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Breast Disease

Gynecology

QuestionAnswer
Spontaneous bloody, serous, or cloudy nipple discharge Intraductal papilloma
Breast mass, nipple retraction, bloody nipple discharge Breast cancer (mass is most common presenting clinical manifestation)
Br Ca: estrogen receptors All invasive lobular and 2/3 of ductal ca are est rec pos
Br Ca typical presentations single nontender firm immobile mass; 45% in UOQ, 25% nipple
Br Ca increases risk of: endometrial ca, and vice versa
Breast exam: lymph nodes Axillary, supraclavicular, and infraclavicular lymph nodes
Polythelia = supernumerary nipples
Duct ectasia = widening of breast ducts; in pts near/past menopause; thick sticky discharge and/or itching around nipple
Fat necrosis Firm round lump; often d/t MVA or trauma
Most common breast complaint = mastalgia (benign breast pain); assoc w/hormonal changes; teens & 40s, usu ends w/menopause
Most common benign breast tumor: Fibroadenoma: hormone influenced abnormal growth of fibrous & ductal tissue. AA women; teens/20s; rapid growth during PG
Fibroadenoma assessment Discrete lump: firm, rubbery, round, mobile, non-tender, smooth, solitary. Usually in UOQ, 1-5 cm
Peau d'orange is associated with: Inflammatory breast ca
Ductal BrCa types In Situ; Invasive; Inflammatory
Lobular BrCa types In situ; Invasive, predominantly in situ; Invasive
Nipple BrCa types Paget disease with intraductal carcinoma. Paget disease with invasive ductal carcinoma
Mastalgia: firstline tx Sports bra, NSAIDs, reduce caffeine & fat in diet, warm compress, avoid premenstrual Na
Fibroadenoma Tx Excision of mass; monitor
mastodynia tx reassurance, vit B6, bromocriptine, tamoxifen, or danazol
mastitis tx cloxacillin, dicloxacillin, or nafcillin; or ceph. May continue breastfeeding
Breast cancer mgmt lumpectomy = mastectomy (partial or radical) re: survival, if f/u w/xrt; poss adjuvant CT; tamoxifen if est-rec pos or postmenopausal
30 – 50 yo female, painful, multiple, bilateral breast masses that increase in pain and size before menses = Fibrocystic breast disease
Mammography: when (ACS) 20-39 yo: q 3 yrs; annual at 40 (average risk); high risk: 5 yrs before age of 1st degree relative dx; individualize for older pt
Mammography: when (USPSTF) 50-74: biennial; <50: individual
CBE: PE Dimpling; Color changes; Retraction; Skin thickening; Pronounced/ recent asymmetry; Spontaneous nipple discharge
BSE recommendations ACS: BSE is an option starting in pts' 20s; USPSTF: Grade D (no benefit)
Mastalgia: secondline tx Suppress ovulation
Most common benign breast condition: Fibrocystic changes; grainy, palpable, small lumps; 30-50 y.o.; mobile, well defined; bilateral, UOQ; tender last half of cycle; dx w/bx
If find mass on CBE: Order a diagnostic mammogram (not screening), unless age <30, then order U/S
Fibroadenoma may grow rapidly during: pregnancy
Fibroadenoma Dx FNA; Cyto study of bloody fluid or solid tumor aspirate; U/S to differentiate solid from cystic mass; definitive dx by excisional bx and tissue exam
Paget dz of breast: progression Begins in breast duct and spreads to nipple and areola; usually occurs w/ infiltrating ductal breast cancer
BrCa RF Genetics (BRCA1&2). FH; PMH/SH, prior abnormal breast bx. Diet may reduce risk. Age (60 yo ave onset). Nulliparous, early menarche, late menopause, delayed childbearing. LT estrogen
BrCa Lifestyle factors No kids/lactation; HRT; Mod to heavy alcohol; Obesity/ high fat diet; Sedentary lifestyle; OCP use?
Malpractice suits: due to failure to: recommend screening; follow-up on or verify woman’s complaints; follow-up on an abnormal clinical breast exam
Age <30 yo, palpable lump, still there after menses, order: unilateral breast U/S
Age > 30yo, palpable lump, order: Unilateral dx mammogram & U/S. If c/w fibroadenoma, FNA or aspiration: excision if change in lesion
Palpable lump, age > 40 yo & due for screening mammo: get mammogram on unaffected side at same time
BI-RADS category 0-4: Needs additional imaging evaluation
BI-RADS category 4: Suspicious abnormality
BI-RADS category 6: biopsy-proven malignancy
Women at high risk (greater than 20% lifetime risk) should get: an MRI and a mammogram every year
Yearly MRI screening is not recommended for women whose lifetime risk of breast cancer is: less than 15%
Congestive breast disorder clinical features bilateral breast pain / swelling (2/2 engorgement) 2-3 days postpartum, low fever, axillary LAD
Mastitis clinical features Unilateral breast pain, fever, chills, tender, erythema, 1 week postpartum.
Clinical breast exam At least Q3 years in pt 20-39 yo, annually after 40 yo
Mammogram guidelines USPSTF: baseline at 50 yo, then QOYr until 74 yo. Begin at age 40 only in pt with RF. ACS: annual starting at 40 yo
BrCa Risk Factors >50 yo. PMHx or FH BrCa. BRCA 1 or 2 gene. Postmenopausal obesity. EtOH. Early menarche / late menopause. Nulliparity >30 yo
Fibrocystic disease sx/sx Bilateral breast involvement; multiple smooth lumps +/- discharge
Polypoid epithelial tumors arising in ducts = Intraductal papilloma (usually solitary; diffuse lesions have increased risk of BrCa)
Stromal tissue with epithelium-lined ductlike structures and absence of elastic tissue = Fibroadenoma
Br Ca stats 11% of US women. AA>white if <40 yo, reversed >40 yo. Whites higher incidence but AA higher mortality. Most are invasive adenocarcinomas: 80% infiltrating intraductal, 10% infiltrating lobular
Types of infiltrating intraductal Br Ca Papillary, intraductal, medullary
Br Ca mets Spread by vascular and lymphatic routes. Adenocarcinomas to bones, lungs, liver, brain. Lobular to meninges, peritoneum, pleura, ovaries, mediastinal, retroperitoneal LNs
Br Ca workup Mammogram. MRI for high-risk pt. FNA. Open bx is definitive. Resection of primary tumor & ipsilateral LN for staging. CXR, bone scan, CT for further dx
Br Ca mgmt Lumpectomy vs mastectomy; +/- post-op XRT. Hormonal tx in mets dz or adjuvant (tamoxifen) in early dz in postmenopausal. Targeted therapy (trastuzumab, lapatinib) in HER2-positive dz. Bisphosphonates for bony mets pain
Created by: Abarnard