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Women's Health > Breast Disorders - Exam 2 > Flashcards

Breast Disorders - Exam 2 Flashcards

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1
Q

What layer of embryonic tissue do the breast come from? What binds the lobes together?

A

Arises from the ectoderm

stroma (fibrous tissue)

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2
Q

How many lobes does a normal breast contain? What is considered the breast base? What is considered the breast apex?

A

12-20 lobes

base is closest to the ribs

apex: contains major excretory duct for the lobe

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3
Q

What does each breast lobe contain? How many visible opening are usually present in the nipple?

A

group of lobules that have several ducts which unite to form the major duct for the lobe

Usually only 6-8 openings visible on nipple surface

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4
Q

Areola also contains _______ which may be visible as punctate prominences. What type are they? What is there job?

A

Montgomery glands

sebaceous glands

function to secrete oil to help a breastfeeding mother’s nipple stay well lubricated

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5
Q

What is 80-85% of normal breast tissue composed of? How does the breast consistency change comparing Nonpregnant, nonlactating breast vs pregnant vs lactating breasts

A

adipose tissue

Nonpregnant, nonlactating - small, tightly packed alveoli

Pregnant - alveoli hypertrophy and lining cells proliferate

Lactation - alveolar cells secrete lipids and proteins (milk)

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6
Q

_______ is on the deep surface of breast to support the breast in upright position

A

cooper’s ligaments

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7
Q

**Where does the majority of the breast lymphatics drain to? **Why is this important clinically? **Which ones specifically?

A

**axillary lymph nodes

most common site of breast cancer metastases

sentinel nodes

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8
Q

fetal breasts arise from the _____. What happens to the prepubertal breast?

A

basal layer of epidermis

rudimentary bud with few branching ducts

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9
Q

In the prepubertal breast, ducts are capped with ______, ______ or _______.

A

alveolar buds, end buds or small lobules

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10
Q

What happens to the breast around puberty? What age? What cell types specifically?

A

estrogen/progesterone affect breast tissue
Communication between epithelial and mesenchymal cells resulting in extensive branching of ductal system and lobule development

age 10-13

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11
Q

Overall, what factors contribute to breast growth? What happens to the nipple/areola during puberty?

A

increased acinar tissue, ductal size and branching, and deposits of adipose

Nipple and areola enlarge during puberty, smooth muscle fibers surround the base of the nipple and nipple sensitivity to touch increases

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12
Q

What is happening in premenstrual breast changes? What phase? What hormones?

A

breast epithelial cells proliferate during the luteal phase when estrogen and progesterone are increased

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13
Q

premenstrual breast changes _____ cells increase in number and size. ______ widen. What happens as a result?

A

acinar cells increase in number and size

ductal lumen widens

Overall increased breast size, turgor/fullness, and tenderness

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14
Q

What happens to breast tissue postmenstrual?

A

breast epithelial cells undergo programmed cell death at the end of the luteal phase when estrogen and progesterone levels decline

DECREASED size and turgor, reduced number and size of breast acini, decreased diameter of ducts

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15
Q

**When does final breast differentiation occur? What 2 hormones influence it?

A

FINAL is completed during the FIRST full-term pregnancy

progesterone and prolactin

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16
Q

How does the breast tissue change during late pregnancy?

A

fatty tissues are almost completely replaced by cellular breast parenchyma

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17
Q

What will estrogen and progesterone level do postpartum? What triggers the onset of milk production? What hormone regulates milk production?

A

Rapid drop in estrogen and progesterone postpartum

Drop in progesterone triggers onset of milk production

Prolactin is main regulator of milk production

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18
Q

What can cause the breast to rapidly return to pre-pregnancy state?

A

stopping nursing

giving estrogens

causes the breast to increase in adipose tissue aka back to pre-pregnancy breasts

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19
Q

How does the breast change during menopause? What elements are lost?

A

the decrease in estrogen and progesterone cause the breast to atrophy and involute, become less elastic, glands and ducts decrease

parenchymal elements (the functional tissue of the mammary gland, primarily consisting of the milk ducts and the glandular tissue responsible for milk production)

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20
Q

Is some nipple discharge normal? What will it look like?

