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Clinical Medication: HEENT > Women's health: breast > Flashcards

Flashcards in Women's health: breast Deck (63):
1

The Breast Ducts are influenced by:
the lobes are influenced by:

Ducts:Estrogen
Lobes: Progesterone

2

Nerves to:
Seratus anteriour
Lat Dorsi
sensory nerve to medial arm and axilla

SA: Long thoracic
LD: Thoracodorsal n
intercostobrachial nerve

3

Vessels
Seratus anteriour
Breast:

thoracodorsal artery – latissimus dorsi

Internal thoracic artery (superior epigastric), intercostal arteries, thoracoacromial artery, lateral thoracic artery all supply the breast

4

Lymphatic drainage of the breast:

97% goes to the axillary nodes, 1-2 % go to the internal mammary nodes.

5

Any quadrant can drain into the internal mammary nods, but what is most common?

Usually the lower inner Quadrent

6

If supraclavicular nodes are + what are you thinking?

it is from a metastic disease

7

if there is primary axillary lymphadenopathy what are you thinking?

it is usually lymphoma not BC

8

Gail Model
What is it:
what does it consider?

Tool to assess risk for breast cancer (cannot use if patient has had breast cancer or LCIS/DCIS)

– Age
– Age at menarche
– Age at first live birth
– Number of first degree relatives with breast cancer – Number of previous breast biopsies
– Atypical hyperplasia
– Race

9

Gail Model
** if greater than 1.66%, the patient should be considered for

tamoxifen therapy to reduce the risk of breast cancer

10

*If you do not feel a discrete mass but feel something that is coarsely nodular (bag of peanuts) what do you need to do?

note whether or not it is symmetrical bilaterally. If it is not symmetrical, evaluate further with imaging

11

US
• Great for _____
• Much more sensitive than:...... esp.....
• Cannot be used for
• When you order an ultrasound, specify the

US
• Great for cysts!!
• Much more sensitive than mammogram,
especially in the dense breast
• Cannot be used for screening
• When you order an ultrasound, specify the area of the breast to be examined (UOQ, etc.)

12

Mammogram
• Best for
• Only about 85% sensitive for:
• If you have a patient with a mass and a negative mammogram, that patient still needs

Mammogram
• Best for screening!!
• Only about 85% sensitive for breast cancer
• If you have a patient with a mass and a negative mammogram, that patient still needs a biopsy!!!***

13

BIRADS classification: 0-6 –

• 0- needs additional imaging
• 1- negative, re-mamm in 1 year
• 2-benign finding, re-mamm in 1 year
• 3-probably benign ~1% malignant, re-mamm in 6 months
• 4-posssibly malignant ~10-50% malignant, biopsy
• 5-probably malignant ~90-97% malignant, biopsy
• 6-knownmalignancy

14

Galactogram/ductogram
- Used to evaluate
• A catheter is placed into the
• This shows the
• Filling defects in the duct are
• The duct must be actively

Used to evaluate nipple discharge from a single duct
• A catheter is placed into the draining duct and contrast is injected, a mammogram is taken
• This shows the shape of the duct
• Filling defects in the duct are suspicious for
malignancy
• The duct must be actively draining in order for this test to be done

15

MRI
• Very
• Indications:
– To assess for
– Following
– To screen for
– Evaluating
– Evaluating

MRI
• Very expensive, so do not use as a general screening tool
• Indications:
– To assess for extent of disease in newly diagnosed
breast cancer
– Following neoadjuvant chemotherapy to plan surgery
– To screen for cancer in young patients with extensive family history of pre-menopausal breast cancer
– Evaluating breast implants
– Evaluating lumpectomy sites for recurrence (after a year)

16

Lipoma

– benign fatty tumor
– treatment is surgical – don’t diagnose this clinically – biopsy is necessary

17

Fat necrosis –

– benign
– lump occurring following trauma
– common in breast reduction

18

Mondor’s disease
• Superficial
• Feels
• Often
• Associated with
• Usually occurs in the
• Treat with

• Superficial thrombophlebitis of the breast
• Feels cordlike
• Often painful
• Associated with trauma or strenuous exercise
• Usually occurs in the lower outer quadrant
• Treat with NSAIDs

19

Fibroadenoma
– Benign tumor of the
– Most common lesion in
– Painless,
– Can change in size with
– NEED
– Core biopsy
– Therefor, often treated
– Can be confused with
– Can have large coarse

