Week 01.Women's Health.Breast Care

Question 1

A patient comes in c/o mastalgia; what do you need to know?

Answer 1

more common before menopause than after
usually not a sign of cancer
often related to the cycle –> find out if it is cyclic or noncyclic

Question 2

What can worsen mastalgia?

Answer 2

changes in meds, hormones

stress

Question 3

Why is mastalgia usually worse in the luteal phase?

Answer 3

increased water content in breast stroma

Question 4

What do you need to know about cyclic mastalgia?

Answer 4

usually worst prior to menses and relieved after menses
usually bilateral
disappears w/ menopause

Question 5

What do you need to know about noncyclic mastalgia?

Answer 5

most common b/w 30-50
unilateral or focal
sharp/burning
can be caused by cyst or fibroadenoma
ligamentous pain from pendulous breasts
can be caused by OCP, HRT, psychotropic drugs, spironalactone

Question 6

Who should get an ultrasound for breast complaints? How about a mammogram?

Answer 6

< 30: ultrasound
30-40: mammogram +/- U/S
> 40: mammogram

Question 7

What is the dose for primrose oil for mastalgia?

Answer 7

1000mg BID for 3-6 months

Question 8

When to use tamoxifen for mastalgia? What are the risks?

Answer 8

(SERM)
used for severe breast pain
increased risk for endometrial cancer and DVT

Question 9

Breast cancer is ________ (rare/common)

but lifetime risk is _________ (low/high)

Answer 9

common

high

Question 10

For women at normal risk, describe screening via mammogram based on a patient’s age (listing risks and benefits)

Answer 10

40-50: offer mammography, but review benefits and risks; benefit: potential mortality benefit of 10% w/ starting at age 40, risk: higher likelihood of detection of DCIS & difficult therapeutic decisions
50-74: mammography every 2 years (10-year mortality reduced by 20-30% with screening)
> 75: optional to offer every 2 years after considering harms and benefits (unknown mortality benefit; possible positive benefit if life expectancy > 10 years)

Question 11

Name a risk assessment tool that can be used to inform breast cancer screening decisions

Answer 11

Gail model

Question 12

Which women are at increased risk of breast cancer?

Answer 12

extremely dense breasts

history of breast cancer in 1st degree relative

Question 13

For women at increased risk of breast cancer, when should screening start and end?

Answer 13

annual screening starting ages 40-49, continuing indefinitely as long as life expectancy > 5 years

supplement with MRI screening for extremely dense breasts and negative mammograms

risks: high false-alarm rate
benefits: potential for reductions in invasive and advanced cancers

Question 14

Who is at very high risk of breast cancer?

Answer 14

personal or family history of breast, ovarian, tubal, or peritoneal cancer
OR who have a family history of BRCA1 or BRCA2

Question 15

In addition to intensive screening, what else should be offered to patients at very high risk of breast cancer?

Answer 15

chem-prevention (SERMs, ASA, NSAIDs)

OR prophylactic mastectomies

Question 16

When a woman presents with a breast mass, what is the first line test?

Answer 16

mammogram

Question 17

If a pregnant or lactating woman presents with a breast mass, what alternate test can be offered?

Answer 17

ultrasound

Question 18

When should MRI be used to image breast tissue?

Answer 18

for diagnostic dilemmas

NOT for the workup of an undiagnosed mass

Question 19

For what patients should caution be used when ordering MRI for breast imaging, and why?

Answer 19

gadolinium used

can be hard on the kidneys; caution in renal disease; consider baseline BUN/Cr

Question 20

What is BIRADS?

Answer 20

Breast Imaging and Data Recording System

a method of standardizing results from mammograms

Question 21

What does BIRADS 0 mean?

Answer 21

more information needed
incomplete
more imaging required

Question 22

What does BIRADS I mean?

Answer 22

negative, symmetrical

no masses, architectural disturbances, suspicious calcifications present

Question 23

What does BIRADS II mean?

Answer 23

benign

may have cysts, lipomas, galactoceles

Question 24

What does BIRADS III mean?

Answer 24

probably benign
short follow up interval recommended
2% chance of malignancy

Question 25

What does BIRADS IV mean?

Answer 25

suspicious abnormality 30% chance of malignancy biopsy should be considered

Question 26

Break down the BIRADS IV designation into subcategories

Answer 26

BIRADS IVa: low level suspicion for malignancy BIRADS IVb: intermediate level suspicion for malignancy BIRADS IVc: moderate level suspicion for malignancy

Question 27

What does BIRADS V mean?

Answer 27

highly suggestive of malignancy (95% chance)

Question 28

What does BIRADS VI mean?

