Breast Disease & Breast Cancer

Question 1

Nerves around the breast / injuries

Answer 1

Intercostobrachial nerve → through axilla; sensory to upper medial arm
Long thoracic nerve (C5-7) → serratus anterior (“winged scapula”)
Thoracodorsal nerve → latissimus dorsi

Question 2

Timing of breast exams

Answer 2

SBE: monthly 5d after menses
CBE: yearly

Question 3

Mammograms:

Answer 3

Should have yearly mammogram starting at age 40; continue as long as the woman is in good health
No upper age limit!
If strong FHx breast cancer (mother or sister), mammogram screening 5 yrs earlier than youngest family member’s diagnosis or 10 years if family member was premenopausal.

Question 4

Breast pain (mastalgia / mastdynia)

Answer 4

If cyclic, can be 2/2 PMS, normal hormonal fluctuations, fibrocystic change
If no signs of malignancy and really low risk, reassure → NSAIDs, support bra, warm compresses
Consider U/S if hx trauma or mammogram if higher risk for cancer

Question 5

Nipple discharge:

Answer 5

Mostly normal physiologic

Worrisome: spontaneous, bloody / SS, unilateral, persistent, from single duct, a/w mass

Question 6

Bloody Nipple discharge:

Answer 6

Think intraductal papilloma / invasive papillary cancer

Question 7

Galactorrhea:

Answer 7

Think pregnancy, pituitary adenomas, hypothyorid, stress, OCPs/antiHTN/antipsychotics

Question 8

Serous nipple discharge

Answer 8

Think normal menses, OCPs, fibrocystic change, early pregnancy

Question 9

Yellow-tinged nipple discharge

Answer 9

Think fibrocystic change, galactocele

Question 10

Green, sticky nipple discharge

Answer 10

Think duct ectasia

Question 11

Purulent nipple discharge

Answer 11

Think breast abscess

Question 12

Breast masses

Answer 12

Never dismiss a mass just because mammogram is negative

Think malignant if firm, nontender, poorly circumscribed, immobile

Question 13

Breast mass work up

Answer 13

Get U/S for women < 30, mammogram for women >30
If concerning on imaging or exam, get tissue
Cystic → aspirate ; excise cyst if bloody fluid or persistent
Solid → fine needle aspiration if < 30 → excisional bx if FNA fails, or nondiagnostic
Core needle biopsy if > 30
Nonpalpable → excisional bx under needle / wire guidance

Question 14

Benign breast disease: Fibrocystic change

Answer 14

Painful breast masses that are multiple / bilateral, hormonal response, fluctuates in cycle
Peak incidence in women 30-40 years old
Treat with less caffeine, tea, chocolate (controversial), avoiding trauma, using support bra
Not associated with increased cancer risk

Question 15

Benign breast disease: Fibroadenoma

Answer 15

Benign tumor with glandular / stromal component
Usually solitary but can be bilateral; rubbery / nontender, can change during cycle
Peak incidence in women 20-35 years old
Classic fibroadenoma in a woman < 30 may be only solid breast mass not requiring tissue dx
Follow clinically if stable!
If concerned, get FNA for cytology to r/o cancer or phyllodes tumor, or excise if large/bothersome

Question 16

Benign breast disease: Cystosarcoma phylloides

Answer 16

Rare variant of fibroadenoma
Any age but mostly premenopausal women
Large, bulky, mobile mass, smooth, well circumscribed, grows quickly
Most benign but may degenerate; need to make pathologic dx after wide local excision with 1cm margin; if really big → simple mastectomy

Question 17

Benign breast disease: Intraductal papilloma

Answer 17

Benign solitary lesion from epithelial lining of lactiferous ducts; rarely degenerate into malignancy
#1 cause of bloody nipple discharge in absence of mass 
But send S/S discharge for cytology to r/o invasive papillary carcinoma
Tx: excise involved ducts.

Question 18

Benign breast disease: Mammary duct ectasia

Answer 18

Subacute inflammation of ducts → dilation → inflammation
Usually at or after menopause
Nipple discharge, noncyclic breast pain, nipple retraction, often bilateral
Get mammogram / excisional bx to r/o carcinoma

Question 19

Risks for malignant breast disease

Answer 19

Increasing age is big one, also personal hx, first degree family hx, esp higher if family member premenopausal or male, BRCA ½, ionizing radiation at young age (Hodgkin lymphoma), atypical ductal o rlobular hyperplasia on bx.

