Benign Disorders of the Breast

Question 1

where is most of the breast pathologies located

Answer 1

upper outer quadrant

Question 2

what nodes are most frequently involved with breast cancer metastases

Answer 2

axillary nodes (sentinel nodes)

Question 3

what drives breast development during puberty

Answer 3

estrogen

Question 4

what inhibits milk production

Answer 4

estrogen and progesterone

Question 5

what drives lactation

Answer 5

prolactin

Question 6

what is an infection of the breast

Answer 6

mastitis/breast cellulitis

Question 7

what is the most common pathogen with mastitis

Answer 7

S. aureus
alternatively Strep and e.coli

Question 8

what is the presentation of bastitis

Answer 8

typically unilateral
indurated, erythematous, edematous, tender area on breast
fever is common - myalgia, chills and malaise
pain including and beyond indurated area

Question 9

if persistent mastitis what should be done for further workup (if post partum)

Answer 9

culture of midstream milk sample

Question 10

when are biopsies completed with mastitis

Answer 10

palpable mass after infection resolves
repeated recurrence or treatment failure

Question 11

what is the treatment options for mastitis

Answer 11

supportive measures: breastfeeding, bed rest, massage, supportive bra
pain control: Tylenol/anti-inflammatories
ABX

Question 12

what is the first line antibiotic for the treatment of mastitis

Answer 12

dicloxacillin (Diclox) every 6 hrs for 7-14 days

Question 13

what is the antibiotic for the treatment of mastitis if MRSA suspected of PCN allergy

Answer 13

clindamycin (cleocin) 4x/day for 5-14 days

Question 14

what are risk factors for mastitis

Answer 14

first time nursing
difficulty nursing
blockage of milk duct
oversupply of milk
maternal stress or fatigue (excessive)
illness of mother or child
cracks or nipple sores

Question 15

what are risk factors for breast absess

Answer 15

maternal age (>30)
primiparity (first time childbirth)
gestational age 41+ weeks
mastitis

Question 16

what is a breast abscess

Answer 16

primarily extension/worsening of mastitis

Question 17

what is the primary pathogen with breast abscess

Answer 17

s. aureus
20% are MRSA

Question 18

what is the clinical presentation of breast abscess

Answer 18

similar to mastitis
PLUS palpable fluctuant mass
+/- spontaneous drainage

Question 19

what is the diagnostic test of choice for breast abscess

Answer 19

aspiration (diagnostic and therapeutic)

Question 20

when do we consider biopsy with breast abscess

Answer 20

mass remains after treatment
fails to improve after 48 hours of treatment
associated lymphadenopathy
MUST r/o inflammatory breast cancer

Question 21

what is the treatment of choice for breast abscess

Answer 21

drainage (aspiration first) - I&D plus wound packing if fails
many will need ABX - bactrim, clinda, doxy

Question 22

what is a galactocele

Answer 22

milk retention cyst
m/c lesion in lactating women
thickening of secretions-> obstruction of milk duct-> cystic collection of fluid

Question 23

what is the clinical presentation of galactocele

Answer 23

palpable mass
soft, non-tender, mobile
NOT associated with systemic symptoms

Question 24

what is the test of choice for galactocele

Answer 24

US imaging test of choice

Question 25

what is the definitive diagnostic test for galactocele

Answer 25

needle aspiration (also therapeutic)

Question 26

what is the treatment of Galactocele

Answer 26

may resolve on its own - warm compress if not- aspiration if develop symptoms of abscess - ABX

Question 27

What are breast cysts

Answer 27

mostly related to hormones - overproduction of estrogen, suppression of progesterone fibrosis of breast tissue - failure in formation of lobules/ducts

Question 28

what is the clinical presentation of breast cysts

Answer 28

many discovered incidentally may have cyclic breast tenderness or pain (cyclic mastalgia) +/- palpable mass depending on size should NOT have any pain, erythema, discharge, nipple or skin changes

Question 29

what is the best initial test of breast cysts

Answer 29

US - differentiate between cystic and solid consider mammography - looks for suspicious calcifications

