WH- Lecture 3 Diseases and Disorders of the Breast fr Oghosa

Polymastia

Congenital anomalies of the breast: True accessory breasts- located anywhere along the "milk lines," which extend from the axilla to the groin

Absence

Congenital anomalies of the breast: _______ of the breast located anywhere along the "milk lines," which extend from the axilla to the groin.

bilateral (but could possibly be unilateral

Does Galactorrhea present as unilateral or bilateral milky (white to clear) discharge?

Noncyclic

not associated with the menstrual cycle and includes such etiologies as tumors, mastitis, cysts, and a history of trauma or breast surgery

Invasive Ductal Carcinoma

- Most Common breast malignancy - Most Common in women in their 50s

Duct Ectasia (Mammary Duct Ectasia)

- Non-cancerous - Milk duct in breast widens(dilation) and its wall thickens which causes periductal fibrosis and inflammation. Duct becomes blocked and can lead to fluid build up - Most Common cause of nipple discharge overall

Proliferative Without Atypia

- These lesions are commonly found on mammography and do not usually cause a palpable mass. - Histologically, they represent proliferation of cells of the ductal or lobular epithelium. - The cells themselves are normal, that is, nonmalignant.

Triple Negative

- These patients do not have any hormone receptors - *Carries worse survival rate - Very aggressive - Higher risk of early recurrence and mets - Nothing to specifically treat their cancer - only option is chemo/rad

Radiation

- Used in conjunction with mastectomy for later stages of breast cancer - Essential component of lumpectomy-Lumpectomy with partial mastectomy for early stages

MRI

- can be a useful adjunct to diagnostic mammography - Also, for early detection in women at high risk

Lumpectomy

(breast conservation) followed by radiation

recommend

**Clinical Pearl - WH providers and most general practitioners _______ BSE - many young women find their own breast mass before the age of screening mammograms - Continue to educate on SBE

Invasive Lobular Carcinoma

- Accounts for 5-15% of breast cancers - Often multifocal and bilateral

cysts

50% of Non-proliferative lesions are ______ (Most common)

Ultrasound

Best imaging for Fibroadenoma?

- Trastuzumab (Herceptin) - Pertuzumab (Perjeta)

Anti-HER2 treatments include the following (2):

cancer

Any dominant mass should be considered ______ until ruled out (biopsy)

97%

Axillary lymph nodes drain ____% of ipsilateral breast

metastasis

Both axillary and internal mammary nodes are common sites for _________

- Persistent fever after antibiotic treatment for Mastitis - Fluctuant mass is present

Breast Abscess manifestations

Most Common finding is in upper outer quadrant (Tail of Spence)

Breast Carcinoma are most commonly found in what quadrant?

- Requires surgical drainage of the abscess with additional antibiotic therapy - Culture to ensure proper antibiotic therapy

Breast abscess treatment (2):

- lobules/glands - milk ducts - connective tissues - fat

Breast are composed of ... (4)

Extramammary (non-breast) pain

Can be caused by many factors and can include à Chest wall trauma, rib fractures, shingles, and fibromyalgia

Paget Disease of the Nipple

Cancer involving the skin of the nipple and the areola

- Used to treat all stages regardless of lymph node status -Kill cancer cells •Combination therapy -Anthracycline- and Cyclophosphamide containing regimens -Methotrexate -5-FU -Doxorubicin *Possibly slightly advantageous use but increased risk of cardiomyopathy

Chemotherapy:

- Multiple masses - bilateral pain - May fluctuate in size - •Mobile

Clinical Manifestations: Fibrocystic Condition:

Rapidly growingà May enlarge the breast or thickness or heaviness - Skin erythematous, pink, purple, or bruised - Sometimes painful, tender, or ache - Often no mass since tumor infiltrates the breast diffusely - Edematous - Warm - Itchy - Affects 1/3 or breast or more - Non-lactating - No trauma •Mild, tender, enlarged axillary lymphadenopathy (also above or below collarbone - Peau d'orange: skin changes that looks like orange peel due to lymphatic obstruction, dimpling associated with poor prognosis

Clinical Manifestations: Inflammatory Carcinoma

- Long history of eczematous skin lesion or persistent dermatitis - Itching, tingling, or redness in the nipple or areola area flaking, crusty, or thickened skin on or around the nipple flatting of the nipple - Yellowish or bloody nipple discharge

Clinical Manifestations: Paget Disease of the Nipple

cancer

Clinical pearl - Always be cautious and rule out _______....

