Tiemann Breast DSA Flashcards
FIBROADENOMA
Most common breast mass in young women (< 30 y/o)
Rare in older women (>45 y/o)
Benign solid tumors consisting of fibrous and epithelial elements
Usually firm, moveable, non-tender smooth or lobulated masses
Can be distinguished from cysts by ultrasound
Mammography rarely needed, unless U/S or other factors raise suspicion of malignancy
FNA helpful in making diagnosis, but FNA cannot distinguish fibroadenoma from phyllodes tumor (see below)
two subtypes of fibroadenoma and what to do
Two subtypes
- Giant fibroadenomas (> 5 cm.)
- Juvenile fibroadenomas (Hypercellular adenoma that develops in adolescents and young adults)
Benign tumors
- Rarely develop malignancy in the epithelial elements of the tumor
May be watched, excised (open or by U/S guidance) or treated with cryoablation
- Should be excised if patient desires, or if mass enlarges rapidly or significantly
PHYLLODES TUMOR
Similar to fibroadenoma, but cellular stroma grows rapidly and tumors usually become quite large
- Stroma forms epithelial-lined clefts resembling leaves (Phyllodes = Leaves in Greek)
- May be benign or malignant, depending on mitotic rate and histologic characteristics
- Benign lesions treated by local excision with margin of normal breast tissue to avoid recurrence
- Malignant lesions treated by wide local excision or mastectomy, w/o node dissection or sentinel node biopsy
FIBROCYSTIC BREAST DISEASE
An individual cyst may be painless, but multiple painful cysts are common.
Most common in women ages 35-55 and fluctuates with menstrual cycle.
Areas of fibrosis in the ducts with destruction and dilatation of terminal ductules and lobules, which fill with cystic fluid
FIBROCYSTIC BREAST DISEASE- cysts may present…
Cysts may present as breast masses and are usually easily identified by U/S and amenable to aspiration
- Cyst fluid may be clear, yellow or green
- If cyst disappears with aspiration and fluid not bloody, cytology not needed
- – Risk of malignancy very low
If cyst recurs, it may be re-aspirated
- Multiple recurrences should be biopsied or excised
FIBROCYSTIC BREAST DISEASE presentation and treatment
Fibrocystic disease of the breast often presents as breast pain, which is bilateral, diffuse and cyclical
- Breasts are usually tender and nodular w/o a dominant mass
- Pain increases prior to menses
- U/S may reveal multiple small cysts
- Mammography reveals dense fibrous breasts, usually w/o a mass
- If a mass is identified, it requires w/u
Difficult to treat
Treatment is directed towards the pain symptoms
- Support bra, analgesics, avoid trauma
- Danazol and tamoxifen can be used in severe cases
- Oil of evening primrose (gamolenic acid)
- Low-fat diet
- ? Avoiding caffeine and chocolate, alcohol
- ? Vitamin E
SCLEROSING ADENOSIS
A common finding in fibrocystic condition
- Proliferation of fibrous stroma and terminal ductules with deposition of calcium
- On mammogram, it appears similar to the microcalcifications seen in breast cancer
- Common histological finding in needle-directed biopsies for microcalcifications
- No known malignant potential
RADIAL SCAR
Complex sclerosing lesions
Microcysts, epithelial hyperplasia, adenosis and central sclerosis
Difficult to distinguish from breast cancer prior to biopsy
- Mass on exam or mammogram
- Spiculation
- May have calcifications
- May cause skin dimpling
- Usually require biopsy
- Associated with slight increase in subsequent development of breast CA
NIPPLE DISCHARGE
Spontaneous vs. expressed
- Expressed nipple discharge usually goes away when the manipulation of the nipple is stopped
- Spontaneous nipple discharge may require evaluation, if the discharge is serous or bloody
Evaluation usually requires cytology, mammogram, and/or ultrasound
If discharge is spontaneous,unilateral, bloody or serous, and coming from a single duct, duct excision is required
- 95% benign papillomas, 5% papillary CA
NIPPLE DISCHARGE- Unilateral vs. bilateral
Unilateral, from a single duct, more concerning for intraductal pathology
Bilateral or unilateral multiple duct
- Fibrocystic disease with duct ectasia
- If patient not lactating
— Hyperprolactinemia, hypothyroidism
— Drug-induced (Oral contraceptives, estrogen
Anti-psychotics)
MASTITIS AND BREAST ABSCESS- two forms
Lactational
Younger, breast-feeding woman with fever, breast erythema and tenderness
- Staph aureus infection treated with antibiotics and emptying of the breast
- Usually clears with the above treatment, but may go on to form abscess, which must be drained surgically
Chronic sub-areolar with duct ectasia
- Older women, especially diabetics who smoke
- Mixed aerobic/anaerobic flora
- Treated with antibiotics, if caught early
- Often require incision and drainage
- Recurrent infections/abscesses may require excision of the entire duct
FAT NECROSIS
Mass created by scarring following trauma, surgery or radiation
- Consists of scar tissue, chronic inflammatory cells and macrophages
- Often contains calcifications, but usually macrocalcifications
- No known malignant potential
MALE GYNECOMASTIA
Two major forms of diffuse male breast hypertrophy, which may be unilateral or bilateral, firm, and tender
- Pubertal
- - Adolescent boys
- - Transient and rarely requires treatment - Senescent
– Males > 50 y/o
– Usually associated with medication
Digoxin, thiazides, estrogens, phenothiazines, theophylline
– Must r/o underlying medical condition s/a hepatic cirrhosis, renal failure or malnutrition
Must be distinguished from male breast cancer which is hard, non-tender and often fixed to surrounding structures.
