Breast Disease -> Flashcards
(142 cards)
1
Q
What is the breast made up of?
A
Glandular ducts and lobules, connective tissue (Cooper’s ligaments), and fat
1
Q
What muscle does the breast lie on top of?
A
Pectoralis major muscle
2
Q
What attaches the pectoralis major muscle and the fascia of the skin of the breast?
A
Cooper’s ligaments (bands)
3
Q
Function of Cooper’s ligaments?
A
Support breast in upright position
4
Q
What would result of cooper’s ligament bands being compressed/invaded by a tumor?
A
Pathologic skin dimpling
5
Q
How many lobes are in the breasts?
A
15-20
6
Q
What do the lobes of the breast contain?
A
Multiple lobules which contain alveoli - which produce milk
7
Q
Which breast structures transport milk?
A
Ductule, ducts, & lactiferous duct
8
Q
Which breast structure stores milk for initial suckling?
A
Lactiferous sinus
9
Q
Which tissue makes up 80-85% of the breast tissue?
A
Adipose tissue
10
Q
Where is half of the glandular tissue located in the breast
A
UOQ (upper outer quadrant)
11
Q
Do all women have the same number of breast lobes? What do the lobes contain that exit the nipple?
A
Yes - regardless of size
*lobes have 6-10 major ducts which exit the nipple
12
Q
Lymphatic drainage?
A
13
Q
What happens to the breast during premenstrual hormonal changes?
A
Alveolar cells inc. in #/size, ductal lumens widen, breast size/turgor inc. slightly, +/- breast tenderness
14
Q
What happens to the breast during postmenstrual hormonal changes?
A
Decreased: size/turgor, #/size of alveoli, diameter of ducts
15
Q
What happens to the breast during pregnancy/lactation hormonal changes?
A
Increased: size/turgor, pigmentation of nipple/areola, nipple size, areolar widening, #/size of glands, branching of ductal system, ductal widening
16
Q
What do pregnancy/lactation hormonal changes of the breast protect against?
A
Breast cancer
17
Q
Does breast size have relation to the amount of milk produced during lactation?
A
No
18
Q
What happens to the breast during postmenopausal hormonal changes?
A
Atrophy of breasts (replaced by adipose tissue), soft/looser
19
Q
What hormonal changes allow for easier interpretation of PE and mammogram of the breast?
A
Postmenopausal
20
Q
Hormonal changes during puberty?
A
Inc. in alveolar tissue/ductal size, excessive branching of ductal system, fat deposits, nipple/areola enlargement, typically takes 3-4 yrs and complete by age 16
21
Q
Rate of breast development is based on what?
A
Tanner stages of breast development
22
Q
Stage 1 of Tanner stages of breast development?
A
Pre-adolescent
23
Q
Stage 2 of Tanner stages of breast development?
A
Breast budding, mean age 11.2
24
Stage 3 of Tanner stages of breast development?
Continued enlargement, mean age 12.2
25
Stage 4 of Tanner stages of breast development?
Areola and papilla form secondary mound, mean age 13.1
26
Stage 5 of Tanner stages of breast development?
Mature female breasts, mean age 15.3
27
What are accessory nipples?
Extra nipples located anywhere along the milk line, usually multiple present (often appear to be moles)
28
Where does accessory breast tissue most often occur?
Underarm area
*breast cancer has been reported from these tissues
29
When would nipple inversion require evaluation?
If suddenly inverted
30
What may inverted nipples require?
Preparation prior to delivery to make nursing easier
31
How can large breast pain be corrected if PT does not work?
Reduction
32
What may cause underdevelopment of breast tissue?
Radiation, trauma, breast bx (removal of breast bud), gonadal dysgenesis, hypogonadotropin hypogonadism
33
What is the test of choice for breast eval?
Mammogram (low dose x-ray imaging)
***ONLY method found to dec mortality of breast cancer
34
What is mammography unable to detect?
Solid vs. cystic lesions
35
Are false positives/negatives with mammography possible?
Yes
36
When is mammography screening used?
In asx women w/o any s/sx of dx
37
When is diagnostic mammography used?
If sx to eval for an abnormal screening/abnormal mass
*takes longer, more views/different angles/magnify certain areas for better view
38
What occurs if there is a false positive on mammography?
10 of 70 will be referred for biopsy where 3.5 will be +, other 6.5 benign
39
2D vs. 3D mammography?
Uses same x-ray technology but 3D takes a bit longer/slightly more radiation exposure
2D: only front and side
3D: slices in different angles, more expensive
40
At what age should annual mammogram screening start?