- Microcalcifications - Spiculated mass - Distortion of the normal architecture - Any discrete nonpalpable lesion

Concerning findings or a diagnostic testing of a breast mass (4):

Polythelia

Congenital anomalies of the breast: Extra nipples - located anywhere along the "milk lines," which extend from the axilla to the groin

- Reassurance -Reassurance is often all that is required - Properly fitting brassiere -Sports bra - Weight reduction - Regular exercise - Other options, but not been shown to provide relief -Decrease caffeine -Vitamin E 400-800IU daily -Primrose oil1000mg tid

Non-Pharmacologic Treatment of Mastalgia is 1st Line:

- 1st with the patient's arms at her sides - 2nd with her hands pressed against her hips, and/or with her arms raised over her - If the patient's breasts are especially large and pendulous, she may be asked to lean forward so that the breasts hang free of the chest, facilitating inspection.

Describe the inspection portion of the Breast Exam (3):

2. Palpation follows inspection - 1st with the patient's arms at her sides - 2nd with the arms raised over her head - This part of the examination is usually done with the patient in the supine position. - Palpation should be done with slow, careful maneuvers, using the flat part of the fingers rather than the tips. The fingers are moved up and down in a wavelike motion, moving the tissues under them back and forth, so that any breast masses that are present can be more easily felt.

Describe the palpation portion of the Breast Exam (3):

Fibrosis (Scar tissue

Non-proliferative Lesions: Can be associated with advancing breast cancer. As cancer advances, causes shortening of the tissue

endocrine

Duct Ectasia (Mammary Duct Ectasia): Monitor for underlying ________ issue

Fibroadenomas

Non-proliferative Lesions: Common tumors found in women in their late teens and early twenties. These masses are solid, round, rubbery, and mobile on examination. The tumors do have structural and glandular components in the mass. Although they do not have malignant potential, they can enlarge in pregnancy and cause discomfort.

less aggressive

ER/PR (+) Well differentiated and exhibit ______ _______ clinical behavior

Adenosis

Non-proliferative Lesions: Increase in the number of glands with associated lobular growth

Lactational adenomas

Non-proliferative Lesions: Increase in the number of glands with associated lobule growth. In lactating women, a palpable lactation adenoma may arise secondary to hormone response. Not painful and usually rubbery.

- Aromatase inhibitors, which include anastrozole (Arimidex), letrozole (Femara), and exemestane (Aromasin) - Fulvestrant (Faslodex) - SERMs: Tamoxifen (Nolvadex) - Bisphosphonates: improve bone density and reduce recurrence in post menopausal patients

Examples of hormonal therapy used for metastatic breast cancer include the following:

Open Biopsy

Excisional biopsy, less common with increased use of core needle. Goal is to remove entire abnormality-Not simply a sample

younger

False positives more common in ________ women

- ***1-5cm masses of proliferative epithelial and supporting fibrous tissue - Often found on PE or SBE - No malignant potential - Can enlarge in pregnancy and cause discomfort - Often discovered accidentally - MC benign tumor of breast - Accounts for 50% of all breast biopsies - Affects late teens and early 20s - Usually, puberty and young adulthood - *MC breast tumor of adolescents - Earlier age in black women - May occur up to age 55

Fibroadenoma

observation

Fibroadenoma treatment (1):

most resolve spontaneously

Fibrocystic Condition treatment:

tamoxifen

Following treatment of both LCIS and DCIS, preventive therapy with SERMs such as ________ has been shown to reduce the risk of invasive breast cancer in these patients.