A

YES! about 80% of women will experience it at some point in their reproductive years

Usually multi-duct with a milky white, dark green, brown discharge

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21
Q

What is green nipple discharge related to?

A

related to cholesterol diepoxides

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22
Q

**Describe the presentation of physiologic nipple discharge? What if it is bloody?

A

Multiduct nonbloody discharge elicited following manual pressure

If bloody and pregnant, no worries

bloody and not pregnant = problem

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23
Q

**What are the 5 red flags for abnormal nipple discharge?

A

Spontaneous
Bloody
Unilateral and/or uniductal
Pt > 40
Associated breast mass

aka 1 pinpoint bead of fluid = concerning

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24
Q

What is the MC cause of pathologic nipple discharge?

A

intraductal papillomas

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25
What are some important questions to ask regarding abnormal nipple discharge?
Unilateral or bilateral Single or multiple ducts Spontaneous or must be expressed Constant or intermittent Elicited by pressure at a single site or general pressure Timing in relation to menstrual cycle Pre- or post-menopausal History of hormone use (contraception, HRT)
26
There are many causes of galactorrhea, what are the 3 highlighted ones from lecture?
antipsychotics because they mess with the dopamine -> prolactin relationship pituitary adenomas chest wall irritation or stimulation (think nipple piercing)
27
What is the classic presentation of galactorrhea?
bilateral multiductal milky discharge in nonlactating patient
28
What tests would you want to order in a pt presenting with galactorrhea?
pregnancy test, prolactin, renal function, thyroid then ENDO consult!!
29
What is the classic pathologic discharge presentation? Does a mass have to be felt?
unilateral, spontaneous serous or serosanguineous discharge from single duct do NOT have to have a mass to be cancerous
30
_____ discharge is more suggestive of cancer but usually due to _____
bloody discharge benign papilloma
31
**What are the 2 first line tests when working up a pt for pathologic nipple discharge? Which one is preferred for which patients?
mammogram or breast US younger than 40 = US older than 40 = mammogram also okay to order both!!
32
**What is the definitive dx for pathologic discharge?
subareolar duct excision (microductectomy)
33
What 5 types of medications/essential oils are high offenders for causing gynecomastia?
androgens anabolic steroids methadone lavender oil tea tree oil
34
How can you tell the difference between true gynecomastia and pseudogynecomastia? How is it graded?
Gynecomastia: true glandular enlargement - CENTRAL, may be tender pseudogynecomastia: Fatty tissue - diffuse, nontender Grade findings according to severity Higher number = more severe
35
What will pubertal gynecomastia present like?
tender 2-3 cm discoid enlargement of glandular tissue beneath areola
36
What are s/s of gynecomastia that are highly suggestive of cancer?
Asymmetry Enlargement not beneath areola Unusual firmness Nipple retraction Bleeding or discharge
37
What 5 labs would you want to order in a pt presenting with gynecomastia?
1. Serum prolactin 2. beta-hCG 3. Serum free testosterone 4. LH 5. Serum estradiol
38
When would a hCG be positive in males? When would it be mildly elevated?
+ beta-hCG usually 2o testicular tumor or other CA (i.e., lung or liver) may see mildly elevated hCG in pts with primary hypogonadism and high LH
39
What does a low testosterone and high LH in the presence of gynecomastia indicate?
primary hypogonadism
40
What does a high testosterone and high LH in the presence of gynecomastia indicate?
androgen resistance
41
What does an increased serum estradiol indicate in the presence of gynecomastia?
Increased - testicular tumors, elevated hCG, liver disease, obesity, adrenal tumor, hermaphroditism, aromatase gene mutations
42
When does pubertal gynecomastia tend to resolve?
usually resolves spontaneously in 1-2 years
43
What is the tx for painful or persistent gynecomastia?
raloxifine or tamoxifen (SERM) anastrozole (Aromatase inhibitor) testosterone therapy for low T sx
44
What is the caution for Aromatase inhibitors? What is the name of the drug?
