Lecture 12: Breast Disorders Flashcards
When should the CBE be performed? (what phase)
Follicular phase
- one week after menses
3 causes of Cyclic breast pain (mastalgia)
- Hormonal changes w/menstrual cycle
- OCPs
- Fibrocystic breast Dz
What phase/days of the menstrual cycle is a/w Cyclic breast pain
Luteal phase
day 14-28
Large, pendulous breasts Mastitis BCA (inflammatory) Poorly-fitting bra Pregnancy Ductal ectasia
Causes of Non-cyclic breast pain
What does extramammary mean?
pain referred from source outside breast (chest wall)
Tx for mastalgia if exam is normal and pain is cyclic?
Meds for pain?
reassurance (+/- adjust OCP)
support/sports bra, wt loss
Pain meds: NSAIDs, acetaminophen
Med Tx for Severe Sxs of mastalgia?
Danazol, Tamoxifen, or Bromocriptine
When is mastitis MC,
normally d/t?
in lactating women
d/t nipple trauma (primigravida)
Main Sx of Mastitis?
Otehers?
Main = UNILATERAL BREAST PAIN (esp in 1 quad)
Others: breast swelling, warmth, tenderness; nipple d/c
MC pathogenic cause of mastitis
Staph Aureus
When should ABX tx for mastitis be started?
What is main ABX?
Pt edu for mothers while taking ABX?
Sxs lasting > 12-24hrs
Dicloxacillin
Mothers CAN continue to nurse/pump while on ABX
3 Nipple D/c Characteristics that are likely benign?
Nipple d/c that is:
- Bilateral
- Milky/clear
- Multiductal
Nipple D/c Characteristics: Spontaneous Unilateral Uniductal Bloody, straw colored, or clear Stains clothes Persistent
Malignant nipple d/c characteristics
Management for Physiologic nipple discharge w/no breast stimulation?
f/u in 2-3 mo
+/- endo referral
What is next step if find malignant nipple d/c, abn findings on US/mammo, or no resolution of Sxs after modifications in meds/lifestyle?
Refer to nipple specialist
are most breast masses/tumors benign or malig?
Benign
What is the MC presenting Sx in pts w/ BCA?
Breast mass
What type of Dx test/Bx used for breat cysts?
FNA w/Bx
also used for low probability CA
What is problem w/FNA Bx
Skill depedent–> High amt false negatives and non-Dx samples
Other Bx methods other than FNA
What type of Bx is specifically used for Paget’s Dz
- CNB (core needle Bx)
- Incisional Bx
- Excisional Bx
- Punch Bx (Paget’s dz)
What type of Bx is for a larger tissue specimen, uses only LA and is US guided
CNB
What can an US determine for breast masses
when is US 1st line Dx test?
whether mass is cystic or solid
1st line in women < 30 w/focal breast Sxs
What dx test used for SCREENING women w/no sxs?
Mammogram
When is SURVEILLANCE mammo used?
F/u in pts w/ Hx of BCA
When is MRI used to evaluate breast masses?
- screening for high risk women
- assess silicone implants
- eval suspicious findings
At what BIRADS categ is Bx recommended
Categ 4 or 5 –> Bx
At what BIRADS categ is the mass definitely malignant
Categ 6
in pts < 30:
1. w/no mass on CBE what is next step?
- w/w/indeterminate mass on CBE
- suspicious mass
what is next step?
in pts > 30:
what is the only difference in next step?
- repeat exam in 2-3 mo
- US
- Dx mammo + directed US w/Bx (FNA)
pts > 30: indeterminate exam –> Dx mammo +/- directed US
What 3 types of breast tumors are benign?
- Simple cyst
- Fibroadenoma
- Fibrocystic changes
What 3 types of findings indicate hyperplasia w/out atypia (not cancerous)
- Epithelial hyperplasia
- Intraductal Papilloma
- Sclerosing adenosis
What are breast cysts influenced by?
hormonal fluctuations
(lobular dev/involution, menses
Difference b/t simple and complex cysts?
When should a mammo be performed
Simple
- ONLY FLUID
- benign
Complex
- Fluid + SOLID
- Small risk of malig
mammo: > 30 or complex cyst
Tx for simple cyst
Aspirate w/FNA
observe 2-3 mos, selfi limited (will resolve on own)
Tx for complex cyst
intervention depends on?
