Breast Disorders/Cancer

Why do fibroadenomas occur?

Etiology unknown. But hormonal relationship is suspected due to increase in size with estrogen therapy and during pregnancy. Regression is seen after menopause.

When would we consider aspiration for a complicated breast cyst?

If aspiration does not clear sonographic abnormality refer for core-needle biopsy

What is a complication of mastitis?

If mastitis does not respond to treatment OR if treatment is delayed a breast abscess may form.

What is mastitis?

Inflammation/infection of the subareolar ducts.

What do complicated breast cysts show on sonography?

Internal echoes, and sometimes indistinguishable from solid masses

Consists of papillary cells that grow from the wall of a cyst into the lumen of the duct. Benign growth within ducts.

Intraductal papilloma

What is the most common cause of bloody nipple discharge?

Intraductal papilloma

What is the more common invasive breast cancer? Invasive ductal carcinoma or Invasive lobular carcinoma?

Invasive ductal carcinoma -- IDC 8 out of 10 invasive breast cancers

What is the benefit of Breast-Conserving Therapy?

It allows the patient to keep most of the breast.

How do we diagnose atypical hyperplasia disease?

It is a pathologic diagnosis usually found as an incidental finding on biopsy due to our workup of imaging abnormalities or palpable breast masses.

How is Axillary Node Dissection (ALND) used in breast cancer treatment and management?

It is a surgical procedure in which removal of lymph nodes from under the arm, about 10 to 40 nodes, and then evaluated for the spread of cancer.

Each lobe of the breast consist of a group of lobules which contain several what?

Lactiferous ducts

Name that benign breast condition: a fatty tumor, typically non-tender, soft and well-circumscribed. (These types of tumors can be found anywhere in the body)

Lipoma

Mammography

Low-dose x-ray looking for changes in breast tissue. Can detect masses before they are palpable. Can be screening or diagnostic.

What are the clinical features of intraductal papilloma?

Lump or nodule, nodule on ultra sound or unilateral bloody nipple discharge

Which has a higher chance of false positives when screening for breast cancer, Mammogram or MRI?

MRI, that is why it is not recommended for women with average risk

How does invasive lobular carcinoma start?

Starts in milk-producing glands and spreads.

How does invasive ductal carcinoma start?

Starts in the cells that line the milk duct, breaks through the walls of the duct and grows into nearby tissues. May also metastasize through the lymph system and blood stream.

What are the steps for a wire-directed excisional biopsy?

Step 1: A mammogram (ultrasound or MRI) used to place a wire in the suspicious area to guide surgeon Step 2: Same-day surgery to remove abnormality. Surgeon uses wire placed to locate and remove lesion. Results are confirmed with radiology and pathology.

What is the mechanism of action for selective estrogen receptor modulators, SERMs do?

Stop estrogen from stimulating caner cells to grow and lowers the changes of recurrence in hormone receptor-positive cancers

Atypical hyperplasia is 1 of the 3 classifications of benign breast disease, what are the risks related to breast cancer?

Substantial increase in the risk of subsequent breast cancer

What stimulates prolactin release?

Suckling, stress, dehydration, exercise, sexual intercourse, sleep, estrogen

Stage I treatment of invasive breast cancer

Surgery is main treatment with BCS or mastectomy. Post surgery radiation. If positive ER or PR add adjuvant therapy with hormones. +/- chemotherapy depending on size of tumor or HER2+, ER-/PR-

Stage II breast cancer treatment

Surgery with BCS or mastectomy. Lymph node biopsy/excision. Radiation. +/- chemotherapy depending on size of tumor or HER2+, ER-/PR-

What is the treatment for gynecomastia?

Surgical reduction or liposuction for pseudo gynecomastia.

What are the side effects of radiation therapy?

Swelling, skin changes, fatigue

Breast cancer staging is based on what system?

TNM system. T = tumor size N = nodal involvement M = metastasis

What is the goal of Breast-Conserving Therapy?

To remove the cancer as well as some surrounding normal tissue.

What is the mechanism of action of Aromatase Inhibitors?

