Concerning symptoms on breast examination?
breast lumps or mass
breast pain or discomfort
nipple discharge
What are breast cancer risk factors?
Female > 40 Genetic mutations BRCA1 and or BRCA2 First degree relatives with early age dx of breast cancer PMH of breast cancer High breast tissue density High dose radiation to chest High bone density (postmenopausal) Late age of first pregnancy >30 Early menarche 55 No full term pregnancy Never breast fed a child Recent oral contraception use Recent and long term use of hormonal replacement therapy PMH of endometrial, ovarian or colon cancer Ashkenazi Jewish ancestry
How and when to screen for breast cancer?
Mammogram
- Women 50-74 years, bienially
- Women under 40- shared decision making, if high risk factors
- Women over 75- on an individual basis
Who should get an adjunct MRI?
A BRCA1 or BRCA2 mutation
- A first-degree relative (parent, sibling, child) with a BRCA1 or BRCA2 mutation, even if they have yet to be tested themselves
- A lifetime risk of breast cancer that has been scored at 20 - 25% or greater
- Had radiation to the chest between ages 10 - 30
- Has high genetic syndrome or first degree relative with high risk syndrome such as; Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba
- Extremely dense breast or unevenly dense breast on mammogram
What 4 positions are needed to inspect the breasts?
- sitting arms to the side
- sitting arms above the head
- sitting arms pressed against hips
- sitting arms pressed against hips leaning forward
Peau d’orange
- literally means orange peel skin
- hair follicles look like little dimples, texture is similar to an orange
- Caused by cutaneous lymphatic edema
- Seen with inflammatory breast cancer
What needs to be inspected on the nipple?
- size
- shape
- direction
- rashes
- discharge or ulceration
- inspect for inversion
- inspect for asymmetry of direction
How will breast tissue finding differ based on age group?
Young: dense
Middle: glandular, nodular,
Older: fat
If any lumps are present, what should you note?
- Location- by clock and cm from nipple
- Size- in cm
- Shape- round, disk-like, irregular in contour
- Consistency- soft, firm, hard
- Delimitation- well circumscribed or not, can you feel the edges?
- Mobility- in relationship to the skin and chest wall, fixed usually means cancer
- Tenderness
- Lymphadenopathy
What are the common lesions for breast masses in 15-25 year olds? What are the characteristics?
Fibroadenoma
- smooth, rubbery, round, mobile, non-tender
What are the common lesions for breast masses in 25-50 year olds? What are the characteristics?
Cysts- soft to firm, round, mobile, tender
Fibrocystic changes- nodular ropelike
Cancer- irregular, firm, maybe mobile or fixed to surrounding tissue
What are the common lesions for breast masses over 50 year old? What are the characteristics?
Cancer until proven otherwise
irregular, firm, maybe mobile or fixed to surrounding tissue
What are the common breast masses in pregnant/lactating women?
Lactating adenomas, cysts, mastitis and cancer
Glactorrhea: definition and causes
nipple discharge
- White/milky- less concerning
- Spontaneous/bloody/pus/unilateral- associated with a mass
- Causes- meds (haldol, anti-depressants) or over stimulation
Where are the central nodes?
high in middle of axilla, receives from other nodes
Where is the pectoral (anterior) node?
along the lateral edge of the pectoralis major muscle, just inside the axillary fold
Where is the subscapular node?
along the lateral edge of the scapula, deep in the posterior axillary fold
Where is the lateral node?
along the humerus bone, inside the upper arm
Paget’s disease of the nipple
Uncommon form of breast cancer
- Starts as a scaly, eczema-like lesion
- may crust, weep or erode
- may have breast mass
- suspect Paget’s disease if dermatitis persists
Mastitis
inflammation of the breast tissue/gland
- common when breast feeding
- warm, tender, painful breasts
- tx: antibiotics
Gynecomastia
- Proliferation of breast glandular tissue in men due to increase ratio of estrogen to androgen activity
- Normal if: resolves after puberty, monitor it
- Causes include:
Persistent pubertal
Drugs
Idiopathic
Hypogonadism
Hyperthyroidism
Testicular tumor
Monilial Intertrigo
- Candida infection
- Occurs between the fold of the breast and other skin. Often seen in older obese women.
- Can be related to an underlying condition such as diabetes or pregnancy.
Fibrocystic Breast Disease
- Age 30-50, regress after menopause except with estrogen therapy
- Single or multiple
- Round
- Soft to firm, usually elastic
- Well delineated
- Mobile
- Often tender
- Fluctuate with menses
Fibroadenomas
- Age 15-25
- Usually puberty and young adulthood, but up to age 55
- Usually single, may be multiple
- Round, disc-like, or lobular
- May be soft, usually firm
- Well delineated
- Very mobile
- Usually non-tender
