Lecture 9: Breast Disorders (Updated with supplemental) Flashcards
1
Q
What derm layer do breasts arise from?
A
Ectoderm
2
Q
What is most of the breast composed of?
A
Adipose tissue
3
Q
What is responsible for keeping the breast upright?
A
Cooper’s ligaments
4
Q
Where does breast lymph eventually drain to?
A
Axillary lymph nodes
5
Q
What is the most common site of breast cancer metastases?
A
Axillary lymph nodes
Sentinel nodes
Most lymph drains through them.
6
Q
During what period does the primordial breast arise from the basal layer of the epidermis?
A
Fetal period
7
Q
During what period does extensive branching of the ductal system and lobule development occur?
A
Ages 10-13
Estrogen & progesterone
8
Q
What happens to nipple sensitivity during puberty?
A
Increased
9
Q
During what phase in the premenstrual period do breast epithelial cells proliferate?
A
Luteal phase
Increased size/fullness/tenderness 1 week before menses
10
Q
When is final breast tissue fully differentiated?
A
At the first-term pregnancy
11
Q
What two hormones modulate final breast differentiation?
A
Progesterone & Prolactin
12
Q
What 6 things characterize final breast tissue differentation?
A
- Marked increase in breast size and turgidity
- Deeping pigmentation of the nipple-areolar complex
- Nipple enlargement
- Areolar widening with increased number and size of lubricating glands
- Branching and widening of breast ducts
- Increased acini
breasts, nipples, areolar enlarge
13
Q
In late pregnancy, what is fatty tissue replaced by?
A
Cellular breast parenchyma
14
Q
What triggers the onset of milk production?
A
Drop of progesterone
15
Q
What regulates milk production?
A
Prolactin
16
Q
How is breast tissue affected by the postmenopausal decreases of estrogen and progesterone?
A
Atrophy and involution of the breast.
17
Q
During what period is fluid most likely to be expressed from the nipple?
A
Within 2 years of lactation
18
Q
What might green nipple discharge suggest?
A
Cholesterol diepoxides
19
Q
What is considered physiologic nipple discharge?
A
Manual pressure required but no blood.
20
Q
When is further evaluation warranted for nipple discharge?
A
- Spontaneous
- Single-duct
Normal is multi-duct
21
Q
What is the MCC of pathologic nipple discharge?
A
Intraductal papillomas
Others: carcinoma or fibrocystic changes
pappilloma = pathologic
22
Q
In general, what medication class can induce galactorrhea?
A
Psychiatric medications/nervous system
23
Q
What is the classic presentation of galactorrhea?
A
Bilateral multiductal milky discharge in a non-lactating patient
24
Q
What is the classic presentation of pathologic nipple discharge?
A
Unilateral, spontaneous serous or sersanguinous discharge from a single duct.
25
What might bloody nipple discharge suggest?
Cancer, but could also be a benign papilloma
26
What is the issue with cytology of nipple discharge?
Does not rule out cancer.
27
What is the definitive dx and tx for pathologic nipple discharge?
Subareolar duct excision (microductectomy)
28
What drug is MC associated with gynecomastia?
Anabolic steroids/Androgens
29
What is the additional layer seen in gynecomasta?
Glandular tissue
30
What does true gynecomastia feel like?
Central, more tender
31
How does pubertal gynecomastia present?
Tender 2-3 cm discoid enlargement of glandular tissue beneath areola
32
If a boy has pubertal gynecomastia, what should you recommend?
Reassurance; 60% resolves in a year on its own.
33
What features might suggest cancerous gynecomastia? (5)
* Asymmetry
* Enlargement not beneath the areola
* Unusual firmness
* Nipple retraction
* Bleeding or discharge
34
What does elevated b-HCG in a male probably suggest?
Testicular tumor or other cancer such as lung/liver
35
What does low testosterone + high LH suggest in a male? High testosterone + high LH?
* Low testosterone + high LH = primary hypogondanism
* High testosterone + high LH = androgen resistance
36
What diagnostics might we recommend for suspicious gynecomastia?
* serum TSH and FT4
* karyotype for klinefelters
* CXR for metastatic or bronchogenic carcinoma
* needle biopsy w cytology
37
How do you treat true gynecomastia? (5)
when do you treat it?
