Breast disorders

May offer every 1-3 years age 25-39

Annually ≥40

what is the ACOG recommendation for clinical breast exams

Begin at age 40

Screen every 2 years

Continue until age 74

for average risk women, what is the recommendation for screening mammography according to USPSTF

Reduce mammographic sensitivity

Increase cancer risk

May require supplemental imaging

risks associated with dense breasts

BRCA1/2 mutation

First-degree relative with BRCA mutation

Strong family history

Chest radiation before age 30

highest risk population for breast cancer

Mammography + MRI annually

Start:

Age 30 (or earlier depending on mutation)

recommendation to start mammography for high risk women

Annual MRI starting 25-29

Add mammogram at 30

breast cancer screening recommendations for women with BRCA gene

ultrasound first

recommendation for CC breast mass in pt under 30

Diagnostic mammogram + ultrasound

recommendation for CC breast mass in patient over 30

mobile, smooth, tender, soft

signs of a benign breast mass

fixed, irregular, non tender, hard

signs of a suspicious breast mass

core needle biopsy

first line if breast imaging is suspicious!

Bilateral

Multiple ducts

Milky/green/yellow

Expressed (not spontaneous)

signs of physiologic (benign) nipple discharge

Spontaneous

Unilateral

Bloody or clear

Single duct

signs of pathologic (concerning) nipple discharge

Intraductal papilloma

Cancer

common causes of pathologic nipple discharge

benign

most breast pain is

-prolactinoma

-hypothyroidism

-dopamine antagonist medications

causes of hyperprolactinemia

Mammary duct ectasia

Periductal mastitis (if inflamed)

most common cause of green or yellow nipple discharge

mammary duct ectasia

A condition in which there is dilation of the lactiferous duct, caused by stagnation of cellular debris. Occurs in women who have lactated. Signs of duct ectasia can include nipple retraction, inversion, pain, and sometimes a bloody discharge.

-green/yellow discharge

30-50 years old

Often premenopausal

patient population associated with intraductal papilloma

intraductal papilloma

Spontaneous unilateral nipple discharge

Often bloody or serous

Usually single duct

May not feel a mass

Bloody discharge from single duct when expressed

Usually non-tender

physical exam findings associated with intraductal papilloma

intraductal papilloma

Most common cause of bloody nipple discharge in middle-aged women.

fibrocystic changes

Cyclic breast pain

Worse before menses

Bilateral symptoms

Fluctuating lumpiness

Teens-20s

typical patient with fibroadenoma

Fibroadenoma

most common benign solid tumor in young women

fibroadenoma

Young woman + mobile rubbery mass =

Firm

Smooth

Well-circumscribed

Highly mobile ("breast mouse")

Non-tender

physical exam findings associated with fibroadenoma

breast carcinoma

most common cancer in women

Age >50

Family history

BRCA

Dense breasts

primary risk factors of breast carcinoma

breast carcinoma

hard, fixed, irregular mass = _______ until proven otherwise

staph aureus

most common organism of mastitis

mastitis

Fever + breastfeeding + red tender breast =

intraductal papilloma

small subareolar mass

skin dimpling

Skin overlying a tumour. Not a change over the full breast

peau d'orange

orange peel appearance of breast due to edema

vertical strip pattern

most validated palpation technique for breasts

Anechoic (black)

Round or oval

Well-circumscribed margins

Thin wall

No vascular flow on doppler

ultrasound findings of a simple breast cyst

simple breast cyst

smooth walls, anechoic, posterior enhancement

If asymptomatic → reassurance

If painful → aspiration

management of a simple breast cyst

Palpable mass

Nipple discharge

Abnormal screening result

Focal pain

indications for diagnostic mammography

0: need additional imaging

1: negative (routine screening)

2: benign (routine screening)

3: probably benign

4: suspicious--> biopsy

5: highly suggestive of malignancy (biopsy)

6: known cancer (surgical planning)

BI-Rads categories of mammography

3

what Bi-Rads score indicates need for repeat imaging in 6 months

4 and 5

Bi-Rads scoring necessitating biopsy

spiculated

a ______ mass on mammography is highly concerning

benign

coarse calcifications on mammography indicate

coarse calcifications

benign calcification

fine pleomorphic calcifications

These guys are not good

You can count them, they have variable shape, and are usually SMALLER than 0.5 mm

If you see these in a linear or a segmental distributiont hen BIRADS 5

DCIS

linear branching calcifications on mammography indicate

Provides histology

Determines receptor status (ER/PR/HER2)

Less invasive than excisional biopsy

-FNA not preferred

why do we do core biopsies for breast masses

Inject radioactive tracer ± blue dye near tumor

Tracer travels to first draining lymph node

Surgeon removes sentinel node

Node examined for metastasis

how is a sentinel lymph node study performed