45 (women 40-44 have option to begin screening)
41
At what age may mammogram screening switched to bi-annual?
55
42
Continue mammogram screening as long as what?
If overall health is good and life expectancy is 10+ yrs
43
Special circumstances for general breast screenings?
Women w/ genetic predisposition to breast CA --> combo screening of mammo and MRI starting at age 25 or based on earliest onset of family
Women w/ family hx of breast CA w/o genetic mutation --> data inconclusive, suggested 5 yrs prior to family onset
44
What is a uniform way for radiologists to describe mammogram findings?
BI-RADS system
0- need addntl imaging
1- negative
2- benign
3- probably benign
4- suspicious abnormal
5- highly suggestive of malignancy
6- known/bx proven malignancy
45
Is breast US used for routine screening in asx women?
No, used to target specific area of concern on mammogram or PE (helps distinguish between cysts and solid mass)
46
Is MRI used for routine screening in asx women?
No, can be used along for screenings in high risk pts --> highly sensitive when combines w mammogram and CBE for malignant changes
47
The ACS recommends annual MRI screening along with mammography in patients with which risks?
- BRCA
- 1st degree relative of BRCA carrier but untested
- Lifetime risk approx 20-25%+ defined by BRCAPRO or other risk models
48
Other special indications for MRI?
Breast implant eval for leaks/rupture, very dense tissue where mammogram inconclusive, palpable abnormalities not visible on US or mammogram, determine extent of breast cancer, assess normal areas after breast surgery/radiation
49
Why is fine needle aspiration (us guided) limited ?
Could miss cancerous cells based on technique, unable to distinguish between invasive/noninvasive dz
50
How many times is a needle inserted during core needle biopsy (US, mammo, MRI guided)?
3-6 to get core samples
51
Is core needle biopsy able to distinguish between invasive/noninvasive dz?
Yes
52
What is surgical/open bx reserved for?
Lesions difficult to reach w/ FNA or core biopsy (excisional vs incisional)
53
Recommendations for genetic testing in non-Ashkenazi jewish women?
2 1st degree relatives w/ BC, 1 which dx at <50, Combo of 3 or more 1st degree relatives w/ BC regardless of age, Combo of both BC/ovarian CA among 1st/2nd degree relatives, combo of 2+ 1st or 2nd degree relatives w/ ovarian CA, 1st/2nd degree relative w/ both breast and ovarian CA, Hx of BC in male relative
54
Recommendations for genetic testing in Ashkenazi jewish women?
Any first degree relative or 2 2nd degree relatives on same side of family, w/ breast or ovarian CA
55
Characteristics of FBC (fibrocystic breast condition)?
Benign, most frequent cause of breast lumps/cysts, cyclic breast pain most prominent in luteal phase (subsides w/ menses)
56
S/sx of FBC?
Inc size of lumpy areas in breast w/ discomfort/pain, may have non-bloody/green/brown d/c
57
Who is FBC most common in?
20-50y/o, less frequent in menopausal women
58
Fibrocystic changes w/ FBC?
Unilateral or bilateral, most frequent in UOQ, may feel on underside of breast as palpable ridge
59
Does FBC increase the risk of CA?
No
60
Ddx for FBC?
Fibroadenoma, BRCA
61
Evaluation of FBC?
US preferred, mammogram not typical if <30, bx may be indicated
62
Tx for FBC?
Conservative: diet (limit saturated fats, eggs, dairy, soy), reduce caffeine, reduce sugar, white flour, refined food
Omega 3's, Vit E, primrose oil, daily exercise, stop smoking
63
What are breast cysts?
Smooth, round, fluid-filled, slightly elastic, movable cysts
, fluid discolored (not concerning), may be clustered, isolated, or widespread, MC in UOQ and underside of breast
64
Do breast cysts cause dimpling?
No, do not connect to underlying tissue
65
What is a simple cyst?
Fluid filled w/ no septa/projections, benign
66
On mammogram, can cysts be differentiated from solid nodules?
No
67
Test for simple cysts?
US
68
Tx for simple cysts?
Monitoring or aspiration if inflammation/infection, bx if cyst does not completely collapse
69
What is a complex cyst?
More than one compartment/contains projections or debris, more likely to be malignant
70
Test for complex cyst
US (determine between simple and complex), Bx required (core needle preferred)
71
What is a fibroadenoma?
