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Flashcards in Breast Disorders Deck (54)
1

1. Adult female breast is actually a what?

2. Histologically primarily composed of:
4

1. modified sebaceous gland, located within the superficial fascia of the chest wall.

2.
-Lobules or glands
-Milk ducts
-Connective tissue
-Fat

2

1. Younger breasts are predominately made of what tissue?

2. Glands are replaced by ______. This process accelerates with ________?

3. What are key components of breast cancer detection programs? 2

1. glandular tissue.

2. fat, menopause.

3.
-Differences in palpable consistency and
-in radiographic density between the glands and fat are

3

1. Organized into 15 to 25 lobules, with a disproportionate amount of the glandular or lobular tissue present in the _______ _______ quadrants of each breast.

2. Lobules consist of clusters of _____________ arranged in an alveolar pattern and surrounded by _______________?

3. Glands drain into a series of collecting _________ that course through the breast.

4. Come together into approximately _______ collecting ducts that lead to and drain at the nipple.

1. upper outer

2. secretory cells, myoepithelial cells.

3. milk ducts

4. five to ten

4

1. What can go wrong with connective tissue? 2

2. Fat tissue problems?

3. Duct system issues? 3

1. Connective tissue
-Fibrocystic changes
-Fibroadenomas

2. Fat tissue
-Necrosis from trauma or may harbor lipomas

3. Duct system
-May become dilated
-Contain papillary neoplasms
-Undergo malignant transformations

5

Rich blood supply
1. Blood supply from where? 5

2. Huge lymphatic system
Superficial and deep nodal chains throughout the trunk and neck, including those located in the what? 3
(Support _________ and overall breast health)

1.
-internal mammary artery,
-lateral thoracic artery,
-thoracodorsal artery,
-thoracocramial artery,
-intercostal perforating arteries

2.
-axilla,
-deep to the pectoralis muscles
-and caudal to the diaphragm
(milk production)

6

1. Breast tissue is very sensitive to hormonal changes, especially the glandular cells.
-Circulating levels of what? 2

2. What is also responsible for the changes that occur during the normal menstrual cycle and for symptoms often reported by patients receiving hormones in pharmacologic doses?

1. estrogen and progesterone


2. Tissue responsiveness to circulating hormones

7

1. During each menstrual cycle, breast tissue tends to _____ from changes in the body’s levels of estrogen and progesterone.

2. The milk glands and ducts enlarge, and in turn, the breasts __________.

3. During menstruation, breasts may temporarily feel what? 4

4. We recommend that women practice monthly breast self exams when?

1. swell

2. retain water

3.
-swollen,
-painful,
-tender, or
-lumpy.

4. the week following menstruation when the breasts are least tender.

8

Risk factors for breast cancer?

1. Age (most significant)
2. Family history
3. Race
4. Genetics
5. Early menarche
6. Late menopause
7. Increased exposure to estrogen
8. Use of estrogen
9. Nulligravid state
10. First pregnancy after age 35
11. Fibrocystic conditions, when accompanied by proliferative changes.
12. Cancer in one breast
13. Endometrial Cancer
14. Not breastfeeding
15. Hx of epithelial hyperplasia with atypia
16. Exposure to ionizing radiation or to other carcinogens.
17. Certain dietary factors (fat, ETOH)

9

Where are most breast cancers found?

Upper outer quadrant
(lots of lymphdrainage there)

10

What patients with family history are at risk for breast cancer?
6

1. 1st degree relative significantly increases risk (sister, mother)
2. Two or more relatives with breast or ovarian cancer
3. Breast cancer occurring in an affected relative younger than 50 years
4. Relatives with both breast cancer and ovarian cancer
5. One or more relative with 2 cancers (breast and ovarian cancer or two independent breast cancers)
6. Male relatives with breast cancer

11

1. Race: Who is more likely to get breast cancer?


2. What nationality would have the highest risk?

1. Caucasian more likely, although incidence in black women is increasing.

2. Individuals of Ashkenazi Jewish descent have a 2-times greater risk.

12

1. Early menarche is a risk factor: before what age?

2. Late menopause: after age what?

1. under age 12

2. After age 50

13

1. Increased exposure to estrogen is a risk factor: What would cause this? 2

2. Use of estrogen therapy is a risk factor: What specifically would make you at risk? 2

1. Increased exposure to estrogen
-Obesity
-Persistent anovulation

2. Use of estrogen therapy
-BSO before age 35 with HRT
-Postmenopausal tx with HRT, especially high doses of estrogen and use of progesterone.

