Module 7: Breast Problems Flashcards
Mastalgia (Benign)
Breast pain
* Most common breast-related complaint
* Cyclic mastalgia coincides with menstrual cycle
and is related to hormonal sensitivity
* Noncyclic mastalgia can be constant or intermittent
May be due to trauma, fat necrosis, duct
ectasia, costochondritis, or arthritic pain
Reassure that it is not a usual sign of breast cancer
Lactational Mastitis (Benign)
Lactational mastitis
Inflammatory breast condition that occurs most often
in lactating women
* Localized area that is red, painful, and tender to
palpation
* Fever is often present
* Pathogens gain access through cracked nipple
* Can be cured with antibiotics in early stages
Periductal mastitis occurs most often in smokers
* Woman not lactating
* Treatment is the same
Lactational breast abscess
From persistent lactational mastitis
* Palpable mass with red, edematous skin over involved
breast; possibly fever
* Drainage of abscess is necessary
Ultrasound-guided needle or surgical incision and
drainage
Cultured and treated with appropriately sensitive
antibiotics
Breastfeeding can usually continue
Fibrocystic Changes (Benign)
Fibrocystic changes
Benign condition with changes in breast tissue
* Development of excess fibrous tissue
* Hyperplasia of the epithelial lining of mammary ducts
* Proliferation of mammary ducts
* Cysts
Occur most commonly between ages 30 and 50
Women with premenstrual abnormalities, nulliparity,
history of spontaneous abortion, nonusers of oral
contraceptives
Possibly due to exaggerated responsiveness to
hormones
* Estrogen and progesterone
Not linked to increased breast cancer risk
* Pone or more palpable round, well-delineated, freely
movable lumps
* Discomfort ranging from tenderness to pain
* Lump usually increases in size and tenderness before
menstruation
* Nipple discharge often green or dark brown
Fibroadenoma (Benign)
Fibroadenoma
Common cause of discrete benign breast lumps in
young women
Painless, round, solid, firm, and rubbery
Growth is slow and ceases at 2 to 3 cm
Most often in blacks than whites
May be due to ↑ estrogen sensitivity
Easily detected by physical assessment
Definitive diagnose by FNA, core, or excisional biopsy
Treatment
* Observation with regular monitoring after ruling out
cancer
* Surgical removal if increases in size and/or
symptomatic
* All new lesions should be evaluated by breast
ultrasound and possible biopsy
Galactorrhea (Benign)
Galactorrhea
Milky secretion due to inappropriate lactation
May result from
* Certain medications
* Endocrine or neurologic problems
* No known cause
Clear, serous, bloody, or brown to green secretions
Cytology slide to determine cause and recommended
treatment
* Benign breast conditions
Fibrocystic changes
Intraductal papilloma
Ductal ectasia
* Usually not caused by cancer
However spontaneous, unilateral discharge needs further evaluation
Intraductal Papilloma
Benign, soft or hard, wart-like growth
In mammary ducts
Usually unilateral
Bloody discharge from nipple
Difficult to palpate- usually beneath areola
Usually occur in 35- to 55-year-old women
Associated with a slightly ↑ risk for developing breast
cancer
* Core biopsy recommended
* If there are abnormal cells surgical excision is done
Ductal Ectasia (benign)
Duct dilation
Benign breast disease of perimenopausal and
postmenopausal women
Involves several bilateral ducts in subareolar area
* Multicolored, sticky nipple discharge- main symptom
* Progresses to burning, itching, pain around nipple
* May see inflammation and nipple retraction
* Not associated with cancer
If abscess develops, warm compresses, antibiotics
Surgical excision of involved ducts may be done
Male Gynecomastia (Benign)
Transient, noninflammatory enlargement of one or
both breasts
Most common breast problem in men
Usually a temporary, benign condition
Not a risk factor for breast cancer
* Can occur in puberty
* May also be a manifestation of other problems
Testicular tumors, adrenal cancer, pituitary adenoma,
hyperthyroidism, liver disease
Side effect of drug therapy
Marijuana may cause
Senescent Gynecomastia (benign)
Occurs in many older men
Likely cause is high plasma estrogen levels
