Week 7 - Breast disorders

Question 1

Types of nipple discharge

Answer 1

‣ normal lactation
‣ galactorrhea unrelated to childbearing
‣ non-milky discharge which is usually benign

Question 2

Galactorrhea unrelated to childbearing s/s

Answer 2

‣ milky nipple discharge in a woman who has not been pregnant or lactated in the past 12 months
‣ usually bilateral and multiductal
‣ may occur spontaneously or with nipple manipulation

Question 3

Cause of galactorrhea

Answer 3

‣ Hyperprolactinemia
‣ Medications (SSRIs, TCAs, MAOIs, CCBs, amphetamines – things that inhibit dopamine hyperprolactinemia

Question 4

Causes of non-milky discharge

Answer 4

‣ Usually benign
‣ Intraductal papilloma and mammary duct ectasia are the most common causes
‣ Nonmilky discharge that is spontaneous, unilateral, from a single duct (uniductal), and clear or bloody is more likely to be associated with cancer than the physiologic discharge that can occur in approximately 50 percent of women with nipple manipulation

Question 5

Assessment of non-milky breast discharge

Answer 5

‣ Duration, color, whether it occurs spontaneously or with manipulation, unilateral/bilateral, comes from one or more ducts or the nipple
‣ Other breast symptoms
‣ Symptoms of hypothyroidism, hyperthyroidism, pituitary tumor, hyperprolactinemia
‣ Menstrual, pregnancy, family and general medical history

Question 6

Physical exam for non-milky nipple discharge

Answer 6

‣ Comprehensive breast/nipple exam – palpate upright and supine
‣ Palpate lymph nodes
‣ Assess for skin changes or breast masses and tenderness

Question 7

Diagnostic testing for milky nipple discharge

Answer 7

‣ Bilateral milky discharge –> pregnancy test
‣ If negative –> serum prolactin level and TSH
‣ If hyperprolactinemia is present –> MRI to rule out pituitary tumor

Question 8

Diagnostics for non-milky discharge with palpable mass

Answer 8

‣ If discharge is spontaneous, unilateral, uniductal, reproducable on exam –> mammogram and US
‣ Tissue biopsy
‣ Referral to surgeon

Question 9

Treatment for non milky nipple discharge only with nipple stimulation that is yellow, brown, green or gray….

Answer 9

avoid nipple stimulation, f/u 3-4 months

Question 10

What tests should you run with black nipple discharge

Answer 10

Fecal occult stool test for blood

Question 11

Fibroadenoma

Answer 11

Solid, non cancerous breast lump composed of dense epithelial and fibroblastic tissue, are usually nontender, encapsulated, round, movable, and firm

Question 12

S/S of fibroadenoma

Answer 12

‣ Discrete, smooth, round or oval, nontender, mobile

Question 13

Diagnosing breast lumps as fibroadenoma

Answer 13

‣ US for women under 30
‣ Mammogram for women over 30

Question 14

Cysts

Answer 14

fluid filled masses commonly found ages 35-50

Question 15

S/S of cysts

Answer 15

Discrete, tender, mobile; size may fluctuate with menstrual cycle

Question 16

Lipoma

Answer 16

area of fatty tissue, occur in later reproductive years

Question 17

S/S of breast lipoma

Answer 17

Discrete, soft, nontender; may or may not be mobile

Question 18

Fat necrosis

Answer 18

results from breast trauma (seat belt pressure in MVA)

Question 19

S/S of breast fat necrosis

Answer 19

Ill defined, firm, nontender, nonmobile

Question 20

Phyllodes tumors

Answer 20

form from periductal stromal cells of the breast and present as a firm, palpable mass. Usually larger than a fibroadenoma

Question 21

Hamartomas

Answer 21

Composed of glandular tissue, fat, fibrous connective tissue. Discrete, nontender, nonmobile; may be nonpalpable with incidental diagnosis on imaging studies.

May be benign or malignant

Question 22

Galactoceles

Answer 22

Milk filled cysts usually occur during or after lactation. Discrete firm sometimes tender

Question 23

In women over 55, what percentage of breast masses are malignant?

Answer 23

85%

Question 24

2/3 of adolescents with a breast mass have this type?

Answer 24

Fibroadenoma

Question 25

What percentages of cases of individuals with fibroadenomas have multiple nodules?

