The breast algorithm

Question 1

What are the benign breast diseases

Answer 1

1. ) Fibroadenoma
2. ) Fibrocystic disease
3. ) Intraductal papilloma
4. ) Fat necrosis
5. ) Mastitis

Question 2

What is fibrocystic disease

Answer 2

Only occurs in women age 30 to 50 that is exaggerated stromal tissue response to hormones and growth factors, and associated with trauma and caffeine use

Question 3

What are the symptoms of fibrocystic disease

Answer 3

Cyclic bilateral mastalgia and swelling with symptoms most prominent just before menstruation

Mammography is limited in this case, just use ultrasound to differentiate cystic from solid mass

Question 4

Breast algorithm: It is divided into two parts - nonsuspicious and suspicious mass. A non-suspicous mass is when their age is less than 35, it is movable and changes size with cycle and no fam hx. What is the work up for a non-suspicious mass

Answer 4

Always do FNA to see if it is cystic or solid

1. ) If it is cystic, FNA will drain fluid and relieve symptoms, however if bloody fluid comes out or residual mass then must do excisional biopsy
2. ) If it is solid, must proceed to cytology and determine if it is benign or malignant

Question 5

Breast algorithm: It is divided into two parts - nonsuspicious and suspicious mass. A suspicious mass is when their age is greater than 35, family hx, firm and rigid, axillary adenopathy. What is the work up for suspicious mass

Answer 5

Must do mammography or exisional biopsy

Question 6

What is the treatment for fibrocystic disease

Answer 6

1. ) Caffeine restriction

2. ) OCPs - reduce hormonal fluctuations

Question 7

What is fibroadenoma

Answer 7

Benign slow growing breast tumor with both epithelial and stromal components that is round, rubbery, discrete, mobile, and non-tender

Happens before menopause but this time it does not fluctuate with menstrual cycle

Question 8

What is the workup for fibroadenoma

Answer 8

Ultrasound or needle biopsy to differentiate cystic from solid

Excisional biopsy if uncertain after that (same as above algorithm)

Question 9

What are the two diseases that cause bloody nipple discharge

Answer 9

1. ) Intraductal papilloma

2. ) Mammary duct ectasia

Question 10

What are some risk factors for breast cancer

Answer 10

1. ) Nulliparity
2. ) Early menarche, late menopause (exposure to estrogen)
3. ) High fat and low fiber diet

Question 11

What are some late manifestations of breast cancer, and signs of metastasis

Answer 11

Late findings: Ulcerations, supracalvicular lymphadenopathy, edema of arm

Metastatic disease: Axillary notdes fixed to skin, infraclavicular node invovlement

Question 12

What is the screening guidelines for breast cancer

Answer 12

1. ) Premenopausal before age 30: Ultrasound
2. ) Postmenopausal after age 30: Mammography to check for increased density with micro-calcifications and irregular borders

Question 13

What are the three ways for which you can biopsy suspicious lesions

Answer 13

1. ) FNA - high false negatives
2. ) Core needle biopsy - larger sample, can test receptor status
3. ) Open biopsy - accurate diagnosis

Question 14

What are some clues to suggest that the breast cancer has metastasized

Answer 14

ESR elevated, alkaline phosphatase elevated (liver or bone invovlement), increased calcium

Question 15

The pharmacalogic treatment for breast cancer depends on whether hormone receptors are present.

Answer 15

1. ) Hormone receptor positive - tamoxifen
2. ) HER2/neu receptor psoitive - trastuzumab - monoclonal antibody
3. ) ER negative: Chemotherapy

Question 16

What are the surgical options for breast cancer

Answer 16

1. ) Breast conserving: Lumpectomy plus axillary disection with radiation - has some contraindications on page 351
2. ) Radical mastectomy with axillary disection

Stage 4 disease should be treated with radiotherapy and hormonal therapy

Question 17

What are the breast cancer stages

Answer 17

1. ) Stage 1: Tumor size less than 2cm
2. ) Stage 2: Tumor size 2 to 5 cm
3. ) Stage 3: Axillary node involvement
4. ) Stage 4: Distant metastasis