TCP Week 1 (Breast Conditions)

lymphatic drainage of the breast

Lateral breast (mostly upper outer quadrant) --> axillary LN (75%)

Medial breast --> internal mammary/Parasternal LN and or posterior intercostal LN

Lymphatic Drainage of the Breast - why it matters?

Primary route for breast cancer metastasis

Determines clinical staging (N stage)

Guides sentinel lymph node biopsy (SLNB) and axillary lymph node dissection (ALND)

m/c LN drainage in the breast? levels 1-3?

Axillary Nodes (≈75%) (Most common drainage)

- Level 1 : lateral/inferior to pectoralis minor

- Level 2: posterior to pectoralis

- Level 3: medical/superior to pectorals minor

other LN drainage of the breast (aside from axillary)?

Internal Mammary Nodes (≈20%)

Along the internal mammary vessels More common with medial breast tumors

Supraclavicular/Infraclavicular Nodes

Secondary drainage pathway Involvement indicates more advanced nodal disease

Contralateral Breast & Abdominal Nodes (

Upper outer quadrant tumors most commonly metastasize to?

Medial tumors have greater likelihood of?

-Upper outer quadrant tumors most commonly metastasize to axillary lymph nodes

-Medial tumors have greater likelihood of internal mammary node involvement

Positive lymph nodes are one of the strongest predictors of?

Positive lymph nodes are one of the strongest predictors of prognosis and adjuvant therapy

Mastitis

define and patho

Inflammation of the breast, usually in breastfeeding/ lactating woman.

PATHOGENESIS: Unknown/poorly understood. Milk stasis, ductal narrowing, nipple trauma

INFECTIOUS mastitis

etiology? presentation?

• S.Aureus (MC)

• Unilateral breast pain, warmth, erythema, tenderness, swelling +/- flu like symptoms

infectious mastitis treatment

Supportive (warm compresses), continue to breastfeed/pump

+/- antibiotic (dicloxacillin)

CONGESTIVE mastitis

sx? tx?

• Bilateral breast pain & swelling.

• Tx: Supportive, NSAIDS, Tylenol

• Lactation specialist consult

Breast Abscess

define and RF

Helps with differentiation mastitis from breast abscess. Usually, a complication of lactation mastitis

RF: first pregnancy, smoking, >30

(also, non-lactating breast abscess)

Breast Abscess... If no improvement in 48-72 hours consider ?

ultrasound!

tx of breast abscess

I&D, needle aspiration

ABX: dicloxacillin or clindamycin

fibroadenoma epi

MC in late teen/early 20's

Benign solid tumors containing glandular/fibrous tissues

fibroadenoma presentation

CM: smooth, non-tender, mobile lump in breast

Can grow over time

Doesn't get bigger nor smaller with menstruation

dx of fibroadenoma

Usually clinical, can biopsy or u/s

If confirmed fibroadenoma then leave it alone

tx of fibroadenoma

Observation, can reabsorb

fibrocystic changes

what is it? s/sx?

Cyst in breast tissues that response to hormones

Change in size with menstrual cycles

Multiple tiny lumps, tender

dx of fibrocystic changes

U/S

FNA (Straw-colored fluid)

tx of fibrocystic changes

Observation

NIPPLE DISCHARGE/GALACTORRHEA

types and workup

Lactation (pregnancy)

Physiologic

Pathologic

physiologic nipple discharge

Galactorrhea, usually bilateral

Clear, yellow, green but no bloody

R/O endocrine disorder (hyperprolactinemia)

pathologic nipple discharge

Usually unilateral, clear, yellow/green, bloody discharge

Benign: papilloma, duct ectasia, mastitis

Cancer

nipple discharge color

WHITE, CLEAR, OR CLOUDY

Breastfeeding, Galactorrhoea, Hypothyroidism, Prolactinoma

nipple discharge color

yellow

YELLOW: Hormonal Fluctuations, Infection

nipple discharge color

GREEN, BROWN, OR BLACK

Duct Ectasia, Intraductal Papilloma

nipple discharge color

RED, PINK, OR BLOODY

Intraductal Papilloma, Breast Cancer

gynecomastia

A non-cancerous condition that causes abnormal breast tissue growth in boys and men, resulting in enlarged breasts. It's caused by an imbalance of estrogen and androgen hormones, and can affect one or both breasts, sometimes unevenly

causes of gynecomastia

Drug Induced

• Anti-androgens: spironolactone, finasteride

Hormonal imbalance

gynecomastia tx

Stop causing agent

Hormonal therapy (referral to endocrine)

Surgery

fat necrosis of the breast

Benign

Usually from breast trauma or surgical

dx of fat necrosis

Mammo & U/S (Oil cyst) or biopsy

tx of fat necrosis

Observation

- Excision is not recommended

- No increased risk of cancer

disorders of augmented breats: breast implant illness (BII)

- Anecdotal reports suggest a potential link between silicone gel implants & systemic illnesses, known as BII.

- Consider periodic breast imaging for symptomatic patients, & explanation if desired.

- no significant evidence supporting a link between breast implants & systemic illness

- may be related to allergies, but further research needed.

- Studies on sx relief post-explantation are inconclusive

anaplastic large cell lymphoma (BIA-ALCL)

- FDA reports from 2011-2019 highlight the association with textured implants.

