Week 7 - Breast disorders Flashcards
Types of nipple discharge
‣ normal lactation
‣ galactorrhea unrelated to childbearing
‣ non-milky discharge which is usually benign
Galactorrhea unrelated to childbearing s/s
‣ milky nipple discharge in a woman who has not been pregnant or lactated in the past 12 months
‣ usually bilateral and multiductal
‣ may occur spontaneously or with nipple manipulation
Cause of galactorrhea
‣ Hyperprolactinemia
‣ Medications (SSRIs, TCAs, MAOIs, CCBs, amphetamines – things that inhibit dopamine hyperprolactinemia
Causes of non-milky discharge
‣ Usually benign
‣ Intraductal papilloma and mammary duct ectasia are the most common causes
‣ Nonmilky discharge that is spontaneous, unilateral, from a single duct (uniductal), and clear or bloody is more likely to be associated with cancer than the physiologic discharge that can occur in approximately 50 percent of women with nipple manipulation
Assessment of non-milky breast discharge
‣ Duration, color, whether it occurs spontaneously or with manipulation, unilateral/bilateral, comes from one or more ducts or the nipple
‣ Other breast symptoms
‣ Symptoms of hypothyroidism, hyperthyroidism, pituitary tumor, hyperprolactinemia
‣ Menstrual, pregnancy, family and general medical history
Physical exam for non-milky nipple discharge
‣ Comprehensive breast/nipple exam – palpate upright and supine
‣ Palpate lymph nodes
‣ Assess for skin changes or breast masses and tenderness
Diagnostic testing for milky nipple discharge
‣ Bilateral milky discharge –> pregnancy test
‣ If negative –> serum prolactin level and TSH
‣ If hyperprolactinemia is present –> MRI to rule out pituitary tumor
Diagnostics for non-milky discharge with palpable mass
‣ If discharge is spontaneous, unilateral, uniductal, reproducable on exam –> mammogram and US
‣ Tissue biopsy
‣ Referral to surgeon
Treatment for non milky nipple discharge only with nipple stimulation that is yellow, brown, green or gray….
avoid nipple stimulation, f/u 3-4 months
What tests should you run with black nipple discharge
Fecal occult stool test for blood
Fibroadenoma
Solid, non cancerous breast lump composed of dense epithelial and fibroblastic tissue, are usually nontender, encapsulated, round, movable, and firm
S/S of fibroadenoma
‣ Discrete, smooth, round or oval, nontender, mobile
Diagnosing breast lumps as fibroadenoma
‣ US for women under 30
‣ Mammogram for women over 30
Cysts
fluid filled masses commonly found ages 35-50
S/S of cysts
Discrete, tender, mobile; size may fluctuate with menstrual cycle
Lipoma
area of fatty tissue, occur in later reproductive years
S/S of breast lipoma
Discrete, soft, nontender; may or may not be mobile
Fat necrosis
results from breast trauma (seat belt pressure in MVA)
S/S of breast fat necrosis
Ill defined, firm, nontender, nonmobile
Phyllodes tumors
form from periductal stromal cells of the breast and present as a firm, palpable mass. Usually larger than a fibroadenoma
Hamartomas
Composed of glandular tissue, fat, fibrous connective tissue. Discrete, nontender, nonmobile; may be nonpalpable with incidental diagnosis on imaging studies.
May be benign or malignant
Galactoceles
Milk filled cysts usually occur during or after lactation. Discrete firm sometimes tender
In women over 55, what percentage of breast masses are malignant?
85%
2/3 of adolescents with a breast mass have this type?
Fibroadenoma
What percentages of cases of individuals with fibroadenomas have multiple nodules?
10-15%
What happens to the fibroadenoma incidence with age?
decreases with increasing age, but they still account for 12 percent of masses in menopausal women
What percentage breast neoplasms are phyllodes?
Phyllodes typically large and fast-growing masses account for fewer than 1 percent of all breast neoplasms.
May be benign or malignant
Average age of breast cancer diagnosis
62
How many women are diagnosed with breast cancer in their lifetime?
1/8
How prevalent is breast cancer?
Second only to skin cancer with 268,000 new invasive cases annually. It is the second leading cause of death in women after lung cancer.
How many breast cancer survivors are there?
3.8 million
Invasive ductal carcinoma
‣ Most common malignancy of the breast
‣ Common spread to bones, liver, brain and lungs
S/S of invasive ductal carcinoma
‣ Discrete solid mass with malignant cells escaping the ducts and infiltrating the breast parenchyma
First steps for breast cancer assessment
Ultrasound and diagnostic mammogram
Ductal carcinoma in situ
The cells lining the milk ducts turn malignant (cancerous) but stay in place (in situ). DCIS is an early form of breast cancer.
S/S of ductal carcinoma in situ
‣ is usually diagnosed in association with microcalcifications seen on mammography; it is rare to find a palpable mass in such cases
Paget disease
‣ rare form of breast cancer (1 percent of all cases) that causes eczematous nipple changes and ulceration, itching, erythema, and nipple discharge
Diagnosis for paget disease is made by…
‣ punch biopsy (may not be dectecd with imaging)
Inflammatory carcinoma
- a rapidly progressive type of breast cancer, with more than half of all cases already demonstrating lymphovascular invasion at the time of diagnosis
s/s of Inflammatory carcinoma
Diffuse inflammatory changes of the breast skin with erythema, edema, warmth, skin thickening, and peau d’orange
Mastalgia
breast pain, may be cyclic (with menses 70% ) or non-cyclic (25%)
Causes of mastalgia
‣ certain medications,
‣ combined estrogen and progestin contraceptives (i.e., pills, vaginal ring, and transdermal patch),
‣ hormone therapy,
‣ antidepressants,
‣ digoxin,
‣ methyldopa,
‣ cimetidine,
‣ spironolactone,
‣ oxymetholone, and
‣ chlorpromazine
Types of mastalgia
‣ Cyclic – begins in luteal phase and ceases with menses
‣ Pain is usually bilateral and poorly localized
‣ Non-cyclic – pain may be constant or intermittent
‣ Not timed in relation to menstrual cycle
‣ More likely to be unilateral, and be sharp or burning pain
‣ Chest wall pain – very localized, worse with movement, affects 5-10% of women with myalgias
First steps of assessment for mastalgia
‣ determine cyclic, non cyclic or chest wall
‣ timing, frequency, nature, location, severity, mitigating factors
‣ other breast symptoms – nipple discharge, breast mass, PMH of breast disease or surgery
‣ caffeine intake can caue dilation of blood vessles and overstimulation of breast cells
Diagnosing mastalgia
‣ Pregnancy test
‣ Under age 30 – targeted breast US
‣ Over age 30 – targeted breast US with diagnostic mammogram
Mastalgia treatment
‣ First line treatment is reassurance
‣ Wearing supportive well fitting bra
‣ Exercise 3x week
‣ Reduction of caffeine and dairy (limited effectiveness)
‣ Reduce dose or route of women receiving HRT
‣ Try a different contraceptive
‣ Danazol – FDA approved treatment
‣ Oral or topical NSAIDS
Breast cancer screening guidelines
Screening mammography every 2 years for women aged 50 to 74
