Disease of the Breast Flashcards
What are coopers ligament?
are bands that attach to the pectoralis major muscle and the fascia of the skin of the breast
Support the breast in the upright position
If these bands are being compressed or invaded by a tumor
What is the breast made up of?
Lies on top of the pectoralis major muscle
Made up of glandular ducts and lobules, connective tissue (Cooper’s ligaments) and fat
Lobes, lobules and alveoli do what?
produce and secrete milk
Ductule, ducts and lactiferous duct are what?
tubes that connect the lobes and nipple to excrete milk
What is the Lactiferous sinus?
Enlargement of the lactiferous duct at the base of the nipple where milk accumulates
What is adipose tissue in the breast
80-85% of breast tissue Holds lobules in place Gives the breast its shape *1/2 of glandular tissue is in the UOQ All women, regardless of size, have the same # of lobes (15-25) w/ 6-10 major ducts that exit the nipple
What are the 7 lymph nodes used to drain the breast?
lateral axillary nodes pectoral nodes subscapular nodes central axillary nodes infraclavicular nodes parasternal nodes supraclavicular nodes
breast development before puberty
Formed early in fetal life from an invagination of the ectoderm
15-25 ducts form the fetal breast at term
Fetal male and female breast tissue
development is the same
Only organ not fully developed at birth
At puberty (in response to stimulation of hypothalamus, pituitary and ovaries) female breast development
Increase in alveolar tissue and ductal size
extensive branching of the ductal system
fat deposits
Nipple and areola enlargement
takes 3 to 4 years
usually complete by age 16
What are the 5 Tanner Stages of Breast Development
Stage I: No breast buds
Stage II: Breast buds develop, papillae slightly elevated and areola enlarges
Stage III: Breasts and areolae confluent, elevated
Stage IV: Projection of areola and papilla to form a secondary mound
Stage V: Projection of papillae only, mature stage
Pregnancy/ lactation changes to the breast
Size and turgor increase, increased pigmentation of nipple/areola, nipple enlargement, areolar widening increased # and size of glands, increased branching of ductal system, ducts widen
Protective against breast cancer
Breast size has no relation to amount of milk produced
Postmenopausal changes to the breast
Atrophy of breasts, lobes involute, gets replaced by adipose tissue which is softer, lose support
PE and mammography are easier to interpret
Accessory Nipples
2-6% of population
Located anywhere along the milk line
Frequently multiple are present
Often appear to be moles
Accessory Breast Tissue
Most often occurs in the underarm area
Breast cancer has been reported in these tissues
3 normal abnormalites of the breast
inverted nipples–> sudden needs to be eval
asymmetrical breast
large breasts
What can cause the underdevelopment of breast tissue
Trauma Radiotherapy Breast biopsy (removal of breast bud no breast development during puberty) Gonadal dysgenesis Hypogonadotropin hypogonadism
What are 6 types of exams to do during breast evaluation?
EXAM Mammogram Ultrasound Digital Mammogram MRI Biopsy
What can you not see on a mammogram
Not all cancers will show up
Cannot tell if a nodule is cystic or solid
3 types of biopsy for the breast
Fine needle
Sterotactic
Sentinal node
Mammogram used for?
Only screening method found to decrease mortality of breast cancer
False positives and false negatives can occur
can be used for diagnostic or just screening
U.S. Preventive Services Task Force (USPSTF) screening for women
Routine screening of average-risk women should begin at age 50, instead of age 40.
Routine screening should end at age 74
Women should get screening mammograms every two years instead of every year.
Breast self-exams have little value, based on findings from several large studies.
2 Special circumstances for screening recommendations for women
Women w/ a genetic predisposition to Breast cancer: Combo screening mammo and MRI beginning at age 25 or based on the age of the earliest onset breast cancer in the family
Women w/ FH of Breast cancer but w/o a genetic mutation: Data is inconclusive. Some suggest 5 years before the age of diagnosis
mammography film
Less expensive Readily available Comparable to old films May be less accurate Dense breasts hard to read
digital mammography
More expensive Limited access Difficult to compare to old films Higher rate of false positives Better for premenopausal and dense breasts
Of every 1,000 U.S. women who are screened about how many are called back?
how many are positive for malignancy?
have cancer?