Answer 28

known biopsy proven malignancy

Question 29

Name some benign breast lumps

Answer 29

``` galactocele fibroadenoma cyst fat necrosis nipple piercing ```

Question 30

What is a fibroadenoma?

Answer 30

``` benign solid mass firm can be rolled solitary, multiple, or bilateral ```

Question 31

What is a cyst?

Answer 31

benign fluid-filled mass premenopausal, perimenopausal, occasionally postmenopausal

Question 32

What is a galactocele?

Answer 32

mild retention cyst common in breastfeeding women

Question 33

What is fat necrosis related to the breast?

Answer 33

benign breast mass that can develop after blunt trauma to breast

Question 34

What is the most common breast cancer?

Answer 34

infiltrating ductal breast carcinoma

Question 35

Name some skin changes that can be seen with breast cancer

Answer 35

``` puckering -- skin pulled by underlying cancer; can also happen with fat necrosis peau d'orange -- edema nodules discoloration ulceration ```

Question 36

You find a breast mass on exam; what to document?

Answer 36

size (in cm), location, mobility, consistency

Question 37

In what position(s) should a woman's breasts be examined?

Answer 37

sitting upright | supine

Question 38

What lymph nodes are examined with a breast assessment?

Answer 38

cervical supraclavicular infraclavicular axillary

Question 39

A patient has a breast lump; what patient characteristics make it more risky?

Answer 39

``` advanced age menarche < age 12 menopause > age 55 obesity, especially after menopause nulliparity > age 35 at first delivery extreme density on mammography BRCA1/2 Caucasian, Ashkenazi Jew first degree relative w/ breast cancer prior breast biopsy history of hyperplasia or carcinoma in situ thoracic exposures (e.g. exposed to radiation for Hodkin's Lymphoma) ```

Question 40

Who is typically affected by mastitis? Who can be affected?

Answer 40

ages 15-45, especially lactating females | can affect neonates and adolescents

Question 41

Most frequent pathogen causing mastitis

Answer 41

staphylococcus aureus

Question 42

Symptoms of mastitis

Answer 42

``` flu-like sx: malaise, myalgia fever breast pain decreased milk outflow warmth, tenderness, firmness, swelling, erythema, edema breast mass fistula ```

Question 43

How is mastitis diagnosed?

Answer 43

U/S

Question 44

Name some signs of possible breast cancer

Answer 44

solitary or dominant breast mass abnormal nipple discharge nipple retraction

Question 45

What is the definitive diagnostic test for a breast mass?

Answer 45

biopsy

Question 46

A nipple discharge that is unilateral, spontaneous, and localized to one duct should be considered ______

Answer 46

pathologic

Question 47

The most worrisome nipple discharge is _________

Answer 47

bloody

Question 48

How do breasts normally change with the menstrual cycle?

Answer 48

hormonal stimulation in the cycle causes proliferation and desquamation of duct lining some areas of the breast overshoot in the monthly preparation for pregnancy; this thickens the breast and causes lumpiness

Question 49

Typically, the first lymph nodes to exhibit lymphedema from breast cancer are the ________ nodes

Answer 49

axillary

Question 50

When does breast pain typically occur in the menstrual cycle?

Answer 50

in the late luteal phase

Question 51

If a patient is determined to have breast cancer, what else needs to be kept in mind?

Answer 51

not all breast cancer is primary; breast cancer can be metastatic disease from another site

Question 52

Describe a dominant nodule on a breast exam

Answer 52

discrete distinctly different from surrounding breast tissue or the same area of the opposite breast unchanging and persistent nature throughout cycle

Question 53

What should happen for a patient with unilateral discharge from multiple ducts?

Answer 53

follow the patient over time

Question 54

What tests can be done for mastitis?

Answer 54

``` breast ultrasound diagnostic needle aspiration drainage cytology of nipple discharge or sample from aspiration C&S: milk, aspirate, discharge pregnancy test blood culture and sensitivity CBC mammogram ```

Question 55

When does a patient need antibiotics for mastitis?

Answer 55

acute pain sx> 24hr fever sign of systemic infection

Question 56

Name some antibiotics that can be used for mastitis

Answer 56

``` oral penicillin w/ activity against MSSA if MRSA ruled out Dicloxacillin 500mg QID Cephalexin 500mg QID Clindamycin 300mg QID Augmentin 875mg BID Bactrim DS BID ```

Question 57

What does tamoxifen do?

Answer 57

blocks estrogen receptors | this keeps estrogen from binding to cancer cells and keeps it from proliferating

Question 58

What is the only FDA approved medication for mastalgia? What does it do? What is the caution/risk?

Answer 58

Danazol --> suppresses gonadatropin secretion androgenic AE that may not be reversible (hirsutism, voice changes)