Question 30

what are the type of breast cysts

Answer 30

simple complicated complex

Question 31

what are simple breast cysts

Answer 31

smooth, thin, regular walls completely fluid filled always benign

Question 32

what are complicated breasts cysts

Answer 32

somewhere between simple and complex some debris but not real solid components, no thick walls

Question 33

what are complex breast cycsts

Answer 33

irregular or scalloped, thick walls some solid components or debris may be malignant

Question 34

what is the definitive diagnostic test for breast cysts

Answer 34

FNA - Cytology +/- culture diagnostic and can be therapeutic

Question 35

what is the treatment of simple breast cysts

Answer 35

aspiration +/- excision if recurrent no monitoring necessary

Question 36

what is the treatment of complicated breast cysts

Answer 36

aspiration +/- cytology/culture re-image (US vs. mammogram) and/or biopsy q6m x 2 years

Question 37

what is the treatment of complex breast cysts

Answer 37

must do FNA or excisional biopsy follow up q6m x 2 years

Question 38

What are fibrotic changes

Answer 38

very common proliferative and non-proliferative

Question 39

what is non-proliferative fibrocystic changes

Answer 39

no epithelial hyperplasia in ducts no increased risk for development of breast cancer

Question 40

what is proliferative fibrocystic changes

Answer 40

some ducts have epithelial hyperplasia if moderate to severe - 1.5-2.0x higher risk of developing breast CA if proliferation is atypical - 4-5x higher risk

Question 41

what is the clinical presentation of fibrocystic breast changes

Answer 41

many asymptomatic cyclical breast mastalgia is often the presenting symptom - pain pain exacerbated by menstruation, chocolate and caffeine cyclical pain, fluctuation in size and multiplicity of lesions help to differentiate these lesion from carcinoma

Question 42

how are fibocystic changes worked up

Answer 42

mammogram if >35, US and/or biopsy

Question 43

what is the treatment for fibrocystic changes

Answer 43

reassurance supportive bra to limit pain role of caffeine/chocolate not supported by literature tylenol/NSAIDs

Question 44

what is the most common benign tumor of the breast

Answer 44

fibroadenoma

Question 45

what population if fibroadenomas usually seen in

Answer 45

females younger than 30 commonly found in adolescence

Question 46

what are fibroadenomas

Answer 46

benign tumors of CT - stromal and epithelial cells - likely related to estrogen (worsen with pregnancy, shrink after menopause)

Question 47

what is the clinical presentation of fibroadenomas

Answer 47

often discovered by accident usualyl solitary but can be multiple may occur bilaterally typically in upper outer quadrant round, discrete, mobile, painless mass rubbery consistency usually around 1-5cm in diameter

Question 48

when can fibroadenomas increase in size

Answer 48

pregnancy and exogenous estrogen use

Question 49

what is the best initial test for fibroadenomas

Answer 49

US mammogram if >35

Question 50

what is the treatment of fibroadenomas

Answer 50

Biopsy confirms benign fibroadenoma - no tx needed

Question 51

when is excision and histology or cryablation for fibroadenomas necessary

Answer 51

uncertain diagnosis rapid growth size >2cm patient request

Question 52

What are intraductal papilloma

Answer 52

benign tumor of ductal epithelial cells solitary or multiple papillomas

Question 53

what are the risk factors for intraductal papilloma

Answer 53

contraceptive use hormonal replacement therapy (HRT) lifetime estrogen exposure family hx

Question 54

what age is most common for intraductal papilloma

Answer 54

between 35-55yo

Question 55

what is the clinical presentation of intraductal papilloma

Answer 55

may be asymptomatic in younger patient - incidental US finding spontaneous nipple discharge (clear or bloody) occasionally palpable - primarily multipel papillomas

Question 56

what is the diagnostic test of choice for a patient < 35 yo with concern of intraductal papilloma

Answer 56

ultrasound

Question 57

what is the diagnostic test of choice for a patient > 35 yo with concern of intraductal papilloma

Answer 57

mammogram

Question 58

what is the definitive diagnostic test for concern of intraductal papilloma

Answer 58

core needle biopsy to rule out malignancy

Question 59

what is the treatment for intraductal papilloma

Answer 59

lumpectomy surgical excision of entire mass

Question 60

what are the screening recommendations for mammogram

Answer 60

over 40 every other year