To stop estrogen production

What are the types of mastectomy procedures that can be used in breast cancer treatment?

Total or Simple mastectomy, Modified radical mastectomy, Radical mastectomy

What is radiation therapy?

Treatment with high-energy rays (i.e. x-rays) to destroy cancer cells

True/False: Breast cancer is the 2nd most common cause of death in women.

True! Breast cancer is the main cause of death in women between 40 and 59 years.

True/False: Most breast cancers begin int he ducts (ductal cancers)

True! Breast cancers can start from different parts of the breast, but most begin in the ducts

True/False: Clear or bloody nipple discharge that occurs spontaneously and unilaterally is is a suspicious symptom for breast cancer.

True! Clear or bloody nipple discharge that is unilateral and spontaneous should be worked up for potential breast cancer.

True/False: Intraductal papilloma is a benign growth within ducts.

True! Intraductal is not concerning unless they have transformed into atypia or ductal carcinoma in situ DCIS. The growths can occur as solitary or multiple lesions.

True/False: Multiple tumors can be found in fibroadenoma.

True! Multiple tumors can be found in one or both breasts in 10 to 15% of patients.

True/False: Although not routine, like mammograms, USPSTF recommends genetic testing for certain individuals to screen for breast cancer risk.

True! Mutations in BRCA1 and BRCA2 elevates risk for breast cancer between 40 and 85%. As well as ovarian, colon, prostate and pancreatic cancer.

True/False: There is evidence for benefit of breast cancer screening in women aged 50 to 69 years.

True! The optimal frequency of screening is unknown in patients over 70 years.

True/False: Cyclical breast pain or tenderness caused by proliferation of normal glandular breast tissue is fibrocystic breast disease.

True! These changes are mediated by estrogen and progesterone.

True/False: Fibroadenomas are considered a benign breast lesion.

True! They are Proliferative without atypia. However, they're associated with a 1.5 to 2 times greater risk of breast cancer compared to general population.

True/False: Atypical ductal hyperplasia and Atypical lobular hyperplasia are classified as benign breast lesions and are apart of atypical hyperplastic disease

True! They are atypical hyperplasias. Even though they are classified as benign they have a substantial risk of subsequent ipsilateral and contralateral breast cancer, especially if multifocal.

True/False: Lobular carcinoma in situ increases risk of developing invasive breast cancer.

True! This breast change is NOT cancer. However, it increases the risk of developing invasive breast cancer in either breast by 7 to 12 times.

True/False: Gynecomastia presents as a concentric, rubbery tissue right beneath areolar area and pseudo gynecomastia presents with no discrete mass.

True! This is how you can differentiate these two on physical breast exam.

True/False: Mammograms are more effective in older than younger women.

True! Women in their 40's have denser breasts, making it more difficult to find breast cancers in women in this age group compared to older women.

True/False: Prolactin inhibits its own secretion by releasing dopamine from the hypothalamus.

True. Dopamine inhibits prolactin.

True/False: Pain and size frequently increase during premenstral phase in Fibrocystic breast disease?

True. Fibrocystic breast disease is the most common cause of cyclic breast pain in reproductive age women.

What is a wire-detected excisional biopsy?

Type of surgical biopsy that removes the entire tumor or abnormal area, maybe some normal breast tissue

80 to 85% of the normal breast is what kind of tissue?

adipose tissue

What is a Total or Simple mastectomy?

removal of the whole breast including the nipple, areola and most of the overlying skin, maybe lymph nodes

What are the advantages of core biopsies?

1. A clip can be placed during the procedure to mark the biopsy site 2. Gives important information about tumor type and grade 3. Can take multiple samples from tumor

What are the advantages of wire-detected excisional biopsy?

1. Accurate with few false negatives 2. Provides information about size, type, grade of tumor 3. Can be therapeutic

What are the modifiable risk factors of breast cancer?

1. Alcohol consumption. Those who consume 2-3 drinks a day increases risk about 20% compared to women who do not drink alcohol. 2. Obesity. Fat can produce estrogen. 3. Lack of physical activity

What are the high risk factors for breast cancer?