Tender, firm, centrally located enlargement
Discrete circumcised mass with gynecomastia
* Biopsy to rule out rare breast cancer
Usually regresses in 6 to 12 months with no treatment
Gerontologic Considerations
Pendulous breasts
Loss of subcutaneous fat
Loss of structural support
Atrophy of mammary glands
Decreased glandular tissue density
Makes breast masses easier to palpate
Increased incidence of breast cancer
Encourage annual mammogram and CBE
Breast Cancer
Many new cases each year in U.S. women
2nd most common cancer
2nd only to lung cancer as leading cause of death in
women
Incidence is slowly decreasing due to
* Decreased use of hormone therapy after menopause
* Early detection and treatment advances
Breast cancer survivors are largest group of any
cancer survivors
Breast Cancer Etiology and Risk Factors
Etiology and risk factors for women
Cumulative and interacting
* Female gender and age are strongest risk factors
* Family history
* Environmental factors
* Genetic link
Most who develop breast cancer have no identifiable
risk factors
Hormonal regulation is related to breast cancer
development
Mechanisms are poorly understood
Combined hormone therapy
* Increased risk of breast cancer
* Increased tumor size at diagnosis
* Increased tumor stage at diagnosis
Estrogen alone may increase risk after 15 years
Modifiable risk factors
Excess weight gain during adulthood
Sedentary lifestyle
Smoking
Fat intake
Obesity
Nightshift work
Alcohol use
Environmental factors
* Radiation exposure, using hair dyes and straighteners
Up to 10% are hereditary
Genetic link stronger if involved family member
Most related to mutations of 2 genes
* BRCA 1 and BRCA 2
* BRCA= BReast Cancer
Also mutations of genes that suppress tumor growth
Had a history of ovarian cancer
Was premenopausal
Had bilateral breast cancer
Is a first-degree relative
* Breast cancer risk doubles
Breast Cancer Risk Factors for Men
Risk factors for men
Estrogen use
Hyperestrogenism
Family history of breast cancer
Radiation exposure
BRCA-positive families
* Consider genetic testing
* Teach self-assessment
* CBE every year starting at age 35
Breast Cancer Screening Guidelines
Yearly mammograms for average-risk women
Starting at age 45
Yearly ages 45 to 54
Every 2 years ages 55 and older
Continue screening mammograms as long as overall
health is good
Clinical breast exams (CBE)
ACS does not recommend CBE among average-risk
women at any age
Women at increased risk
Earlier 3D mammography screening
Breast MRI
More frequent CBEs
Consistent BSE may facilitate breast self-awareness
Normal look and feel of breasts
Review technique regularly through return
demonstration
Breast Cancer Diagnostic Studies
Radiologic studies
Mammography
* Digital mammography
More accurate in younger women
* 3-D mammography (tomosynthesis)
Ultrasonography
MRI
* For women at high risk
Biopsy
Fine-needle aspiration (FNA)
Core needle biopsy
Vacuum-assisted biopsy
Excisional biopsy
Prophylactic oophorectomy and mastectomy in
women with BRCA1 or BRCA2 mutations can ↓ risk
of breast and ovarian cancers
Ovaries are main source of estrogen in
premenopausal women
Oophorectomy does not decrease breast cancer risk
in postmenopausal women
Metastatic breast cancer
Most common sites are bone, liver, lungs, and brain
Factors that affect prognosis
* Tumor size
* Axillary node involvement
* Tumor differentiation
* Estrogen and progesterone receptor status
* Human epidermal growth factor receptors
Metastatic breast cancer is breast cancer that
has spread to other organs
Most common sites are bone, liver, lung, and brain
Types of Breast Cancer based on tissue types
Ductal carcinoma (affects milk ducts)
Medullary
Tubular
Colloid (mucinous)
Lobular carcinoma (affects milk-producing glands)
Other
Inflammatory
Paget’s disease
Phyllodes
Breast Cancer Types - based on invasiveness
Noninvasive (in situ)- 20% of breast cancers
Ductal carcinoma in situ (DCIS)
Paget’s disease
Invasive (spreading to other locations)
Invasive (infiltrating) ductal carcinoma (80%)
Invasive lobular carcinoma (10-15%)
Breast Cancer Types - based on hormone receptor status
Estrogen and progesterone receptor status
Estrogen receptor positive
Estrogen receptor negative