Question 20

Diagnosis of malignant breast disease

Answer 20

Often SBE / CBE / mammmo; masses / skin change / dimpling; bloody discharge should be ruled out
50% of tumors in upper outer quadrant. Mets: to bone, liver, lung, pleura, brain, LNs

Question 21

Noninvasive disease: Lobular carcinoma in situ (LCIS)

Answer 21

Neoplastic epithelial cells in breast lobules without invasion of stroma
Multicentric & bilateral; often picked up incidentally on bx for another finding (can’t see on mammograms and can’t palpate on PE)
Premalignant lesion - 25-30% risk of invasive breast cancer w/in 15 yrs in either/both breasts

Question 22

Treatment of Lobular carcinoma in situ (LCIS)

Answer 22

Observe only; may consider SERM to decrease risk - otherwise close followup

Question 23

Noninvasive disease: Ductal carcinoma in situ (DCIS)

Answer 23

Malignant epithelial cells in mammary ducts, not stroma
Higher capacity to progress to outright invasive ductal cancer in same site
Mammogram → clustered microcalcs +/- palpable mass
Dx: needal localization bx or excisional bx if palpable

Question 24

Treatment of ductal carcinoma in situ

Answer 24

Surgical excision of all microcalcifications with wide margins
May need simple mastectomy if extensive only

Question 25

Invasive breast disease types

Answer 25

Infiltrating ductal carcinoma (70%) Invasive lobular carcionoma (10-20%) Paget disease of nipple (1-3%) Inflammatory breast carcinoma (1-4%)

Question 26

Infiltrating ductal carcinoma (70%)

Answer 26

From ductal epithelium, usually unilateral

Question 27

Invasive lobular carcionoma (10-20%)

Answer 27

From lobular epithelium, often bilateral

Question 28

Paget disease of nipple (1-3%)

Answer 28

Often with DCIS / invasive carcinoma in subareolar area | Malignant cells invade nipple epidermis → eczematous changes w/ scaling, erosion, etc.

Question 29

Inflammatory breast carcinoma (1-4%)

Answer 29

Really aggressive, poorly differentiated | Dermal lymphatic invasion → peau d’orange

Question 30

Treatment of invasive breast disease

Answer 30

Modified radical mastectomy or [lumpectomy + radiation] but need to be able to get rads Get sentinel LN biopsy Breast reconstruction afterwards

Question 31

Hormone status of invasive breast disease

Answer 31

ER/PR+ = better prog HER2/neu = worse prognosis If ER+, usually use tamoxifen x 5 yrs; letrozole / anstrozole (aromatase inhibitors) even better if postmenopausal (most estrogen coming from fat!) Remember tamoxifen predisposes to endometrial cancer! If HER2/neu+, may try trastuzumab (mAb vs HER2/neu) Metastatic / recurrent ER-: combo chemo ER+: consider oophorectomy / GnRH antagonists if premenopausal, consider tamoxifen / aromatase inhibitors if postmenopausal Systemic adjuvant chemo along with hormonal therapy if indicated often used

Question 32

Prognosis of invasive breast disease

Answer 32

Stage is #1 predictor, also ER/PR status and lymph node status

Question 33

Follow up of invasive breast disease

Answer 33

PE q3-6mo x 3y, then space to q6mo x 2y, then q12mo Mammogram @ 6mo, then annually Avoid HRT

Question 34

Low transverse incision risk:

Answer 34

Can damage the iliohypogastric or ilioinguinal nerves (both pass through psoas and then go through transversus abdominus to anterior abdominal wall, where they run between internal and external oblique. At risk if low transverse incision extended beyond lateral border of rectus

Question 35

Iliohypogastric nerve

Answer 35

Provides cutaneous sensation to the groin and the skin overlying the pubis

Question 36

Ilioinguinal nerve

Answer 36

Provides cutaneous sensation to the groin, symphysis, labium and upper inner thigh.