1. BRCA 1 or 2 gene mutation AND 1st degree relative 2. Personal history of invasive breast cancer OR ductal carcinoma in situ (DCIS), lobular carcinoma in situ (LCIS) or atypical hyperplasia 3. Other genetic mutations 4. Greater than 20% lifetime risk of invasive breast cancer based mainly on family history

What is the treatment/management of lobular carcinoma in situ (LCIS)?

1. Close monitoring w/ clinical breast exam every 6 to 12 months, mammogram, MRI 2. Excision biopsy 3. Reduce risk factors (lifestyle changes, adjuvant therapy) 4. Prophylactic bilateral mastectomy

How do we manage a fibroadenoma?

1. Core needle biopsy for confirmation 2. Observation for 3 to 6 months with a follow-up examination and ultrasound 3. Surgical excision if large, painful or anxiety-provoking

What are the non-invasive breast cancer types?

1. Ductal carcinoma in situ -- DCIS -- also known as intraductal carcinoma 2. Lobular carcinoma in situ -- LCIS -- also known as lobular neoplasia

How do we diagnose intraductal papilloma?

1. Ductograms x-rays of the breast ducts 2. Mammography mass or calcification 3. Sonography solid mass w/ cyst or dilated duct 4. Core needle biopsy (CNB)

What are the limitations of mammography?

1. False-negatives -- women w/ dense breast tissue 2. False-positives -- require extra testing, more common in women with denser breast tissue, highest risk in 1st ever mammogram 3. "Over diagnosis" 4. Radiation exposure

What are the non-modifiable risk factors for breast cancer?

1. Female sex; aging 2. Family history with gene mutations or 1st degree relative with breast or ovarian cancer. 3. Personal history of breast cancer. 4. Dense breast tissue 5. Certain breast conditions like atypical hyperplasia 6. Early menarche, before the age of 12 7. Late menopause, after age 55 8. Chest radiation for another cancer

What are the types of ultasound guided biopsies?

1. Fine needle aspiration (FNA) 2. Core needle biopsy 3. Stereotactic core biopsy

What are the indications for chemotherapy in a breast cancer patient?

1. Hormone receptor negative cancers 2. Tumors greater than 1 cm 3. Positive lymph nodes; high-grade disease (invasive) 4. Metastatic breast cancer 5. Inflammatory breast cancer

When is MRI used in breast cancer screening?

1. In women who have already been diagnosed w/ breast cancer 2. To measure the cancer, look for other tumors, or check for tumors on the opposite breast

What are the less common types of breast cancer?

1. Inflammatory breast cancer 2. Paget's disease

What are the invasive breast cancer types?

1. Invasive ductal carcinoma 2. Invasive lobular carcinoma

What are the benefits to an ultrasound-guided biopsy?

1. Less invasive than a surgical biopsy 2. Visually verify the sample being taken 3. Able to make a diagnosis from the sample 4. No exposure to ionizing radiation

What is ultrasound of the breast most useful for?

1. Looking at breast changes such as lumps, seen on mammogram 2. Evaluation of women w/ dense breast tissue 3. Guiding biopsy needles

What are the risks of lymph node removal in Axillary Node Dissection?

1. Lymphedema: swelling in the arm or chest on the ipsilateral side 2. Nerve damage: long thoracic nerve, thoracodorsal nerve

How can we educate patients on reducing the risk of breast cancer?

1. Maintain a normal weight. 2. Physical activity of 150 minutes of moderate or 75 minutes of vigorous activity weekly 3. Limit/avoid alcohol and smoking 4. Diet of fruits and vegetables 5. Breastfeeding for at least several months 6. Avoid hormone therapies for menopause symptoms

What is the management of atypical hyperplasia disease?

1. Mammograms and breast exams 2 times a year 2. Discontinue oral contraceptives and avoid hormone replacement therapies 3. Breast specialist referral

What does the Susan G. Komen Breast Cancer Foundation recommending for breast cancer screening on "high risk" individuals?

