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Breast Medicine
Masses, Nipple d/c, Breast infx, Mastodynia/mastalgia
| Question | Answer |
|---|---|
| Breast masses ddx | simple cyst, fibrocystic condition, fibroadenomas, breast cancer |
| Nipple discharge ddx | galactorrhea, intraductal papilloma, carcinoma |
| Breast infections | mastitis, abscess |
| Mastodynia, mastalgia | cyclic, non-cyclic breast pain |
| Describe a breast mass | hard, firm, soft, mobile, non-mobile, tender, non-tender, defined border, diffuse border (cancer is usually non-mobile, diffuse border), location (clock position/quadrant, distance from nipple) |
| Evaluation of a breast mass | < 30 y.o. = sonogram; > 30 y.o. = mammogram |
| Cyst | fluid-filled sac, usually benign, most likely middle age |
| Cyst description | palpable, unilateral, soft or firm, mobile, round, often tender |
| Cyst diagnosis | sonogram or mammogram |
| Cyst treatment | aspiration (evaluate aspirate if bloody or turbid) |
| Cyst excision indications | rapid fluid re-accumulation (within 2 weeks), bloody aspirate, cyst recurrence after 2 aspirations, palpable cyst after aspiration |
| Fibrocystic breast disease/Fibrocystic condition | multiple cysts; breast tissue is fibrous, bumpy, and thickened; benign; middle age; rarely occurs postmenopausal (often disappears after menopause) |
| Fibrocystic breast disease/condition description | bilateral, symmetrical, clumpy, mobile, cyclic tenderness, cyclic breast changes |
| Fibrocystic breast disease/condition diagnosis | clinically, if in doubt use sonogram/mammogram, if still in doubt use FNA (fine-needle aspiration) |
| Fibrocystic breast disease/condition treatment | alleviate pain (ibuprofen, good-fitting bra) |
| Fibroadenoma | benign, young women |
| Fibroadenoma description | unilateral, round, firm, smooth, mobile, non-tender, 1 cm or larger |
| Phyllodes tumor | fast-growing adenoma, large (> 5 cm), requires excision |
| Fibroadenoma diagnosis | sonogram/mammogram, if in doubt use FNA |
| Fibroadenoma treatment | none necessary unless patient has FH of breast cancer or if phyllodes tumor develops |
| Breast cancer | malignant neoplastic disease |
| Breast cancer presenting s/s | breast mass (most common), nipple discharge, breast shape changes, skin changes, weight loss, fatigue, night sweats, anorexia |
| Breast cancer description | firm or hard, usually non-tender, non-mobile, unilateral, often difficult to distinguish from surrounding tissue |
| Breast cancer pathology (types) | infiltrating ductal carcinoma (80%), invasive lobular carcinoma (2nd most common), ductal carcinoma in situ (DCIS), lobular carcinoma in situ (LCIS) |
| In situ means: | confined to duct or lobe |
| Paget disease of the nipple | form of ductal carcinoma, epidermis of nipple is affected; scaling, erosion, crusting of nipple epidermis; discharge is common |
| Inflammatory breast carcinoma | aggressive; warm, erythematous, peau d'orange skin; palpable axillary lymph nodes; often misdiagnosed/treated as mastitis |
| New-onset breast mass in women > 50 y.o., suspect: | breast cancer (until proven otherwise) |
| Newly discovered breast mass or lump usually require: | diagnostic, directed, targeted mammogram or sonogram |
| BRCA 1 and 2 | tumor suppressor genes; mutation causes uncontrolled cell growth; 5-10% of breast cancers due to mutations at these genes; penetrance varies so cannot determine patient's risk simply from mutation |
| High RFs for breast cancer | > 50 y.o.; BRCA 1/2 genetics; 2 1st-degree relatives (premenopausal) with breast/ovarian cancer; 1 1st-degree relative (premenopausal) with bilateral breast cancer; personal breast cancer hx; atypical hyperplasia; high-dose radiation to chest |
| Moderate RFs for breast cancer | > 40 y.o.; 1 1st-degree relative w/breast cancer (esp. premenopausal or bilateral); 1st pregnancy > 34 y.o.; nulliparous; high breast tissue density; white race; hx of endometrial/ovarian/colon cancer |
| RFs for breast cancer | menarche < 12 y.o.; menopause > 55 y.o.; Jewish heritage; obesity; long-term use of HRT; high socioeconomic status; EtOH consumption |
| Breast cancer screening | (breast self-exams monthly); clinical breast exam q 3 years if 20-40 y.o. and q year if > 40 y.o.; mammogram q 2 years if 50-74 y.o. (or q 1-2 years > 40 and q year > 50) |
| Breast cancer screening if 1st-degree relative with premenopausal breast cancer | start screening q year 10 years before relative's age when diagnosed with cancer |
| Breast cancer treatment | if mammogram/sonogram is abnormal refer for biopsy (FNA, core); if mammogram is negative try sonogram and vice versa; TNM staging; lumpectomy, mastectomy, lymph node dissection, radiation, hormone therapy, chemotherapy, tissue-targeted therapy |
| Breast cancer hormone treatment | raloxifene, tamoxifen; only useful in hormone-receptor-positive breast cancer; should be prescribed for 5 years following initial treatment |
| Breast cancer chemotherapy | used if positive lymph nodes or if tumor > 1 cm |
| Nipple discharge | usually benign; yellow-tinged or serous d/c without red flags may be physiologically normal (with menses, OCPs, fibrocystic changes) |
| Nipple discharge red flags | bloody, unilateral, spontaneous, persistent, bloody, associated with a mass |
| Nipple discharge documentation | spontaneous/expressed, color, unilateral/bilateral, color, presence/absence of lymphadenopathy or mass, associated skin changes, hx of trauma |
| Most common cause of bloody nipple discharge | intraductal papilloma (benign), order mammogram & subareolar US |
| Intraductal papilloma | excise the duct (or, according to Mallory, "exorcise the duct!" ;) ) |
| Galactorrhea | spontaneous flow of milk |
| Galactorrhea causes | high blood levels of prolactin; pregnancy, pituitary tumor, hypothyroidism, excessive exercise, side effect of certain meds (meds that lower dopamine levels: antipsychotics, SSRIs, TCAs, verapamil, metoclopramide, etc.) |
| Galactorrhea diagnostic work-up | r/o pregnancy and meds; if both are negative check prolactin and TSH/T4; if thyroid is normal but prolactin is high then order MRI to check for pituitary tumor |
| Mastitis | inflammation of the breast, usually caused by Staph. aureus, common in breast-feeding women |
| Mastitis s/s | localized erythema, warmth, tenderness, lymphadenopathy, fever |
| Mastitis treatment | Dicloxacillin 500 mg bid x 10 years, hospitalize if severe s/s, continue to breast feed |
| Breast abscess | localized collection of pus, usually in blocked duct/galactocele, commonly Staph. aureus, may be associated with mastitis, (consider carcinoma if patient is not lactating) |
| Breast abscess treatment | Dicloxacillin 500 mg bid x 10 days; if MRSA is suspected then treat with Bactrim; I&D; biopsy may be necessary (if no prompt resolution or patient is not lactating) |
| Mastodynia/Mastalgia | breast tenderness, usually cyclic with menstrual cycle, increases with OCP or HRT |
| Mastodynia/Mastalgia treatment | NSAIDs, vitamin B6, tamoxifen, danazol, and/or well-fitted bra |
Created by:
Carrie D.
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