About 7% (70) will be called back for a diagnostic session
About 10 of the 70 will be referred for a biopsy
3.5 will be positive for malignancy
6.5 will be benign
The remaining 60 are found to be of benign cause
Of the 3.5 who do have cancer
2 have a low stage cancer
What is MRI used for with breast evaluation
MRI can be used along with mammograms for screening women at high risk
Used to better examine suspicious areas found by a mammogram
Used for better calculation of size/other cancerous lesions once a diagnosis of Breast Cancer has been made
What is breast U/S used for with breast evaluation
Breast US is used to target a specific area of concern found on the mammogram
Helps distinguish between cysts (fluid-filled sacs) and solid masses and sometimes can help tell the difference between benign and cancerous tumors
What are some indications for MRI in breast eval
Evaluate breast implants for leaks or ruptures
Imaging very dense breast tissue
Palpable breast abnormalities which are not visible with mammography or ultrasound
Determine the extent of breast cancer
To assess abnormal areas after breast surgery or radiation therapy
What is Fine needle aspiration (FNA) biopsy
A thin needle is injected into the suspicious lump and fluid or tissue is aspirated pathology
May be US guided
Limited- could miss cancerous cells based on technique, unable to distinguish invasive from noninvasive disease
What are core needle biopsy
A larger, hollow needle is used to withdraw small cylinders (or cores) of tissue from the abnormal area
The needle is put in 3 to 6 times to get the core samples
May be US guided or mammogram guided (stereotactic)
Able to distinguish invasive from noninvasive disease
What is a sentinal node biopsy
Surgeon removes the first lymph node(s) to which a tumor is likely to drain which is called the sentinal node which is the one most likely to contain cancer cells if the cancer has spread into the lymph
2 major breast cancer predisposition genes
BRCA1 and BRCA2
What occurs with mutations to the 2 predisposing genes for breast cancer?
Mutations in these genes result in increased risk for breast cancer as well as ovarian, colon, prostate and pancreatic cancers
5-10% of all women w/ BRCA have a mutation
Risk of developing BRCA if you have a mutation is 40-85%
Ashkenazi Jewish population has an increased risk of certain mutations
Genetic testing is recommended for members of high risk families
What are 4 benign breast disorders?
Fibrocystic
Fibroadenoma
Gynecomastia
Nipple discharge
Fibrocystic Breast Condition (FBC) is what?
associated with?
Benign condition
Most frequent cause of breast lumps
Cyclic breast pain that is most prominent during the luteal phase and subsides w/ menses
Associated w/ an increase in size of the lumpy areas in the breast as well as discomfort/pain
May be associated w/ nonbloody, green or brown discharge
FBC epidemiology
Most common b/w 20-50 years of age 70% of women in their 20’s 60% in their 30’s Less frequent in menopausal women ** does not increase the risk for breast cancer
3 ways to evaluate FBC
Ultrasound
Mammogram not indicated in women <30
Biopsy may be indicated
Treatment for FBC
Reduce fat
<20% of the diet, particularly saturated fats
Limit eggs, chicken, and dairy products
Avoid soy protein products
Reduce or eliminate caffeine
Reduce or eliminate sugar, white flour, and refined foods
Vitamins and minerals (?Vitamin E and primrose oil)
Consume omega-3 fatty acids (fish, fish oil supplements)
Daily exercise
Stop smoking
What are breast cysts?
Smooth, round, fluid-filled, slightly elastic and mobile
cause for concern if fluid is bloody
May be an isolated lump, in clusters, or widespread
Frequently occur in the upper outer quadrant and the underside of the breast.
What do breast cysts not do?
Do not attach themselves to underlying breast tissue so they do not produce tissue deviation or dimpling unless very large
What is a simple cyst
Fluid filled with no septa or projections
Not malignant
Ultrasound is used to determine if the nodule is cystic or solid; and if a cyst, whether it is simple or complex.
How do you treat a simple cysts
simply follow it–> repeact U/S in 3-6 months
aspirate it.
biopsy/remove which is definitive tx if it increases in size
What is a complex cyst
More than one compartment or contains projections or debris
Ultrasound – differentiates simple cysts from complex cysts or solid masses
More likely to be cancerous
Fine needle aspiration or a biopsy is needed
Fibroadenoma is most common in?