1. Mammography and MRI beginning at age 25 or based on age of earliest breast cancer in the family -- Family history and genetic mutation 2. Individual option to mammography prior to age 40 -- Family history with no genetic mutation

What are the risks of wire-directed excisional biopsy?

1. More invasive than non-surgical biopsy methods 2. More recovery time 3. Higher risk of infection and bruising

What are the 3 classifications of benign breast lesions?

1. Non-proliferative: simple breast cysts, fibrocystic breast changes 2. Proliferative without atypia: intraductal papilloma, fibroadenoma 3. Atypical hyperplasia: atypical ductal hyperplasia, atypical lobular hyperplasia

What are the risks associated with core biopsy procedures?

1. Possibility of missing the tumor on biopsy and taking normal tissue samples, leading to a false-negative 2. Surgical biopsy may still be needed

What are the limitations for an ultrasound-guided biopsy?

1. Possible to miss a lesion or underestimate extent of disease 2. Very small lesions difficult to target 3. Clustered calcifications are not shown as clearly on ultrasound versus x-ray

What are the 3 types of breast cysts?

1. Simple non-proliferative 2. Complicated 3. Complex

When is nipple discharge considered pathologic?

1. Spontaneous 2. Persistent 3. Arises from a single duct 4. Contains blood

What is the management for intraductal papilloma?

1. Surgical excision -- ductal excision 2. Discuss breast cancer prevention -- there's no increased risk w/ solitary papilloma

What is the significance of using radiation therapy after surgical excision of breast cancer?

1. To reduce the recurrence risk 2. Improve survival 3. Kill undetected cancer cells 4. Localized treatment if cancer has spread to other parts of the body (bones, brain)

Screening mammograms

1. Used to evaluate women with NO breast complaints 2. Pictures are taken from 2 angles

Diagnostic mammograms

1. Used to evaluate women with abnormal screening mammograms or specific breast complaints 2. May include additional views 3. Also used to screen women with a history of breast cancer

How many lobes of glandular tissue does the breast have?

12 to 20

What are the adult causes of gyecomastia?

25% Persistent from puberty 25% Idiopathic 10 to 25% Drugs -- including estrogen, spironolactone 8% Cirrhosis or malnutrition 3% Testicular tumors -- due to hCG secretion 1.5% Hyperthyroidism

At what BI-RADS score are we suspicious for malignancy?

4A, 4B, 4C

What is Breast-Conserving Therapy?

A partial mastectomy, lumpectomy or quadrantectomy surgery in which only the part of the breast containing the cancer is removed.

What is a fine needle aspiration (FNA)?

A type of biopsy in which a small needle is inserted through the skin to the site of an abnormal growth to collect and remove a sample of cells for analysis. Can choose without ultrasound guided if lump is easily palpated

When is radiation therapy initiated?

About 6 weeks after surgical scars have healed from initial cancer removal OR after chemotherapy is completed, if necessary

What are the grape-like clusters of tissue that secrete milk?

Alveoli cells

What organizations recommend annual mammograms starting at 40 years?

American Cancer Society American College of Radiology American Medical Association (AMA)

What organizations recommend women aged 40 to 49 to get a mammogram every 1 to 2 years, then annually after?

American College of Obstetricians and Gynecologist (ACOG)

What is the management for mastitis?

Antibiotics Continue nursing and pumping to clear clogged duct Warm compresses and massage to area

How are majority of breast cancers in the USA detected?

As a result of an abnormal screening study.

Proliferative without atypia is 1 of the 3 classifications of benign breast disease, what are the risks related to breast cancer?

Associated with a 1.5 to 2 times greater risk of breast cancer compared to general population

What is the BI-RADs score that we want to see for all of our patients after breast cancer screening?

BI-RADS 1; No abnormalities identified; Normal fat and fibroglandular tissue

What BI-RADS score tells us we know there is biopsy-proven carcinoma?

BI-RADS 6

What is gynecomastia?

Benign proliferation of the glandular tissue of the male breast.

What are the most common years we see fibrocystic breast changes?

