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Women's health trigger > Lecture 9: Breast Disorders (Updated with supplemental) > Flashcards

Lecture 9: Breast Disorders (Updated with supplemental) Flashcards

1
Q

What derm layer do breasts arise from?

A

Ectoderm

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2
Q

What is most of the breast composed of?

A

Adipose tissue

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3
Q

What is responsible for keeping the breast upright?

A

Cooper’s ligaments

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4
Q

Where does breast lymph eventually drain to?

A

Axillary lymph nodes

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5
Q

What is the most common site of breast cancer metastases?

A

Axillary lymph nodes

Sentinel nodes

Most lymph drains through them.

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6
Q

During what period does the primordial breast arise from the basal layer of the epidermis?

A

Fetal period

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7
Q

During what period does extensive branching of the ductal system and lobule development occur?

A

Ages 10-13

Estrogen & progesterone

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8
Q

What happens to nipple sensitivity during puberty?

A

Increased

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9
Q

During what phase in the premenstrual period do breast epithelial cells proliferate?

A

Luteal phase

Increased size/fullness/tenderness 1 week before menses

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10
Q

When is final breast tissue fully differentiated?

A

At the first-term pregnancy

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11
Q

What two hormones modulate final breast differentiation?

A

Progesterone & Prolactin

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12
Q

What 6 things characterize final breast tissue differentation?

A
  1. Marked increase in breast size and turgidity
  2. Deeping pigmentation of the nipple-areolar complex
  3. Nipple enlargement
  4. Areolar widening with increased number and size of lubricating glands
  5. Branching and widening of breast ducts
  6. Increased acini

breasts, nipples, areolar enlarge

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13
Q

In late pregnancy, what is fatty tissue replaced by?

A

Cellular breast parenchyma

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14
Q

What triggers the onset of milk production?

A

Drop of progesterone

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15
Q

What regulates milk production?

A

Prolactin

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16
Q

How is breast tissue affected by the postmenopausal decreases of estrogen and progesterone?

A

Atrophy and involution of the breast.

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17
Q

During what period is fluid most likely to be expressed from the nipple?

A

Within 2 years of lactation

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18
Q

What might green nipple discharge suggest?

A

Cholesterol diepoxides

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19
Q

What is considered physiologic nipple discharge?

A

Manual pressure required but no blood.

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20
Q

When is further evaluation warranted for nipple discharge?

A
  • Spontaneous
  • Single-duct

Normal is multi-duct

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21
Q

What is the MCC of pathologic nipple discharge?

A

Intraductal papillomas

Others: carcinoma or fibrocystic changes

pappilloma = pathologic

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22
Q

In general, what medication class can induce galactorrhea?

A

Psychiatric medications/nervous system

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23
Q

What is the classic presentation of galactorrhea?

A

Bilateral multiductal milky discharge in a non-lactating patient

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24
Q

What is the classic presentation of pathologic nipple discharge?

A

Unilateral, spontaneous serous or sersanguinous discharge from a single duct.

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25
Q

What might bloody nipple discharge suggest?

A

Cancer, but could also be a benign papilloma

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26
Q

What is the issue with cytology of nipple discharge?

A

Does not rule out cancer.

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27
Q

What is the definitive dx and tx for pathologic nipple discharge?

A

Subareolar duct excision (microductectomy)

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28
Q

What drug is MC associated with gynecomastia?

A

Anabolic steroids/Androgens

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29
Q

What is the additional layer seen in gynecomasta?

A

Glandular tissue

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30
Q

What does true gynecomastia feel like?

A

Central, more tender

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31
Q

How does pubertal gynecomastia present?

A

Tender 2-3 cm discoid enlargement of glandular tissue beneath areola

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32
Q

If a boy has pubertal gynecomastia, what should you recommend?

A

Reassurance; 60% resolves in a year on its own.

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33
Q

What features might suggest cancerous gynecomastia? (5)

A
  • Asymmetry
  • Enlargement not beneath the areola
  • Unusual firmness
  • Nipple retraction
  • Bleeding or discharge
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34
Q

What does elevated b-HCG in a male probably suggest?

A

Testicular tumor or other cancer such as lung/liver

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35
Q

What does low testosterone + high LH suggest in a male? High testosterone + high LH?

A
  • Low testosterone + high LH = primary hypogondanism
  • High testosterone + high LH = androgen resistance
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36
Q

What diagnostics might we recommend for suspicious gynecomastia?

A
  • serum TSH and FT4
  • karyotype for klinefelters
  • CXR for metastatic or bronchogenic carcinoma
  • needle biopsy w cytology
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37
Q

How do you treat true gynecomastia? (5)

when do you treat it?