14

1. BRCA 1 and BRCA 2 are what kind of genes?

2. Function? 2

3. Directly involved in repair in what?

4. Mutations that occur with BRCAs to cause cancer? 3

5. What do the mutations result in? 2

1. Tumor suppressor genes.

2.
-Prevent cells from growing and dividing too rapidly or in an uncontrolled way.
-Inhibits the growth of cells that line the milk ducts in the breast.

3. Directly involved in the repair of damaged DNA.

4. Mutations is these:
-disrupt protein production, resulting in an abnormally small, nonfunctional version of the BRCA2 protein.

-change one of the protein building blocks (amino acids) used to make the BRCA proteins.

-defective BRCA protein is unable to help fix damaged DNA.

4.
-Results in the build up of mutations.
-Causes cells to divide in an uncontrolled way and form a tumor.

15

1. Harmful BRCA1 mutations may also increase a woman’s risk of developing the following cancers (in addition to breast ca)? 4

2. Harmful BRCA2 mutations may also increase the risks of? 4

1.
-cervical
-uterine
-pancreatic
-colon cancer

2.
-pancreatic CA
-stomach CA
-gallbladder and bile duct cancer
-melanoma

16

1. Men with harmful _______ mutations also have an increased risk of breast cancer and, possibly, of pancreatic cancer, testicular cancer, and early-onset prostate cancer.

2. However, male breast cancer, pancreatic cancer, and prostate cancer appear to be more strongly associated with ________ gene mutations .

1. BRCA1


2. BRCA2

17

Breast Cancer mass characteristics
7

1. Solitary nodule
2. Non-tender
3. Firm to hard
4. Ill defined margins
5. Not mobile
6. Skin nipple retractions
7. Axillary lymphadenopathy


Remember, a good number of breast masses are found by mammogram with no palpable mass.

18

Breast Care Guidelines from the ACS
1. Women ages _______ should have the choice to start annual breast cancer screening with mammograms (x-rays of the breast) if they wish to do so.

2. Women age _______ should get mammograms every year.

3. Women ________ should switch to mammograms every 2 years, or can continue yearly screening.

4. Screening should continue as long as a woman is in good health and is expected to live how long?

1. 40 to 44

2. 45 to 54

3. 55 and older

4. 10 more years or longer.

19

What is the most frequent lesion of the breast?

Fibrocystic change

20

1. Fibrocystic change represents what?

2. Common ages?

3. Rare in who?

4. How will the mass present?

5. Exacerbated by what?

1. Represents an exaggerated physiologic response to a changing hormonal environment.


2. Common in women 30-50 years old.

3. Rare in postmenopausal women who are NOT taking HRT.

4. Painful mass which often exacerbates or increases in size during the premenstrual phase of the cycle.

5. Exacerbated by ETOH

21

Physical presentation of fibrocystic conditions?
5

1. Often multiple, usually bilateral masses
2. Rapid fluctuation in size is common
3. Painful and tender
4. Pain occurs or increases during the premenstrual phase of the cycle
5. Size increases during the premenstrual phase of the cycle.

22

Specific diagnostics and treatments: Fibrocystic changes?
8

1. Reexamine patient at intervals
(Negative cyst that does not resolve over several months may need to be excised.)

2. Reassure patient that discomfort is not a sign of cancer

3. Symptoms usually improve with the cyclical decrease in hormonal stimulation

4. Use support bra

5. Vitamin E supplements

6. Avoid chocolate, alcohol, and caffeinated beverages.

7. Teach and encourage monthly BSE.

8. May need to be biopsied.

23

Fibroadenoma:
1. What is it?
2. Can occur in what pattern and which is indicitive of cancer?
3. Occurs most frequently in who?
4. Tends to occur early in what population?
5. Women over ____, need to distinguish from fibrocystic change or cancer.

1. Benign neoplasm made from an overgrowth of glandular and fibrous breast tissue.

2. Can occur alone, in groups or as complex. Complex fibroadenomas can raise risk of breast cancer slightly

3. Occurs most frequently in young women, usually within 20 years after puberty. Clinical diagnosis is not difficult.

4. Tends to occur at an earlier age in black women.

5. 30

24

Physical presentation
Fibroadenoma?
7

Fibroadenoma
-Round or ovoid
-Non tender
-Smooth margins
-Rubbery
-Discrete
-Relatively movable
-1-5cm in diameter

25

Fibroadenomas: Specific diagnostics 3



Rx?
4

Fibroadenomas
1. Ultrasound can distinguish cystic. Fibroadenomas show up well on ultrasound.
2. FNB can confirm cytology.
3. Teach and encourage BSE.