Between 30 and 50 years of age

When are stereotactic core biopsies used?

Biopsy suspicious micro calcifications or smaller tumors that cannot be seen clearly on an ultrasound

What is the clinical presentation of mastitis?

Breast becomes hot, red, swollen and painful. Typically unilateral.

After the diagnosis of breast cancer what is used to figure out if cancer has spread, and if so, how far?

Breast cancer staging describes how much cancer is in the body at the time of diagnosis. Staging is used to discuss survival statistics.

What is the most common female cancer?

Breast cancer. The average age of women with breast cancer is 60 to 61 years. The highest incidence is among white patients.

Benign, smooth, well-defined; mobile

Breast cysts general physical exam findings

What are the surgical options for breast cancer treatment and management?

Breast-Conserving Therapy Mastectomy Axillary node dissection Breast Reconstruction

What is the treatment options for ductal carcinoma in situ breast cancer?

Breast-Conserving Therapy (BCS) Mastectomy Hormone therapy after surgery

Galactorrhea is considered physiologic nipple discharge frequently caused by what?

Caused by hyperprolactinemia, secondary to endocrine abnormalities, pituitary adenomas or medications.

What is the treatment for Inflammatory breast cancer?

Chemotherapy and surgery. Can get radiation following surgery.

When is the use of a fine needle aspiration (FNA) most appropriate?

Chosen when the lesion is suspected to be fluid-filled (cyst)

What are the suspensory ligaments called that support the breast in the upright position?

Cooper's ligaments

What is Paget's disease of the breast commonly misdiagnosed or treated as?

Dermatitis or infection

How is treatment of invasive breast cancer determined?

Determined by stage and hormone receptor status

How do we diagnose Paget's disease of the breast?

Diagnosed with biopsy of the lesion which will show carcinoma cells within the epidermis of the nipple

In what breast cancers is the Breast-Conserving Therapy frequently used?

Ductal carcinoma in situ (DCIS), Stage 1 and 2 cancers

What is the difference between gynecomastia and pseudo gynecomastia?

Due to enlargement of glandular tissue versus excessive adipose tissue

What breast cancers would be a good indication for the use of selective estrogen receptor modulators, SERMs?

ER+; invasive breast cancers, ductal carcinoma in situ (DCIS), and chemoprevention in high-risk patients

What is the clinical presentation of Paget's disease of the breast?

Eczematous rash or ulcer of the nipple or areola. Pain, itching, burning, erosion. 50% have an underling palpable mass.

At the time of presentation of inflammatory breast cancer what is likely the stage?

Either stage IIB or IV at time of diagnosis. Cancer has already invaded the skin and 35% usually have metastases

What does Tamoxifen increase a patient's risk for?

Endometrial cancer and clots due to increased estrogen activity outside of the breast

How do we best manage recurrent or symptomatic simple breast cysts?

Excision

True/False: Lipomas, Fat Necrosis and Hamartoma's can put an individual at risk for breast cancer and should be biopsied or removed.

False! All of these breast conditions are benign and do not increase risk for breast cancer, but they may need to be biopsied or removed.

True/False: If a patient uses SERMs as an adjuvant therapy for their breast cancer using a Aromatase Inhibitor is contraindicated.

False! Aromatase Inhibitors are used following tamoxifen course and have been shown to work better in prevention of recurrence when compared to use of tamoxifen alone.

True/False: Aromatase Inhibitors have just as many side effects as selective estrogen receptor modulators, SERMs.

False! Aromatase Inhibitors have fewer side effects than tamoxifen.

True/False: An Axillary Node Dissection (ALND) cannot be done at the same as mastectomy or breast-conserving surgery.

False! Axillary Node Dissection (ALND) can be done at same time as mastectomy or breast-conserving surgery.

True/False: Breast pain is not a sign of breast cancer.

False! Breast pain can be a sign of breast cancer if unilateral, focal and non-cyclical.

True/False: We only use chemotherapy for breast cancer AFTER surgical removal.

