Gen Surg: Breast Disease Flashcards
DDx for breast mass, including benign and malignant conditions (VINDICATE)
Vascular: hematoma, AVM
Inflammatory: mastitis, abscess.
Neoplastic: benign (e.g. fibroadenoma), malignant.
Congenital: breast bud.
Autoimmune/allergic: non-infectious mastitis.
Traumatic: fat necrosis.
Endocrine: fibrocystic change, cysts, gynecomastia.
Breast mass history taking + PEx
Lump: duration, tenderness, change with menses.
Nipple discharge: color, spontaneous, unilateral or bilateral.
Nipple inversion, scaling.
Breast dimpling, ulceration, erythema, edema.
Symptoms of mets/extension: felt nodes in axilla, elsewhere. SOB, chest pain, swelling/edema of arms. Wt loss, fatigue, fevers.
Get Ob/Gyne Hx: age of menarche/menopause, parity, age at first pregnancy, breastfeeding history. Use of OCP/hormone replacement.
PMHx: previous breast disease, recent breast trauma, prior breast radiation. Screening interventions in past?
FamHx: breast disease, breast or related cancers (e.g. ovarian). If FamHx breast Ca, age at Dx, breast & ovarian, premenopausal at time of Dx.
PEx: Start at hands, looking for swelling. Examine both breasts, axilla and supraclavicular areas. Use pads of fingers to examine (not tips). Look for vertebral percussion tenderness for ?mets.
Breast Cysts
Epidemiology/RF: excess estrogen stimulation, age 40-60 yrs, may have multiple or solitary.
SS: mobile, smooth, round. Not always fluctuant (squishy vs firm if more fluid filled). Fluctuate in size and degree of tenderness with menstrual cycle. Tender to palpation.
Investigations:
1st line: FNA to diagnose and treat. Clear, cloudy or green/straw tinged is normal. Re-examine breast afterward to ensure mass is gone (simple cyst). If fluid normal and mass gone after aspiration- discard. If old blood or persistence of mass, send for cytology and arrange breast imaging.
Can do US or mammogram but does not need to be done as 1st line. US will show well defined, round, hypoechoic mass. Mammogram will show dense, well-defined, round mass.
Mgmt: aspirate fluid. May recur after aspiration (reassess in 6 weeks). Only aspirate again if symptomatic.
Describe fibrocystic breast changes
Common, occur in almost all women. Related to menstrual cycle (part of normal physiologic changes). Microscopic cysts embedded in dense fibrous tissue.
SS: ‘lumpy’ breast (pain and lumpiness increase before menstrual cycle) but no discrete lump palpable. Bilateral symptoms.
Imaging does not need to be done.
Mgmt: reassurance. Manage pain (reduce salt, caffeine, dietary fat intake). Can hormonally manipulate if severe (OCPs, danazole, tamoxifen).
Fibroadenoma: features, investigations, mgmt
Benign breast mass with 1/1000 risk of malignancy.
Features: smooth, oval, well-defined, firm mass. Non-tender, very mobile (‘breast mouse’), no change with menstrual cycle.
Investigations:
US: oval, hypoechoic (not as dark as cyst), well-defined with shadowing at edges.
Tissue confirmation: no fluid will be aspirated with attempt of FNA. Can do FNA biopsy if not worried (will look at cytology and tell you if benign or malignant only). Alt can do core biopsy to look at architecture which will tell you if invasive or non-invasive.
Tissue confirmation not necessary if very young (18-24 yrs) and unlikely malignant. Confirm though if older patient with atypical imaging.
Mgmt:
If <3 cm, may get smaller, be stable or enlarge. May enlarge during pregnancy but usually will regress.
Remove if: enlarging, symptomatic or pt requests (not removed for malignancy risk).
Follow with US imaging for growth (repeat q6 mos)
Describe lactational mastitis
Obstructed milk ducts –> stasis of milk –> infection.
SS: breast erythema, tenderness, nodularity. Progressively worsening.
Mgmt: directed massage to facilitate emptying. Abx (cover staph aureus), continue nursing.
Describe breast abscesses
SS: increasing erythema, pain, edema + central fluctuance (raised, squishy feeling). febrile.
Mgmt: drain + send fluid for culture (note that incision may cause milk fistula). If systemically unwell, IV abx. Continue nursing.