Needle aspiration and decompression may be curative

Galactoceles can resolve on its own after several weeks, but how do you treat painful or persistent cases?

- Discharge can be sent for staining and microscopic analysis - Prolactin level - TSH - Pregnancy test - Renal function

Galactorrhea Clinical Evaluation (5):

- Discontinue medication if suspected cause - Treat underlying cause - Referral to endocrinologist when applicable

Galactorrhea Treatment (3):

Non-proliferative Lesions

Generally, not associated with an increased risk of breast cancer

collecting milk

Glands/lobules drain into ________ ________ ducts, which drain at nipple

palliation

Goal of metastatic disease is __________

more aggressive tumor

HER2 usually indicates a _______ _________ ______ and fast growing

- SERMs (selective estrogen receptor modulators) -Tamoxifen -Anti-estrogen -ER+ tumors - Aromatase inhibitors -Postmenopausal -ER + tumors - Monoclonal Ab treatment HER2+ •Used in conjunction with chemotherapy - Biphosphonates

Hormonal/Endocrine Therapy (4):

Will be reported as positive or negative. - ER , PR positive - HER2 positive - Triple Positive (positive for ER/PR/HER2) - Triple Negative (Negative for ER/PR/HER2)

Hormone Receptor Status possibilities:

Presents as a "lump in the breast" and can be a large as a golf ball - Most common in lactating women

How do Galactoceles present ?

4

How many quadrants are the breast divided into?

Ultrasound

How would you differentiate cystic from solid?

3 months

IF initial examination fails to yield a dominant mass, the options (based on the patient's risk factors), when should they return for another examination?

prolactin, TSH, UPT

If patient has amenorrhea, irregular menses, headaches or visual disturbances check _______, ________, ______

40 years old

In women older than ______ years, mammography is often used as the first-line study in evaluating a patient presenting with a breast mass

Yellow tinged

Nipple Discharge: fibrocystic, duct ectasia, galactocele

Bloody

Nipple Discharge: intraductal papilloma or invasive papillary cancer

- Often no lump felt on exam or seen on mammogram - Diagnosed by biopsy

Inflammatory Carcinoma diagnosis:

- Rarely curable due to early spread - Radiation - Targeted hormone therapy à if hormone receptor + - Systemic chemotherapy - Surgery if chemo and radiation resulted in clinical remission with no evidence of metastasis

Inflammatory Carcinoma treatment:

extremely aggressive; most malignant

Inflammatory Carcinoma: Rare, but ________ _________ and ______ ________ form of breast CA

3%

Internal mammary nodes drain ____%

bloody

Intraductal Papilloma is the most common cause of _______ nipple discharge

Excision of duct

Intraductual Papilloma definitive diagnosis and treatment?

no, not bloody

Is there blood in Galactorrhea?

- U/S - Mammogram - Core needle biopsy Will normally undergo spontaneous regression after pregnancy and lactation

Lactational Adenoma Diagnostic :

Bromocriptine (Parlodel) -Used to reduce the size by suppressing prolactin secretion

Lactational Adenoma treatment

2 years

Mammography can detect lesions approximately ____ years before they become palpable

40 years old

Mammography every year is recommended after what age?

excisional biopsy

Management of LCIS:

Modified radical mastectomy

Mastectomy plus axillary lymph nodes removed

Non-lactating women

Mastitis Manifestation: When do you consider inflammatory breast cancer?

