Disorders of the Breast Flashcards
Benign Breast Masses
Fiberoadenoma
Cysts
Fibrocystic Changes
Galactocele (milk retention cysts)
Fat Necrosis (death of tissue after trauma or surgery)
Breast Abcesses
Malignant Breast Masses
noninvasice cancer
invasive cancer
Paget’s Disaese
phyllodes tumor
lymphoa
breast sarcoma
Mastalgia
Etiology
classifications: cyclical, non and extra mammary
Mastalgia Etiology
- mastaliga = breast pain
- can be realted to breast cancer but very uncommon
Classifications of Mastalgia
- cyclical: related to the hormonal cycles of the period& ovulation : bilateral pain thats cyclical
- Noncyclical: occuing not in releation to the cyce
- Extra Mammart: pain which is in the areas but not a result of the breast itself (Example: chest wall pain)
Possible Reasons for Noncyclical mastalgia
large pendulous (hanging breasts = pain)
diet, lifestyle related (smoking and high fat)
horome replacement thearpy
cysts (creating discomfoty)
Ductal Ectasis (inflammaion, not an infection of the ducts)
Mastitis
iflammatory BC
Hidradentisi supperativa
Workup and Evalauation of Mastalgia
- rule out mastitis (reddness, fever, etc.)
- rule out breast cancer (masses, skin change, bloody discharge)
- rule out chest wall as the pain souce (extra mammary)
Focal Breast Pain
- a little sus for BC : get US/mamo.
Diffuse Breast Pain
- not BC or worried about it
- supportive treatment, bras, NSAIDS, HRT changes, contraceptive changes
- 6 months without relief: tamoxifen
Galactorrhea
Etiology
Causes
Symptoms
Etiology
- milk secretion from the breast in a non-breast feeding women
- physiologic nipple discharge
- can be due to stress or nipple stimulation
Symptoms
- non-bloody bilateral discharge
females : premenopausal
- hypogonadism: infertility, oligomenorrhea or amennorrhea
- low BMD
Males
- decrese libiod
- impotence
- gynecomastia
Causes
- most often caused by hyperprolactinemia which can be secondary to
- medications
- endocrine tumors (pituitary adenomas)
- endocrine abnormalities
(rearely)
- idopathc
- hypothyroid
- chest wall injury
- chronic renal failure
- estrogen administeration
Galactorrhea
Work Up
Treatment
Work up
- pregnancy test
- prolactin levels
- creatinine (for renal)
- TSH
if any of the above = abnormal, refer to endocrine
Treatment of Galactorrhea : depends on cause
- Dopamine Agonist cabergoline (because decreased Dopamine increased proactin; so increasing dopamine will decrease prolactin)
- ovulation induction
- surgery (if pituriaty adenoma)
- gondal steroid replacement (if needed)
Symptoms of pathologic nipple discharge
Symptoms
- unilateral
- involving one duct
- spontaneous
- persistant
- serous or serosanguineous(blood tinged) fluid
- associated with masses or skin changes
can be due to papilloma, duct ectasia, infection or cancer
Papilloma
Etiology
Diagnosis
Treatment
Etiology
- MCC of pathologic nipple discharge
- benging tumor which grows within the lining of the breast duct
- due to HPV in 70% of cases
- can harbor atypia and DCIS (if solidary tumor) : rule this out via imaging/biopsy
Diagnosis
- clinically made
- if sus for malignancy: can do biopsy and imaging
Treatment
- surgical removal
Duct Ectasia
Etiology
Symptoms
Diagnosis
Treatment
Duct Ectasia : Etiology
- benign condition of breast duct wall thickening and widening which leads to blockage and fluid build up
- common in pre-menopausal women
Symptoms
- discharge: sticky and thick
- can be assocaited with nipple changes, skin changes and masses (sccar tissue around the duct = mass)
Diangosis
- rule out cancer and infection (if needed via imaging and biopsy)
Treatment
- no treatment needed; usually resolves on own
- can be surgically removed
Gynecomastia
Etiology & causes
Evaulation
Etiology
- enlargement of the breast tissue in men
Causes
- persistant pubertal gynecomastia
- drugs
- idopathic
- cirrhosis/malnutrtion
- male hypogondaims
- testicualr tumor
- hyperthyroid (increased ratio of estrogen:androgens)
- chronic kidney disease
Evaluation
- need to do a through evaluation of the breast in men to ensure its not breast cancer!!: exam
