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RN Refresher Course > Module 7: Breast Problems > Flashcards

Module 7: Breast Problems Flashcards

1
Q

Mastalgia (Benign)

A

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

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2
Q

Lactational Mastitis (Benign)

A

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

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3
Q

Fibrocystic Changes (Benign)

A

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

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4
Q

Fibroadenoma (Benign)

A

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

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5
Q

Galactorrhea (Benign)

A

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

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6
Q

Intraductal Papilloma

A

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

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7
Q

Ductal Ectasia (benign)

A

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

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8
Q

Male Gynecomastia (Benign)

A

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

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9
Q

Senescent Gynecomastia (benign)

A

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

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10
Q

Gerontologic Considerations

A

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

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11
Q

Breast Cancer

A

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

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12
Q

Breast Cancer Etiology and Risk Factors

A

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

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13
Q

Breast Cancer Risk Factors for Men

A

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

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14
Q

Breast Cancer Screening Guidelines

A

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

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15
Q

Breast Cancer Diagnostic Studies

A

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

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16
Q

Metastatic breast cancer

A

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

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17
Q

Types of Breast Cancer based on tissue types

A

Ductal carcinoma (affects milk ducts)
 Medullary
 Tubular
 Colloid (mucinous)
 Lobular carcinoma (affects milk-producing glands)

Other
 Inflammatory
 Paget’s disease
 Phyllodes

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18
Q

Breast Cancer Types - based on invasiveness

A

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%)

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19
Q

Breast Cancer Types - based on hormone receptor status

A

Estrogen and progesterone receptor status
 Estrogen receptor positive
 Estrogen receptor negative
 Progesterone receptor positive
 Progesterone receptor negative

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20
Q

Breast Cancer Types - based on genetic status

A

HER-2 genetic status
 HER-2 positive
 HER-2 negative

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21
Q

Noninvasive breast cancer

A

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

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22
Q

Invasive ductal carcinoma

A

Invasive (infiltrating) ductal carcinoma
 Most common type of breast cancer
 Starts in milk ducts, then breaks through walls to
invade surrounding tissue
 Multiple subtypes

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23
Q

Invasive Lobular Carcinoma

A

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

24
Q

Inflammatory Breast Cancer

A

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)

25
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
26
Phyllodes Tumor
Very rare tumor  Develops in connective tissue of the breast  Tends to grow quickly  Most are benign  Treatment—Excision with wide margin
27
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
28
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
29
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
30
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)
31
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
32
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
33
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
34
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
35
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
36
Treatment Options
All options should be considered and discussed  Surgical intervention  Radiation therapy  Drug therapy  Hormone therapy  Immunotherapy and targeted therapy
37
Surgical Therapy
Most common surgical procedures for operable breast cancer  Breast conservation surgery * Lumpectomy * Segmental mastectomy  Mastectomy, with or without reconstruction
38
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
39
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
40
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
41
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
42
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
43
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
44
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”
45
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
46
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)
47
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
48
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
49
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
50
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
51
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
52
Breast Implants and Tissue Expansion
Implants  Silicone shell * Silicone gel * Saline * Cohesive gel
53
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
54
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
55
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
56
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
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