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Disease of the Breast Flashcards

1
Q

What are coopers ligament?

A

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

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2
Q

What is the breast made up of?

A

Lies on top of the pectoralis major muscle

Made up of glandular ducts and lobules, connective tissue (Cooper’s ligaments) and fat

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3
Q

Lobes, lobules and alveoli do what?

A

produce and secrete milk

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4
Q

Ductule, ducts and lactiferous duct are what?

A

tubes that connect the lobes and nipple to excrete milk

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5
Q

What is the Lactiferous sinus?

A

Enlargement of the lactiferous duct at the base of the nipple where milk accumulates

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6
Q

What is adipose tissue in the breast

A 
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
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7
Q

What are the 7 lymph nodes used to drain the breast?

A 
lateral axillary nodes
pectoral nodes
subscapular nodes
central axillary nodes
infraclavicular nodes
parasternal nodes
supraclavicular nodes
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8
Q

breast development before puberty

A

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

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9
Q

At puberty (in response to stimulation of hypothalamus, pituitary and ovaries) female breast development

A

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

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10
Q

What are the 5 Tanner Stages of Breast Development

A

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

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11
Q

Pregnancy/ lactation changes to the breast

A

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

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12
Q

Postmenopausal changes to the breast

A

Atrophy of breasts, lobes involute, gets replaced by adipose tissue which is softer, lose support
PE and mammography are easier to interpret

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13
Q

Accessory Nipples

A

2-6% of population
Located anywhere along the milk line
Frequently multiple are present
Often appear to be moles

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14
Q

Accessory Breast Tissue

A

Most often occurs in the underarm area
Breast cancer has been reported in these tissues

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15
Q

3 normal abnormalites of the breast

A

inverted nipples–> sudden needs to be eval
asymmetrical breast
large breasts

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16
Q

What can cause the underdevelopment of breast tissue

A 
Trauma
Radiotherapy
Breast biopsy (removal of breast bud no breast development during puberty)
Gonadal dysgenesis
Hypogonadotropin hypogonadism
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17
Q

What are 6 types of exams to do during breast evaluation?

A 
EXAM
Mammogram
Ultrasound
Digital Mammogram
MRI
Biopsy
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18
Q

What can you not see on a mammogram

A

Not all cancers will show up

Cannot tell if a nodule is cystic or solid

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19
Q

3 types of biopsy for the breast

A

Fine needle
Sterotactic
Sentinal node

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20
Q

Mammogram used for?

A

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

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21
Q

U.S. Preventive Services Task Force (USPSTF) screening for women

A

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.

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22
Q

2 Special circumstances for screening recommendations for women

A

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

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23
Q

mammography film

A 
Less expensive	
Readily available
Comparable to old films
May be less accurate
Dense breasts hard to read
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24
Q

digital mammography

A 
More expensive
Limited access
Difficult to compare to old films
Higher rate of false positives
Better for premenopausal and dense breasts
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25
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
26
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
27
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
28
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
29
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
30
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
31
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
32
2 major breast cancer predisposition genes
BRCA1 and BRCA2
33
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
34
What are 4 benign breast disorders?
Fibrocystic Fibroadenoma Gynecomastia Nipple discharge
35
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
36
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 ```
37
3 ways to evaluate FBC
Ultrasound Mammogram not indicated in women <30 Biopsy may be indicated
38
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
39
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.
40
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
41
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.
42
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
43
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
44
Fibroadenoma is most common in?
``` Common, benign neoplasm Most common: b/w ages of 20-30 years African American Near nipple or UOQ ```
45
Fibroadenoma pathology and etiology
Pathology: Structural (fibro) and glandular (adenoma) tissue Etiology: Unknown
46
Workup for fibroadenomas
US first | All solid lesions require biopsy (FNA)
47
Clinical findings for fibroadenomas
Round, firm, smooth and mobile w/ clear margins | Painless and non-tender, averaging 1-5cm in size
48
Treatment for fibroadenomas
Local excision of the mass w/ a margin of normal breast tissue
49
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
50
what is Gynecomastia
development of breast tissue in males
51
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
52
What are some medical causes of gynecomastia
``` Aging Hyperthyroid Renal failure/Cirrhosis Testosterone deficiency Obesity Pituitary tumors Malnutrition ```
53
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 ```
54
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
55
What is the treatment of galactorrhea
Treat underlying disease/discontinue offending agent | Surgical excision of involved duct may be necessary
56
What is the workup of galactorrhea
Imaging | Labs: Pregnancy test, prolactin level, renal and TFTs
57
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
58
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
59
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
60
What are 5 disorders of lactation
``` Engorgement Painful nipples Galactocele Mastitis Breast Abscess ```
61
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
62
What is the treatment for engorgment?
Mild: analgesics, cool compresses and partial expression of milk before nursing Severe: Empty breasts
63
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 infectionmastitis
64
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
65
Galactocele
Milk retention cyst that is caused by a blocked milk duct Lack of erythema, warmth, fever/chills, etc Treatment: Warm compresses Continue breastfeeding
66
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
67
What happens if mastitis is left untreated?
abscess formation occurs I&D if it is present Abx
68
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 ```
69
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
70
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
71
>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
72
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 ```
73
What are most breast cancers being diagnosed as a result of?
Majority are diagnosed as a result of an abnormal mammogram
74
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
75
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
76
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
77
Diagnostic for breast cancer is what?
biopsy HER2 test hormone receptor test
78
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 ```
79
What are 3 types of surgical treatment for breast cancer
Radical Mastectomy- Modified radical mastectomy (MRM) Breast conservation therapy (BCT)
80
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
81
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
82
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
83
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
84
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
85
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
86
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
87
Where is the most common site of metastasis for breast cancer?
bone | goal of treatment- palliative

Womens Health (5 decks)

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