Fibroadenoma
– Benign tumor of the fibrous stroma (compresses epithelial cells on pathology)
– Most common lesion in adolescents and young women
– Painless, slow-growing, well circumscribed, firm, rubbery,
very mobile
– Can change in size with menses and grow in pregnancy
– NEED BIOPSY
– Core biopsy can be useful in establishing diagnosis but the lump is not removed
– Therefor, often treated surgically
– Can be confused with phylloides tumor on ultrasound
– Can have large coarse (popcorn) calcifications on mammogram

20

Juvenile hypertrophy or prepubertal gynecomastia
– Symmetrical enlargement
– Can be treated

– Symmetrical enlargement of breast tissue before age 12
– Can be treated surgically if severe

21

Poland’s syndrome
• hypoplasia of
• Surgical

• hypoplasia of the chest wall, amastia, hypoplastic shoulder, no pectoralis muscle
• Surgical reconstruction of the breast after puberty

22

Polythelia

Accessory nipples – most common anomaly

23

Cyclical Mastalgia
• Pain usually occurs
• No differences in
• Women with Cyclical Mastalgia may have

• Pain usually occurs prior to the start of menses each month, suggesting a hormonal link
• No differences in hormone levels between women with mastalgia and women with no pain
• Women with Cyclical Mastalgia may have breast tissue that is more sensitive to hormones

24

Treating Cyclical Mastalgia
• Properly
•)




• Properly fitting bra
• Caffeine cessation (not reduction)
• Vitamin E supplementation (400 IU/day)
• Oil of Evening Primrose
• Change in any exogenous or endogenous hormones
• NSAIDs
• Tamoxifen 10mg/day for six weeks – Aspirin daily while on this medication

25

Mastodynia
what is it:
cause is:
-
-
-
-
-

Constant severe breast pain unrelated to the menstrual cycle

• Cause is unknown
– Periductal mastitis or adenosis
– Can be musculoskeletal
– Tietze’s syndrome is costochondritis causing breast pain
– Consultation with a pain specialist for injection
– OMM consultation for manipulation

26

treatment of mastodynia?

Standard therapies for cyclical mastalgia are sometimes ineffective but should be tried
• As a last resort, mastectomy can be utilized for treatment and is generally effective for treating breast pain, provided that the pain is actually from the breast

27

Mastitis and Abscess
• Frequently associated with
• ________ are effective in most cases of mastitis
• Persistent symptoms necessitate


• Frequently associated with nursing
• Antibiotics are effective in most cases of mastitis
• Persistent symptoms necessitate ultrasound to look for an abscess
• Abscess needs to be drained for antibiotics to be effective
• I&D of an abscess in a lactating breast can lead to milk fistula so needle aspiration is preferred

28

Mastitis and Abscess Beware of:

Beware of inflammatory breast cancer!! If it does not get better with antibiotics, do an ultrasound. If the ultrasound does not show an abscess, then biopsy is necessary.

29

Galactocele
• Associated with


• Treated with:

• Associated with pregnancy/nursing
• Milk-filled cyst
• Smooth mass
• Treated with drainage/I&D

30

Breast Cysts
Affect ____% of women in Western countries
• Represent ____% of discrete breast lumps
• More common in women in their

Affect 7% of women in Western countries
• Represent 15% of discrete breast lumps
• More common in women in their 40s and 50s

31

Breast cysts
• Simple cyst –
• Complex cyst –

• Simple cyst – round, regular, thin-walled, no internal echoes or septations, no solid component
• Complex cyst – irregular, thick walls, internal echoes, septations, solid component

32

Breast cysts
• Complex cysts should be

• Complex cysts should be aspirated and confirmed to resolve or at least followed with ultrasound every six months out to two years to document stability. Change in the complex cyst should prompt biopsy.

33

Breast cysts
• FNAs
• FNAs
• An aspirated cyst that recurs, should be
• Bloody aspirate is another trigger for

Breast cysts
• FNAs are 80% accurate and most women don’t like needles
• FNAs are useful for cysts
• An aspirated cyst that recurs, should be re- aspirated and if it recurs again, it should be excised
• Bloody aspirate is another trigger for excision of a cyst

34

Duct Ectasia
• Occurs as
• Can lead to
• More common cause

Duct Ectasia
• Occurs as subareolar ducts dilate and shorten
• Can lead to nipple inversion and nipple discharge which is often bloody
• More common cause of nipple inversion than cancer

35

Intraductal papilloma
• Most common cause of

Intraductal papilloma
• Most common cause of bloody nipple discharge from a single duct

36

• Nipple discharge is common but is rarely

associated with cancer.