Sudden-onset fever and localized pain and swelling. §Most common in 1st 3 months of lactation

Mastitis Manifestations

- Continuation of breastfeeding or emptying the breast with a breast pump. - Use of appropriate antibiotics - Dicloxacillin 500mg q6 hours or cephalosporin for 10-14 days if cellulitis - Warm compresses to breast

Mastitis Treatment (3):

increase

Mastitis Treatment: Cessation of breastfeeding will ________ engorgement and delay resolution of the infection as well as worsen the pain associated with mastitis

abscess; resistance

Mastitis Treatment: If no response in 3 days may represent _______ or ________

- Staphylococcus aureus - group A or B streptococci - β Haemophilus species - Escherichia coli

Mastitis is associated with infection by (4):

- Antipsychotics (Haldol) - TCAs - Antidepressants (SSRIs, SNRIs, bupropion) (Not common) - Antiemetic and GI (metoclopramide Reglan) - Anti-HTNs: Verapamil & methyldopa all others rare - Opioid analgesics (methadone, morphine) transient increase for several hours - OCPs or ERT

Medications Commonly Associated Hyperprolactinemia:

Fibrocystic Condition

Most common benign breast condition

- pain - concern about a mass

Most common breast complaints are (2):

Estrogen receptor (ER) and Progestin receptor (PR)

Name 2 biomarkers

- *BRCA 1 and 2 mutations - *First degree family hx

Name 2 risk factors for breast cancer:

serous colored

Nipple Discharge: can be from normal menses, duct ectasia(clogged milk duct) OCP, fibrocystic condition or early pregnancy

- Skin scraping - Mammogram findings-Microcalcification - Ultrasound or MRI - Biopsy is Definitive

Paget's Disease of the Nipple diagnosis:

- Conservative management if localized - Local excision - Wedge resection - Mastectomyà If Palpable mass or invasive carcinoma *Standard of care

Paget's Disease of the Nipple treatment:

Intraductal Papilloma

Papillary tumor growing from the lining of the breast duct (intraductal)- Small, benign tumor of milk ducts - Presentation: Spontaneous bloody discharge from the breast that is usually unilateral, single-duct

- Monitor every 3-4 months if no palpable mass or bloody discharge - Treat underlying cause: Antibiotics if infection (abscess) or Thyroid hormone if low TSH - Surgical management with excision

Pathologic (Suspicious) Nipple Discharge treatment:

less than 30

Pathologic (Suspicious) Nipple Discharge: Patients _______ ______ _______ should just do U/S and only perform mammogram if suspicious finding on U/S

ductal carcinoma in situ (DCIS)

Pathologic (Suspicious) Nipple Discharge: What is the most common malignancy associated with nipple discharge *IN THE ABSENCE* of other findings?

in patients with symptoms and negative U/S and mammogram

Pathologic (Suspicious) Nipple Discharge: When are MRIs performed?

Complex sclerosing lesions

Proliferative Without Atypia - Lesions (radial scar)-a nidus of tubules entrapped in a densely hyalinized stroma surrounded by radiating arms of epithelium. The lesion mimics an invasive carcinoma

Sclerosing adenosis

Proliferative Without Atypia - Lesions increased fibrosis within the expanded lobule with distortion and compression of the epithelium, the lesion

Papilloma

Proliferative Without Atypia - Lesions intraductal growths composed of abundant stroma and lined by both luminal and myoepithelial cell (Women -30-50) Cause a serous or serosanguinous discharge - MOST COOMON CAUSE OF NIPPLE D/C

Epithelial hyperplasia

Proliferative Without Atypia - Lesions: 2 layers of luminal cells rest on the basement membrane

- Lobular carcinoma in situ (LCIS) -Ductal carcinoma in situ (DCIS)

Proliferative with atypia 2 main types of carcinoma in situ:

Mastectomy

Remove all breast tissue and nipple areola but preserve pectoralis muscle

follicular phase

The best time to perform a breast examination is in the ________ _______ of the menstrual cycle.

40 to 74 years

Screening reduces breast cancer mortality in women aged ______ to _______

ruled out

Serious causes of chest pain, such as angina, need to be ______ ______

TNM system

Staging required: most reliable indicator of prognosis based on...

Presence or absence of distant Metastasis

TNM system: M

Lymph Node involvement

TNM system: N

Tumor size

TNM system: T

Lymph node

TNM system: ______ _______ status has most significant impact

invasive

Surgical resection is required in ALL patients with _______ breast cancer

support

Suspensory ligaments provide _________ (Cooper's ligament)

danazol

The only medication approved by the FDA for treating mastalgia is ________, but it has significant side effects.

