Nonproliferative breast
This breast lesion is very common, especially in premenopausal women, can be related to the menstrual cycle and is associated with breast tenderness
What are fibrocystic changes?
This lesion is the MCC of blood nipple discharge
What is intraductal papilloma?
These are generally not concerning but can harbor DCIS; may be a solitary lesion or multiple.
Proliferative lesions w/out atypia in general have a small risk of developing CA (approx 1.5 to 2x that of the general population)
Frequently occurs in lactating individuals. Presents as a painless subareolar mass.
What is galactocele
This is the #1 choice of abx for uncomplicated lactational mastitis (no allgs)
Dicloxacillin
this is diagnosed clinically; will present with edematous/erythematous breast typically unilateral, may experience flu-like symptoms and reactive LAD
For BRCA 1 we recommend BSO between age _ and _
For BRCA 2 we recommend BSO between age _ and _
1. What is between age 35-40
2. What is between age 40-45
This can occur following trauma to the chest, or can also occur after breast surgery such as reconstruction, or radiation therapy
What is fat necrosis?
This is the MC benign breast tumor (1/2 of all breast biopsies)
What is fibroadenoma?
This is composed of glandular and fibrous tissue, will present as a well defined and mobile mass on examination
1. Reassurance +/- physical support (bra), tylenol, NSAIDS
(more placebo than anything these have been long in practice and are not harmful for your patient: limiting caffeine, and evening primrose oil)
2. w/ mastalgia refractory to 6mo of conservative tx rec tamoxifen-->adminster only during luteal phase to minimize androgenic SE; could also exchange for Danazol but worse SE profile
3. if on HRT or cOCP, decrease or DC HRT/decrease estrogen concentration in OCP
-would also accept bromocriptine for #3 although it is less effective than Danazol and has poor SE profile (dizziness/HAs)
A woman is diagnosed with mastitis. She is prescribed an antibiotic. She is still experiencing symptoms however her fever begins to improve. Should she continue to breast feed?
Yes, with mastitis your patient should continue breastfeeding
Rare cancer. 1-4% of all breast cancers. May present with nipple ulceration, erythema, and pruritus. This may be confused with eczema on examination. 50-60% of the time presents with palpable breast mass. Occassionally bloody discharge may be present. Is typically unilateral.
What is Paget's disease?
This is associated with underlying breast cancer (DCIS) 85-88% of the time (meaning DCIS has invaded the stroma as well)
DX can actually be made with punch bx because the paget cells will be within the epidermis
This is a benign mass that is composed of mature fat cells. It does not contain histologic elements of the breast. These can be present elsewhere on the body. Dx can be confirmed on core or excisional biopsy
What is a lipoma?
This is a proliferation of uniform epithelial cells with round nuclei filling part of the duct but not all OR if it does fill the entire duct it measures less than 2mm. This shares cytologic features with low grade DCIS.
What is atypical ductal hyperplasia (ADH)?
Standard of care after biopsy is surgical excision due to risk of upgrade to ductal carcinoma
A 15 year old patient is being seen in your office for nipple discharge. She reports it is clear/white in color and has been produced by both breasts. On exam it is reproducible. She has no breast masses and no bloody discharge. Should you order a breast US?
No. The patient has no palpable masses. She has physiologic discharge (galactorrhea). She should be evaluated for ^prolactin (any psych meds?), endocrine tumors like pituitary adenoma, pregnancy test, and thyroid function
This breast DO is more common in middle aged/perimenopausal women. Smoking and parity are risk factors. On mammography it will present as micro-calcifications. Patients may experience nipple discharge (typically unilateral--may be bloody or green), nipple inversion, a palpable subareolar mass, noncyclical mastalgia, or infection.
What is mammary duct ectasia?
This condition does not require surgery and can be managed conservatively
Malignant proliferation of cells within the ducts that does not cross the basement membrane. Does not usually present with a mass. May see calcifications on mammography. Treatment is typically breast conserving excision (lumpectomy) w/ postop radiation and Tamoxifen
What is DCIS?
This accounts for 25% of all breast cancers. Core stereotactic biopsy is preferred for dx, FNA is insufficient as it cannot distinguish between invasive and in situ disease. There is 20-30% upstaging risk at the time of surgery
Patient complains of mastalgia. This is noncyclical in nature. On exam she has tenderness with palpation and has a palpable cord noted. This is erythematous with linear skin dimpling.
What is Mondor disease?
Superficial thrombophlebitis if the lateral thoracic vein.
-when this is diagnosed, age-appropriate breast imaging should be performed d/t increased risk of cancer
-otherwise tx is conservative involving NSAIDs and supportive care
This is monomorphic evenly spaced dyshesive cells that fill part of the lobule but may also involve ducts. This is usually found incidentally on breast biopsy performed for other reasons.