Progesterone receptor positive
Progesterone receptor negative
Breast Cancer Types - based on genetic status
HER-2 genetic status
HER-2 positive
HER-2 negative
Noninvasive breast cancer
Noninvasive breast cancer
Comprises 20% of breast cancers
Ductal carcinoma in situ (DCIS)
* Tends to be unilateral
* May progress to invasive if untreated
Paget’s disease
Lobular carcinoma in situ (LCIS)
* Reclassified as benign, but with a risk for developing
breast cancer
Invasive ductal carcinoma
Invasive (infiltrating) ductal carcinoma
Most common type of breast cancer
Starts in milk ducts, then breaks through walls to
invade surrounding tissue
Multiple subtypes
Invasive Lobular Carcinoma
Begins in the milk-producing glands of the breast
(lobules)
Accounts for 10-15% of invasive breast cancers
Presents as a subtle thickening in the upper-outer
quadrant of the breast
Often not detected by mammography
Inflammatory Breast Cancer
Aggressive and fast growing
High risk for metastasis
Cancer cells block lymph channels in skin of breast
Breast looks red, feels warm
Breast skin has a thickened appearance, looks like an
orange peel (peau d’orange)
Paget’s Disease
Rare breast cancer
Different from Paget’s disease of the bone
Starts in breast ducts and spreads to nipple and
areola
Itching, burning, bloody nipple discharge,
ulceration
Nipple changes often diagnosed as an infection
or dermatitis, which can lead to treatment delays
Phyllodes Tumor
Very rare tumor
Develops in connective tissue of the breast
Tends to grow quickly
Most are benign
Treatment—Excision with wide margin
Triple Negative Breast Cancer
Tests negative for all 3 receptors
Estrogen, progesterone, HER-2
Higher incidence
* Blacks
* Hispanics
* Premenopausal women
* BRCA1 mutation
More aggressive tumors, poorer prognosis
Does not respond to hormone therapy,
chemotherapy more successful
Clinical Manifestations of
Breast Cancer
Detected as lump, thickening, or mammography
abnormality in breast
Rate of lesion growth varies
If palpable, hard, irregular, poorly delineated,
nonmobile, and nontender
May be nipple discharge or retraction
Complications of Breast Cancer
Recurrence and metastasis
Local: skin
Regional: lymph nodes
Distant: bones, brain, lungs, liver
* Metastatic disease can be found at any distant site
Diagnostic Studies
Some tests are used to predict risk of local or
systemic recurrence
Axillary lymph node analysis
Tumor size
Estrogen and progesterone receptor status
Cell-proliferative indices
Genetic/genomic assays
Axillary lymph node analysis
An important prognostic factor
The more lymph nodes involved, the greater the risk
of recurrence
* Sentinel lymph node biopsy (SLNB)
Helps identify lymph nodes that drain first from the tumor site
May indicate need for a complete axillary lymph node
dissection (ALND)
Tumor Size
Tumor size
Larger the tumor, poorer the prognosis
More well differentiated the tumor, the less
aggressive
Poorly differentiated tumors appear morphologically
disorganized and are more aggressive
Estrogen/Progesterone Receptor Status
Estrogen and progesterone receptor status
Receptor-positive tumors
* Often well-differentiated
* Lower chance for recurrence
* Diploid DNA content and low proliferative indices
* Frequently hormone dependent and responsive to
hormone therapy
Receptor-negative tumors
* Poorly differentiated
* Often recur
* High incidence of aneuploidy and higher proliferative
indices
* Unresponsive to hormonal therapy
Ploidy status
Number of chromosomes in a cell
Correlates with tumor aggressivenes
Genomic Assay
Genomic assay
HER-2 is a prognostic indicator associated with
* Unusually aggressive tumor growth
* Greater risk for recurrence
* Poorer prognosis
Presence helps in selection and sequence of
drug therapy and predicts response
Gene Expression Assay Test
Gene expression assay test
Uses a sample of breast cancer tissue to analyze
activity of a group of genes that can affect how a
cancer is likely to behave and respond to treatment
* Oncotype DX—most often used
* MammaPrint, PAM50 (Prosigna), EndoPredict, Breast
Cancer Index
Cell-proliferative indices indirectly measure rate
of tumor cell proliferation
Patients with cells that have high S-phase
