Normal and Abnormal Breasts Flashcards
What is a part of the normal anatomy of the breast?
- Modified sebaceous gland
- Composed of glands, milk ducts, connective tissue and fat
- 12-20 lobes with disproportionate amount of glandular tissue in the upper outer quadrants
- Lobules consist of clusters of secretory cells lined with myoepithelial cells
- Rich in blood supply and lymphatic systemic
What is estrogen responsible for in the breast?
- Growth of adipose tissue and lactiferous ducts
What is progesterone responsible for in the breast?
- Stimulation of lobular growth and alveolar budding
What are some congenital anomalies of the breast?
- Absence of the breast
- Accessory breast tissue along the milk line
- Extra nipples (polythelia)
- Accessory breast (polymastia)
What are the two most common complaints with the breast?
- Breast pain
- Mass
What is needed from the patient history when they come in for breast complaints?
- Location
- Duration
- Nipple discharge
- Changes in size
- Associated with menstrual cycle
- Risk factors
What are some risk factors for breast cancer?
- Age
- Personal history of breast, endometrial, or ovarian cancer
- History of atypical hyperplasia
- High breast tissue density
- First degree relatives with breast or ovarian cancer
- Early menarche
- Late cessation of menses
- No term pregnancies
- Never breastfed
- Recent and long term use of OCPs
- Postmenopausal obesity
- Height (tall)
- High socioeconomic status
- Ashkenazi jews
What is done during the PE for a breast exam?
- Evaluate both breasts
- Complete exam including axilla and chest wall
- Palpable mass always gets a biopsy
What are some diagnostic tests done for a breast complaint?
- Mammogram
- U/S
- MRI
- Fine needle aspiration
- Core biopsy
What are some details about a mammogram?
- Able to detect lesions about 2 years before they become palpable
- Densities and calcifications are suspicious findings and clinically inapparent masses of less than 1 cm can be detected
Who is a mammogram best used for?
- Women 40 years and older
What does a screening mammogram look like?
- No complaint/concerns
- 4 images: 2 craniocaudal and 2 mediolateral, can be done by standard radiograph versus digital enhancement
What does a diagnostic mammogram look like?
- Done in women with a complaint or palpable mass or to adjunct an abnormal screening mammogram
- Contralateral breast should be imaged at same time
What are some details about ultrasound?
- Useful for evaluating inconclusive mammogram findings
- Allows to differentiate between cystic versus solid lesions as well as show solid tissue within or adjacent to a cyst that may be malignant
- May be used when performing core needle biopsies
Who is an ultrasound best used for?
- Women under the age of 40 and others with dense breast tissue
What are some details for an MRI?
- Useful adjunct to diagnostic mammography in suspicious masses
- Used post cancer diagnosis for further evaluation of staging
Who is an MRI best used for?
- Women at high risk for breast cancer like BRCA carriers
What is a fine needle aspiration biopsy?
- Useful for determining solid versus cystic mass
- Done in office
- Aspiration using 22-24 gauge needle
- Return for clinical breast exam in 4-6 months if cyst completely disappears with aspiration
What is done with the results from a fine needle aspiration biopsy?
- Clear fluid: no further evaluation
- Bloody fluid: sent for cytology and patients need a diagnostic mammogram/US
What happens if the cyst reappears or does not resolve with aspiration?
- Diagnostic mammogram/US and perform biopsy
What is a core needle biopsy?
- Uses a large needle (14-16 gauge)
- Used to get tissue from larger solid masses for diagnosis
- 3-6 samples about 2 cm long are obtained
What are some types of mastalgia?
- Cyclic
- Noncyclic
- Extramammary
What is cyclic mastalgia?
- Breast pain that starts at the luteal phase of the menstrual cycle and ends after onset of menses
What is noncyclic mastalgia?
- Not associated with menstrual cycle
- Due to tumors, mastitis, cysts
- Could be associated with meds like antidepressants, antihypertensives, hormonal meds
What is extramammary mastalgia?
- Pain due to chest wall trauma, shingles, fibromyalgia
What are some treatment options for mastalgia?
- Danazol: side effects basically make the pt more masculine
- SERMS (tamoxifen): increased risk of hyperplasia and DVT
- OCPs may help
- Symptoms relief: properly fitting bra, weight reduction, exercise, decrease caffeine intake
What are some details with nipple discharge?
