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Flashcards in Breast Deck (33):
1

lymph nodes draining breast

lymph drains from central axillary nodes to infraclavicular and supraclavicular

Not all drain into axilla. Malignant cells from breast ca may spread directly to infraclavicular or internal mammary chain

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2

etiology of gynecomastia

  • be no identifiable cause, uni or bilateral.
  • Can be caused by meds: digoxin, estrogen, thiazides, phenothiazines.
  • Manifestation of illnesses: hepatic cirrhosis, renal failure, malnutrition

3

breast changes in pregnancy/menstrual cycle

  • progesterone & estrogen go up in pregnancy (2nd row of image). Responsible for a lot of breast changes.
  • Luteal phase – rise in estrogen & progesterone, then drop off w/menstruation. What underlies cyclical breast pain.
  • W/hormonal contraceptives, have slightly higher level of E&P but never as high as pregnancy. Those sensitive to hormones may also have breast tenderness w/hormonal contraceptives – may or may not be cyclical

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4

Best time to examine breasts

right after menstruation. 5-10 days after beginning of menstruation. Postmenopausal w/hormone replacement: w/in first 5 days of estrogen component.

5

benign masses

  • Fibrocystic changes
  • Fibroadenoma
  • Ductal cysts

6

fibrocystic changes

  • benign
  • Occur in 50-60% women
  • Reproductive age: common 30s and 40s
  • Most common luteal phase
  • Pain, nodularity, tender to touch
  • Rarely postmenopause on HRT
  • May be cysts or masses, or nonspecific nodularity

Often premenstrual cyclic mastalgia, pain and tenderness to touch, may increase breast size. Food st thought to have role. 

7

Fibroadenoma    

  • benign
  • Most common lesion < 25
  • Mobile, smooth, painless, rubbery, fibroepithelial
  • usually single, may be multiple
  • Size may vary; round, disclike, or lobular
  • Not cyclic
  • U/S can aid diagnosis
    • May biopsy
  • Management
    • Expectant mgmt – some resolve
    • Excision

8

Ductal Cysts

 

 

  • Age 30-50
  • Dull, achy pain
  • Benign, fluid filled
  • single or multiple
  • Distinct borders
  • Difficult to distinguish on exam from solid
    • Diagnosis may be by U/S
    • Simple or complex
  • Aspiration may be treatment
  • Rare postmenopause unless on HRT

 

9

Mastalgia: what to find out in history

  • Cyclic, non-cyclic (unilateral, localized - differential, e.g. costochondritis)
  • Discharge, mass
  • Exercise? May affect pecs

10

Mastalgia​: what to find out in PE

mass, nodularity, d/c, location of pain

11

Mastalgia​: management

  • Education
  • Reassurance – benign 90% cases. 70% women experience
  • Medication
  • RTC at another point in cycle
  • Refer

12

Benign nipple discharge

nonspontaenous, bilateral, serous: likely physiologic

 

  • 95% benign or physiologic
  • Evaluation Hx and PE for all women
    • Spontaneous or expressed?
    • Duration
    • Color
    • Breast mass present?
    • Recent lactation most importantly
  • Physiologic
  • Galactorrhea: milk production unrelated to current nursing. Most common cause but can be other – e.g. endogenous/exogenous hormones, chronic breast stimulation.

 

13

pathologic nipple discharge: presentation, Hx, etiology

  • Unilateral
  • Spontaneous
  • Green, grey, bloody
  • Hx, full breast exam
    • Mass?
    • Skin breakdown nipple or areola?
  • CA, mammary duct ectasia (benign, post/perimenopausal – tender hard erythematous mass adjacent to areola) fibrocystic
  • Cytology low sensitivity
  • Consult or refer (radiographic)

14

Mastitis + treatment

  • Pain, redness, warmth (acute cellulitis, most often d/t staph aureus)
  • Tx:
    • Emptying of breasts
    • Fluid
    • Compresses
    • Antibiotics 

15

Describe A through D

Q image thumb

A: paget’s dz of the nipple (assoc w/ intraductal carcinoma)