SERMs:
* Raloxifene PO QD (more effective)
* Tamoxifen PO QD
Aromatase inhibitors: (**not recommended in teens d/t risk of osteoporosis**)
* Anastrazole 1mg PO QD
Testosterone therapy if hypogonadism
Radiation therapy (Prophylaxis if you have prostate cx + antiandrogen tx)
Surgery last resort
## Footnote
tx if painful or persistent. tx for 9-12 mo
38
Who is mastitis MC seen in?
Lactating/nursing
| If not this population, check for breast cx.
39
What is the MCC of mastitis?
Staph Aureus
40
What is the presentation of mastitis? (3)
* **Classic:** Painful, erythematous lobules in the outer quadrant of breast, esp during **2nd-3rd week of puerperium**
* S/S of systemic infection
* Abscess
| Puerperium = 6 weeks after childbirth
41
What finding within milk might suggest mastitis?
Antibody-coated bacteria in milk.
42
Non-pharm Tx of mastitis (4)
* Avoid milk stasis **(keep breastfeeding!)**
* Warm compresses
* Well-fitted bra
* Acetaminophen or ibuprofen
| Baby is unlikely to be infected.
43
ABX for mastitis
* Dicloxacillin or keflex
* Alt: Clinda or Bactrim DS
* Severe: IV Vanco + rocephin/zosyn
| 10-14d
44
When must bactrim be avoided in treatment of mastitis? (2)
* BFeeding infant is < 1 month old
* Hx of G6PD, jaundice, or prematurity.
45
What causes a subareolar breast abscess?
Keratin-plugged milk ducts behind the nipple
46
How is a subareolar breast abscess treated?
Subareolar duct excision and removal of sinus tracts.
| Also need to biopsy abscess wall to r/o cx
47
How can you differentiate fat necrosis from breast cancer on exam?
You can't
| You need US and mammograms
48
How do you manage fat necrosis?
Only biopsy it if it doesn't go away after a few weeks.
49
What is the MCC of Cyclic breast pain or mastalgia in reproductive aged women?
Fibrocystic breast change
| MC age = 30-50
50
Why is cyclic breast pain rare after menopause UNLESS on HRT?
Estrogen and progesterone cause the cyclic changes, so breast shouldn't really change cyclically after.
51
What is the main potential risk factor for fibrocystic breast changes?
Drinking alcohol while 18-22
52
When are fibrocystic breast changes most painful?
During premenstrual period (days **12-14, 21-28**)
53
What substance may worsen the S/S of fibrocystic breast changes?
Caffeine
54
What are the S/S of fibrocystic breast changes? (4)
* Pain/tenderness associated with a mass
* Fluctuations in size
* Multiplicity of lesions
* Nonbloody green/brown discharge
55
When is a mammogram not indicated for evaluating fibrocystic breast changes?
< 30 y
56
If a **dominant fibrocystic mass** is seen on the breast, what procedure should you do?
Biopsy
| Checking if it is a fibroadenoma
57
What is the first thing you should tell a patient with fibrocystic breast changes?
Its not cancer
58
When do fibrocystic breast changes tend to resolve?
After menopause
59
Who is fibroadenoma MC in?
Young women (within 20 years of puberty)
60
What is a fibroadenoma?
Focal abnormality of breast lobule that is common & benign.
61
What is the classic presentation of a fibroadenoma?
* Round, firm, discrete, relatively **mobile, nontender mass that is 1-5cm.**
* On US: well-defined solid mass with benign features.
| Usually found accidentaly.
62
How is a fibroadenoma definitively diagnosed?
**Core biopsy** or mass excision
63
What tumor seems similar to a fibroadenoma but has a higher chance of malignancy? How do you check it?
Phyllodes tumor, which can be checked via mammogram
64
How do you treat unclear dx or rapid growth fibroadenoma?
Surgery: **excision** with margins of normal tissue
| Also the same tx for a phyllodes tumor.
65
How do you tx an asymptomatic fibroadenoma? (2)
* **Monitor** via US/breast exam every 3-6m
* Can do core needle bx to confirm
66
Image of Fibrocystic changes vs fibroadenoma
67
What is the MCC cancer in women?