- Gynecomastia: rubbery-to-firm, cocentric disk of tissue, moblie and loacted directly beneath the areoa area
- masses assocaited with cancer: will be eccentrically positioned
Labs
- testosterone (eval. hypogonad), LH, Estrogen, HcG (germ cell CA)
Treatment
- observation
- withdraw any agents (like meds) if causes
- treat underlying issues
- tamoxifen can be used for idopathic
- surgery
Fibroadenoma
Etiology
Symptoms
Diagnosis
Etiology
- most common benging tumor in the breast
- single, benign tumor with glandual and fibrous tissue
- possibly due to hormones; common in reproductive yeras, enlarge with pregnancy and estrogen therapy
Symptoms : mass characterisitcs
- typically oval or round
- rubbery and discrete
- non tender
- moblie
- accidental finding
Diagosis
- US, mammogram, MR (to r/o cancer and infection)
- biopsy: FNA/core needle or excisional/incisional
Fiberoadenoma
Surgical Indications
Surgical Indications of a fiberoadenoma
- large size > 2.5 cm
- causing discomfort or deformity
- age > 35 (cancer concern)
- immoblie or poorly circumscribed
- patitent desire
- indeterminate biopsy
Fibrocystic Changes of Breast Masses
general clinical symptoms of these
evaluation: waht are your options
general clinical symptoms
- masses: asymptomaticor can be painful/tender
- can fluctuate with menstrual cycle
- can be bilateral
- can be associated with serous nipple discharge
Evaluation
- for those < 40 y/o = US sufficient
- for those > 40 y/o = mammogram
- aspiration: if mass is cyst-like
- biopsy
Fiberocystic Changes in Breasts
Aspiration protocol
when to send for cytology
what to do if recurred 2nd or 3rd
Aspiration
when to send aspiration for cytology
- turbid or grossly bloody fluid
- only minial fluidobtained
- the mass remains after its been aspirated
Follow up 4-8 weeks
- if the cyst is no longer palpable = benign
- aspirate and send for cytology if it recurred; regardless of fluid appearance; need to assess
a third recurrance/persistant mass warrents a biopsy even if cytology came back negative
Fiberocystic Changes in Breasts
Biopsy criteria
Biopsy Criteria for the mass
- a solid mass
- no fluid aspirated
- mass failed to resolved with aspiration
- a third recurrance/presistant cyst
Breast Cyst
Etiology
Symptoms
Diagnosis and Work up
simple v complicated v complex
Breast Cyst
- a flid filled rounded or oval shape
- usually found incidental on exam or imaging
Symptoms
- discomft, but usally painless
Diagnosis (usually US then can do biopsy depending on what you find)
US, FNA or CNB
US
- if benign; benign needs no intervention
Simple: benign
Complicated
- follow up 1 year to assess stability
- benign if it collapses after FNA
- FNA fails to collapse it: need further work up with cytology or biopsy
Complex
- must be biopsed
Breast Abcess
Etiology and Risk Factors
Symptoms
Evaluation
Etiology and Risk Factor s
- inflammed/infected breast
Risk Factors
- nursing: age > 30
- first pregnancy nursing
- gestational age > 41 weeks
- untreated mastitis or cellulitis of the breast tissue
- smoking
Symptoms
- red, tender and fluctuant indurated mass of the breast
- fever
- assoicated cellulitis or mastitis
Evaluation
- US
- need to rule out inflammatory breast cancer in non-lactating breast or in a non resolving infection despite treatment
- I&D to obtain culture
Treatment
Drainage: needle aspiration or surgical drainage
obtain culutres
Breast Abcess Treatment
Treatment
Drainage is needed, thearpeudic and to obtain culuter
- needle
- surgical
Management: antibiotics
outpatient, nonsevere infection with no MRSA risk
- cephalexin
- clindamycin
- dicloxacillin
outpatient, nonsevere infection but MRSA risk
- bactrum
- clindamycin
severe infection
- IV vancomycin
Mastitis : Lactational Mastitis
etiology
Risk Factors
Etiology
- inflammation +/- infection
- due to prolonged engorgment
- obstructed drainage (not fully expressing milk)
- dince breast milk contains soe bacteria: if not fully expressed these bacteria proliferate and infect staph aureus or mrsa are possible