Answer 25

10-15%

Question 26

What happens to the fibroadenoma incidence with age?

Answer 26

decreases with increasing age, but they still account for 12 percent of masses in menopausal women

Question 27

What percentage breast neoplasms are phyllodes?

Answer 27

Phyllodes typically large and fast-growing masses account for fewer than 1 percent of all breast neoplasms.

May be benign or malignant

Question 28

Average age of breast cancer diagnosis

Answer 28

62

Question 29

How many women are diagnosed with breast cancer in their lifetime?

Answer 29

1/8

Question 30

How prevalent is breast cancer?

Answer 30

Second only to skin cancer with 268,000 new invasive cases annually. It is the second leading cause of death in women after lung cancer.

Question 31

How many breast cancer survivors are there?

Answer 31

3.8 million

Question 32

Invasive ductal carcinoma

Answer 32

‣ Most common malignancy of the breast
‣ Common spread to bones, liver, brain and lungs

Question 33

S/S of invasive ductal carcinoma

Answer 33

‣ Discrete solid mass with malignant cells escaping the ducts and infiltrating the breast parenchyma

Question 34

First steps for breast cancer assessment

Answer 34

Ultrasound and diagnostic mammogram

Question 35

Ductal carcinoma in situ

Answer 35

The cells lining the milk ducts turn malignant (cancerous) but stay in place (in situ). DCIS is an early form of breast cancer.

Question 36

S/S of ductal carcinoma in situ

Answer 36

‣ is usually diagnosed in association with microcalcifications seen on mammography; it is rare to find a palpable mass in such cases

Question 37

Paget disease

Answer 37

‣ rare form of breast cancer (1 percent of all cases) that causes eczematous nipple changes and ulceration, itching, erythema, and nipple discharge

Question 38

Diagnosis for paget disease is made by…

Answer 38

‣ punch biopsy (may not be dectecd with imaging)

Question 39

Inflammatory carcinoma

Answer 39

• a rapidly progressive type of breast cancer, with more than half of all cases already demonstrating lymphovascular invasion at the time of diagnosis

Question 40

s/s of Inflammatory carcinoma

Answer 40

Diffuse inflammatory changes of the breast skin with erythema, edema, warmth, skin thickening, and peau d’orange

Question 41

Mastalgia

Answer 41

breast pain, may be cyclic (with menses 70% ) or non-cyclic (25%)

Question 42

Causes of mastalgia

Answer 42

‣ certain medications,
‣ combined estrogen and progestin contraceptives (i.e., pills, vaginal ring, and transdermal patch),
‣ hormone therapy,
‣ antidepressants,
‣ digoxin,
‣ methyldopa,
‣ cimetidine,
‣ spironolactone,
‣ oxymetholone, and
‣ chlorpromazine

Question 43

Types of mastalgia

Answer 43

‣ Cyclic – begins in luteal phase and ceases with menses
‣ Pain is usually bilateral and poorly localized
‣ Non-cyclic – pain may be constant or intermittent
‣ Not timed in relation to menstrual cycle
‣ More likely to be unilateral, and be sharp or burning pain
‣ Chest wall pain – very localized, worse with movement, affects 5-10% of women with myalgias

Question 44

First steps of assessment for mastalgia

Answer 44

‣ determine cyclic, non cyclic or chest wall
‣ timing, frequency, nature, location, severity, mitigating factors
‣ other breast symptoms – nipple discharge, breast mass, PMH of breast disease or surgery
‣ caffeine intake can caue dilation of blood vessles and overstimulation of breast cells

Question 45

Diagnosing mastalgia

Answer 45

‣ Pregnancy test
‣ Under age 30 – targeted breast US
‣ Over age 30 – targeted breast US with diagnostic mammogram

Question 46

Mastalgia treatment

Answer 46

‣ First line treatment is reassurance
‣ Wearing supportive well fitting bra
‣ Exercise 3x week
‣ Reduction of caffeine and dairy (limited effectiveness)
‣ Reduce dose or route of women receiving HRT
‣ Try a different contraceptive
‣ Danazol – FDA approved treatment
‣ Oral or topical NSAIDS

Question 47

Breast cancer screening guidelines

Answer 47

Screening mammography every 2 years for women aged 50 to 74