and cons of core needle biopsy?
Pros
- less invasive than surgical biopsy
- lower cost
- can plan definitive surgery if malignant
Cons
- lesion is disrupted so may be hard to stage
- may get inadequate sample
- requires followup
What are the 2 indications for getting a sterotactic [x-ray guided] breast biopsy?
- BIRADs score of 4 (suspicious) or 5 (highly suggestive of malignancy) that are not visible on ultrasound
- lesion identified in one mammographic view only
What is BIRAD score 0 1 2 3 4 5 6
What are indications for surgical referral?
When should the primary physician order the recommended follow-up imaging?
0 = incomplete assessment, get additional imaging
1 = negative finding 2= benign finding 3 = probably benign, 4-6 month followup 4= suspicious abnormality, biopsy 5= probable malignancy, appropriate action 6 = known, biopsy proven malignant, appropriate action
Surgical referral for 4,5
Order follow-up imaging for 3
A significant nipple discharge should be what 3 things?
- spontaneous
- persistent
- non-lactational
What 6 factors increase the risk of a nipple discharge being cancer?
- serous, sanguinous or watery
- associated with a mass
- unilateral
- single duct
- abnormal cytology or abnormal mammogram
- patient >50 yrs
A woman presents with a complaint of nipple discharge that is multi-ductal, multicolored, bilateral and elicited with manual compression. What is the likely cause?
Fibrocystic changes
What tests should be obtained if a patient presents with spontaneous non-lactational galactorrhea?
Prolactin and thyroid function tests
What are 5 common causes of non-lactational milky discharges from the nipple?
- prolactin secreting adenoma
- trauma to the chest or stimulation
- contraceptives
- thyroid disease
- medications [methyldopa, reserpine]
What tests should be ordered if the patient is having bloody nipple discharge?
bloody discharge should be hemoccult tested and cytologic examination may be done
What are the 6 most common etiologies of breast pain?
- diffuse fibrocystic changes
- sudden enlargement of a gross cyst
- breast infection
- cancer
- hormone cycle [physiologic or exogenous]
- costochondritis
What percent of women with breast cancer present with pain as their chief complaint?
Who is the concern greatest for?
<10%
Concern for breast cancer is greatest for older women who are not on hormone replacement therapy with new onset pain
You patient presents with breast pain that waxes and wanes related to hormone cycling. What is the most likely cause?
FCD
What interventions provide relief from breast pain?
NSAIDS, tamoxifen, OCPs, vit E, primrose, danazol, abstinence from caffeine
What is the DDx for inflammatory conditions of the breast?
- mastitis
- abscess
- recurring subareolar abscess
- folliculitis or sebaceous cyst [skin infections]
- superficial thrombophlebitis
- cancer
Why is mammography not helpful with diffuse inflammation of the breast?
- There will be an overall density to the glandular tissue and the mammogram had many false negatives with dense tissue
- patient may not be able to tolerate the compression
In breast inflammation that is diffuse with erythema and swelling, what should you attempt to find? Then what?
Find the area of fluctuance and aspirate it to confirm an abscess and obtain material to culture
How dues a recurring subareolar abscess present?
How is it treated?
spontaneous drainage of pus from around the nipple areolar complex,
Treat with drainage and antibiotics
If it recurs a lot, ductal excision can be performed
A patient has an erythematous, edematous firm breast. She doesn’t have fever or other systemic signs of infection. She hasn’t responded to antibiotic therapy.
What diagnosis are you suspicious of?
inflammatory breast cancer
What breast cancer screening technique is recommended by the ACS for a woman:
- over 20
- 20-40
- 40+
- 40-49
- 50+
- self breast exams monthly
- physical exam by a health profession every three years
- physical exam by health professionals yearly
- mammogram annually
- mammogram annually