37

Treatment of Nipple Discharge
• Collect discharge for
• Unilateral discharge from a single duct needs
• All patients with nipple discharge should have a _____ level drawn

• Collect discharge for cytology
• Unilateral discharge from a single duct needs attention, involving cytology, ductogram, ultrasound and biopsy if indicated
• All patients with nipple discharge should have a prolactin level drawn, especially in cases of galactorrhea

38

Epithelial Hyperplasia
• An increase in the number of
• Atypical hyperplasia is the only
• Atypia found on core needle biopsy need to be:

Epithelial Hyperplasia
• An increase in the number of cells lining the terminal duct lobular unit
• Atypical hyperplasia is the only benign breast condition that significantly increases breast cancer risk
• Atypia found on core needle biopsy needs to be excised to evaluate for adjacent carcinoma

39

Proliferative breast disease





Proliferative breast disease
• Proliferative Fibrocystic change
• Sclerosingadenosis
• TypicalHyperplasia
• Metaplasia
• All of these proffer a small increase in breast cancer risk
• Only atypical hyperplasia increases breast cancer risk significantly

40

Treatment of proliferative breast disease
• Many studies have
-
-
-

Treatment of proliferative breast disease
• Many studies have looked at different modes of chemoprevention since proliferative breast lesions are associated with an increased risk of breast cancer and may be on the pathway to invasive breast cancer.
• Calcium plus vitamin D • Progestins
• Tamoxifen

41

Calcium plus vitamin D
• In vitro both
• Epidemiologic data
• Dose-effect curve is

• In vitro both calcium and vitamin D have anti- proliferative, pro-differentiating and pro- apoptotic effects
• Epidemiologic data are somewhat lacking
• Dose-effect curve is not well established

42

Tamoxifen
• Tamoxifen should not be used
• It should be offered to patients at

• Preferable to start therapy prior to

Tamoxifen
• Tamoxifen should not be used indiscriminately due to its side effect profile
• It should be offered to patients at high risk of breast cancer (>1.66 on Gail Model Risk Assessment)

• Preferable to start therapy prior to age 50

43

Diffuse papillomatosis
• Affects
• Usually have
• Mammogram shows
• Increased risk of

• Affects multiple ducts in both breasts
• Usually have serous discharge
• Mammogram shows Swiss cheese appearance
• Increased risk of breast cancer (40% get breast cancer)

44

Radial scar
• appears as a
• treated like

• appears as a stellate density on mammogram
• treated like atypia, i.e. excise radiographic finding (margins not necessary)

45

What increases breast cancer risk?

• Greatly increased risk
– BRCA gene in patient with a family history of breast CA
– >1 first degree relatives with bilateral or premenopausal breast cancer
– DCIS and LCIS
– Atypical ductal or lobular hyperplasis (5% RR)
• Moderately increased risk
– Family history of breast cancer other than above – Early menarche (55)
– Nulliparity or first birth after age 30
– Radiation
– Previous breast cancer
– High fat diet/obesity
• First-degree relative with bilateral premenopausal breast cancer increases breast CA risk to 50% (from 12%)
• 99% of male breast cancers are related to BRCA 1&2 (especially BRCA 2)
• BRCA 1 is associated with ovarian CA (30-45%) of patients with the gene develop ovarian CA, so consider TAHcBSO in BRCA1 pts

46

DCIS (Ductal Carcinoma In Situ)
Malignant cells of the
• 50%-60% get
• 5-10% get cancer in
Is it palpable?
Presents as a:
with excision you need:
Types of DCIS:

Malignant cells of the ductal epithelium without invasion of the basement membrane
• 50%-60% get invasive cancer in ipsilateral breast if not resected
• 5-10% get cancer in contralateral breast
• Usually not palpable
• Presents as cluster of microcalcifications on mamm
• Need 2-3mm margin with excision
• Types: solid, cribriform, papillary and comedo
patterns

47

what is the most aggressive type of DCIS?

