Normal and Abnormal Breasts

Question 1

What is a part of the normal anatomy of the breast?

Answer 1

• Modified sebaceous gland
• Composed of glands, milk ducts, connective tissue and fat
• 12-20 lobes with disproportionate amount of glandular tissue in the upper outer quadrants
• Lobules consist of clusters of secretory cells lined with myoepithelial cells
• Rich in blood supply and lymphatic systemic

Question 2

What is estrogen responsible for in the breast?

Answer 2

• Growth of adipose tissue and lactiferous ducts

Question 3

What is progesterone responsible for in the breast?

Answer 3

• Stimulation of lobular growth and alveolar budding

Question 4

What are some congenital anomalies of the breast?

Answer 4

• Absence of the breast
• Accessory breast tissue along the milk line
• Extra nipples (polythelia)
• Accessory breast (polymastia)

Question 5

What are the two most common complaints with the breast?

Answer 5

• Breast pain

- Mass

Question 6

What is needed from the patient history when they come in for breast complaints?

Answer 6

• Location
• Duration
• Nipple discharge
• Changes in size
• Associated with menstrual cycle
• Risk factors

Question 7

What are some risk factors for breast cancer?

Answer 7

• Age
• Personal history of breast, endometrial, or ovarian cancer
• History of atypical hyperplasia
• High breast tissue density
• First degree relatives with breast or ovarian cancer
• Early menarche
• Late cessation of menses
• No term pregnancies
• Never breastfed
• Recent and long term use of OCPs
• Postmenopausal obesity
• Height (tall)
• High socioeconomic status
• Ashkenazi jews

Question 8

What is done during the PE for a breast exam?

Answer 8

• Evaluate both breasts
• Complete exam including axilla and chest wall
• Palpable mass always gets a biopsy

Question 9

What are some diagnostic tests done for a breast complaint?

Answer 9

• Mammogram
• U/S
• MRI
• Fine needle aspiration
• Core biopsy

Question 10

What are some details about a mammogram?

Answer 10

• Able to detect lesions about 2 years before they become palpable
• Densities and calcifications are suspicious findings and clinically inapparent masses of less than 1 cm can be detected

Question 11

Who is a mammogram best used for?

Answer 11

• Women 40 years and older

Question 12

What does a screening mammogram look like?

Answer 12

• No complaint/concerns

- 4 images: 2 craniocaudal and 2 mediolateral, can be done by standard radiograph versus digital enhancement

Question 13

What does a diagnostic mammogram look like?

Answer 13

• Done in women with a complaint or palpable mass or to adjunct an abnormal screening mammogram
• Contralateral breast should be imaged at same time

Question 14

What are some details about ultrasound?

Answer 14

• Useful for evaluating inconclusive mammogram findings
• Allows to differentiate between cystic versus solid lesions as well as show solid tissue within or adjacent to a cyst that may be malignant
• May be used when performing core needle biopsies

Question 15

Who is an ultrasound best used for?

Answer 15

• Women under the age of 40 and others with dense breast tissue

Question 16

What are some details for an MRI?

Answer 16

• Useful adjunct to diagnostic mammography in suspicious masses
• Used post cancer diagnosis for further evaluation of staging

Question 17

Who is an MRI best used for?

Answer 17

• Women at high risk for breast cancer like BRCA carriers

Question 18

What is a fine needle aspiration biopsy?

Answer 18

• Useful for determining solid versus cystic mass
• Done in office
• Aspiration using 22-24 gauge needle
• Return for clinical breast exam in 4-6 months if cyst completely disappears with aspiration

Question 19

What is done with the results from a fine needle aspiration biopsy?

Answer 19

• Clear fluid: no further evaluation

- Bloody fluid: sent for cytology and patients need a diagnostic mammogram/US

Question 20

What happens if the cyst reappears or does not resolve with aspiration?

Answer 20

• Diagnostic mammogram/US and perform biopsy

Question 21

What is a core needle biopsy?

Answer 21

• Uses a large needle (14-16 gauge)
• Used to get tissue from larger solid masses for diagnosis
• 3-6 samples about 2 cm long are obtained

Question 22

What are some types of mastalgia?

Answer 22

• Cyclic
• Noncyclic
• Extramammary

Question 23

What is cyclic mastalgia?

Answer 23

• Breast pain that starts at the luteal phase of the menstrual cycle and ends after onset of menses

Question 24

What is noncyclic mastalgia?

Answer 24

• Not associated with menstrual cycle
• Due to tumors, mastitis, cysts
• Could be associated with meds like antidepressants, antihypertensives, hormonal meds

Question 25

What is extramammary mastalgia?

Answer 25

- Pain due to chest wall trauma, shingles, fibromyalgia

Question 26

What are some treatment options for mastalgia?

Answer 26

- Danazol: side effects basically make the pt more masculine - SERMS (tamoxifen): increased risk of hyperplasia and DVT - OCPs may help - Symptoms relief: properly fitting bra, weight reduction, exercise, decrease caffeine intake

Question 27

What are some details with nipple discharge?