A

SERMs:

  • Raloxifene PO QD (more effective)
  • Tamoxifen PO QD

Aromatase inhibitors: (not recommended in teens d/t risk of osteoporosis)

  • Anastrazole 1mg PO QD

Testosterone therapy if hypogonadism

Radiation therapy (Prophylaxis if you have prostate cx + antiandrogen tx)

Surgery last resort

tx if painful or persistent. tx for 9-12 mo

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38
Q

Who is mastitis MC seen in?

A

Lactating/nursing

If not this population, check for breast cx.

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39
Q

What is the MCC of mastitis?

A

Staph Aureus

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40
Q

What is the presentation of mastitis? (3)

A
  • Classic: Painful, erythematous lobules in the outer quadrant of breast, esp during 2nd-3rd week of puerperium
  • S/S of systemic infection
  • Abscess

Puerperium = 6 weeks after childbirth

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41
Q

What finding within milk might suggest mastitis?

A

Antibody-coated bacteria in milk.

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42
Q

Non-pharm Tx of mastitis (4)

A
  • Avoid milk stasis (keep breastfeeding!)
  • Warm compresses
  • Well-fitted bra
  • Acetaminophen or ibuprofen

Baby is unlikely to be infected.

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43
Q

ABX for mastitis

A
  • Dicloxacillin or keflex
  • Alt: Clinda or Bactrim DS
  • Severe: IV Vanco + rocephin/zosyn

10-14d

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44
Q

When must bactrim be avoided in treatment of mastitis? (2)

A
  • BFeeding infant is < 1 month old
  • Hx of G6PD, jaundice, or prematurity.
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45
Q

What causes a subareolar breast abscess?

A

Keratin-plugged milk ducts behind the nipple

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46
Q

How is a subareolar breast abscess treated?

A

Subareolar duct excision and removal of sinus tracts.

Also need to biopsy abscess wall to r/o cx

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47
Q

How can you differentiate fat necrosis from breast cancer on exam?

A

You can’t

You need US and mammograms

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48
Q

How do you manage fat necrosis?

A

Only biopsy it if it doesn’t go away after a few weeks.

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49
Q

What is the MCC of Cyclic breast pain or mastalgia in reproductive aged women?

A

Fibrocystic breast change

MC age = 30-50

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50
Q

Why is cyclic breast pain rare after menopause UNLESS on HRT?

A

Estrogen and progesterone cause the cyclic changes, so breast shouldn’t really change cyclically after.

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51
Q

What is the main potential risk factor for fibrocystic breast changes?

A

Drinking alcohol while 18-22

52
Q

When are fibrocystic breast changes most painful?

A

During premenstrual period (days 12-14, 21-28)

53
Q

What substance may worsen the S/S of fibrocystic breast changes?

A

Caffeine

54
Q

What are the S/S of fibrocystic breast changes? (4)

A
  • Pain/tenderness associated with a mass
  • Fluctuations in size
  • Multiplicity of lesions
  • Nonbloody green/brown discharge
55
Q

When is a mammogram not indicated for evaluating fibrocystic breast changes?

A

< 30 y

56
Q

If a dominant fibrocystic mass is seen on the breast, what procedure should you do?

A

Biopsy

Checking if it is a fibroadenoma

57
Q

What is the first thing you should tell a patient with fibrocystic breast changes?

A

Its not cancer

58
Q

When do fibrocystic breast changes tend to resolve?

A

After menopause

59
Q

Who is fibroadenoma MC in?

A

Young women (within 20 years of puberty)

60
Q

What is a fibroadenoma?

A

Focal abnormality of breast lobule that is common & benign.

61
Q

What is the classic presentation of a fibroadenoma?

A
  • Round, firm, discrete, relatively mobile, nontender mass that is 1-5cm.
  • On US: well-defined solid mass with benign features.

Usually found accidentaly.

62
Q

How is a fibroadenoma definitively diagnosed?

A

Core biopsy or mass excision

63
Q

What tumor seems similar to a fibroadenoma but has a higher chance of malignancy? How do you check it?

A

Phyllodes tumor, which can be checked via mammogram

64
Q

How do you treat unclear dx or rapid growth fibroadenoma?

A

Surgery: excision with margins of normal tissue

Also the same tx for a phyllodes tumor.

65
Q

How do you tx an asymptomatic fibroadenoma? (2)

A
  • Monitor via US/breast exam every 3-6m
  • Can do core needle bx to confirm
66
Q

Image of Fibrocystic changes vs fibroadenoma

A
67
Q

What is the MCC cancer in women?

