Lecture 12 - Breast Disorder Flashcards
Where are the majority of breast cancers?
upper outer quadrant
axillary tail
When is the best time to perform clinical breast exam?
during follicular phase (one week after menses)
Mastalgia
breast pain
Cyclic mastalgia
related to menstrual cycle luteal phase (day 14 - 28)
What conditions can cause cyclic mastalgia?
luteal phase of menses
OCPs
fibrocytic breast disease
What is the treatment for mastalgia?
reassurance (assuming exam is normal and pain is cyclic)
support bra or sports bra; weight reduction
Mastitis
infection of breast tissue -- mainly with lactating women breast pain swelling warmth redness
pathogen: MC staph aureus
tx:
if sxs >12-24 hours
dicloxacillin 500mg PO QUID x 10-14 days
if no improvement, r/o breast abscess with US
-consider inflammatory breast cancer
What are the sxs of mastitis?
women breast pain swelling warmth redness
What is the MC pathogen of mastitis?
Staph Aureus
What is the treatment for mastitis?
if sxs >12-24hr
Dicloxacillin 500 mg PO QID x 10-14 d
if no improvement, r/o breast abscess with US
-consider inflammatory breast cancer
Nipple discharge affects ____% of women in their reproductive years
50-80%
Bilateral nipple discharge vs unilateral nipple discharge
bilateral is more commonly benign
unilateral is more commonly malignant
What characteristics of nipple discharge suggest benign?
bilaterally
multiductal
milky
What characteristics of nipple discharge suggest malignant?
spontaneous unilateral uniductal blood, straw colored, or clear stains clothes persistent
What labs should you order on a pt with nipple discharge?
TSH
Prolactin
B-hCG
If you think the nipple discharge is related to OCPs, how long after changing the OCPs should you re-evaluate?
3 cycles
What percentage of breast masses are benign?
80-85%
What is the most common presenting sx in pts dx’d with breast cancer?
breast mass
What is the biggest risk factor for the development of breast cancer?
age
Nipple retraction
tumor is pulling on ligaments –this is different than nipple eversion
CNB
core needle biopsy
- larger tissue specimen
- image-guided (US)
- local anesthesia
Punch biopsy
differentiate benign vs malignant skin changes (Paget’s disease)
What is the first line imaging choice in women <30 and pregnant women with focal breast sxs?
US
Who gets MRIs for breast masses?
reserved for women of high-risk
good for implants
BIRADS
breast imaging reporting and data system
0-6
gives likelihood of malignancy and recommendation for follow up/biopsy
If a pt <30 comes in complaining of a breast lump and you don’t find anything, what do you do next?
repeat exam in 2-3 months
What are cysts influenced by?
hormonal fluctuations
occur during lobular development, menses, and lobular involution
Simple vs complex cyst?
simple - fluid only, benign
complex - fluid + solid components
- small risk of malignancy
What is the management of a simple cyst vs. complex cyst?
simple:
aspirate cyst (FNA)
observe 2-3 months (cycles)
Complex:
must be biopsied - image guided CNB
surgical intervention based on pathology
Fibrocystic breast disease
MC benign breast condition
associated with imbalance of progesterone and estrogen
sxs: bilateral cyclic pain, breast swelling, palpable mass and heaviness; “lumpy breasts”
premenopausal women affected 20-40 years
dx:
US
FNA + pathology evaluation
dx mammogram for women >30 y
Management of fribrocystic breast disease?
low fat diet avoid caffeine, coffee, soda, chocolate, EtOH manage contraception and HRT supportive bra medication as needed
Fibroadenoma
benign solid tumors containing glandular + fibrous tissue
-proliferative - breast masses that you can define on exam - less likely to occur during menopause d/t decrease in hormones
increase in size during pregnancy/estrogen therapy
usually regresses after menopause
What age women get fibroadenomas?
reproductive age women
What do you feel on PE for fibroadenoma?
well-defined mobile mass
How do you dx fibroadenoma?
US
mammogram
CNB or excision
What is the management for fibroadenoma?
short term f/u with repeat sono/breast exam
expectantly manage
surfical excision
What is the leading cause of death in women 40-49?
breast cancer
What is the MC breast cancer?
ductal carcinoma makes up 80% of breast cancers
Hyperplasia with atypia
DCIS - ductal carcinoma in situ
LCIS - lobular carcinoma in situ
not cancer but predisposes to cancer
What are the risk factors of breast cancers?
Advanced age family hx personal hx early menarche late menopause late first pregnancy HRT radiation
BRACA
breast cancer susceptibility gene –tumor suppressors
carriers have 45-65% chance of breast cancer by 70
What are they typical clinical features of breast cancer?
most often single, non-tender, firm, immobile mass
45% in upper outer quadrant
Inflammatory breast cancer
dermal lymphatic invasion of tumor cells actue onset (sx <6 months) of erythema, edema, and peau d'orange appearance
ddx: mastitis
Paget’s disease of the breast
ductal carcinoma presenting as eczematous lesion of the nipple
Breast conserving therapy
lumpectomy
depends on size of mass vs size of breast
Look over breast cancer treatment and screening
NOT DONE
What are the ACS guidelines for breast cancer screening?
offer mammograms at age 40-44
recommend annual screening 45-55
continue screening as long as life expectancy >10 years
What medical management is used to decrease RECURRENCE of breast CA coming back?
Adjuvant hormone therapy
SERM - selective estrogen receptor modulator -anti estrogen -Tamoxifen -AI treated for 5-10 years