1. Nonproliferative lesions 2. Proliferative without atypia 3. Proliferative with atypia

Three morphologic categories and their risk of developing invasive breast cancer (•Relative risk of developing invasive breast cancer increases with each category) (3):

Young

________ women have more glandular tissue -More lumpy/bumpy -Dense tissue difficult to image

Hormonal/Endocrine Therapy

Used in treatment for estrogen receptor positive breast cancer

Ultrasonography

Useful in evaluating inconclusive mammographic findings - Used for evaluating the breasts of young women and others with dense tissue, allowing better differentiation between a solid and cystic mass - Also used for guiding tissue core-needle biopsies

- bone - lung - brain - liver

What are the 4 most common sites for metastasis?

A computer-based tool to allow clinicians to estimate a woman's risk of developing invasive breast cancer over the next 5 years and in their lifetime (up to age 90 years).

What is Gail Risk Assessment Prediction Model?

Often misdiagnosed as a dermatologic eruption

What is Paget Disease of the nipple often misdiagnosed as?

Diagnostic mammogram

What is the first line work up for Pathologic (Suspicious) Nipple Discharge?

Surgical resection with sentinel lymph node biopsy is GOLD STANDARD

What is the gold standard treatment for breast carcinoma?

Hyperprolactinemia - Secondary to medications, pituitary tumors, endocrine abnormalities

What is the most common cause of Galactorrhea

Axillary ode status

What is the most important outcome predictor for breast carcinoma?

5%

What percent of nipple discharge have underlying malignancies ?

Spontaneous -Bloody -Unilateral -Persistent -From single duct -Associated with mass -Purulent -Woman >40 years old

When is discharge concerning?

- The American College of Obstetrician and Gynecologist (ACOG) supports BSEs - U.S. Preventative Service Task Force (USPTF) does not support.

Which organization supports Breast Self-Exams (BSEs), which doesn't?

40 to 49; 60 to 69

Women aged _____ to _____ years benefit the least and women aged ______ to _______ years benefit the most

- chemoprevention with the SERMs tamoxifen and raloxifene - prophylactic mastectomy

Women at high risk Current prophylactic options include:

invasive

Women with DCIS are at increased risk for developing _______ cancer or a recurrence of the DCIS l

Older

______ patients have more fatty tissue

Core Needle Biopsy

_______ _______ ______ is Diagnostic procedure of choice for both palpable and image detected abnormalities

Cyclic

_______ begins with the luteal phase of the menstrual cycle and resolves after the onset of menses

HER2

_______ is a protein found in all breast cells, but at varying levels

Tail of spence

_______ of ________ is the most common location of breast CANCER

Increasing age

________ ________ is MOST IMPORTANT risk factor for most women

History; anxiety

________ is the single most important step in initial evaluation. Evaluation also relieves patient ________

Glandular

________ tissues are sensitive to hormonal changes

Inflammatory breast cancer (IBC)

breast looks swollen, red, or "inflamed" Peau de orange

Lobular carcinoma in situ (LCIS)

characterized by obliteration of the lumina of the glandular acini by a uniform population of small, atypical cells

grenn sticky

ductal ectasia or fibrocystic

Ductal carcinoma in situ (DCIS)

ducts are filled with atypical epithelial cells.

Borwn

fibrocystic and duct ectasia

Core-needle biopsy

large needle (14-16 gauge) is used to obtain samples from larger, solid breast masses. Three to six samples of tissue approximately 2 cm long are obtained and are evaluated for abnormal cells.

Simple breast cysts

single or multiple, soft to firm, mobile, often tender, no retraction, may aspirate to confirm

purulem

superficial or central breast abscess

Fine-needle aspiration

useful in determining if a palpable lump is a simple cyst. The procedure is performed in the office with or without the aid of local anesthesia.