BREAST MASS HISTORY
Age
Fibroadenoma most common mass in ages < 30
Fibrocystic mass most common in ages 30-50
Majority of cancers found in patients > age 60
HOWEVER, CANCERS CAN OCCUR AT ANY AGE!
Length of time mass has been present
Growth or change in mass
Pain
Associated symptoms (eg. Areolar rash)
Menstrual Status—Menarche to menopause “Estrogen Window” Age of 1st full-term pregnancy 1.5-3 x increased risk if >35 or nulliparous History of other malignancy breast Ovarian (BRCA gene?) Endometrial CA Other systemic disease cardiac, respiratory, blood dyscrasias, etc. (that might affect the patient’s candidacy for surgery) Prior surgeries breast biopsies, TAH-BSO, endocrine Meds BCP, estrogens, tamoxifen/raloxifene, anticoagulants,
breast mass history- family history
Breast CA in first degree relative(s)
- 2-3 x increased risk, especially if pre-menopausal relative developed breast cancer
Ovarian CA (BRCA gene)
- BRCA1—up to 80% lifetime risk
- BRCA2—up to 80% lifetime risk
Endocrine Disease
breast mass ROS
Looking for symptoms suggestive of metastatic disease Bone Brain Lungs Liver Adrenal
BREAST MASS PHYSICAL EXAM
Look for causes of a breast lump, signs of metastases and suitability for surgery
Lymph Nodes
- Axillary chain is primary drainage of the breast
CV-Respiratory
Abdomen (liver, masses, nodes)
Pelvic/rectal
Neurological (looking for any signs of brain mets)
Musculoskeletal (bone tenderness suggestive of bone metastases)
Skin (erythema, skin nodules, areolar eczema)
BREAST MASS BREAST EXAM
Observation (Sitting and lying down, with arms at rest and then extended) Visible Mass Skin retraction -- Cooper’s ligaments shortened by tumor Nipple/Areolar eczema -- Paget’s Disease Nipple Discharge Erythema/Induration -- Inflammatory CA
Palpation (Sitting and Supine)
Size of mass
Consistency
Tenderness
Fixation
Regional Lymph Nodes
BREAST MASS ASSESSMENT OF RISK
Probability of Malignancy (Gail Model)
Patient’s Psyche
Form an appropriate plan with the patient
close follow-up
radiology/ultrasound
biopsy
BREAST MRI
High sensitivity, but lower specificity
Results in more false-positive readings and biopsies
Expense
USES:
Screening in very high-risk patients (BRCA)
Dense Breasts
Small multicentric lesions
Implants
BREAST BIOPSY: fine needle
Fine Needle Aspiration
- Minimally Invasive
- Can be done in office
- Requires good and experienced cytopathologist
- Usually requires confirmatory tissue biopsy
Breast biopsy: core needle
- Obtains tissue for diagnosis, Estrogen Receptor/Progesterone Receptor analysis
- Local Anesthesia
- Can be done by palpation, ultrasound, or
stereotactic (mammotome) - Treatment plan can be based on results
- Does not interrupt lymphatic pathways
breast biopsy: Open biopsy
Incisional—only removes a portion of the mass
Excisional—removes the entire mass
Needle Localization Biopsies
- Wire placed through needle to localize non-palpable lesions. Lesion and wire then excised
Core Needle Biopsy exhibiting atypia requires excisional biopsy
** REMEMBER: Atypia on FNA or core needle biopsy always requires excision of the entire lesion to R/O malignancy
Fibroadenoma
if growing, pt. anxious, or suspicion of Phyllodes tumor
BIOPSY RESULTS
Benign
- Fibroadenoma, Fibrocystic Changes
Atypical Hyperplasia
- 3-6 times increased risk of later invasive CA
Lobular CA in-situ
- Treated as a risk factor, not invasive CA
- 15-20% risk of invasive ductal CA bilaterally
- Requires close follow-up and usually chemoprophyllaxis with tamoxifen or aromatase inhibitor
Ductal CA in-situ
- Usually treated the same as small invasive CA with lumpectomy and irradiation, but no lymph node evaluation required
Invasive CA
Other
- Phyllodes tumor, sarcoma