- can also be non-infectious! just a clogged duct and inflammed
Risk Factors
- blocked milk duct
- pressure on breast
- oversuppl of milk
- infrequent feeding
- nipple excoriations or cracking
- rapid weaning
- illness in mo or baby
- maternal stress or fatigue
- maternal malnutrtion
Lactation Mastitis
Symptoms
Diagnosis
Treatment
Symptoms
- firm, red tender ares of the breast
- fever think infection
- constitutional symptoms think infection
Diangosis
- usually clinical
- US possible
- can culutre the breast milk
Treatment
non-infectious
- NSAIDS/tylenol
- cold/warm compresses
- emptying! expression or pumping
- fluids
- avoid tight clothing
Infectious
Outpt, not severe and no MRSA
- cephalexin
- clindamycin
- dicloxacillin
Outpt, not severe but MRSA risk
- bactrum
- clindamycin
severe infection
- IV vancomycin
Mastitis: Nonlactational Mastitis (peridutal)
etiology
symptoms
diagnosis
Etiology
- breast feeding
- younger age
Symptoms
- periareolar tenderness
- warmthand redness
- nipple changes or discharge
- abcess formulation
Diagnosis
- culture the nipple discharge or the abcess
- US
- mammogram (if at risk and concern for CA)
Treatment
- usaully a chronic condition
- abx: amoxicillin-clavulanate (augmentin)
- if abcess: I&D or surgical excision
- stop smoking
Nonlactational mastitis: idopathic granulomatous
etiology & risk factors
symptoms
Etiology
- also causes lobulat mastitis
- a rare benign inflammatory breast disease
- unknone origin
Risk Factors
- parous younger women
- TB infections
- sarcoidosis
Symptoms
- often peripheral breast masses and mutiple of them
- abcess formations
- skin inflammation and ulcerations
- nipple retraction
- sinus formuation
- peau d’orange
- axillary adenopathy
Nonlactational mastitis: idopathic granulomatous
work up
treatmetn
Work up
- US
- mamo.
- biopsy
Treatment
- self limiting
- assocaited infections: can use amoxicillin-clavulante and assocaited I&D
Breast Cancer
Risk Factors
Risk Factors
- increased age
- female
- white
- increased weight
- post menopasue
- tall stature
- high estrogen
- benging breast diseases
- denser breast tissue
- HRT or contraceptive pills
- age > 30 at first delivery/pregnancy
- BMD (decreased?)
- elevated testosterone
- exposure to diethlysilbestrol in utero (older women)
- early menarche, late menopause
- no kids
- family history or personal hsitory of cancer
- geneitc mutations
- smoking, alcohol use
- Exposure to radiation: to teh chest
Breast Cancer Screening Recommendations
Recommendations
High RIsk
- personal history of breast, ovarian, peritoneal or fallopian cancer
- genetic mutations (BRCA!,2)
- history of previous radiotherapy to the chest : age 10-30
average-moderate risk pt
- those under 40 = no screening recommended
- those 40 - 49 years: every 1-2 years or individual conversation with provider
- those 50-74: every 1-2 years
- those over 75: continue if expectancy of life is > 10 years; otherwise conversation with provider
Types of breast cancer
in situ
invasive
In situ: confied to the mammary ductal system
- ductal
- lobular
Invasive: into the breast tissue
- infilterative ductal is most common type
- invasive lobular
- ductal/lobualr
- inflammatory
- etc.
Ductal Carcinoma in Situs (DCIS)
DCIS
- malignant cells confined within the mammary ductal system: not invading surroudning breast tissue
Subtypes of Dutal in situ: calssified by cytology and architectural necrosis
low/intermediate grade cancers
- papillary
- cribiform
- solid
high grade cancers
- comedo
these are precurosrs to invasive breast cancer: so we do NOT wait to treat
Mammogram preferred to see the micro-calcifications
treatment: lumpectomy v masectomy + radition
Breast Cancer: Classification by Receptor Type
Receptor Type
Estrogen (ER)
Progesteron (PR)
human epiderma growth factor (HER2)
tumor without these three receptor types = triple negative cancer
Sites of Breast Cancer Metastisis
MOST COMMON METS LOCATION: axillary lymph nodes: 1 –> 2 –> 3
2nd: goes to the bone
then to the
lungs, liver and the brain
