Eval of Common Breast Problems

Question 1

What skin findings are significant in a breast exam?

Answer 1

1. Rash
2. Retraction
3. Erythema

Question 2

What imaging is the best in evaluating a breast mass?

Answer 2

Ultrasound

Question 3

What are the most common causes of breast masses?

Answer 3

1. Fibrocystic changes
2. Cysts
3. Fibroadenomas
4. Lipomas

Question 4

What group of women should always have biopsies of breast masses?

Answer 4

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.

Question 5

What are the physical exam findings for fibrocystic change of the breast?

Answer 5

Vague thickening or rubbery, ill-defined mass or density

Question 6

What are the physical exam findings for a breast cyst?

Answer 6

Discrete fluid-filled mass

Question 7

What are the physical exam findings for a fibroadenoma?

Answer 7

Smooth-margined solid mass in a premenopausal woman

Question 8

What are the physical exam findings of a breast lipoma?

Answer 8

Smooth, soft, mobile mass

Question 9

What are the physical exam findings of breast cancer?

Answer 9

Discrete solid mass with irregular edges

Question 10

What size mass can be evaluated by FNA?

Answer 10

At least 7 mm

Question 11

What kind of biopsy can be done for masses not visualized by US, but seen on mammography?

Answer 11

Stereotactically guided core needle bx

Question 12

Mastalgia is usually related to

Answer 12

Hormonal and fibrocystic changes of the breast

Question 13

What are common benign causes of focal persistent breast pain?

Answer 13

Cysts, fibroadenomas, mastitis, and abscess

Question 14

What classes of medications are associated with noncyclical mastalgia?

Answer 14

Antidepressants and antihypertensives

Question 15

What are two chest wall syndromes that may manifest as breast pain?

Answer 15

Costochondritis and Tietze syndrome

Question 16

What is Tietze syndrome?

Answer 16

SWELLING and inflammation of the costal cartilages

Question 17

What is costochondritis?

Answer 17

Temporary inflammation (not swelling) of the costal cartilage - the cartilage that connects each rib to the sternum at the costosternal joint

Question 18

How does one differentiate between costochondritis and Tietze syndrome

Answer 18

There is inflammation of the costal cartilage in both diseases, but Tietze syndrome has swelling as well

Question 19

What is the treatment of Tietze syndrome and costochondritis?

Answer 19

NSAIDs and rest

Question 20

What is the treatment for cyclical mastalgia?

Answer 20

Evening primrose oil, NSAIDs, caffeine/chocolate abstinence, low-fat diet or 3-to-6 month trial of tamoxifen.

Question 21

What kind of nipple discharge warrents surgical evaluation?

Answer 21

Spontaneous, recurrent, unilateral and from a single duct

Question 22

What is “normal” nipple discharge

Answer 22

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.

Question 23

Is testing for occult blood or cytology of nipple discharge recommended?

Answer 23

No - results are confusing and often misinterpreted.

Question 24

Evaluation of nipple discharge begins with

Answer 24

H&P, mammogram and sometimes an US

Question 25

If an abnormal targetable lesion is found on imaging obtained for nipple discharge is found, what should be done?

Answer 25

Core needle biopsy or needle-localized biopsy

Question 26

If no suspicious lesion is found on imaging to correlate with nipple discharge, what should be done?

Answer 26

Excisional biopsy of the offending duct for diagnosis and rule out cancer

Question 27

Is a ductogram needed for pre-op planning for nipple discharge?

Answer 27

Generally no. It is a painful procedure for the paitent and challenging for the radiologist. The results are often fraught with misinterpretation.

Question 28

Describe the steps of a duct excision

Answer 28

1. Place lacrimal duct probe if possible 2. Subareolar incision and dissect just under the nipple 3. Follow dissection down to chest wall or terminal ducts

Question 29

What are the most common causes of nipple discharge?

Answer 29

Papillomas, duct ectasia and fibrocystic changes.

Question 30

Bloody nipple discharge is most commonly due to?

Answer 30

Benign papilloma

Question 31

What are the causes of true galactorrhea?

Answer 31

Hyperprolactinemia 2/2 pituitary tumor, hypothyroidism or druge side effect

Question 32

What are the two groups of acute mastitis?

Answer 32

Those associated with pregnancy w/lactation andthose associated with a bacterial infection of unknown origin

Question 33

Acute mastitis in a lactating patient is usually 2/2

Answer 33

Staphylococcus

Question 34

How is acute mastitis in lactating patient usually treated?

Answer 34

Oral abx, warm packs, and massage to decompress the plugged duct

Question 35

After an I&D for acute mastitis, should breast feeding cease on the affected side?

Answer 35

Yes, to allow the breast to heal.

Question 36

What is the treatment for acute mastitis in a non-lactating patient?

Answer 36

Early oral abx - may take several weeks. IV abx if necessary.

Question 37

If skin changes that accompany an underlying breast infection occur, when should a punch biopsy and core bx of underlying tissue be performed?

Answer 37

Within a month if the changes do not resolve with abx or steroids within 1 month

Question 38

If persistent scaling or iching of the nipple or areola do not resolve with steroid ointment, what should be done?

Answer 38

Skin punch bx to rule out Paget disease

Question 39

Can fibroadenomas fluctuate in size with menses or grow with oral contraceptives and pregnancy?

Answer 39

Yes

Question 40

When does a fibroadenoma require excision?

Answer 40

If it grows over time, is \>2-3 cm at diagnosis, or if is painful

Question 41

Is there a risk of cancer with a fibroadenoma?

Answer 41

No

Question 42

When should breast cyst fluid be sent for cytopathology?

Answer 42

If it is bloody

Question 43

When should a breast cyst be biopsied?

Answer 43

A complex cyst on ultrasound or associated with a solid component

Question 44

In pregnancy, a complex cyst may be the result of

Answer 44

A lactating adenoma

Question 45

Do lactating adenomas resolve without treatment

Answer 45

Yes. However, follow-up imaging is warranted if there is a low-risk of CA

Question 46

Performing an open breast bx duirng lactation often leads to

Answer 46

A milk fistula. This may require cessation of breast feeding for resolution

Question 47

Does one need to excise a breast lipoma?

Answer 47

No

Question 48

A painful fatty tumor is likely the result of

Answer 48

An angiolipma. Excise to relieve pain.

Question 49

What benign breast abnormalities warrant a needle-localized excisional bx?

Answer 49

Atypical ductal hyperplasia, atypical lobular hyperplasia, LCIS, complex sclerosing lesion, or a radial scar.

Question 50

Gynecomastia is common in what two age groups?

Answer 50

20-30s and \> 60 years of age

Question 51

Is unilateral breast enlargement directly behind the nipple common in gynecomastia?

Answer 51

Yes

Question 52

What work-up is needed to rule out breast cancer in males?

Answer 52

Same work-up as women: breast exam, mammogram, and bx if indicated

Question 53

What are the causes of gynecomastia?

Answer 53

Drug interactions, alcoholism, loss of testosterone, elevation of estrogen levels due to thyroid orliver problems, or hormone-secreting tumors