1. Since fibroadenomas are benign, treatment will vary depending on the diagnosis.
2. If it is small, painless, remains the same size, and a biopsy shows no problems, further treatment not needed but likely follow-up ultrasounds.
3. If it is large (more than 3cm), painful, growing, or a biopsy results in atypical cells, the tumor can be removed.
4. It is recommended that fibroadenomas be removed in women over age 40.

26

If rapidly growing need to rule out what?

phyllodes

27

Two key differences between fibroadenomas and phyllodes tumors are?

1. phyllodes tumors tend to grow more quickly and
2. develop about 10 years later in life — in the 40s as opposed to the 30s. These differences can help doctors distinguish phyllodes tumors from fibroadenomas.

28

History we need for patient with a breast lump?
8

1. Age of patient (already have)
2. Disease History
3. Family History
4. Medication History
5. Onset of menarche
6. LMP
7. Where are you in your cycle?
8. Onset of Menopause

29

1. What on social history would be pertinant info for a breast mass? 2

2. Ingestion habits? 2

3. Previous pregnancies? 4

4. Have you had a mammogram? 1

5. Exams? 2

1. Social habits
-ETOH
-Smoking

2. Ingestion habits
-Caffeine
-High fat

3. Previous pregnancies
-How old were you with your first pregnancy?
-Was it term?
-Abortions?
-Did you breastfeed?

4. Have you ever had a mammogram?
0When was the last time you had a mammogram?

5. Exams
-How often do you do breast self exam?
-When was the last time you had an exam by a provider?

30

HPI questions to ask about a lump?
6

1. When did you discover this lump?
2. Is it only in one breast?
3. Where is it located?
4. Is there any pain or tenderness associated with this lump?
5. Is there any correlation between the mass and your menstrual cycle?
6. Any discharge from the nipple?
How does it feel?

31

1. What characteristics suggests a benign process? 3

2. Finding what kind of mass if breast cancer until proven otherwise?

3. What can of women have difficult breasts to examine? 2

4. When is the ideal time for a breast exam?

1.
-Easy mobility within the breast,
-regular borders and a
-soft or cystic feel all suggest a benign process, although this is not totally reliable.

2. Finding of a DOMINANT mass is considered cancer until proven otherwise.

3. Young women with
-multiple nodules and
-diffuse thickening consistent with fibrocystic change have difficult breasts to evaluate.

4.
The ideal time for the breast examination is seven to nine days after a period.

32

Who is US imaging the preferred examination for? 3

Ultrasonography
is preferred if a
1. palpable mass is found,
2. if a patient is younger than 30 years, or
3. if the patient is pregnant.

33

1. US can differentiate between what types of masses?

2. Why is this important?

3. US is also used for what?

1. Can differentiate a cystic from a solid palpable mass.

2. This distinction is important because cysts are usually not treated, but a solid lump must be biopsied to rule out cancer. In a breast biopsy, a piece of the lump is taken out and tested for cancer.

3. US is also used for guidance for needle localization if mass is not palpable, but found on mammogram.

34

1. Who is mammography the preferred method of imaging for? 3

2. Sensitivity is much reduced in who?

3. Usually follow-up with ___ if determination between cystic and solid mass is needed.

1. Mammography -
-if the patient has a palpable mass, is
-older than 30-35 years, and is
-not pregnant.

2. Sensitivity is much reduced in
-younger or denser breasts; therefore, mammography is considered inappropriate in patients younger than 35 years.

3. US

35

What are the kind of biopsies for breast masses?
3

1. Fine Needle Aspiration

2. Core Needle Aspiration

3. Excisional Biopsy

36

Fine Needle Aspiration
1. Uses what kind of needle?

Core needle aspiration
2. What needle?

3. What is the only definitive dx of breast cancer?

1. Uses small gauge needle (21-25) to make multiple passes of solid and cystic masses with cytologic exam of material aspirated.

2. Uses large gauge needle (14-18) to obtain tissue

3. Excisional Bx
-Only definitive diagnosis of breast cancer
-Often therapeutic without additional surgery.

37

A 24y/o female complains of sore nipple with redness and tenderness on her left breast. This is her first baby and she is worried about this condition. She says she is having a hard time nursing from that breast due to the discomfort.
What do you think the dx is?

Mastitis

38

Symptoms of Mastitis?
6

1. Breast tenderness or warmth to the touch
2. Generally feeling ill (malaise)
3. Swelling of the breast
4. Pain or a burning sensation continuously or while breast-feeding
5. Skin redness, often in a wedge-shaped pattern
6. Fever of 101 F (38.3 C) or greater

39

Mastitis Presentation
4

1. Unilateral
2. Most frequently begins within 3 months after delivery
3. May start as a sore or fissured nipple.
4. May have a lump if starting to form an abscess

40

Mastitis Treatment
1. What bug is the culprit?
2. Abx? 2
3. Other treatments? 2
4. Failure to respond to treatment in 3 days should prompt what?