What is atypical lobular hyperplasia (ALH)
This in contrast to ADH, is rarely upgraded <3% of the time. Thus incidental ALH does NOT require surgical excision
Does ACOG recommend our patients perform self breast exams? What about clinician breast exams?
1. No ACOG does not recommend 2/2 the false positive rate and subsequent invasive/expensive evaluation that often ensures. However should have breast self-awareness
2. Shared decision making. May be offered to average risk women. Uncertainty regarding benefits in this patient population. If performed, recommend every 1-3 yrs age 25-39 and annually after 40. In high risk women it should be performed AND in women with symptoms
A 35 year old woman is diagnosed with mastitis. She is prescribed dicloxaccilin 2 weeks ago without relief. Last week she was transitioned to broad spectrum antibiotics and still does not have adequate treatment response. On exam she has skin edema of the left breast with warmth and erythema. The erythema involves >1/3 of her breast tissue. She is tender to palpation but has no palpable masses. You are able to express blood from the nipple. She does not have a fever.
What is inflammatory breast cancer?
This is a rare form of advanced invasive carcinoma of the breast. Clinical features include skin edema (peau d'orange), pts may have breast mass but our pt did not in this instance. If breast mass is present it grows rapidly. Many women will have axillary LAD and 1/3 will have distant mets at time of diagnosis
-Think of IBC in a patient with rapidly progressive breast inflammation who does not improve with abx
-These patients should undergo mammogram and ultrasound, however a core needle biopsy is needed for dx
A patient comes into your office and would like to know the difference between a BIRADS score of 0 and 1. She says she got these numbers on 2 different mammograms recently and would like to know the difference. What is BIRADS 0 vs BIRADS 1?
BIRADS 0=incomplete, pt needs additional scans to further evaluate
BIRADS 1=negative 0% likelihood of malignancy-->pt can resume routine screening mammos annually
BIRADS 2=benign, rest same as 1
BIRADS3 =probably benign, rec short interval f/u 6mo; <2% likelihood of malignancy
BIRADS 4=suspicious, needs tissue diagnosis
4A low suspicion-- >2 but <95% chance of malignancy
4B moderate-- >2 but <10% chance of malignancy
4C-high- >50 to <95% chance of malignancy
5 highly suggestive, needs tissue, >95% chance
6 known bx proven CA, needs surgical excision
This is a rare inflammatory disease of the breast: it usually presents as a painful, firm, and ill-defined mass that can have erythema and edema of the skin
What is idiopathic granulomatous mastitis?
This is almost always an incidental finding diagnosed on breast biopsy performed for other reason, such as an area of fibroadenoma or fibrocystic change. Most of the time it is not picked up on clinical PE or mammo. On histo it presents as a noninvasive lesion arising from the lobules and in the terminal ducts of the breast
What is lobular carcinoma in situ? (LCIS)
Mean age at diagnosis: 44-46yo, 80-90% occur in premenopausal women. LCIS cells are strongly estrogen receptor (ER) positive. B/l breast involvement 20-40% of the time. LCIS is detected w/ concurrent invasive CA ~5% of the time. Unlike DCIS, LCIS is usually NOT considered a precursor lesion to breast CA
3 forms
-Classic (has signet ring cells), pleomorphic, florid
-surgical excision is recommended for any nonclassical LCIS
(this is a Dr. Marcus question) This tumor was given its name because when viewed under a microscope the tumor cells appear in a leaf-like pattern
*****DAILY DOUBLE****
What is a phyllodes tumor?
'Phyllon' is Greek for leaf
Phyllodes tumors of the breast are uncommon fibroepithelial tumors (0.3-0.5% of breast tumors). These can be benign however have capability to develop into sarcoma (only 5% of cases). Median age at presentation is 40. Presents as a single enlarging breast mass, typically bigger than other fibroadenomas but similar characteristics. Will be firm, circumscribed and mobile. Excisional biopsy is most appropriate to accurately diagnose with a wide margin >1cm
Describe the treatment/steps for a lactational breast abscess
&
and do these patients require IV ABX?
1. clinically diagnose
2. ultrasound (can also utilize to guide drainage)
3. drainage: needle aspiration vs surgical drainage
4. continue antibiotics: ABX can be PO/outpt unless hemodynamically unstable otherwise pt can continue docloxacillin (no RF for MRSA), or clinda if allg; Bactrim for non severe infxn with MRSA, or if severe hemodynamic instability-->IV vanco
Name MC RF for breast cancer (14 possible answers, will give points for 7/14)
1. family hx or breast, ovarian, or hereditary syndrome
2. known gene mutation [BRCA higher in Ashkenazi jewish population]
3. prior biopsy with abnml path such as ALH ADH LCIS
4. early menarche
5. late menopause
6. nulliparity
7. never breastfed
8. HRT with estrogen AND progesterone (decreased risk w/ estrogen alone)
9. old age
10. obesity
11. alcohol
12. smoking
13. dense breasts on mammo
14. prior exposure to high dose chest radiation