Common, benign neoplasm Most common: b/w ages of 20-30 years African American Near nipple or UOQ
Fibroadenoma pathology and etiology
Pathology:
Structural (fibro) and glandular (adenoma) tissue
Etiology:
Unknown
Workup for fibroadenomas
US first
All solid lesions require biopsy (FNA)
Clinical findings for fibroadenomas
Round, firm, smooth and mobile w/ clear margins
Painless and non-tender, averaging 1-5cm in size
Treatment for fibroadenomas
Local excision of the mass w/ a margin of normal breast tissue
atypical fibroadenoma
A fibroadenoma with abnormal growths or abnormal cell changes (seen on US)
Fibroadenomas do not become cancerous, however, they can act as markers for the disease
what is Gynecomastia
development of breast tissue in males
Life cycle of males for gynecomastia?
infants, puberty, middle age
Infants
50% male infants – due to maternal estrogen
Resolves in 2-3 weeks after birth
Puberty
Relatively common – due to hormonal changes
Resolves within 6 month – 2 years without treatment
Middle Age
Peaks age 50 -80
25% men affected
What are some medical causes of gynecomastia
Aging Hyperthyroid Renal failure/Cirrhosis Testosterone deficiency Obesity Pituitary tumors Malnutrition
What are some medications that cause gynecomastia
Estrogen exposure Anabolic steroids Diazepam (Valium) Tricyclic antidepressants Cimetidine Chemotherapy Digoxin (Lanoxin) Calcium channel blockers Alcohol Amphetamines Marijuana
What is nipple discharge characterized as?
Normal lactation
Galactorrhea (benign physiologic nipple discharge)
Pathologic nipple discharge
Most common cause is intraductal papillomas
Others: Carcinoma and fibrocystic change w/ ectasia of ducts
What is the treatment of galactorrhea
Treat underlying disease/discontinue offending agent
Surgical excision of involved duct may be necessary
What is the workup of galactorrhea
Imaging
Labs: Pregnancy test, prolactin level, renal and TFTs
Signs and symptoms of nipple discharge
Usually unilateral, spontaneous serous or serosanguinous d/c from a single duct
Bloody d/c is more suggestive of cancer, but also benign papilloma of duct
Palpable mass may not be present
Fat necrosis of the breast
Benign condition
Mimics carcinoma
Damaged or disintegrating fatty tissue produces painful/painless, round, firm lumps that are sometimes accompanied by skin or nipple retraction and the appearance of ecchymoses
Etiology of fat necrosis of the breast
Etiology: Trauma or prior surgery
Mass typically resolves after several weeks; therefore if it persists= biopsy
no tx
What are 5 disorders of lactation
Engorgement Painful nipples Galactocele Mastitis Breast Abscess
What is engorgment
Occurs during the first week postpartum
Due to vascular congestion and accumulation of milk
With moderately severe engorgement, the breasts become firm and warm, with significant discomfort and slight fever
If areola is engorged, the baby will not be able to grasp the nipple
What is the treatment for engorgment?
Mild: analgesics, cool compresses and partial expression of milk before nursing
Severe: Empty breasts
painful nipples occur when?
Common during first few days of breastfeeding
Usually resolves once milk begins to flow
Nipple fissures can develop and can cause severe pain and lead to infectionmastitis
What are some treatments for painful nipples
Dry heat b/w feedings
Lanolin cream/A and D ointment
Apply expressed breast milk to nipples and let it dry b/w feedings
Nipple shield
OTC pain relievers prn
Hydrogel pad
If persistent w/o any physical findings of fissures, think Candidal infection
Galactocele
Milk retention cyst that is caused by a blocked milk duct
Lack of erythema, warmth, fever/chills, etc
Treatment:
Warm compresses
Continue breastfeeding
What is mastitis?
Bacterial infection of the breast
Staph aureus and Streptococcus sp= MC
Often occurring postpartum after 5th day
May be limited to the subareolar region but usually involves an obstructed lactiferous duct and the surrounding breast parenchyma
What happens if mastitis is left untreated?
abscess formation occurs
I&D if it is present
Abx
Signs and symptoms of mastitis?
Painful erythema in wedge shape distribution Warmth and tenderness to the area Fever >101 often with chills Cracking of the nipple may be present Flu like symptoms
What is the treatment for mastitis?