False! Chemotherapy can be used after surgery to kill cancer cells left behind; reduce recurrence and improve survival. OR chemotherapy can be used BEFORE surgery to shrink tumors that are too large to be removed at the time of diagnosis

True/False: Hamartoma's are benign and do not need excision.

False! Even though Harmartoma's are benign excision is recommended.

True/False: We don't need to investigate nipple discharge in galactorrhea because it is benign.

False! Even though benign, the underlying cause needs investigation. 1. Hyperprolactinemia -- prolactin level 2. Thyroid abnormality -- TSH or other endocrine abnormality with hypothalamus 3. Medications inhibiting dopamine -- examples include: metoclopramide, domperidone, haloperidol 4. Neurogenic stimulation

True/False: Fine needle aspiration (FNA) can distinguish between invasive and non-invasive breast cancer?

False! FNA cannot distinguish between invasive or non-invasive. May not be diagnostic

True/False: Symptoms of fibrocystic breast disease only last a few years and do not persist.

False! Fibrocystic breast disease is a benign diagnosis which warrants reassurance and symptomatic management. Symptoms may persist until menopause

True/False: Fibrocystic breast disease can lead to cancer.

False! Fibrocystic breast disease is non-proliferative and is not associated with increased risk of breast cancer.

True/False: Fibrocystic breast disease is not common.

False! It is common and affects more than 50% of women of reproductive age

True/False: Mammograms do not use radiation.

False! Mammograms do use radiation, but the risk of harm from screening mammograms is extremely low.

True/False: A woman needs 1+ of the factors that are considered "High Risk" for breast cancer in order to be in the high risk population.

False! Patient is considered high risk even if there is 1 high risk factor.

True/False: The BRCA1 and BRCA2 gene mutations that increase risk for breast cancer are not more common in certain ethnic groups.

False! The Ashkenazi Jewish population is at higher risk for the BRCA mutations.

True/False: There is evidence that supports screening for breast cancer between the ages of 40 and 49 years has benefit.

False! There is small benefit in screening ages 40 to 49. Evidence for benefit is 50 to 69 years. Decision to start screening earlier is individual per AAFP.

True/False: Intraductal papilloma's are non-proliferative benign breast lesions.

False! They are proliferative without atypia. They are associated with a 1.5 to 2 times greater risk of breast cancer compared to general population.

True/False: Lobular carcinoma in situ (LCIS aka lobular neoplasia) is breast cancer.

False! This breast change is NOT a cancer. Cells LOOK like cancer in the lobules of the milk-producing glands, but they do NOT grow through the walls of the lobules.

Name that benign breast condition: most commonly occurs following breast trauma or surgery. Tender, firm mass with indistinct borders

Fat Necrosis

27 year old female presents to the clinic with a firm, round, discrete, non-tender mobile mass in one of her breasts. The mass is between 1 and 5 centimeters in diameter. What do we think the diagnosis is?

Fibroadenoma

What is the most common cause of cyclic breast pain in reproductive age women?

Fibrocystic Breast Disease

Painful, often multiple, typically bilateral mobile masses in the breast that may fluctuate in size

Fibrocystic breast disease

A woman in her 30's presents to clinic with the complaint of feeling breast lumps after showers with palpation. She also reports that she has noticed before a rapid appearance and disappearance of a breast mass. Patient also reports that she notice these things at different points in her cycle, what do we think the diagnosis is?

Fibrocystic breast disease. The breast tenderness and proliferation of normal glandular tissue is mediated by estrogen and progesterone.

Typically bilateral milky discharge in a non-lactating breast

Galactorrhea

Non-proliferative is 1 of the 3 classifications of benign breast disease, what are the risks related to breast cancer?

Generally not associated with increased risk of breast cancer

What are the side effects of chemotherapy?

Hair loss; nausea, vomiting, fatigue, toxicity with neuropathies or cardiopathies, mouth sores, nail changes

Name that benign breast condition: a smooth, painless lump formed by the overgrowth of mature breast cells. May be made up of fatty, fibrous or glandular tissues. Excision is recommended.

Hamartoma

What is the single best screening procedure for the early detection of breast cancer?