Common benign solid tumor composed of glandular & fibrous tissue
72
Who is most commonly affected by fibroadenoma?
women 20-30, AA
73
Where are fibroadenomas most common?
Nipple, UOQ
74
Clinical findings w/ fibroadenoma?
Round, firm, smooth, mobile w/ clear margins
Painless, non-tender, average 1-5cm
75
Workup for fibroadenoma?
US first then core bx
76
Tx for fibroadenoma?
Conservative vs. local excision of mass w/ margin of normal tissue
77
What is a complex/atypical fibroadenoma?
Fibroadenoma w/ abnormal growths or abnormal cell changes on US
78
Do complex/atypical fibroadenomas become cancerous?
No, but can act as markers for dz (women w/ fam hx of breast CA who develop them at higher risk)
79
Infant gynecomastia is due to what?
Maternal estrogen, resolves 2-3 wks after birth
80
Puberty gynecomastia cause?
Hormonal changes, resolves w/in 6mos-2yrs
81
Middle age gynecomastia peak age?
50-80 (25% men)
82
Meds that can cause gynecomastia?
Estrogen, anabolic steroids, diazepam, tricyclic antidepressants, cimetidine, chemo, digoxin, CCBs, alcohol, amphetamines, marijuana, heroin, methadone
83
Medical causes of gynecomastia?
Age, hyperthyroid, RF/cirrhosis, testosterone deficiency, obesity, pituitary hormones, malnutrition, herbals (tea tree and lavender)
84
How is nipple discharge characterized?
1. Normal lactation
2. Galactorrhea (usually underlying dz, benign)
3. Pathologic (underlying CA, MC cause --> intraductal papillomas)
85
Hx and PE for nipple d/c?
Type, mass?, unilateral or bilat, spontaneous vs persistent, does it need to be expressed, single site pressure or pressure on all of breast produces it, relation to menses, pre or postmenopasual, hx of OCP//estrogen
86
Cause of galactorrhea?
Result of hyperprolactinemia: meds (phenothiazines), endocrine/pituitary tumors, endocrine abnormality (hyperthyroid, pituitary, hypothalamic dz)
87
S/Sx of galactorrhea?
Bilat multi-ductal milky d/c
88
Workup for galactorrhea?
Imaging, labs (pregnancy, prolactin, renal, TFTs)
89
Tx for galactorrhea?
Tx underlying cause, remove offending agent
90
S/Sx of pathologic nipple discharge?
Unilateral, spontaneous, bloody d/c (cancer or benign papilloma of duct), eczematous nipple lesion (Paget disease of breast), +/- palpable mass
91
Workup for pathologic nipple discharge?
Imagine (mammogram +/- US), ductography
92
Tx for pathologic nipple d/c?
Surgical excision and CA tx
93
Disorders of lactation?
Engorgement, painful nipples, galactocele, mastitis, breast abscess
94
When does engorgement occur?
1st week postpartum if waiting long between breastfeeding
95
Cause of engorgement?
Vascular congestion/accumulation of milk
96
S/sx of engorgement?
Firm/warm breasts w/ discomfort and slight fever, if areola engorged baby cannot grasp nipple
97
Tx for mild engorgement?
Analgesics, cool compresses, partial milk expression before nursing
98
Tx for severe engorgement?
Empty breasts (manually or pump)
99
What causes painful nipples?
First few days of breastfeeding, usually resolves once milk begins to flow/become desensitized to breastfeeding
100
How can painful nipples cause mastitis?
Nipple fissures/cracks may develop/get infected
101
Tx for painful nipples?
Dry heat between feedings, Lanolin cream/ A&D ointment after feeding, apply expressed milk to nipples and let dry between feedings, nipple shield, OTC pain relievers PRN, hydrogel pads between feedings
102
If painful nipples are persistent w/o any physical findings of fissures, what is suspected?
Candidal infection
103
What is a galactocele?
Milk retention cyst caused by blocked milk duct
104
S/sx of galactocele?
Painless, lacks redness/warmth/fever etc.
105
Tx for galactocele?
Warm compress, milk area to open duct, continue breast feeding
106
Most common causes of mastitis?
S. aureus and Strep spp
107
If mastitis goes untreated, what develops?
Abscess
108
S/sx of mastitis?
Painful redness in wedge shape w/warmth & tenderness, fever >101 w chills, cracking of nipple (predisposition), flu like sx
109
Ts for mastitis?
Abx: Dicloxacillin or Cephalexin, continue breastfeeding, arm/cold compress and OTC pain meds PRN
110
Multiple episodes of breast infections may indicate what?
