Normal and Abnormal Breast Flashcards
Risk factors for breast cancer
Age (>50) Caucasian Personal hx of breast cancer Hx of atypical hyperplasia High breast tissue density First degree relatives w/ cancer hx Early menarche (age <12) Late cessation of menses (age>55) No term pregnancies Never breastfed Recent and long-term OCP use Postmenopausal obesity Personal hx of endometrial cancer Personal hx of ovarian cancer BRCA 1 or 2 carrier Radiation exposure Alcohol consumption Height (tall) High SES Ashkenazi jewish heritage
Steps in evaluation of breast signs/symptoms
Physical exam — evaluate both breasts; complete exam includes axilla and chest wall
Diagnostic tests — mammogram, US, MRI, FNA, core biopsy
Palpable masses almost always get a biopsy!
What test is able to detect lesions about 2 years before they become palpable, raising suspicion in cases of densities and calcifications?
Mammography
Mammography is most useful in women of what age group?
40+ years old
Differentiate screening vs. diagnostic mammography
Screening — no complaint/concerns, 4 images: 2 craniocaudal and 2 mediolateral. Can be done by standard radiograph vs. digital enhancement
Diagnostic — done in women with a complaint or palpable mass or to adjunct an abnormal screening mammogram, contralateral breast should be imaged at the same time
What test is useful in evaluating inconclusive mammogram findings, and is best for evaluating young women (<40 y/o) and others with dense breast tissue?
Ultrasonogrophy
Allows to differentiate between cystic vs. solid lesions as well as show solid tissue within or adjacent to a cyst that may be malignant
Also used for guidance when performing core needle biopsy
What type of imaging is useful in adjunct to diagnostic mammography in suspicious masses, post-cancer dx for further evaluation of staging, with breast implants, and with women at high risk for breast cancer like BRCA carriers?
MRI
_______ biopsy is useful in determining solid vs. cystic mass and can be performed in office
FNA
Describe further workup for FNA bx that return clear fluid vs. bloody fluid
Clear fluid needs no further evaluation
Bloody fluid is sent for cytology and pt needs a diagnostic mammogram/ultrasound
Either way, pt returns for clinical breast exam in 3 months if cyst completely disappears with aspiration. If the cyst reappears or does NOT resolve with aspiration, diagnostic mammogram/US + biopsy is done
_______ biopsy requires a larger needle and is used to get tissue from larger solid masses for diagnosis
Core needle
Describe types of mastalgia (breast pain)
Cyclic — starts at luteal phase of menstrual cycle and ends after onset of menses
Noncyclic — not associated with menstrual cycle; includes tumors, mastitis, cysts, can be associated with certain medications (antihypertensives, hormonal meds, OCPs)
Extramammary — chest wall trauma, shingles, fibromyalgia
Tx for mastalgia
Only FDA approved is danazol (bad AEs: menstrual irregularity, benign intracranial HTN, altered BG, deep voice, hirsutism, weight gain)
Can also try SERMs, OCPs, or Depo provera
Symptomatic relief: properly fitting bra, weight reduction, exercise, decrease caffeine, vitamin E supplements, evening primrose oil
Nipple discharge is usually benign but could be a sign of endocrine disorder or cancer. Unilateral or bilateral, color, consistency, spontaneous or expressed all give clues.
T/F: non-spontaneous, non-bloody, and bilateral nipple discharge is most consistent with fibrocystic change or ductal ectasia
True
T/F: bloody nipple discharge is considered cancer until proven otherwise
True — concern for intraductal carcinoma or invasive ductal carcinoma
Could be a benign intraductal papilloma
Evaluated with breast ductography and requries ductal excision
What PE findings with breast masses raise concern for malignancy?
Greater than 2 cm size Immobility Poorly defined margins Firmness Skin dimpling/retraction/color change Bloody discharge Ipsilateral LAD
Nonproliferative benign breast masses
Fibrocystic change Cysts Fibrosis Adenosis Lactational adenoma
Fibroadenoma (most common benign tumor in female breast)
Galactocele (cystic dilation of fluid filled with milky fluid)
Proliferative benign breast masses without atypia are usually not palpable and are found on imaging. What are examples?
Epithelial hyperplasia
Sclerosing adenosis
Complex sclerosing lesions (radial scar)
Papillomas
Proliferative breast masses with atypia and their tx
LCIS
DCIS
Both are treated with excision, then followed up with treatment with SERMS
The Gail Model-Breast cancer risk tool is used to determine risk of development of breast cancer. What is the recommendation for women considered high risk (5 year risk of 1.7% or more)
Prophylactic therapy (may include chemoprevention, mastectomy, oophorectomy)
Surgical therapy options for breast cancer
Lumpectomy with radiation
Mastectomy
[note: lumpectomy with radiation outcomes are equal to mastectomy]
Medical therapy for breast cancer
Adjuvant therapy is used in all stages — reduces risk of reoccurance by 1/3 and reduces risk of death by 30%
Chemotherapy — kills cancer cells
Hormonal therapy (tamoxifen) — antagonizes estrogen in breast, reduces risk of cancer in contralateral breast
Aromatase inhibitors (arimedex, femara) — prevent production of estrogen in postmenopausal women
Trastuzumab (herceptin) — acts on Her2/neu positive cancers; BAD side effects including heart failure, respiratory problems, allergic rxns
Treatment follow up in breast cancer
Every 3-6 months in the first 2 years after diagnosis
Annually after the first 2 years
[Most reoccurences will happen w/i first 5 years after tx]