Non-lactational mastitis
Rare. Associated with smoking. Get change in lining of ducts allowing bacteria to enter.
SS: periareolar mastitis with abscess formation. Recurrent. Associated with draining sinuses at areolar margin.
Mgmt: resection of involved ducts if recurrent.
Describe gynecomastia
Imbalance of estrogen and testosterone in men leads to growth of normal breast tissue.
Causes:
Physiologic: neonatal period, puberty, aging (reduced T)
Medications (e.g. spironolactone).
Drugs: EtOH, anabolic steroids, MJ, amphetamines, heroin.
Diseases: hypogonadism, hormone producing tumors, hyperthyroidism, renal or liver failure, malnutrition.
SS: tender lump around nipple, mobile, dense. unilateral or bilateral. nipple normal. normal hair pattern/testicles.
Imaging: US should show normal breast tissue. Mammogram same.
Mgmt:
Reassurance if developmental. Tx underlying disease or stop offensive agent. Symptom control with tamoxifen or raloxifine. Surgical resection if requested. Not associated with increased breast Ca risk.
Describe non-surgical nipple discharge
Uniductal: not from central duct, only from a single duct opening (surgical tx).
Multiductal: several ducts releasing discharge (not surgical, more common).
Galactorrhea: bilateral milky discharge. Physiologic (post-nursing), drug related, pituitary prolactinoma.
Duct ectasia: bilateral green/yellow multiductal, non-spontaneous d/c. Dilated retroareolar ducts filled with debris, fibrocystic changes. Manage by avoiding squeezing and quitting smoking.
Intraductal papilloma
Benign growth of the duct.
SS: spontaneous, unilateral, uniductal, serous or bloody nipple discharge. No breast masses and nipple normal.
Investigations: Do NOT need to do cytology of discharge. Mammgram should be normal, can be done to exclude an underlying cancer. US can be done and should show normal or dilated retroareolar duct (better than mammogram for viewing areola).
Can do galactogram (shows filling defect).
Mgmt: surgical excision of involved duct. Intraductal papillary cancer rare but excluded by excision.
Recommendations for breast Ca screening.
If no FamHx: start screening mammography q2 yrs at 50 yrs. (Can start billing MSP for mammograms at 40 yrs, but no proven survival benefit).
If FamHx: start screening mammography q2 yrs at 40, then q1yrs at 50.
After 74 yrs, only continue screening mammography if expected to survive >10 yrs more.
Risk factors for breast cancer: major, moderate, minor
MAJOR:
Female.
FamHx in 1st degree relative (esp if premenopausal, bilateral or ovarian cancer).
BRCA1/2 mutation carrier.
PMHx: lobular CIS, atypical hyperplasia, chest wall irradiation to developing breast, mammographic density >75% of breast volume.
MODERATE: Older age. PMHx breast cancer. North American/North European residence. Breast hyperplasia without atypia. Mammographic density >50% breast vol.
MINOR: Increased E exposure: nulliparity, early menarche (<11 yrs), late menopause (>55 yrs), late age at first delivery (>33 yrs). FamHx postmenopausal breast cancer. High SES. Postmenopausal obesity. Diet and EtOH consumption.
Describe the ‘triple assessment’ of a breast mass.
Triple test = clinical assessment, imaging, cytology.
Triple test considered negative if all 3 are benign. (98% chance benign, follow mass).
Triple test is positive if any one of the components is indeterminate, suspicious or malignant.
Breast Ca: types, SS, investigations.
Types of breast cancer (tx same for both):
- Invasive ductal carcinoma: malignant cells originate from ductal epithelium (more common).
- Invasive lobular carcinoma: malignant cells originate from lobular cells. More difficult to see on mammogram, more likely to be bilateral, may be larger than they feel.
SS: enlarging mass, firm/irregular/mobile. Indrawing of overlying skin.
Investigations:
Bilateral diagnostic mammogram -> evaluate the rest of hte involved breast and bilateral breast. assess the size on imaging.
US of involved breast: determine if mass visible on US to allow biopsy guidance.
Tissue Dx: Core Bx needed (US, mammography or clinically guided). FNA Bx can determine malignant/benign but does not tell you if invasive or non-invasive.