1. Staph aureus is the culprit.
2. Antibiotics against PCN-resistant staph:
-Dicloxacillin or a
-cephalosporin (Keflex) for 5-7 days.

3.
-Regular emptying of the breast by nursing followed by expression of any remaining milk by hand or with a mechanical suction device.
-Warm compresses to breast.

4. Failure to respond within 3 days should prompt consideration of resistant staphylococci. (MRSA)

41

1. If the Mastitis is MRSA what should you do?

2. Delay in treatment could cause what?

1. Pt may need to be admitted for IV therapy.

2. Delay in treatment could result in breast abscess.

42

Mastitis Prevention
5

1. Breastfeed equally from both breasts.
2. Empty breasts completely to prevent engorgement and blocked ducts.
3. Use good breastfeeding techniques to prevent sore, cracked nipples.
4. Avoid dehydration by drinking plenty of fluids.
5. Practice careful hygiene:
Handwashing
Cleaning the nipples
Keeping the baby clean.

43

1. What is a breast abscess?
2. Bug?
3. Early stage tx?
4. Later? 3

1. Area of redness, tenderness and induration on breast during nursing or otherwise.

2. Staph Aureus is likely the culprit.

3. Early stages of infection can be treated while nursing from that breast, but if infection not controlled within 24 hours, an abscess may form

4. If abscess progresses,
-surgical drainage is performed and
-nursing is D/C’d.
-Patient likely admitted for IV therapy and I&D.

44

What is the most common cause of spontaneous nipple discharge from a single duct?


Intraductal papilloma

45

1. What is an intraductal papilloma?

2. What can it cause?

3. What are they composed of? 2

4. What age most commonly?

5. What can the discharge look like? 3

1. An intraductal papilloma is a tiny wart-like growth in breast tissue that sometimes punctures a duct.

2. can cause benign nipple discharge.

3. Benign tumors that are composed of
-fibrous tissue and
-blood vessels that grow inside milk ducts

4. Occurs most often in women ages 35 – 55.


5. Discharge can be
-serous,
-bloody or
-cloudy
ONE NIPPLE ONLY

46

Intraductal Papilloma
What are the two types?

What is the one related condition?

Two types, and one related condition:
1. Solitary intraductal papillomas
2. Multiple papillomas

3. Papillomatosis

47

Intraductal Papilloma
Describe the following:
1. Solitary intraductal papillomas 3
2. Multiple papillomas 4

3. Papillomatosis 3

1. –
-one lump,
-usually near a nipple,
-causes nipple discharge

2. –
-groups of lumps,
-farther away from a nipple,
-usually doesn't cause discharge, and
-can't be felt

3. –
-very small groups of cells inside the ducts,
-a type of hyperplasia,
-more scattered than multiple papillomas

48

Intraductal papilloma tests?
3

Tx?

1. A breast biopsy to rule out cancer.
2. An examination of the discharge to see if the cells are cancerous.
3. An x-ray with contrast dye injected into the affected duct (ductogram)


1. The involved duct is surgically removed and the cells are checked for cancer.

49

Causes of nipple discharge
7

1. Papilloma
2. Premenopausal Women- spontaneous
3. Prolactinoma
4. Oral Contraceptive Agents
5. Abscess
6. Medications
7. Hypothyroidism

50

1. What would make nipple discharge suspicious to us? 7

2. not suspicious?
6

1. Suspicious
-1 breast
-1 duct
-Associated with a lump
-Leaks out on it’s own
-Most days of the month
-Watery or bloody (red, brown or black)
-A lot

2. Not Suspicious
-Both breasts
-Several ducts
-Squeezing brings it on
-Occasional
-Different colors (green, yellow, white)
-A little

51

What is breast tenderness usually related to? 1

Could be associated with? 2

1. Usually related to fibrocystic changes

1. May be associated with breast cancer
2. May be related to dietary habits

52

What foods may be related to breast tenderness?
3

1. caffeine
2. chocolate
3. salt

53

Evaluation of Breast Tenderness
Breast examination checking for? 5

1. areas of tenderness
2. mass
3. trauma (bruising)
4. nipple discharge

5. US/Mammogram, if necessary

54

Treatment of Breast Tenderness
5

When should you recheck if symptoms do not resolve?

1. NSAIDS
Eliminate:
2. caffeine
3. chocolate
4. salt
5. Monthly SBE


1. Return for recheck if symptoms do not resolve within 1-2 months