Study Guide : breast conditions

Question 1

1. Describe the anatomy and physiology of the female breast.

Answer 1

Anatomy: mammary glands which are large modified sebaceous glands. Nipple, lobes (15-20 lobes- formed lobules-subdivided into secretory alveoli), ducts (connect glands), and fibrous & fatty tissues. Cooper’s ligament connect the chest wall to the skin of breast giving its shape and elasticity.
Physiology: Prolactin (PRL) & Growth hormone (GH) from anterior pituitary stimulate mammary gland development.
Estrogen promote growth of the gland & ducts.
Progesterone: stimulate milk producing cell.
Lymphatic system- empties the breast tissue of excess fluid. Lymph nodes along the pathway of drainage monitor for foreign bodies such as bacteria and virus. Although the main flow moves toward the axilla and anterior axilla nodes, lymph drainage has been shown to pass in all directions from the breast.

Question 2

Mammogram:

Answer 2

most frequent use for breast cancer. To identify cancers that are too small to palpate on physical examination. Also detect benign & malignant calcifications. Benign calcification are identified by large, coarse, and scattered appearance. Malignant are smaller appearing as grains of sand. calcification, densities and architectural distortion*

Question 3

Ultrasound:

Answer 3

Breast cancer, ultrasound can further characterize solid or fluid filled. (solid=further investigation, fluid-filled=cyst generally do not)

Question 4

Magnetic resonance imaging

Answer 4

recommend for screening women at high risk for breast cancer. Tissue with increase blood flow such as tumor.

Question 5

Serum prolactin level

Answer 5

if the woman has bilateral milky discharge & negative pregnancy test then obtain serum prolactin level
nipple discharge

Question 6

TSH:

Answer 6

for nipple discharge

Question 7

Hemoccult testing:

Answer 7

guiac testing & cystology are generally not recommended because they do not change the management

Question 8

Fine-needle aspiration biopsy (FNA):

Answer 8

required to definitely ascertain whether a mass is solid versus cystic and benign versus malignant. FNA is a minimally invasive way to differentiate solid and cystic masses and provides cytologic evaluation of palpable mass. ***for Benign breast mass or thickening

Question 9

Stereotactic core needle biopsy:

Answer 9

large bore needle used to obtain cores of tissue for histologic examination, sereotactic mammography used for localization and targeting. For **density or calcification seen on mammogram

Question 10

Ultrasound-guided core needle biopsy:

Answer 10

large bore needle used to obtain cores of tissue for histologic examination, ultrasound used for localization and targeting. For solid lesion seen on ultrasound

Question 11

Needle-localized breast biopsy:

Answer 11

use of wire to localize an occult mammographic abnormality prior to excision biopsy. For density or calcification seen on mammogram in a location that cannot be effectively assess with core biopsy.

Question 12

Excisional breast biopsy:

Answer 12

surgical procedure that requires a skin excision, mass or mammographic abnormality is removed w/ surrounding margin of normal-appearing tissue. For Palpable breast mass , thickening or skin change, only used for initial dx when needle biopsy is not feasible.

Question 13

Mammary duct ectasia:

Answer 13

common cause of non-milky nipple discharge. This usually occurs in women older than 50 y.o. & result from dilation of the ducts w/ surrounding inflammation and fibrosis.

Question 14

Intraductal papilloma:

Answer 14

frequently in women aged 45-50, results from a small benign growth in the duct. The discharge typically bloody, unilateral, and uniductal.

Question 15

Galatorrhea:

Answer 15

milky nipple discharge in women who has not been pregnant or lactated in last 12 mos. Usually bilateral & multiductal, and occur spontaneously or only with nipple/breast manipulation. It is result from hyperprolactinemia which may caused by pituitary prolactin secreting tumors, medication, hypothyroidism, stress, trauma, chronic renal failure, hypothalamic lesions, previous thoracotomy, and herpes zoster.

Question 16

Fibroadenoma:

Answer 16

composed of dense epithelial & fibroblastic tissue, are usually nontender, encapsulated, round, movable, and firm. They are COMMON type in adolescent and young women. Their incidence decreases with increase age. estrogen effect

Question 17

Cyst:

Answer 17

fluid-filled masses that are COMMONLY in women 35-50. cystic lobular involution*

Question 18

Lipoma:

Answer 18

area of fatty tissue that may occur the breast or other ares of the body (arm, legs, & abdomen). accumulate fat in later reproductive years*

Question 19

Fat necrosis:

Answer 19

trauma to the breast external force or from surgical manipulation*

Question 20

Harmartoma:

Answer 20

glandular tissue, fat, and fibrous connective tissue

Question 21

Galactoceles:

Answer 21

milk-filled cysts that usually occur during or later lactation. Galactoceles result from duct dilation and often have inflammatory commonent.

Question 22

Carcinoma in situ→

Answer 22

Ductal carcinoma in situ (DCIS) or intraductal carcinoma is the earliest manifestation of breast cancer and involves abnormal cells that are confined to the ducts. Dx: microcalcification seen on mammography, rare palpable mass. Paget Disease is a rare form of breast cancer causes eczematous nipple changes as well as ulceration/itch/red/discharge/may or may not have palpable mass that usually underlying DCIS or invasive ductal carcinoma.

Question 23

Lobular carcinoma in situ →

Answer 23

1) abnormal cells are limited to the breast lobules. It is noninvasive lesion that does not always progress to invasive cancer. Dx: may be bilateral & is often incidental finding noted during biopsy for another lesion.