fractions have higher risk for recurrence and
earlier cancer death
Breast Cancer Staging
Staging of breast cancer
TNM system
Tumor size (T)
Nodal involvement (N)
Presence of metastasis (M)
Stage of breast cancer describes size and extent to
which it has spread
Treatment Options
All options should be considered and discussed
Surgical intervention
Radiation therapy
Drug therapy
Hormone therapy
Immunotherapy and targeted therapy
Surgical Therapy
Most common surgical procedures for operable
breast cancer
Breast conservation surgery
* Lumpectomy
* Segmental mastectomy
Mastectomy, with or without reconstruction
Surgical Therapy
Breast-Conserving Surgery
Lumpectomy
Removing the entire tumor with a margin of normal
tissue
Radiation therapy after surgery
Delivered to entire breast, ending with a boost to
tumor bed
Chemotherapy before radiation therapy
Surgical Therapy
Breast-Conserving Surgery
Contraindications include
Size of breast in relation to size of tumor
Multifocal masses and calcifications
Multicentric masses- in more than one quadrant
Diffuse calcifications in more than one quadrant
Prior radiation therapy
Surgical Therapy
Mastectomy
Total or simple mastectomy
Removes entire breast
Modified radical mastectomy
Removes breast and axillary lymph nodes
Preserves pectoralis major muscle
Nipple-sparing mastectomy
Underlying tissue is removed
Breast reconstruction can be done with the
mastectomy or it can be delayed
Reconstruction is optional
2 main types of procedures
Implant reconstruction
Tissue flap
Radiation Therapy
Adjuvant therapy goals
Prevent local cancer recurrences after breast-
conserving surgery
Prevent local and lymph node recurrences after
mastectomy
Relieve pain caused by local, regional, or distant
spread of cancer
External radiation
Done after breast cancer surgery
Decision based on chance that residual cancer cells
are present
* Includes radiating axilla and/or supraclavicular nodes
when indicated
* Does not prevent distant metastasis
Fatigue, skin changes, breast edema may be
temporary side effects
Brachytherapy
Internal radiation
Minimally invasive
* Delivered directly into cavity left after lumpectomy
Requires 5 treatments, 5-10 minutes eac
Palliative Radiation Therapy
Decreases pain by reducing primary tumor mass
Treatment option for symptomatic metastatic lesions
in
Bone, soft tissue organs, brain, chest
Often relieves pain, controls recurrent or metastatic
disease
Drug Therapy
Systemic therapy including
Chemotherapy
Hormone therapy
Immunotherapy
Targeted therapy
Patients at ↑ risk for recurrent or metastatic disease
Neoadjuvant therapy
Given before surgery to shrink size of tumor
Adjuvant therapy
Given after therapy to decrease rate of recurrence
and increase length of survival
Chemotherapy
Use of cytotoxic drugs to destroy cancer cells
Combination drug therapy is usually superior to use of a single drug
Usually given for 3 to 6 months
With metastasis, may receive for the rest of their life
Combinations of drugs effective
Different mechanisms of action
Work during different parts of the cell cycle
Common combination-therapy protocols used in
adjuvant and neoadjuvant setting
CMF
AC
CEF or CAF
Side effects are related to
Drug combination, schedule, dosage
Involve rapidly dividing cells in
* GI tract (nausea, anorexia, weight loss)
* Bone marrow (anemia)
* Hair follicles (alopecia)
“Chemobrain”
Hormone Therapy
Blocks effect and source of estrogen, promoting
tumor regression
Estrogen can promote growth of breast cancer cells if
cells are estrogen receptor (ER) positive
Receptor assays have been developed for both
estrogen and progesterone
* Predict whether hormone therapy is a treatment option
Hormone therapy
Block ERs
Suppress estrogen synthesis
Ovarian ablation
Premenopausal women with ER-positive breast
cancer
Accomplished surgically or with LHRH hormone
analogs
ER blockers
Tamoxifen
* Agent of choice in ER-positive women with all stages of
breast cancer
* Drug alert
Toremifene (Fareston)
Fulvestrant (Faslodex)
Aromatase inhibitors
Stops aromatase, an enzyme in fat tissue, from
changing other hormones into estrogen
Anastrozole (Arimedex), letrozole (Femara),
exemestane (Aromasin)