– Comedo variants are most aggressive, high risk of multicentricity, microinvasion, and recurrence

48

DCIS
• Treatment


– Mastectomy is indicated if:

– Mastectomy OR lumpectomy plus radiation – (no radiation if mastectomy is done)
– Mastectomy is indicated if tumor is multicentric, if tumor is large or if re-excision fails to get adequate margins

49

LCIS
• 40%
• Considered a marker for
• is it palpable
- calcifications?
• Found:
• Usually found in:

LCIS
• 40% get cancer invasive lobular CA
• Considered a marker for getting cancer (risk factor) but the lesion itself is not pre-maligant
• No calcifications, not palpable
• Found incidentally
• Usually found in premenopausal women

50

LCIS
• 70% of patients with LCIS who go on to develop breast cancer get
• 5% risk of
• Do not need
• Tx:

LCIS
• 70% of patients with LCIS who go on to develop breast cancer get DUCTAL carcinoma
• 5% risk of synchronous breast cancer (usu ductal)
• Do not need negative margins
• Tx: nothing, tamoxifen, bilateral subcutaneous mastectomies, NO SLN

51

Invasive ductal carcinoma
• ___% of all breast cancer
• Various subtypes:
-
-
-
-
Treatment

• 85% of all breast cancer
• Various subtypes:
– Medullary breast CA
– Tubular CA – small tubule formation
– Mucinous CA – produces an abundance of mucin
– Scirrhotic CA
– Treatment: mastectomy +/- reconstruction and SLN or lumpectomy + radiation and SLN

52

what type o invasive ductal carcinoma has the worse prognosis

Scirrhotic CA

53

Invasive lobular carcinoma
• These do not always
• _____ of all breast cancers
• Does not form
• _________ confer a worse prognosis

• These do not always show up on mamm/US
• 10% of all breast cancers
• Does not form calcifications, extensively infiltrative, more often bilateral, multifocal.
• Signet ring cells confer a worse prognosis

54

Cystosarcoma phyllodes
• 10% are
• No nodal
• Resembles
• Tx:

• 10% are malignant
• No nodal metastasis – hemoatogenous spread if any (rare)
• Resembles giant fibroadenoma
• Tx: wide local excision with negative margins, no SLNbx

55

Inflammatory breast cancer
• s/sx:
• Can mimic:
• Should be treated with :
• prognosis
• looks like:

• Erythematous and warm
• Can mimic mastitis, so if mastitis does not respond to antibiotics, do an incisional biopsy, including the skin
• Should be treated with chemo and XRT prior to mastectomy
• Very aggressive, median survival is 36 months
• Has dermal lymphatic invasion, which causes peau d’orange lymphedema

56

Paget’s disease
• looks like:
• Biopsy shows
• Patients have
• Tx:

Ductile carcinoma that spread to the nipple
• Scaly skin of the nipple
• Biopsy shows Paget’s cells
• Patients have DCIS or invasive ductal carcinoma of the breast
• Tx: MRM Modififed raidcal mastectoy ( mastectomy with complete axillary disection)

57

Male breast cancer
• ___% of all breast cancer
• Usually
• Prognosis
• Increased ________ involvement
• Associated with :
• Tx:

• <1% of all breast cancer
• Usually ductal
• Have poorer prognosis because of late presentation
• Increased pectoral muscle involvement
• Associated with steroid use, previous XRT, family history, Klinefelter’s syndrome, prolonged hyperestrogenic state
• Tx: MRM

58

Lumpectomy vs. “excisional biopsy”

“Lumpectomy” is a cancer procedure

“excisional biopsy” is a biopsy procedure but if clear margins are obtained, it can double as a lumpectomy

Techniques are roughly the same, purposes are different, so don’t say “lumpectomy” if the person does not have cancer

59

Lumpectomy + XRT
• 10% chance :
• Usually occurs in
• Need ____________ local recurrence
• Need negative

• 10% chance of local recurrence (same as for mastectomy)
• Usually occurs in first 2 years
• Need salvage MRM for local recurrence
• Need negative margins before starting XRT

60

Absolute contraindications to breast conservation
• Two or more
• Persistent positive

• History of
• Diffuse malignant

• Two or more primary tumors in different quadrants
• Persistent positive margins after reasonable surgical attempts
• Pregnancy
• History of prior radiation
• Diffuse malignant appearing calcifications

61

Relative contraindications to breast conservation
• History of
• Extensive gross
• Large tumor in
• Very large or pendulous breasts

• History of scleroderma or active SLE
• Extensive gross, multifocal disease in the same
quadrant
• Large tumor in a small breast where lumpectomy would result in unacceptable cosmesis
• Very large or pendulous breasts if reproducibility of radiation dose is not possible

62

Breast reconstruction
• Studies have shown that the age of the patient has
• Implants are placed
• The more tissue that is over the implant:
• ***Radiation:

• Studies have shown that the age of the patient has NOTHING to do with preference for breast reconstruction.
• Implants are placed in almost all reconstructions for size
• The more tissue that is over the implant, the more natural it will look
• ***Radiation wrecks implants

63

Breast Reconstruction

• Four common types
– Implant only (tissue expander)
– Latissimus flap
– TRAM flap
– GAP flap