Question 24

Invasive breast cancer→ infiltrating ductal carcinoma

Answer 24

is the MOST COMMON MALIGNACY of the breast cancer. DISCRETE SOLID MASS W/ MALIGNANT CELLS escaping the confines of the ducts and infiltrating the breast parenchyma. Metastases: lymph node, liver, and lungs.

Question 25

Invasive breast cancer→ Infiltrating lobular carcinoma

Answer 25

are less common, characterized by bilateral involvement & associated with unusual spread of metastases including carcinomatous
meningitis, intra-abdominal metastases with intestinal ureteral obstruction and metastases to the uterus and ovaries.

Question 26

Invasive breast cancer –> Inflammatory carcinoma

Answer 26

red/warmth/thicken/peau d’orange (fine dimple) skin **rapid progressive type of breast cancer **

Question 27

Mastalgia:

Answer 27

determine if pain is cyclic (premenstrual) or non-cyclic (unknown). The pain is usually bilateral poorly localized and described as soreness or aching. Causes: menstrual, pregnancy, lactation, medications including exogenous hormones, caffeine, fatty food intake.

• **cancer sign: mastalgia occurs postmenopause in absence of hormone therapy, or when breast pain is accompanied by skin changes or palpable abnormality. Mastalgia occur only in one area of one breast and unrelated to cyclic pattern *
  management: reassurance, wear supportive bra, reduction in caffeine & dietary fat, supplementation w/ vit. A, B, or E. Modified HT (reduce dose or route). Medications for mastalgia: Danazol, tamoxifen, and bromocriptine –n/v & headache are common ASE* NSAID diclofena diethyl ammonium gel relieve cylic/noncylic mastalgia . Lidocaine & methyp prednisone for noncyclic mastalgia.

Question 28

nipple discharge:

Answer 28

normal → occurs only with manipulation, multiductal, yellow, green, gray or black = observe & advised to avoid stimulation, follow up in 3-4 months.
Abnormal discharge→ spontaneous, unilateral, uniductal, & reproducible on examination & bloody
Management: avoid stimulation, pituitary tumor may be tx surgically with medication or expectantly. Bromocriptin and cabergoline can be use to tx galactorrhea but symptoms often recur upon discontinuation of these medications. Long term therapy require. Intraductal papilloma= duct excision. Mammary duct ectasia= expectantly manage or surgically tx w/ removal of the subareolar duct system.

Question 29

Breast masses:

Answer 29

normal → discrete, smooth, round or oval, nontender, mobile. Abnormal → irregular border,immobile/fixed.
Management: fibroadenoma =nothing , cyst =nothing or aspiration if it is painful, lipoma = nothing, phyllodes tumor = excision, hamartomas=excision or expectant, galactocele=aspiration

Question 30

What interventions are used to prevent breast cancer in women at high risk for the disease?

Answer 30

Estrogen receptor modulators (SERMs) –risk for endometrial cancer & thromboembolic event
Aromatase inhibitors (Arimidex) – risk for decreased bone mineral density that increase fx risk
Tamoxifen (Nolvadex)
Raloxifene (Evista)
For very high risk for breast cancer -→ prophylactic mastectomy
Salpingo-oophorectomy for BRCA1 &BRCA2 women.

Question 31

1. Renee is a 24 year-old with mastalgia. No malignancy or nonbreast causes of mastalgia are identified after thorough evaluation. What would the management plan be?

Answer 31

Reassuring ! wear supportive bra, reduction in caffeine & dietary fat, supplementation with vitamin A B E
Try different hormonal contraception such as combined oral contraceptive to patch or ring
Danazol tamoxifen and bromocriptine are primarily tx mastalgia but significant ASE n/v & headach.
NSAID diclofena diethyl ammonium gel 3x daily for six month
CAM: primrose oil, agnus castus, isoflavones
Surgery for macromastia & refractory mastalgia (risk/benfit )

Question 32

Susan is a 40 year-old woman who presents with nipple discharge. What would your assessment (history, physical examination, and diagnostic testing) include?

Answer 32

Hx: color?
Spontaneous or only with manipulation?
Unilateral or bilateral?
Come from one or more ducts?
Medication
Other symptoms: mastalgia, breast mass, and any breast disease or surgery?
Hypo/hyper-thyroidism
Pituitary tumor (h/a visual change)
Hyperprolactinemia (irregular menses, infertility, decrease libido)
Menstrual
Pregnancy
Lactation
General medical & family histories
Physical examination: inspect & palpation in both upright and supine positions & palpation of lymph nodes. Assess for skin changes, breast masses, and tenderness. Additional assessment based on hx of thyroid with thyroid palpation OR examination of the visual fields for women with galactorrhea who are not pregnant/breastfeeding.
Diagnostic testing: pregnancy test, serum prolactin and thyroid-stimulating hormone (TSH) measurement.
**if hyperprolactinemia present image of sella turcica with MRI should performed r/o pituitary prolactin secreting tumor.
Manmmogram & ultrasound indicated for spontaneous discharge, unilateral, uniductal, and reproducible on examination.
Do nothing & follow up in 3-4 months for discharge upon manipulation, multiductal, and yellow green gray or black.

Question 33

What known risk factors for breast cancer have been identified?

Answer 33

Female
Advancing age
Early menarche (before 12 y.o) 
Late menopause (after 55 y.o) 
Current COC use 
Nulliparity
First pregnancy after age 30 y.o. 
High breast tissue density
High bone mineral density
Biopsy-confirmed hyperplasia
High-dose radiation to chest typically r/t cancer tx. 
Personal hx breast cancer
Family hx. Breast cancer
Inherited genetic mutations (less than 1% of the population) 
Weight gain after 18 y.o 
Overweight or obese
Physical inactivity
Consumption of one or more alcoholic beverage