NOT recommended in use in teenagers because of the risk of osteoporosis and delayed epiphyseal fusion anastrozole (Arimidex)
45
What can anastrozole (Arimidex) do to estradiol and testosterone levels?
Causes decreased serum estradiol and increased testosterone
46
When is radiation therapy recommended in gynecomastia?
Prophylactic - men with prostate CA receiving antiandrogen tx
47
What are the 2 MC pathogens in mastitis?
Staph aureus Group B strep
48
______ increases risk for mastitis. When is it commonly seen
smoking 2-3rd week after birth, UNCOMMON in non-nursing pts
49
What is the classic presentation of mastitis?
painful erythematous lobule in outer quadrant of breast noted during 2nd or 3rd week of puerperium may have signs of systemic infections
50
What is the tx for mastitis?
Continue breastfeeding or use breast pump!!! warm or cold compresses supportive care: rest, fluids, NSAIDs, acetaminophen abx: Dicloxacillin or cephalexin (500 mg QID) alt: clinda or bactrim
50
T/F: Mothers with mastitis should pump and dump until infection has resolved
FALSE!! babies can still drink the milk from the infected breast
51
What is the severe IV abx tx for mastitis?
Vancomycin + ceftriaxone OR piperacillin-tazobactam
52
What should you do if mastitis is NOT improving after 48-72 hours
Evaluate for abscess Consider biopsy/inflammatory breast CA
53
What am I? What does it usually arise from?
breast abscess pre-existing mastitis
54
What is the tx for peripheral breast abscess?
I&D abx: Dicloxacillin or cephalexin alt: clinda or bactrim
55
What is the tx for subareolar breast abscess? What is the underlying cause?
usually requires subareolar duct excision and complete removal of sinus tracts because normal I&D has a 40% recurrence rate also want to bx abscess wall to r/o breast CA due to keratin-plugged milk ducts behind nipple
56
fat necrosis breast masses are usually accompanied by _____ or ______. +/- ____ and _____. Should order _____ or ____ to help with dx
skin or nipple retraction +/- ecchymosis, tenderness US or mammo to help with dx
57
if you leave a fat necrosis mass untreated, what will happen? If it does not, what should you do next?
mass gradually disappears If no resolution after several weeks - bx
58
What is a galactocele? What causes it?
Milk retention cyst Caused by obstructed duct in lactating or galactorrhea patient
59
Are US or mammo better at dx galactocele? What is the best way to dx?
US is better at distinguishing fluid from mass but can order either or both aspiration of cyst!! will yield a milky substance
60
Which masses do NOT increase risk of subsequent breast cance?
Fat necrosis Galactocele single, nonproliferative lesions in fibrocystic breast changes fibroadenoma
61
______ are the MC cause of cyclic breast pain in reproductive age women. What is the age range? What is it due to? _____ increases you risk
Fibrocystic Breast Changes age 30-50 benign changes in breast epithelium due to ESTROGEN levels alcohol
62
Pain or tenderness associated with a mass Fluctuations in size Multiplicity of lesions +/- Nonbloody green or brown nipple discharge What am I? **What is the highlighted s/s from lecture? What makes it worse?
Fibrocystic Breast fluctuations in size caffeine
63
How do you dx fibrocystic breast changes?
US or mammo aspiration to determine cystic vs solid bx dominant mass
64
premenopausal breast tissue is (dense/fatty) and post menopausal breast is (dense/fatty)
premenopause = dense = hard to read on mammo postmenopause = fatty = easier to read on mammo
65
What is the tx for fibrocystic breast changes? When can you expect s/s to resolve?
reassurance!!! avoid trauma, good bra, weight loss, no caffeine, coffee, chocolate, low fat diets, increase in fresh fruits and veggies CAM: evening primose oil or vit E Symptoms usually resolve following menopause
66
________ or _____ have been used in severe pain cases caused by fibrocystic breast changes. ______ is severe refractory cases
danazol or tamoxifen sx
67
_____ is the MC benign tumor in the breast. What age range?
Fibroadenoma young women age 15-35
68
What is the classic presentation of fibroadenoma? What is the definitive dx?
round, firm, discrete, relatively mobile, nontender mass about 1-5 cm in diameter core biopsy or mass excision
69
What will the US report show on a fibroadenoma?
well-defined solid mass with benign features
