GENERAL- Breast Flashcards
Assessing risk for breast cancer (history, PE)
Always suspect in woman with palpable breast mass.
History: Increased risk with
- increasing age
- FHx (higher risk at younger age)
- history of trauma does not r/ou cancer
PE: Risky features include:
- ill-defined fixed mass
- retraction of overlying skin
- “orange peel” skin
- recent nipple retraction
- eczematoid lesions of areola
- reddish orange peel skin over mass (inflammatory cancer)
- palpable axillary nodes
*only sure way to rule out cancer is biopsy
Use of Mammography
- NOT a substitute for tissue diagnosis
- adjunct to PE
Mammogram guidelines
- Screening starting at age 40 (earlier if FHx).
- Never done before age 20 (breast too dense) or during lactation (all you see is milk).
- May be done during pregnancy (but if found, no radiotherapy during pregnancy and no chemo during 1st trimester)
Methods of breast biopsy
- mammographically guided
- sonographically guided
A 22yo woman presents to her famly physican after noticing a mass in her breast. The physician notes that it is firm, rubbery, and easily mobile.
- Likely diagnosis
- Benign or malignant
- Dx
- Tx
- Fibroadenoma
- in young women (teens, early twenties)
- firm, rubbery, mobile - Benign
- Fine-need aspiration or Sonogram
- Removal is optional
A 13yo female presents to the office because she noticed a breast mass. She has grown a good deal since her yearly physical about 8 months ago. The mass is large, firm, and rubbery. It moves easily under the skin.
- LIkely diagnosis
- Malignant or benign?
- Dx
- Tx
- Giant juvenile fibroadenoma
- in very young adolescents, where they have rapid growth - Benign
- Fine-needle aspiration or Sonogram
- Removal necessary to avoid deformity/distortion of the breast
A 28yo woman presents with a mass in her breast which has been enlarging over years to a now impressive size. Her entire breast is displaced and distorted by the mass, which remain surprisingly mobile.
- Likely diagnosis
- Malignant or benign?
- Dx
- Tx
- Cystosarcoma phyllodes
- become very large over years, yet do not invade or become fixed - Most are benign; potential to become outright malignant sarcomas
- Core or excisional biopsy (FNA NOT sufficient)
- Mandatory removal
A 37 yo woman and her 42 yo sister both present with tenderness of both breasts as well as multiple lumps. They have noticed that the tenderness seems to worsen in the last two weeks of their menstrual cycle and that the lumps come and go. While the younger sisters lumps are all fairly equal in size and quality, the older sister has one particularly dominant lump in her right breast that she says doesn’t always completely go away.
- Likely diagnoses
- Malignant or benign?
- Dx
- Mammary dysplasia (fibrocystic disease, cystic mastitis)
- in women in their 30s and 40s
- bilateral tenderness worse during last two weeks of menstrual cycle
- bilateral multiple lumps that come & go w/menses (cysts) - Benign
- Dx: Mammo for younger sister, aspiration (with needle/syringe larger than FNA) for older sister
- Older sister has a dominant and more persistent mass, which is likely a cyst but potentially a tumor
- –If fluid is clear and the mass goes away, end of story
- –if fluid is bloody, send for cytology
A 32yo woman presents with bloody nipple discharge.
- Likely diagnosis
- Malignant or benign?
- Dx
- Tx
- Intraductal papilloma
- young women (20s-40s) - Malignant
- Dx:
Mammogram to ID other possible lesions (will not show papilloma…too tiny)
Galactogram - diagnostic + guides surgery
A new mother comes in due to a painful firm lump in her breast. She is breastfeeding her newborn, but the pain makes it difficult. A small lump is palpated on exam; it is red, firm and tender.
- Likely diagnosis
- Malignant or benign?
- Dx
- Tx
- Breast abscess
- ONLY in lactating women (if not lactating, what looks like an abscess is cancer until proven otherwise) - Benign
- Dx: I&D with biopsy of abscess wall
- Tx: I&D
Appearance of breast cancer on mammogram
Irregular area of increased density with fine microcalcifications, not present in previous studies
Treatment of breast cancer (3 basic types)
Resection:
- lumpectomy + axillary sampling + post-op radiation
- modified radical mastectomy + axillary sampling
- Axillary sampling via ID & removal of sentinel lymph nodes.
- Lumpectomy only possible in low tumor:breast size ratio and if tumor is away from nipple/areola.
Chemo +/- Radiation
- if inoperable (based on local extent & metastases)
- may render the cancer operable
Adjuvant systemic therapies
= follow surgery in virtually all patients (esp. if +nodes).
-chemo
-hormonal tx if receptor positive tumor
-tamoxifen if premenopausal
-anastrozole if postmenopausal
*frail elderly women with aggressive tumors may be offered hormonal tx alone
- Standard form of breast cancer
- Variant with much worse prognosis & tx
- Other variants & tx
- Infiltrating ductal carcinoma
- Inflammatory cancer; requires pre-op chemo
- Lobular, medullary, mucinous; treated as standard infiltrating carcinoma
* Lobular has higher incidence of bilaterality, but not so much to justify bilateral mastectomy
Treatment of ductal carcinoma in situ (DCIS)
- cannot metastasize so no axillary lymph node sampling necessary
- high incidence of recurrence if only locally excised
- total simply mastectomy recommended for multicentric lesions throughout the breast
- some add sentinel node biopsy to r/out missing invasive focus of the multi-focal disease
- lumpectomy + radiation if lesion(s) confined to 1/4 of the breast
A patient who recently had a mastectomy presents with a persistent headache as well as back pain. On exam, she has areas of local tenderness along spine.
- Likely diagnosis
- Dx
- Tx
- Metastasis to brain and bone
- most commonly on vertical pedicles of the spine - Dx: MRIs diagnostic
- Tx: Brain mets radiated or resected.