Used in treatment of breast cancer in
postmenopausal women
* Do not block ovarian estrogen production
* May be harmful in premenopausal women
* May cause osteoporosis in postmenopausal women
Estrogen receptor modulators
In breast: estrogen-antagonistic effects
In bone: estrogen-agonistic effects, for example:
* Raloxifene (Evista)
Other drugs used to suppress hormone-dependent
breast tumors
Targeted Therapy
Trastuzumab (Herceptin) is a HER-2 inhibitor
Attaches to HER-2 receptors on surface of breast
cancer cells; blocks them from receiving signals to
proliferate
Can be used alone or in combination with other
chemotherapies
Drug alert
Other drugs that target HER-2
pertuzumab (Perjeta), ado-trastuzumab emtansine
(Kadcyla), lapatinib (Tykerb), nerotinib (Nerlynx)
Kinase inhibitors prevent cells from dividing, slowing
growth
For ER-positive, HER-2 negative cancer in
postmenopausal women
palbociclib (Ibrance), ribociclib (Kisquali), and
abemaciclib (Verzenio)
Drug that block mTOR, protein that promotes cell
growth- everolimus (Afinitor)
Immunotherapy
Atezolizumab (Tecentriq), immune checkpoint
inhibitor, is 1st FDA-approved immunotherapy agent
Used with chemotherapy to treat locally advanced
triple negative breast cancer with PD-L1 positive
biomarker
Pembrolizumab- option with advanced breast cancer
that tests MSI-H (microsatellite instability-high) when
no other therapies are available
Surgical Therapy
Postbreast Therapy Pain
Syndrome
Postbreast therapy pain syndrome (PBTPS)
Nerve injury during surgery
* Intercostobrachial nerves
* Provide sensation to shoulder and upper arm
Chemotherapy
Radiation therapy
Symptoms range from mild to debilitating
Chest and upper arm pain, tingling, aching, burning,
numbness, shooting or pricking pain, edema,
unbearable itching
Treatment includes
NSAIDS, low dose antidepressants, topical
anesthetics (EMLA), antiseizure drugs (gabapentin)
Biofeedback, physical therapy, guided imagery
Phantom Breast Pain
Feeling pain in breast after a mastectomy
Occurs for same reasons phantom limb sensation
occurs after limb amputations
Brain continues to send signals to nerves in breast
area that were cut during surgery
Gerontologic Considerations for Breast Cancer
Major risk for breast cancer is increasing age
More than half of all breast cancers occur in women
age 55 or older
Older women are less likely to have mammograms
Screening and treatment decisions are based on
health status, not age
Mammoplasty
Surgical change in size or shape of the breast
Elective surgery for cosmetic purposes
Breast reconstruction after mastectomy
Consider
* Body image
* Cultural values placed on the breast
* Outcomes and complications
Breast reconstruction
Achieve symmetry
Restore or preserve body image
* Timing is based on patient’s physical and psychologic
needs
Immediate or delayed
* Can restore contour of the breast
* Cannot restore lactation, nipple sensation, or erectilit
Breast Implants and Tissue
Expansion
Implants
Silicone shell
* Silicone gel
* Saline
* Cohesive gel
Tissue Flap Procedures
Use of autologous tissue to recreate a breast mound
Abdomen
Back
Thighs
Buttocks
TRAM flap
2 types of TRAM: pedicle and free
Extensive procedure with lengthy recovery period
DIEP flap
Version of the free flap that does not involve use of
muscle tissue
SIEAP
Another option using abdominal are, no muscle
Latissimus dorsi flap
Block of skin and muscle removed from patient’s back
Nipple-Areolar Reconstruction
More natural-appearing breast
Usually done several months after breast
reconstruction
Tissue is taken from breast tissue to create a new
nipple
* Tattooing with permanent dye may be used
* Polyurethane removable nipples also available
Breast Augmentation
Augmentation mammoplasty
Procedure to enlarge the breasts
* Implant is placed in a surgically created pocket
between capsule of breast and pectoral fascia
* Ideally under pectoralis muscle
Breast Reduction
Large breasts can be a source of discomfort
Wedges of tissue are resected from the upper and
lower breast quadrants
* Excess skin is removed
* Areola and nipple are relocated
* Lactation usually can still occur
Can have positive effect on psychologic and physical
health