Skin cancer, then breast cancer.
68
What is the MCC of death due to Cx in women?
Lung cancer, then breast cancer
69
What is the average age of breast cx?
60-61
70
What is the lifetime risk of developing invasive breast cancer for any female patient?
1 in 8
71
Why do we screen breast cx so thoroughly?
50% of women who get it have no identifiable RFs for it.
72
What gene mutations are associated with increased breast cx risk?
BRCA1 and BRCA2 (autosomal dominant)
| BRCA1 is the worse of the two
## Footnote
Also tied to ovarian cx
73
What is the greatest RF for breast Cx?
Personal hx of breast cx
74
What are the RFs for breast cx?
* Nulliparity
* First full term pregnancy after 30
* Early menarche (b4 12)
* Late natural menopause (after 50)
* Postmenopausal combinattion HRT
* Hx of uterine cx
* **PERSONAL HX of Breast Cx**
| More menstrual cycles = more cell turnover = higher cx risk
75
How is the majority of breast cancer diagnosed?
Mammogram
76
What labs should you check in initial eval of breast cx? (3)
* CBC
* LFTs (or CMP)
* ALP
| Checking for signs of early metastases
77
How does breast cancer usually present?
Painless breast mass in the **upper outer quadrant**
| Tail of spence
78
What findings might suggest metastases of breast cancer? (3)
* Axillary mass or swelling of arm
* Bone pain or back pain
* Wt Loss
79
What are the concerning findings for breast cancer on exam? (3)
* **Change** in breast size/contour
* Nipple or skin **retraction**
* **Edema or erythema**
80
What features make a lymph node suspicious?
* Firmness or nodes > 5 mm
* Matted or fixed axillary => locally advanced
| But 40% can be clinically negative
81
What swollen lymph nodes might suggest distant metastases of breast cx?
* Supraclavicular
* Infraclavicular
82
What is the usual finding on exam for breast cancer?
**Nontender, firm**, or hard lump with **poorly delineated margins** generally caused by local infiltration
83
What findings suggest advanced breast cancer? (4)
* Appearance changes
* LAN (esp axillary or supra/infraclavicular)
* Edema of ipsilateral arm
* Large primary tumor > 5 cm
84
What is paget's carcinoma?
Eczematoid eruption and ulceration
| Associated with underlying carcinoma
## Footnote
Kinda like a burnt appearance
85
What is the usual presentation of paget's disease of the breast?
Pain, itching or burning of breast along with **superficial erosion or ulceration.**
86
How do you dx paget's disease of the breast?
Full-thickness biopsy
87
How do you tx paget's disease of the breast?
Mastectomy
88
What is the characteristic description of inflammatory breast carcinoma?
Orange peel skin
89
What is inflammatory carcinoma?
Diffuse, brawny edema of skin with an **erysipeloid border** due to tumor emboli.
90
When do you biopsy for inflammatory carcinoma?
**1-2 weeks of non-responsiveness** for suspected mastitis
91
How do you tx inflammatory carcinoma?
* Chemo
* Surgery
* Radiation
92
How accurate is a mammogram?
90% of the time, and does it 2 yrs before its even palpable.
| Both a high sens and high spec test.
## Footnote
Still do a CBE!
93
How do you definitively dx breast cx?
Bx (preferably core needle)
94
What is the least invasive method of bx for breast cx?
FNA
| Also the least helpful
95
What is the recommendation regarding CBE?
You can do it if you want
96
What is the general consensus regarding mammogram screening frequency?
Q2 years by 50, and continue past 75 if pt has good life expectancy (> 10y)
97
What are the two primary components in breasts that become cancerous?
* Ductal
* Lobular
| Epithelium
98
What is the majority of breast cancer receptive to in terms of hormones?
Estrogen
99
Where does ER(-) breast cx tend to metastasize to?
* Liver
* Lungs
* Brain
| LLB
100
Where does ER/PR/HER2+ breast cx tend to metastasize to?
* Bone
* Soft tissue
* Genital organs
101
What is the usual surgery for breast cx?
Breast conservation therapy (All the non-radical mastectomies)
102
What drug treats ER/PR/HER2+ breast cx?
