Eval of Common Breast Problems Flashcards
What skin findings are significant in a breast exam?
Rash, retraction, erythema
What imaging is the best in evaluating a breast mass?
US
What are the most common causes of breast masses?
Fibrocystic changes, cysts, fibroadenomas, and lipomas
What group of women should always have biopsies of breast masses?
Postmenopausal women because their breasts are not changing as much (e.g. with the menstrual cycle) and they have an increased risk for breast CA.
What are the physical exam findings for fibrocystic change of the breast?
Vague thickening or rubbery, ill-defined mass or density
What are the physical exam findings for a breast cyst?
Discrete fluid-filled mass
What are the physical exam findings for a fibroadenoma?
Smooth-margined solid mass in a premenopausal woman
What are the physical exam findings of a breast lipoma?
Smooth, soft, mobile mass
What are the physical exam findings of breast cancer?
Discrete solid mass with irregular edges
What size mass can be evaluated by FNA?
At least 7 mm
What kind of biopsy can be done for masses not visualized by US, but seen on mammography?
Stereotactically guided core needle bx
Mastalgia is usually related to
Hormonal and fibrocystic changes of the breast
What are common benign causes of focal persistent breast pain?
Cysts, fibroadenomas, mastitis, and abscess
What classes of medications are associated with noncyclical mastalgia?
Antidepressants and antihypertensives
What are two chest wall syndromes that may manifest as breast pain?
Costochondritis and Tietze syndrome
What is Tietze syndrome?
SWELLING and inflammation of the costal cartilages
What is costochondritis?
Temporary inflammation (not swelling) of the costal cartilage - the cartilage that connects each rib to the sternum at the costosternal joint
How does one differentiate between costochondritis and Tietze syndrome
There is inflammation of the costal cartilage in both diseases, but Tietze syndrome has swelling as well
What is the treatment of Tietze syndrome and costochondritis?
NSAIDs and rest
What is the treatment for cyclical mastalgia?
Evening primrose oil, NSAIDs, caffeine/chocolate abstinence, low-fat diet or 3-to-6 month trial of tamoxifen.
What kind of nipple discharge warrents surgical evaluation?
Spontaneous, recurrent, unilateral and from a single duct
What is “normal” nipple discharge
Present in premenopausal women. A small amount of induced nonspontaneous discharge that can occur after a warm shower or mammogram. Can also be elicited with massage.
Is testing for occult blood or cytology of nipple discharge recommended?
No - results are confusing and often misinterpreted.
Evaluation of nipple discharge begins with
H&P, mammogram and sometimes an US
If an abnormal targetable lesion is found on imaging obtained for nipple discharge is found, what should be done?
Core needle biopsy or needle-localized biopsy
If no suspicious lesion is found on imaging to correlate with nipple discharge, what should be done?
Excisional biopsy of the offending duct for diagnosis and rule out cancer
Is a ductogram needed for pre-op planning for nipple discharge?
Generally no. It is a painful procedure for the paitent and challenging for the radiologist. The results are often fraught with misinterpretation.
Describe the steps of a duct excision
- Place lacrimal duct probe if possible
- Subareolar incision and dissect just under the nipple
- Follow dissection down to chest wall or terminal ducts
What are the most common causes of nipple discharge?
Papillomas, duct ectasia and fibrocystic changes.
Bloody nipple discharge is most commonly due to?
Benign papilloma
What are the causes of true galactorrhea?
Hyperprolactinemia 2/2 pituitary tumor, hypothyroidism or druge side effect
What are the two groups of acute mastitis?
Those associated with pregnancy w/lactation andthose associated with a bacterial infection of unknown origin
Acute mastitis in a lactating patient is usually 2/2
Staphylococcus
How is acute mastitis in lactating patient usually treated?
Oral abx, warm packs, and massage to decompress the plugged duct
After an I&D for acute mastitis, should breast feeding cease on the affected side?
Yes, to allow the breast to heal.
What is the treatment for acute mastitis in a non-lactating patient?
Early oral abx - may take several weeks. IV abx if necessary.
If skin changes that accompany an underlying breast infection occur, when should a punch biopsy and core bx of underlying tissue be performed?
Within a month if the changes do not resolve with abx or steroids within 1 month
If persistent scaling or iching of the nipple or areola do not resolve with steroid ointment, what should be done?
Skin punch bx to rule out Paget disease
Can fibroadenomas fluctuate in size with menses or grow with oral contraceptives and pregnancy?
Yes
When does a fibroadenoma require excision?
If it grows over time, is >2-3 cm at diagnosis, or if is painful
Is there a risk of cancer with a fibroadenoma?
No
When should breast cyst fluid be sent for cytopathology?
If it is bloody
When should a breast cyst be biopsied?
A complex cyst on ultrasound or associated with a solid component
In pregnancy, a complex cyst may be the result of
A lactating adenoma
Do lactating adenomas resolve without treatment
Yes. However, follow-up imaging is warranted if there is a low-risk of CA
Performing an open breast bx duirng lactation often leads to
A milk fistula. This may require cessation of breast feeding for resolution
Does one need to excise a breast lipoma?
No
A painful fatty tumor is likely the result of
An angiolipma. Excise to relieve pain.
What benign breast abnormalities warrant a needle-localized excisional bx?
Atypical ductal hyperplasia, atypical lobular hyperplasia, LCIS, complex sclerosing lesion, or a radial scar.
Gynecomastia is common in what two age groups?
20-30s and > 60 years of age
Is unilateral breast enlargement directly behind the nipple common in gynecomastia?
Yes
What work-up is needed to rule out breast cancer in males?
Same work-up as women: breast exam, mammogram, and bx if indicated
What are the causes of gynecomastia?
Drug interactions, alcoholism, loss of testosterone, elevation of estrogen levels due to thyroid orliver problems, or hormone-secreting tumors