B: skin dimpling due to tumor (best seen arms raised)

C: nipple discharge from single duct orifice. May signify underlying dz in discharging duct

D: Peau d’orange. Edema of skin. Can be d/t many causes. Most common: inflammatory carcinoma in which malignant cells plug lymphatic ducts

16

Risk Factors Breast Cancer

  • Female
  • Advancing age
  • Early menarche (<12)
  • Late menopause (>55)
  • Obesity
  • Weight gain >age 18
  • 1st preg > 30
  • Physical inactivity
  • Nulliparity
  • ETOH > 1 drink/day
  • HRT with E and P
  •  
  • High breast density
  • High BMD (bone marrow density)
  • Hx/FH breast CA
  • Hx/FH ovarian CA
  • Jewish ethnicity
  • Radiation to  chest
  • Inherited mutations
  • Biopsy atypical hyperplasia or LCIS
  • Developed countries

 

17

OCPs and breast cancer

OCPs protective

18

Breast cancer: Findings Suggestive of Malignancy

  • Palpable lesion:
    • Unilateral
    • Hard, painless, irregular borders
    • Immobile, fixed to skin
    • Drag on surrounding tissue
  • Enlargement of lymph nodes
  • Discharge - not milky (bloody, clear)
  • Skin changes – don’t heal
  • Skin puckering or dimpling

19

Breast Cancer Screening: USPTF (2009)

Mammogram:

50-74 biennial
≥ 75 lack data

CBE lack data
BSE not advised – no longer rec monthly. Be aware of breasts, come in if having issues

20

Breast Cancer Screening: ACS (2012)/ACOG (2011)

Mammogram:

≥ 40 yearly;
>75 ACS yes; ACOG: discuss with “doctor”

CBE: 20-30 q 1-3 years; ≥40 yearly
BSE: “option” starting in 20s

21

Breast Cancer Mgmt in high risk women

  • Close surveillance
    • Mammography 5-10 years earlier
    • More frequent CBEs
    • MRIs
  • Consider genetic counseling/testing
  • Risk modification
    • Estrogen-receptor modulators
    • Prophylactic surgery ↓ risk >90%

22

mammary duct ectasia

benign but sometimes painful condition of dilated ducts w/surrounding inflammation. Sometimes assoc w/masses. You may note tender cords on palpation

23

mobile mass that becomes fixed when arm relaxes is attached to...

ribs adn intercostal muscles

24

mobile mass that becomes fixed when hand is pressed against hip is attached to

pectoral fascia

25

thickening of nipple and loss of elasticity suggest

unlerlying cancer

26

hidradenitis suppurativa

sweat gland infectio - may be found on inspection of axilla

27

acanthosis nigricans at axilla

one form is assoc w/internal malignancy 

28

lymph nodes & malignancy

>= 1cm, firm or hard, matted together, or fixed to skin or underlying tissues

29

milky discharge unrelated to pregnancy

nonpuerperal galactorrhea - e.g., d/t hypothyroidism, pituitary prolactinoma, drugs that are dopamine agonists, e.g., psychotropic agents & phenothiazines

30

spontaneous unilateral bloody discharge from one or two ducts suggests

possible intraductal papilloma, ductal carcinoma in situ, or paget's dz of the breast

31

clear, serous, green, black, or nonbloody discharges that are multiductal suggest...

usually benign

32

cancer: population & characteristics

  • 30-90yo most common >50
  • usually single, though may coexist w/nodules
  • irregular or stellate shape
  • firm or hard
  • not clearly delineated from surrounding tissues
  • may be fixed to skin or underlying tissues
  • usually nontender
  • retraction signs may be present

33

Paget's Dz of nipple

  • uncommon form of breast ca.
  • Usually starts scaly, eczemalike lesion that may weep, crust, or erode.  
  • Possible breast mass.
  • Suspect in any persisting dermatitis of nipple and areola.
  • Can present w/invasive BC or ductal carcinoma in situ