Tamoxifen or aromatase inhibitors
103
What drug may be used as an adjuvant for **negative ER/PR/HER2+** breast cx?
Pembrolizumab (keytruda)
104
What is the difference between tamoxifen and raloxifene in terms of estrogen modulation?
* Tamoxifen: Blocks in breast, **mimics in uterus & bone**.
* Raloxifene: Blocks in breast & uterus, only mimics in bone.
| Raloxifene has less SE.
105
MC SE of SERMs? (6)
* Hot flashes
* Nausea
* Muscle aches/cramps
* Hair thinning
* HA
* Paresthesias
106
Main DDI for SERMs?
QT-prolongation
107
Who can aromatase inhibitors NOT be used in?
Pregnant women
108
On average, what is the median time to recurrence to breast cx?
4 years
109
What kind of breast cx is more likely to recur?
Hormone receptor negative
110
What are fulvestrant and elacestrant primarily used in?
| Antineoplastics
ER/PR+ but HER- breast cx.
| Blows up estrogen receptors.
## Footnote
Used for metastatic breast cancer
111
After breast cancer tx, how soon do you followup in the first 2 years for PEs?
PE Q4mo for 2 years
112
What drugs cannot be used with Aromatase inhibitors?
* Estrogen
* Immunomodulating drugs
* Hormone-modulating anti-CA therapy
113
Describe the views used for a **Screening** mammogram.
1. Craniocaudal (CC): compression of breasts from above/horizontally.
2. Mediolateral oblique (MLO): compression of breasts from the side/vertically.
114
What is the additional view that a **diagnostic** mammogram can add?
Spot compression view
115
What are the **3 types of soft tissue/architecture abnormalities** on mammogram that are considered significant?
1. **Spiculated focal mass:** **MOST SPECIFIC FEATURE OF BREAST CANCER**
2. Irregularly shaped mass
3. Architectural distortion: change in normal lay of breast tissue
116
What is more suspicious of breast cancer: High-density or low-denisty masses?
High-density
117
What kind of **clustered microcalcifications are most suspicious of breast cancer?**
| 0.1-1 mm calcium particles grouped as > 4-5 per cubic centimeter
Linear branching microcalcifications
| Granular can also be sus
118
What kind of clustered microcalcifications are **least suspicious of breast cancer?**
| 0.1-1 mm calcium particles grouped as > 4-5 per cubic centimeter
* Vascular
* Skin
* Rim-like
* Large & coarse
* Smooth round/oval
119
What are the 4 categories to rank breast density?
1. Predominantly fatty (0-25)
2. Scattered fibroglandular densities (26-50)
3. Heterogenously dense (51-75)
4. Dense (76+)
120
Predominant quadrant for breast cancer
Outer Upper Quadrant
121
What does BI-RADS 0 mean?
Not enough info to be conclusive.
| Need more scanning or rescan
122
What do BI-RADS 1 and 2 mean?
1. 1 is negative, **routine f/u only**
2. 2 is benign, **routine f/u only**
| Usually fibroadenomas or vascular calcifications
123
What does BI-RADS 3 mean and f/u frequency?
* Probably benign (< 2% risk of cancer)
* Screening recommendations: **Diagnostic mammo/US every 6 months x1 year, then annually for x2 years.**
| Can downgrade during these scans.
124
What does BI-RADS 4 mean?
* Suspicious abnormality; biopsy should be considered.
* Chance of cancer is 2-94%
* Rated A-C.
## Footnote
4A = 2-9% risk
4B = 10-49% risk
4C = 50-94% risk
125
What does BI-RADS 5 mean?
Highly suggestive of malignancy; appropriate action should be taken (95-100% cancer)
| Spiculated, sus calcifications, skin retraction
126
What does BI-RADS 6 mean?
* **Biopsy proven malignancy.**
* Yet to be surgically excised.
127
My summary of BI-RADS
* 0 = not enough info, poor scan
* 1 = negative, just routine f/u. (Q1-2 years)
* 2 = benign, just routine f/u (Q1-2 years)
* 3 = tiny chance of cancer, f/u (Q6 mo)
* 4ABC = wide range, could be cancer
* 5 = very sus!
* 6 = yea you have cancer