IV drug use
111
S/sx of abscess from mastitis?
pitting edema over palpable, fluctuant tender mass
112
Tx of abscess from mastitis?
I&D, Abx, wound culture
113
Second most common cancer in women?
Breast CA, 2nd leading cause of death in women
114
What population has higher mortality rates from breast CA?
AA
115
>90% of breast cancer arises where?
Ducts or lobules
-Ductal carcinoma MC
-Lobular carcinoma 2nd MC
*multiple subtypes of each
116
RF for breast CA?
Personal or fam hx of BRCA, age, early menarche, late menopause, age at first live birth (>30 inc risk), nulliparity, # breast biopsies, inc. breast density, race, BRCA, chest wall radiation, long term HRT, hx of DES, personal hx of uterine CA, obesity, lack of exercise
117
Sx of breast CA?
Painless mass, breast pain, nipple d/c; retraction/inversion, enlargement or itching of nipple, redness, hardness, enlargement or breast
RED FLAGS: back/bone pain, systemic complaints, weight loss (metastasis)
118
Signs of breast CA?
Mass (nontender, firm, poor margins), nipple retraction/dimpling of breast, axillary/supraclavicular lympadenopathy, Peau d/orange ---> INFLAMMATORY BC, eorisons of nipple ---> PAGETS CARINOMA
119
Initial workup for breast mass?
B/I diagnostic mammogram and breast US over mass
Labs: CBC, CMP, LFTs, alkaline phosphate
Metastasis concerns: pet/bone scan, etc.
120
Diagnosis of breast CA?
Bx, send for cytology and hormone GF receptor staining (if + can determine tx options), HER2 test (if + monoclonal antibody targeting for HER2 protein)
121
What kind of staging system for breast CA?
TNM (tumor, node, metastasis)
122
Testing required for breast CA staging?
Lymph node biopsy, CT of chest/abd/pelvis (modality of choice), bone scan to r/o metastasis to bone
Possible PET scan/MRI
123
MRM (modified radical mastectomy) for breast CA tx?
Removal of affected breast and underlying pectoral major fascia, evaluation of selected axillary lymph nodes
124
Breast conversion therapy for breast CA tx?
Lumpectomy, partial mastectomy, segmental mastectomy along w/ axillary lymph node eval
*plus postop radiation
*no real difference in results between this and MRM
125
When is hormonal therapy recommended for BC?
Estrogen and progesterone hormone receptor positive cancers
Tamoxifen: premenopausal and postmenopausal, 5 yrs
Aromatase inhibitors (Anastrozole, Letrozole, Exemestane) in postmenopausal women for 5yrs
126
When can aromatase inhibitors be used for premenopausal women for hormone + BC?
If combined w/ ovarian ablation
127
Benefits of aromatase inhibitors vs Tamoxifen?
Smaller risk of endometrial CA and VTE
128
S/E of Aromatase inhibitors?
muscle pain, joint stiffness, bone thinning, higher risk of MSK disorders, osteoporosis compared to Tamoxifen
129
When is chemo used for breast cancer?
Recommended for early and advanced stages, goal to eliminate microscopic mets responsible for recurrence
Multiple agents > single agent
130
Duration of chemo for breast CA?
3-6 mos or 4-6 cycles has most benefit
131
Follow up care for breast CA after primary tx?
For life to detect: recurrence, second primary dz in same breast, new CA in opposite breast
--> q3-6mos for first 3yrs, q6-12 mos until yr 5, annually after
132
Mammogram frequency post breast CA tx?
Annual
133
Annual lab work for post-breast CA tx?
CBC, Chem panel, LFTs
134
If taking Tamoxifen, what annual exams?
Pelvic
135
If taking AI's, what periodic exams?
Bone density
136
Local recurrence of BC correlates w/ what?
stage, tumor size, lymph nodes, margins, grade, histologic type
137
Majority of breast cancer recurrence happens when?
first 5 yrs, but after MRM/BCT --> varies
138
Single most reliable indicator of breast cancer prognosis?
Stage of CA
139
5 year survival rates for breast CA?
Localized: 90%
Regional: 86%
Distant: 30%
*also differ depending on subtype
140
Most common site of mets at initial presentation of recurrent breast CA?
Bone
141
Goal of tx once recurrent breast CA metastasizes to bone?
Palliative over curative: local therapy (surgery, radiation), hormonal, chemo, bisphosphonates to diminish pain/dec. skeletal events
