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Breast Medicine

Masses, Nipple d/c, Breast infx, Mastodynia/mastalgia

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.