- Usually benign
- Could be sign of endocrine disorder or cancer
- Unilateral or bilateral, color, consistency, spontaneous, or expressed all give clues
What does bloody nipple discharge indicate?
- Cancer until proven otherwise
- Concern for intraductal carcinoma or invasive ductal carcinoma
- Could be benign intraductal papilloma
How is bloody nipple discharge evaluated?
- With breast ductography and requires ductal excision
What are some concerns for breast malignancy?
- Greater than 2cm
- Immobility
- Poorly defined margins
- Firmness
- Skin dimpling/retraction/color changes
- Bloody nipple discharge
- Ipsilateral lymphadenopathy
What are the three categories of breast masses?
- Non proliferative- RR of developing cancer is 1.0
- Proliferative without atypia- RR 1.5-2
- Proliferative with atypia- RR 8-10
What are fibrocystic changes seen in nonproliferative breast masses?
- Spectrum of changes observed in the normal breast present in about 50% of women
What is adenosis?
- Lobular growth with increased number of glands
What is lactational adenomas?
- Due to hormonal response
What are fibroadenomas?
- Most common benign tumor in female breast
- Solid, rubbery, mobile, and typically solitary
- Usually 2-4 cm but could reach 15 cm which causes in increased risk of cancer
Who usually presents with fibroadenomas?
- In late teens or early 20s
What is a galactocele?
- Cystic dilation of duct filled with milky fluid
- Occurs near time of lactation
- Secondary infection may produce acute mastitis
How is a galactocele treated?
- Typically can be needle aspirated
What are some details about proliferative without atypia breast masses?
- Usually not palpable- found on imaging
- Epithelial hyperplasia
- Sclerosing adenosis
- Complex sclerosing lesions
- Papillomas
What is epithelial hyperplasia?
- Overgrowth of cells that line the ducts
What is sclerosing adenosis?
- Increased fibrosis within breast lobules
What are complex sclerosing lesions?
- Tubules trapped in a dense stroma surrounded by radiating arms of epithelium
What are papillomas?
- Intraductal growths
- Typically seen in women 30-50
- Cause serous or serosanguinous discharge
What happens in proliferative breast masses with atypia?
- Malignant cells replace the normal epithelium lining the ducts or lobules (carcinoma in situ)
- Lobular carcinoma in situ (LCIS)
- Ductal carcinoma in situ (DCIS)
What is LCIS?
- Not a precursor to breast cancer but risk factor for developing breast cancer
What is DCIS?
- Ducts are filled with atypical epithelial cells and women are increased risk for developing invasive disease or reoccurrence of DCIS
How are LCIS and DCIS treated?
- With excision and then followed with treatment with selective estrogen receptor modulators
How is age a risk factor for developing breast cancer?
- Majority occur after 50
- Caucasian women at greater risk except black women less than 45 are at greater risk
How does family history and genetics affect developing breast cancer?
- Women with first degree relatives with breast cancer have a 1.5 higher risk
- BRCA genes
- BRCA1: women have up to a 72% lifetime risk for developing breast cancer and the mutation rarely causes cancer in men
- BRCA2: women have a 69% chance of developing cancer and men have a 6.8%
How can radiation exposure affect developing breast cancer?
- > 20 cGy
- Time to develop lesion from exposure is 5 to 10 years
What is the Gail model for breast cancer risk?
- Usefulness decreased in second degree relatives with breast cancer
- Falsely elevated in patients with multiple breast biopsies
- Women considered high risk are counseled on prophylactic therapy
What is the most common breast cancer?
- Ductal: most common in women in their 50s and spreads to regional nodes
What does the treatment options for breast cancers depend on?
- Depends on stage and use receptor status in addition to staging to determine prognosis (estrogen, progesterone)
What are some treatment options for breast cancer?
- HER2/NEU (oncogene)- worse prognosis and is found in 20-30% of invasive cancers
- Surgical therapy: lumpectomy with radiation or mastectomy (outcomes are equal)
What medical therapy is used for breast cancer?
- Adjuvant therapy is used in all stages which reduces risk of recurrence by 1/3 and reduces death by 30%
- Chemotherapy kills cancer cells
- Hormonal therapy: antagonizes to estrogen, reduces risk of cancer in bilateral breast
- Aromatase inhibitors: prevent production of estrogen in postmenopausal women
- Trastuzumab: acts on protein made by HER2/NEU