A

Skin cancer, then breast cancer.

68
Q

What is the MCC of death due to Cx in women?

A

Lung cancer, then breast cancer

69
Q

What is the average age of breast cx?

A

60-61

70
Q

What is the lifetime risk of developing invasive breast cancer for any female patient?

A

1 in 8

71
Q

Why do we screen breast cx so thoroughly?

A

50% of women who get it have no identifiable RFs for it.

72
Q

What gene mutations are associated with increased breast cx risk?

A

BRCA1 and BRCA2 (autosomal dominant)

BRCA1 is the worse of the two

Also tied to ovarian cx

73
Q

What is the greatest RF for breast Cx?

A

Personal hx of breast cx

74
Q

What are the RFs for breast cx?

A
  • Nulliparity
  • First full term pregnancy after 30
  • Early menarche (b4 12)
  • Late natural menopause (after 50)
  • Postmenopausal combinattion HRT
  • Hx of uterine cx
  • PERSONAL HX of Breast Cx

More menstrual cycles = more cell turnover = higher cx risk

75
Q

How is the majority of breast cancer diagnosed?

A

Mammogram

76
Q

What labs should you check in initial eval of breast cx? (3)

A
  • CBC
  • LFTs (or CMP)
  • ALP

Checking for signs of early metastases

77
Q

How does breast cancer usually present?

A

Painless breast mass in the upper outer quadrant

Tail of spence

78
Q

What findings might suggest metastases of breast cancer? (3)

A
  • Axillary mass or swelling of arm
  • Bone pain or back pain
  • Wt Loss
79
Q

What are the concerning findings for breast cancer on exam? (3)

A
  • Change in breast size/contour
  • Nipple or skin retraction
  • Edema or erythema
80
Q

What features make a lymph node suspicious?

A
  • Firmness or nodes > 5 mm
  • Matted or fixed axillary => locally advanced

But 40% can be clinically negative

81
Q

What swollen lymph nodes might suggest distant metastases of breast cx?

A
  • Supraclavicular
  • Infraclavicular
82
Q

What is the usual finding on exam for breast cancer?

A

Nontender, firm, or hard lump with poorly delineated margins generally caused by local infiltration

83
Q

What findings suggest advanced breast cancer? (4)

A
  • Appearance changes
  • LAN (esp axillary or supra/infraclavicular)
  • Edema of ipsilateral arm
  • Large primary tumor > 5 cm
84
Q

What is paget’s carcinoma?

A

Eczematoid eruption and ulceration

Associated with underlying carcinoma

Kinda like a burnt appearance

85
Q

What is the usual presentation of paget’s disease of the breast?

A

Pain, itching or burning of breast along with superficial erosion or ulceration.

86
Q

How do you dx paget’s disease of the breast?

A

Full-thickness biopsy

87
Q

How do you tx paget’s disease of the breast?

A

Mastectomy

88
Q

What is the characteristic description of inflammatory breast carcinoma?

A

Orange peel skin

89
Q

What is inflammatory carcinoma?

A

Diffuse, brawny edema of skin with an erysipeloid border due to tumor emboli.

90
Q

When do you biopsy for inflammatory carcinoma?

A

1-2 weeks of non-responsiveness for suspected mastitis

91
Q

How do you tx inflammatory carcinoma?

A
  • Chemo
  • Surgery
  • Radiation
92
Q

How accurate is a mammogram?

A

90% of the time, and does it 2 yrs before its even palpable.

Both a high sens and high spec test.

Still do a CBE!

93
Q

How do you definitively dx breast cx?

A

Bx (preferably core needle)

94
Q

What is the least invasive method of bx for breast cx?

A

FNA

Also the least helpful

95
Q

What is the recommendation regarding CBE?

A

You can do it if you want

96
Q

What is the general consensus regarding mammogram screening frequency?

A

Q2 years by 50, and continue past 75 if pt has good life expectancy (> 10y)

97
Q

What are the two primary components in breasts that become cancerous?

A
  • Ductal
  • Lobular

Epithelium

98
Q

What is the majority of breast cancer receptive to in terms of hormones?

A

Estrogen

99
Q

Where does ER(-) breast cx tend to metastasize to?

A
  • Liver
  • Lungs
  • Brain

LLB

100
Q

Where does ER/PR/HER2+ breast cx tend to metastasize to?

A
  • Bone
  • Soft tissue
  • Genital organs
101
Q

What is the usual surgery for breast cx?

A

Breast conservation therapy (All the non-radical mastectomies)

102
Q

What drug treats ER/PR/HER2+ breast cx?