Must be Bx
surgical intervention based on pathology
What is Fibrocystic Breast Dz & what is it d/t?
fluid filled breast d/t exaggerated response to hormones (progesterone & estrogen)
- menstrual hormone changes
Sxs of Fibrocystic Breast Dz?
What is not seen in this dz?
- bilateral cyclic breast pain/tenderness
- multiple, mobile, well demarcated lumps
- breast size incr/decr w/menstrual hormonal changes
usu no axillary involvement or nipple d/c
What is typical dx tool?
What is seen w/Dx FNA
US (mammo if >30)
FNA –> straw colored fluid
When can FNA fluid removal be performed for Fibrocystic Breast Dz?
if pt is symptomatic
Most Fibrocystic Breast lumps resolve on own what can be done to manage Sxs?
Diet → Low fat, Avoid: caffeine, coffee, soda, chocolate, ETOH
Manage contraception (stop, less estrogen) & HRT
Supportive bra
What is a fibroadenoma?
makeup?
BENIGN, SOLID TUMOR
makeup: glandular + fibrous tissue (collagen)
Smooth, well-defined/circumscribed, NT, rubbery, mobile mass
Fibroadenoma
How does the size of Fibroadenoma change over time?
Gradually incr over time
- may incr w/preg or estrogen therapy
- decr after menopause
*doesnt change w/menses
Differences b/t fibrocystic breast dz and fibroadenoma?
Fibrocystic breast dz
- fluid filled
- size change w/menses
Fibroadenoma
- solid tumor
- doesnt change w/menses
Tx for most fibroadenoma?
Observation → most resorb w/time
- Short-term f/u w/ repeat US or CBE
MC type of BCA
Ductal carcinoma (infiltrative/invasive)
2 types of NON-invasive BCA (hyperplasia w/atypia)
- DCIS (ductal carcinoma in situ)
2. LCIS (lobular carcinoma in situ)
2 types invasive BCA
Which one a/w lymphatic mets (esp axillary)
- Ductal carcinoma→ a/w lymphatic METS (esp axillary)
2. Lobular carcinoma
What is the biggest risk factor for BCA?
AGE
What ethnicity is at very high risk for having BRCA 1/2 mutation?
Ashkenazi Jewish women
How is estrogen exposure linked to BCA?
more/longer estrogen exp = incr risk
- early menarche
- late menopause
- late age 1st pregnancy
- HRT, OCPs
MC location for BCA
Upper outer qudarant
Main Sxs of BCA
Single, NT, firm/fixed/immobile mass
- Unilateral nipple d/c
- Dimpling (if Cooper’s lig involved)
- Breast pain
- Skin thickening
- Nipple inversion
- Changes in breast size/contour
- Skin discoloration,ulceration, redness, retraction
Sxs of BCA
What is Inflammatory BCA d/t?
lymphatic invasion of tumor cells
Main sign w/Inflammatory BCA?
what is it d/t?
Peau de orange appearance of breast
d/t lympahtic obstruction
note: a/w poor prognosis
Main sign w/Paget’s Dx?
Chronic eczematous rash of nipple and areola
may ooze
Difference b/t Inflammatory BCA and Pagets Dz
Inflammatory BCA
- lump uncommon
Pagets Dz
- lump common
What is seen on mammo that is highly suspicious for BCA?
microcalcifications & spiculated masses
What is considered breast conserving therapy?
Lumpectomy
Which type of mastectomy spares pect muscles and axillary content?
Simple/total mastectomy
Which type of mastectomy removes everything (breast, overlying skin, pectoralis major and minor, and entire axillary contents)?
Radical mastectomy
What types of CA can hormonal therapy tx?
2 Types of hormonal tx?
Txs estrogen/progesterone-receptor (+) CA and HER2 (+) CA
- SERM (selective estrogen rec modulator)
- Monoclonal Ab Tx
SERM drugs?
note: can also be used for BCA prevention in high risk pts
- Tamoxifen
- Aromatase inhibitors
(Letrozole, Anastrozole)
Risk w/Tamoxifen?
type of drug/MOA?
endometrial CA, DVT
anti-estrogen: blocks it from binding to rec
when are aromatase inhibitors helpful?
MOA?
AI useful in post menopausal woemn
MOA: reduces estrogen production
Monoclonal Ab Tx drug?
used for what types of CA?
Trastuzumab/herceptin
for CA w/HER2 (+)
Tx for early stage CA
Lumpectomy or mastectomy + radiation
Evaluation of axillary nodes - look for METs
what LN impacted 1st by BCA
sentinel nodes