- In 2019, the FDA recalled certain textured implants due to increased BIA ALCL risk

- No recommendation for removal in ASX women with these implants.

squamous cell carcinoma (BIA-SCC)

- Reported in capsule surrounding breast implants (textured or smooth).

- Limited experience suggests it's an aggressive pathology.

- Mortality rate is high compared to BIA-ALCL

MAMMOGRAM 2016 USPSTF (2023 IN PROGRESS)

Women ages 50-74: Biennial (every 2 years) screening mammography is recommended (Grade B).

Women ages 40-49: The decision to begin screening before age 50 should be individualized based on patient values, risk factors, and potential benefits/harms (Grade C)... more on this in slides

BI-RADS categories

FNA

biopsy - helps us identify things like straw colored fluid (fibrocystic changes)

BREAST CANCER

types

Ductal Carcinoma

Lobular Carcinoma

Paget's-Inflammatory

presentation of breast CA

Breast Mass Hard, fixed usually painless, non-mobile lump +/- lymphadenopathy

Unilateral nipple discharge

MC found in the upper outer quadrant

ductal carcinoma types

Infiltrative ductal carcinoma

Ductal carcinoma in situ (DCIS)

Infiltrative ductal carcinoma

IDC is the most common type of breast cancer!

Arises from the milk ducts within the breast tissue.

Can infiltrate nearby tissues and potentially spread to other parts of the body.

Ductal carcinoma in situ (DCIS)

DCIS is a non- invasive form of breast cancer where abnormal cells are found in the lining of a breast duct but have not spread outside the duct. No invasion of the basement membrane Considered stage

Lobular carcinoma in situ (LCIS)

Not a cancer it's a proliferation of cells limited to the breast ducts and lobules

Not associated with increased density or lump, usually diagnosed incidentally on biopsy.

Increases risk of becoming a cancer.

Infiltrative lobular carcinoma

type of lobular carcinoma

DCIS, LCIS, & other breast cancers (chart overview)

Paget carcinoma

Paget's disease of the Breast (PDB) is rare form of breast cancer that affects the skin of the nipple and areola

presentation of Paget's disease of the Breast (PDB)

persistent itching, burning, or pain in the nipple area

eczematous, flaking, or crusting of the skin on the nipple or areola

inflammatory breast carcinoma (IBC)

rare, aggressive breast cancer

rapid onset and distinct clinical features

presentation of IBC

- redness, swelling, warmth, and "peau d'orange" (orange peel) appearance of skin from lymphatic destruction

- lacks palpable lump, difficult to detect

treatment of breast cancer

chemo/radiation: pending staging and patho

hormone tx:

- tamoxifen (ER positive): blocks estrogen receptors in breast tissues, increase risk of endometrial cancer

- aromatase inhibitor: letrozole (ER positive) reduces estrogen

- monoclonal Ab tx: herceptin (HER positive), can cause cardiotoxicity, need ECHOs

mastectomy

surgical removal of the breast

treatment and prevention

reconstruction can be done - expanders

genetic mutation

BRCA1 mutation carriers - risk of?

breast CA - 72%

ovarian CA - 44%

genetic mutation

BRCA2 mutation carriers - risk of?

breast CA - 69%

ovarian CA - 17%

genetic mutation

Li-Fraumeni/TP3

lifetime CA risk approaching 100%

breast 50% by the age of 60 y/o

genetic mutation

PTEN/Cowden

increased risk of uterine, breast (40-50%), kidney, thyroid, and GI

BRCA gene mutation increases risk of which types of cancer?

pancreatic, breast, and ovarian cancer

A 35-year-old woman presents with a milky discharge from both breasts that has been occurring for the past six months. She is not pregnant and is not currently breastfeeding. What is the most appropriate next step in her management?

A) Initiate hormonal therapy

B) Order a prolactin level

C) Refer to a breast surgeon

D) Perform a mammogram

B) Order a prolactin level

if positive = brain MRI for adenoma

A 22-year-old male presents with bilateral breast enlargement & tenderness that has been present for past 3 months. His physical examination reveals no other abnormalities. Which of the following is the most common cause of gynecomastia in this age group?

Medication side effect

Hormonal imbalance related to puberty

Testicular cancer

Liver disease

Medication side effect

A 32-year-old breastfeeding woman presents with a painful, swollen area on her left breast. Examination reveals a fluctuant mass with overlying erythema. What is the most appropriate initial treatment for this condition?

a. Oral antibiotics alone

b. Needle aspiration of the abscess

c. Immediate surgical intervention

d. Observation & supportive care

b. Needle aspiration of the abscess

bc it is fluctuant (movable).... sign of abscess

A 28-year-old woman who has been breastfeeding for the past 2 weeks presents with a fever, chills, and localized redness and warmth in her right breast. What is the most appropriate treatment for acute mastitis?

a. Antifungal therapy

b. Oral antibiotics & cont. breastfeeding

c. Surgical incision and drainage

d. High-dose corticosteroids

b. Oral antibiotics & cont. breastfeeding

A 52-year-old woman presents with a painless, firm, immobile breast mass in the upper outer quadrant. What is the most appropriate initial diagnostic step?

Breast MRI

Mammo w/ u/s

Surgery

FNA

Mammo w/ u/s

Which receptor status is associated with the worst prognosis?

A) ER-positive, PR-positive, HER2- negative

B) Triple-negative

C) HER2-positive only

D) ER-positive, PR-negative, HER2- positive

B) Triple-negative