A

Tamoxifen or aromatase inhibitors

103
Q

What drug may be used as an adjuvant for negative ER/PR/HER2+ breast cx?

A

Pembrolizumab (keytruda)

104
Q

What is the difference between tamoxifen and raloxifene in terms of estrogen modulation?

A
  • Tamoxifen: Blocks in breast, mimics in uterus & bone.
  • Raloxifene: Blocks in breast & uterus, only mimics in bone.

Raloxifene has less SE.

105
Q

MC SE of SERMs? (6)

A
  • Hot flashes
  • Nausea
  • Muscle aches/cramps
  • Hair thinning
  • HA
  • Paresthesias
106
Q

Main DDI for SERMs?

A

QT-prolongation

107
Q

Who can aromatase inhibitors NOT be used in?

A

Pregnant women

108
Q

On average, what is the median time to recurrence to breast cx?

A

4 years

109
Q

What kind of breast cx is more likely to recur?

A

Hormone receptor negative

110
Q

What are fulvestrant and elacestrant primarily used in?

Antineoplastics

A

ER/PR+ but HER- breast cx.

Blows up estrogen receptors.

Used for metastatic breast cancer

111
Q

After breast cancer tx, how soon do you followup in the first 2 years for PEs?

A

PE Q4mo for 2 years

112
Q

What drugs cannot be used with Aromatase inhibitors?

A
  • Estrogen
  • Immunomodulating drugs
  • Hormone-modulating anti-CA therapy
113
Q

Describe the views used for a Screening mammogram.

A
  1. Craniocaudal (CC): compression of breasts from above/horizontally.
  2. Mediolateral oblique (MLO): compression of breasts from the side/vertically.
114
Q

What is the additional view that a diagnostic mammogram can add?

A

Spot compression view

115
Q

What are the 3 types of soft tissue/architecture abnormalities on mammogram that are considered significant?

A
  1. Spiculated focal mass: MOST SPECIFIC FEATURE OF BREAST CANCER
  2. Irregularly shaped mass
  3. Architectural distortion: change in normal lay of breast tissue
116
Q

What is more suspicious of breast cancer: High-density or low-denisty masses?

A

High-density

117
Q

What kind of clustered microcalcifications are most suspicious of breast cancer?

0.1-1 mm calcium particles grouped as > 4-5 per cubic centimeter

A

Linear branching microcalcifications

Granular can also be sus

118
Q

What kind of clustered microcalcifications are least suspicious of breast cancer?

0.1-1 mm calcium particles grouped as > 4-5 per cubic centimeter

A
  • Vascular
  • Skin
  • Rim-like
  • Large & coarse
  • Smooth round/oval
119
Q

What are the 4 categories to rank breast density?

A
  1. Predominantly fatty (0-25)
  2. Scattered fibroglandular densities (26-50)
  3. Heterogenously dense (51-75)
  4. Dense (76+)
120
Q

Predominant quadrant for breast cancer

A

Outer Upper Quadrant

121
Q

What does BI-RADS 0 mean?

A

Not enough info to be conclusive.

Need more scanning or rescan

122
Q

What do BI-RADS 1 and 2 mean?

A
  1. 1 is negative, routine f/u only
  2. 2 is benign, routine f/u only

Usually fibroadenomas or vascular calcifications

123
Q

What does BI-RADS 3 mean and f/u frequency?

A
  • Probably benign (< 2% risk of cancer)
  • Screening recommendations: Diagnostic mammo/US every 6 months x1 year, then annually for x2 years.

Can downgrade during these scans.

124
Q

What does BI-RADS 4 mean?

A
  • Suspicious abnormality; biopsy should be considered.
  • Chance of cancer is 2-94%
  • Rated A-C.

4A = 2-9% risk
4B = 10-49% risk
4C = 50-94% risk

125
Q

What does BI-RADS 5 mean?

A

Highly suggestive of malignancy; appropriate action should be taken (95-100% cancer)

Spiculated, sus calcifications, skin retraction

126
Q

What does BI-RADS 6 mean?

A
  • Biopsy proven malignancy.
  • Yet to be surgically excised.
127
Q

My summary of BI-RADS

A
  • 0 = not enough info, poor scan
  • 1 = negative, just routine f/u. (Q1-2 years)
  • 2 = benign, just routine f/u (Q1-2 years)
  • 3 = tiny chance of cancer, f/u (Q6 mo)
  • 4ABC = wide range, could be cancer
  • 5 = very sus!
  • 6 = yea you have cancer

Women's health trigger (23 decks)

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