Pumping and discarding of milk
Antibiotics - Dicloxacillin, Cephalexin are tx if choice
Heat to area
prevent by frequent nursing
Breast Cancer epidemiology
Most common non-skin cancer in women
2nd most common cause of cancer death in women
Main cause of death for women b/w 40-59 years
an estimated 2,829,041 women currently living with breast cancer
white women
african american women high incidence before 40
> 95% of breast cancer arise from what?
epithelial elements of the breast (ducts or lobules)
Ductal carcinoma- most common
Lobular carcinoma- 2nd most common
There are multiple subtypes of each
Risk factors for Breast Cancer
Personal or FH of BRCA gene mutation Increasing age Early menarche (50) Age at first live birth (>30 increase risk) Nulliparity # breast biopsies Increased breast density
What are most breast cancers being diagnosed as a result of?
Majority are diagnosed as a result of an abnormal mammogram
What are some symptoms of breast cancer
Back/bone pain, systemic complaints, wt loss
Painless mass, breast pain, nipple d/c; retraction, enlargement or itching of nipple; redness, hardness, enlargement of breast
what are some signs of breast cancer
Nipple retraction; nipple d/c; edema, redness or skin retraction/dimpling of breast; axillary and supraclavicular LAD; breast mass non-tender, firm/hard w/ poor margins
Advanced disease: edema, redness, nodularity, ulceration of skin, >5cm mass, fixation to chest wall, marked axillary lymphadadennopathy, edema of ipsilateral arm, supraclavicular LAD
Initial Work-Up of a breast mass
B/l mammogram
Breast ultrasound
Labs: CBC, CMP including LFT’s, alkaline phosphatase
Further imaging may be recommended initially if there are signs/symptoms of distant metastasis
Diagnostic for breast cancer is what?
biopsy
HER2 test
hormone receptor test
Testing requirements for staging?
Lymph node biopsy CT- imaging modality of choice Chest, abdomen and pelvis Bone scanning To rule out skeletal metastases ?PET Scan/MRI
What are 3 types of surgical treatment for breast cancer
Radical Mastectomy-
Modified radical mastectomy (MRM)
Breast conservation therapy (BCT)
What is Modified radical mastectomy (MRM)
Involves removal of the affected breast and underlying pectoral major fascia (not the muscle), and evaluation of selected axillary lymph nodes
Variations of this as well
Better cosmetic and functional results
What is Breast conservation therapy (BCT)
Involves a surgical procedure (ex. Lumpectomy, partial mastectomy, segmental mastectomy), an axillary evaluation and postoperative irradiation
No significant difference in local relapse, distant mets, or overall survival b/w conservative surgery w/ radiation and MRM
Treatment option for Stage I and II and selected stage III disease
What is hormonal therapy used for?
Recommended for estrogen or progesterone hormone receptor protein or both
Benefits are seen across all subgroups of breast cancer patients
Ex. Tamoxifen–5 year duration
Aromatase inhibitors–more effective in postmenopausal
What is chemotherapy recommended for?
Recommended for early stage and advanced stages
Goal is to eliminate microscopic mets responsible for recurrent dz
Beneficial in early disease, the majority of locally advanced disease
Use of multiple agents is superior to single-agent chemotherapy tx
Duration of 3-6 months or 4-6 cycles achieve optimal benefit
What are 3 goals for close follow up for women diagnosed with breast cancer?
To detect recurrences and
To detect second primary disease in the same breast
To detect new cancers in the opposite breast
What is the local recurrence rate?
Correlates w/ stage, tumor size, lymph node involvement, margin status, grade and histologic type
Median time to recurrence is 4 years
1-2% risk per year for 1st 5 years
1% risk per year thereafter
Risk of recurrence after MRM or BCT is <15% 20 years after tx
Many pts w/ locally recurrent dx will develop distant mets w/in 2 years
What is the prognosis for breast cancer?
Single most reliable indicator of prognosis is the stage of breast cancer
Cure rate for localized breast cancer w/o evidence of spread following tx is 75-80%
Cure rate for pts w/ small ER- and PR- positive tumors w/o axillary spread is 90% at 5 years
Survival rate w/ axillary lymph node involvement is 50-60% at 5 years and <25% at 10 years
Where is the most common site of metastasis for breast cancer?
bone
goal of treatment- palliative