Mammography

What is the treatment for Paget's disease of the breast?

Mastectomy or BCS followed by radiation

What is the prognosis of inflammatory breast cancer?

Median survival time of 21-57 months

Grade 2 breast cancer grading

Moderately-differentiated

If a female patient with a history of fibrocystic breast disease presents to clinic with the complaint of the appearance of noticing a dominant mass on the her breast what should we do?

Monitoring cysts is an important patient education point. The appearance of a dominant mass should be evaluated by biopsy.

How do we manage simple breast cysts (benign)?

No special management, can be aspirated if painful

Compared to a mastectomy, does the Breast-Conserving Therapy change long-term survival when paired with radiation?

No, the long-term survival is unchanged compared to mastectomy.

If a female in reproductive years presents with what we think is fibrocystic breast disease with breast pain, masses or lumps that fluctuate in size and multiplicity should we be concerned about carcinoma?

No. The pain, fluctuation in size and multiplicity should point us away from carcinoma.

Ductal carcinoma in situ (DCIS)

Non-invasive or pre-invasive 1 in 5 new breast cancers will be this type Stage 0 breast cancer; nearly all women can be cured!!! Over time may spread (become invasive) and could metastasize so most women are treated

What is our patient education for atypical hyperplastic disease?

Nutrition and lifestyle changes for risk mitigation. 1. Physical activity and weight reduction. 2. Plant-based diet, abstinence from smoking and alcohol. 3. Lower LDL levels and increase fiber intake. 4. Avoid melatonin suppression -- shift work, lights while attempting to sleep

Stage III breast cancer treatment

OPTION TO START WITH MASTECTOMY Chemotherapy +/- hormonal HER2 therapy (before surgery) BCS or mastectomy, if tumor still large lymph node biopsy/excision radiation + additional chemo after surgery Hormone therapy as appropriate (HER2+, ER+, PR+)

Why does gynecomastia occur?

Occurs due to increased levels of estrogen compared to androgens.

What is physiologic gynecomastia?

Occurs during the neonatal, pubertal and older males and generally resolves spontaneously.

What is mastitis often associated with?

Often associated with lactation, clogged milk ducts or bacterial infiltration into the breast tissue.

What is the clinical presentation of a breast abscess?

Palpable mass with local and systemic signs of infection. Patient can present with induration, redness, heat, fever, chills

What is the downside of Breast-Conserving Therapy?

Patient will still require radiation.

Identify the signs and symptoms of breast cancer

Photo signs and symptoms breast cancer

Grade 3 breast cancer grading

Poorly-differentiated. Faster-growing, more likely to spread.

When would the use of Aromatase Inhibitors be indicated in patients with breast cancer?

Post-menopausal ER+ breast cancer

What is the clinical presentation of inflammatory breast cancer?

Presents with breast swelling, erythema, pitting or thickening of the breast skin. Often no lump palpable. Rare and aggressive form of breast cancer.

What are the non-surgical options for breast cancer treatment and managment?

Radiation Chemotherapy Adjuvant therapy -- SERMs and Aromatase Inhibitors

When is screening with a MRI recommended?

Recommended in women with HIGH RISK for breast cancer in addition to mammogram. MRI will miss some cancers that mammography will find.

How do we manage complex breast cysts?

Refer for excision

What is a Radical mastectomy?

Removal of the ENTIRE breast including the nipple, areola, overlying skin, axillary lymph nodes AND the chest muscles under the breast (RARE to do, but will if cancer is spread to chest muscles)

What is a Modified Radical Mastectomy?

Removal of the entire breast including the nipple, areola, the overlying skin AND the lining over the chest muscles. Some of the axillary lymph nodes are excised as well.

How do we manage a breast abscess?

Requires surgical incision and drainage.

What are mammographies looking for?

Searching for calcifications, masses and breast density

What is Tamoxifen?

Selective Estrogen Receptor Modulator (SERM) usually taken 5-10 years

What are the types of Adjuvant therapy for breast cancer patients?

