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.