70
What is a Phyllodes tumor? What is the tx?
a fibroepithelial tumor that clinically resembles fibroadenomas and has a small chance of becoming malignant tx with excision with wide local margins
71
If the fibroadenomas contains ____ or ______ should be more concerning. What should you do next?
calcifications or scarring (anything making it more complex) excision of the mass
72
What is the tx for an unclear diagnosis or rapid growth of a fibroadenoma?
sx with good margins of normal tissue!
73
If the fibroadenoma is asymptomatic and you choose to monitor it, what are the monitor requirements?
Core needle biopsy to confirm dx OR repeat US and breast exam in 3-6 months
74
What is the average age of breast cancer? What is the lifetime risk of developing breast cancer in female pts?
60-61 **1 in 8
75
breast cancer is the main cause of death in women _____. Breast cancer is the ____ MC cause of cancer death in women
40-59 2nd death (1st is lung cancer)
76
_____ 2x increases risk of breast CA ______ 3x increases risk of breast CA ______ puts you at higher risk for developing breast CA
1 first degree relative (mother/sister) - 2x risk 2 first degree relatives - nearly 3x risk Younger age of family at dx = higher risk
77
What percent of pts with breast CA report a positive family hx? What genes? How are they inherited?
15-20% BRCA1 and BRCA 2 - autosomal dominant
78
What are the 6 breast cancer risk factors? **What is the greatest risk factor?
Nulliparity OR first full term pregnancy age 30 or later increased number of periods (early menarche or late menopause) combination HRT hx of uterine CA hx of breast mass **personal hx of breast cancer
79
How are most breast cancers dx?
after abnormal mammogram
80
What is the usually presentation of breast cancer? What quadrant is the most common?
painless breast mass Usually hard, fixed, irregular margins, nonmobile Most breast cancers are in the upper outer quadrant!
81
What are concerning PE findings that would point towards breast cancer?
Change in breast size/contour Nipple or skin retraction Edema or erythema
82
What lymph nodes should you palpate if concerned for breast cancer? What would increase your suspicion for breast cancer?
axillary, pectoral, supraclavicular, infraclavicular, subscapular, epitrochlear and lateral chain Firm nodes or nodes >5 mm or matted/fixed axillary lymph nodes
83
What 2 lymph nodes strongly indicate possibility of distant metastases?
+ supraclavicular or infraclavicular nodes
84
What is the characteristic finding of Paget's carcinoma? What is it mistaken for?
may only see small (1-2 mm) nipple erosions Eczematoid eruption and ulceration dermatits or infection of the nipple
85
If you see edema of ipsilateral arm, what should that make you think?
advanced breast cancer
86
If a palpable mass is associated with paget's disease, what does that mean? non-palpable mass?
Palpable mass - 50% (if present, 95% are invasive cancer, usually infiltrating ductal) no palpable mass: noninvasive cancer or ductal carcinoma in situ present in 75% of cases
87
What is the usual presentation of Paget's disease? How do you dx? What is the tx?
pain, itching or burning of breast along with superficial erosion or ulceration May see bloody nipple discharge, **retracted nipple** full-thickness biopsy of lesion Mastectomy is traditional therapy
88
What am I?
Paget's disease
89
**What is the characteristic finding for Inflammatory Breast Carcinoma (IBC)?
“Peau d’orange” (orange peel skin) may be seen Diffuse, brawny edema of skin with erysipeloid border with usually NO palpable underlying mass can present like mastitis that doesnt get better
90
What is the tx for Inflammatory Breast Carcinoma (IBC)?
Tx - multiple rounds of chemo, followed by surgery and radiation
91
_____ is the breast imaging modality of choice. How accurate is it?
mammo correct in about 90% of cases
92
Up to ____ of cancers detected on CBE not seen on mammogram. What should you do next?
15% Biopsy should still be done if dominant or suspicious mass
93
What kind of biospy is needed to definitively define breast cancer?
core needle bx
94
What is the general consensus for mammogram screening?
at least once every 2 years among women 50-74
95
What is the ACS breast cancer screening recommendation? When should you STOP screening for breast cancer?