Answer 27

- Usually benign - Could be sign of endocrine disorder or cancer - Unilateral or bilateral, color, consistency, spontaneous, or expressed all give clues

Question 28

What does bloody nipple discharge indicate?

Answer 28

- Cancer until proven otherwise - Concern for intraductal carcinoma or invasive ductal carcinoma - Could be benign intraductal papilloma

Question 29

How is bloody nipple discharge evaluated?

Answer 29

- With breast ductography and requires ductal excision

Question 30

What are some concerns for breast malignancy?

Answer 30

- Greater than 2cm - Immobility - Poorly defined margins - Firmness - Skin dimpling/retraction/color changes - Bloody nipple discharge - Ipsilateral lymphadenopathy

Question 31

What are the three categories of breast masses?

Answer 31

- Non proliferative- RR of developing cancer is 1.0 - Proliferative without atypia- RR 1.5-2 - Proliferative with atypia- RR 8-10

Question 32

What are fibrocystic changes seen in nonproliferative breast masses?

Answer 32

- Spectrum of changes observed in the normal breast present in about 50% of women

Question 33

What is adenosis?

Answer 33

- Lobular growth with increased number of glands

Question 34

What is lactational adenomas?

Answer 34

- Due to hormonal response

Question 35

What are fibroadenomas?

Answer 35

- Most common benign tumor in female breast - Solid, rubbery, mobile, and typically solitary - Usually 2-4 cm but could reach 15 cm which causes in increased risk of cancer

Question 36

Who usually presents with fibroadenomas?

Answer 36

- In late teens or early 20s

Question 37

What is a galactocele?

Answer 37

- Cystic dilation of duct filled with milky fluid - Occurs near time of lactation - Secondary infection may produce acute mastitis

Question 38

How is a galactocele treated?

Answer 38

- Typically can be needle aspirated

Question 39

What are some details about proliferative without atypia breast masses?

Answer 39

- Usually not palpable- found on imaging - Epithelial hyperplasia - Sclerosing adenosis - Complex sclerosing lesions - Papillomas

Question 40

What is epithelial hyperplasia?

Answer 40

- Overgrowth of cells that line the ducts

Question 41

What is sclerosing adenosis?

Answer 41

- Increased fibrosis within breast lobules

Question 42

What are complex sclerosing lesions?

Answer 42

- Tubules trapped in a dense stroma surrounded by radiating arms of epithelium

Question 43

What are papillomas?

Answer 43

- Intraductal growths - Typically seen in women 30-50 - Cause serous or serosanguinous discharge

Question 44

What happens in proliferative breast masses with atypia?

Answer 44

- Malignant cells replace the normal epithelium lining the ducts or lobules (carcinoma in situ) - Lobular carcinoma in situ (LCIS) - Ductal carcinoma in situ (DCIS)

Question 45

What is LCIS?

Answer 45

- Not a precursor to breast cancer but risk factor for developing breast cancer

Question 46

What is DCIS?

Answer 46

- Ducts are filled with atypical epithelial cells and women are increased risk for developing invasive disease or reoccurrence of DCIS

Question 47

How are LCIS and DCIS treated?

Answer 47

- With excision and then followed with treatment with selective estrogen receptor modulators

Question 48

How is age a risk factor for developing breast cancer?

Answer 48

- Majority occur after 50 | - Caucasian women at greater risk except black women less than 45 are at greater risk

Question 49

How does family history and genetics affect developing breast cancer?

Answer 49

- Women with first degree relatives with breast cancer have a 1.5 higher risk - BRCA genes - BRCA1: women have up to a 72% lifetime risk for developing breast cancer and the mutation rarely causes cancer in men - BRCA2: women have a 69% chance of developing cancer and men have a 6.8%

Question 50

How can radiation exposure affect developing breast cancer?

Answer 50

- >20 cGy | - Time to develop lesion from exposure is 5 to 10 years

Question 51

What is the Gail model for breast cancer risk?

Answer 51

- Usefulness decreased in second degree relatives with breast cancer - Falsely elevated in patients with multiple breast biopsies - Women considered high risk are counseled on prophylactic therapy

Question 52

What is the most common breast cancer?

Answer 52

- Ductal: most common in women in their 50s and spreads to regional nodes

Question 53

What does the treatment options for breast cancers depend on?

Answer 53

- Depends on stage and use receptor status in addition to staging to determine prognosis (estrogen, progesterone)

Question 54

What are some treatment options for breast cancer?

Answer 54

- HER2/NEU (oncogene)- worse prognosis and is found in 20-30% of invasive cancers - Surgical therapy: lumpectomy with radiation or mastectomy (outcomes are equal)

Question 55

What medical therapy is used for breast cancer?

Answer 55

- Adjuvant therapy is used in all stages which reduces risk of recurrence by 1/3 and reduces death by 30% - Chemotherapy kills cancer cells - Hormonal therapy: antagonizes to estrogen, reduces risk of cancer in bilateral breast - Aromatase inhibitors: prevent production of estrogen in postmenopausal women - Trastuzumab: acts on protein made by HER2/NEU