Selective Estrogen Receptor Modulators, SERMs and Aromatase Inhibitors

What would a complex breast cyst show on sonography?

Septa or intracystic masses

Asymptomatic and found on mammogram or palpable; Sonolucent, smooth margin

Simple Cysts (Breast Cysts)

What population does inflammatory breast cancer tend to occur in?

Slightly younger women, African Americans, overweight/obese

How do we diagnose and classify breast cysts?

Sonography

If fibrocystic breast disease is unclear based on history and physical exam, what can we use to help in guiding our diagnosis?

Sonography Aspiration Biopsy

What is a stereotactic core biopsy?

Special type of core needle biopsy that uses mammogram to take pictures from different angle to pinpoint biopsy site

What are the bacteria associated with mastitis?

Staphylococci, enterococci, anaerobic streptococci

What can we use to determine the prognosis of breast cancer after diagnosis?

The grade and stage

What is breast cancer grading?

The grade given to breast cancer cells when they are removed and analyzed with a microscope. The grade is dependent on how much the cancer looks like normal cells. The grades are 1 through 3. Low number = slow, less likely to spread High number = fast, more likely to spread

What is the clinical presentation of gynecomastia?

The presence of a concentric, rubbery to firm disk of tissue, often mobile, located directly beneath the areolar area of males.

What role does the breast exam play in breast cancer screening?

The utility of breast exam is debated. It is offered as adjunct to regular screening. Educate patients about limitations and self-breast exams.

What is the patient education point we want to communicate to a patient with complex fibroadenomas?

They are at a slightly higher risk for breast cancer compared to simple fibroadenomas.

Why do normal breast cells become cancerous and develop into breast cancer?

They become cancer due to DNA mutations. These can be inherited or acquired gene mutations. Most are acquired mutations.

What is the patient education point we want to communicate to a patient with simple fibroadenomas?

They have a slightly increased risk of breast cancer. About 1.5 times the risk of women with no breast changes.

What organization recommends biennial screening (every 2 years) mammography for women aged 50 to 74 years, category B?

U.S. Preventive Services Task Force -- USPSTF

What are the diagnostic options used in determining breast cancer?

Ultrasound guided biopsies and Wire-directed excisional biopsy

What is Paget's disease of the breast?

Underlying intraductal cancer growing into the skin of the nipple

What is a core needle biopsy?

Use of a wide, hollow needle to take out pieces of breast tissue. Needle attached to a spring-loaded tool that moves the needle in and out quickly. Can be used on palpable and non-palpable masses

When is the appropriate use of a core needle biopsy?

Used for large lesions or high suspicion of malignancy on imagining. Can also be used on micro calcifications without palpable mass

27 year old female presents to the clinic with a firm, round, discrete, non-tender mobile mass in one of her breasts. The mass is between 1 and 5 centimeters in diameter. What do we do next?

We think it's a fibroadenoma based on age and physical exam. Do imagining on mammogram or ultrasound. Will see benign characteristics of smooth, well-defined margins

Grade 1 breast cancer grading

Well-differentiated. Slow, less likely to spread

When is a wire-detected excisional biopsy performed?

When an abnormality is seen on mammography but is non-palpable.

If breast infections like mastitis or abscesses do not respond to antibiotic treatment what must we consider?

With no response to antibiotic treatment we must consider inflammatory breast cancer as a differential diagnosis.

Fibroadenoma's occur most frequently in what population?

Young women less than 30 years old

What is a Fibroadenoma?

a common, benign, painless, neoplasm/tumor containing glandular and fibrous tissue

Stage IV/Metastatic breast cancer treatment

cancer has spread beyond breast and lymph nodes hormone therapy, if appropriate, chemotherapy, surgery, radiation. Assess other organs for targeted radiation -- bones, liver, lungs, brain treatment is to shrink tumors, slow growth, improve symptoms and prolong survival

What is ultrasound best for differentiating?

cyst vs solid mass

What are the imaging options for breasts?

mammography, ultrasound, MRI

Lactiferous ducts unite to form a major duct that drains the lobes toward the what?

nipple-areolar complex