Q 1 yr starting 40-45, may transition to Q2 yrs at 55 If 75+ years old, may continue screening as long as the pt has at least estimated 10 years life expectancy
96
Where are more than 95% of breast cancer are in _____ components of the breast
epithelial component ductal and lobular
97
invasive or carcinoma-in-situ (CIS) arise mostly from the _______ and are _____
intermediate ducts invasive! aka not a good thing
98
knowing the presence or absence of _______ is very important in the management of breast cancer. What are the 3 options?
hormone receptor sites! estrogen, progesterone or HER2 receptors
99
If the cancer is ER/PR/HER2 +, where is it more likely to metastasize to? What if there are no receptors present?
ER/PR/HER2 + - metastasize to bone, soft tissue, genital organs No Receptors - metastasize to liver, lung, brain
100
Are most cancers positive or negative for receptors? Which kind is associated with worse outcomes?
most are positive! 80% - ER + and/or PR + 23% - HER2 + (human epidermal growth factor receptor 2) 13% - no hormone receptors** associated with worse outcomes
101
What is the difference between radical mastectomy and modified radical mastectomy? Which one is used frequently
Radical Mastectomy - en bloc removal of breast, PECTORAL MUSCLES, axillary lymph nodes Modified Radical Mastectomy - removal of breast and underlying pectoralis major fascia with evaluation of select axillary nodes Modified Radical Mastectomy used frequently!!
102
______ is the excision of tumor mass with negative margin, axillary evaluation and postoperative irradiation. When is it an option?
breast conservation therapy For stage I and II and certain stage III cancers
103
What type of breast cancer is hormonal therapy indicated?
If positive for ER/PR/HER2 5 years of tamoxifen (SERMs) tx of choice or aromatase inhibitors (anastrozole)
104
What 2 events does tamoxifen increase your risk for?
Increased risk of endometrial cancer and VTE
105
What is the adjuvant therapy for hormonal receptor negative breast cancer?
pembrolizumab (Keytruda)
106
When is systemic chemotherapy used in breast CA?
reduce occult metastases
107
_____ may be used for chemoprevention of breast CA in some high-risk women
tamoxifen (Nolvadex), raloxifene (Evista) SERM
108
What does SERM stand for? what is the MOA?
Selective Estrogen Receptor Modulators bind to estrogen receptors; block estrogen in some (not all) tissues
109
How does the MOA differ slightly between tamoxifen and raloxifene?
tamoxifen - blocks estrogen in breasts; mimics estrogen in uterus and bone aloxifene - blocks estrogen in breasts and uterus; mimics estrogen in bone
110
Which SERM has a less potent estrogen blockade andsmaller reduction in new cancer but with less estrogenic SE (endometrial CA, VTE)?
Raloxifene
111
What are the SEs of SERM and aromatase inhibitors? Can you use a SERM and aromatase inhibitor at the same time?
think menopausal symptoms hot flashes, nausea, muscle aches and cramps, hair thinning, headache, paresthesias NO!! one or the other
112
What is the MOA of aromatase inhibitors? How does it compare to tamoxifen?
inhibit aromatase (enzyme that produces estrogen) May be slightly MORE effective at reducing recurrence of breast CA May be LESS effective than tamoxifen at initial chemoprevention
113
______ are contraindicated in pregnant women and may increase serum concentration of _____
Aromatase Inhibitor methadone
114
________ MOA attach to and cause destruction of estrogen receptors. What drug class?
Fulvestrant (Faslodex), elacestrant (Orserdu) SERD does NOT mimic effects of estrogen
115
______ are used to reduce release of GnRH and FSH/LH
GnRH agonists/antagonists
116
What is the follow up recommended for breast cancer pts? What is the median time to recurrence?
PE Q 4 mo x 2 yrs, then Q 6 mo x 3 yrs, then yearly Mammogram 6 months after radiation, then yearly Routine laboratory tests 4 years
117
What type of breast cancer has the higher chance of recurrence? If ________ is present, survival rate decreases
Hormone receptor negative cancers axillary lymphadenopathy
118
Consider chemoprophylaxis with _____ or _______ if patient is ≥ 35 years old and has ??????
SERM or aromatase inhibitor 5-year risk of breast cancer ≥ 3% 10-year risk of breast cancer ≥ 5% consider prophylactic mastectomy if a strong family history
119

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