GYN- Breast

How does insulin affect the breast?

promotes growth

What can in excess of insulin / insulin resistance increase the risk of?

Estrogen dependent breast cancer

What influences development of the breast during puberty?

Hypothalamus, anterior pituitary, ovaries, insulin, thyroid hormone

What happens in pre-menopausal women 3-4 days before menses?

2nd inc of estrogen & progesterone peak mid leutal phase → fuller, tender, sensitive breasts & nipples

estrogen: breast ductal enlargement & water retention

progesterone: inc proliferation of mammory/alveoli cells → swelling of milk ducts

What happens to the breasts after menstruation?

Cellular proliferation regresses and water is lost

How are the breasts affected during pregnancy?

Cellular proliferation occurs under influence of estrogen, progesterone, placental lactose, prolactin, hCG

What happens to the breasts at delivery?

Dec estrogen and progesterone & lactation occurs under influence of prolactin

What happens to the breasts after menopause?

Involution/shirnkage occurs due to progressive loss of estrogen and glandular tissue; “fatty replacement”

What tool?

• breast CA assessment tool

• considers age, menarche, age at first live birth, # first degree relatives w/ breast CA, # previous biopsies, & presence of atypical hyperplasia

Gail model

What tool?

• acts as risk assessment tool to help determine 10 yr & lifetime risk for developing breast CA against common population & risk for BRCA mutation

Tyrer-Cuzick scoring (TC)

What is CBE?

Clinical breast exam

What does ACOG recommend for breast exams?

CBE annually for all females ≥19 y/o & provide education about SBE

What is one of the best early detection methods of breast CA"?

Mammograms

What ages should be given the option to start screening with a mammogram every year?

women 40-44

What ages should get mammograms every year?

women 45-54

What ages can switch to mammogram every other year, unless they want to continue yearly mammograms?

women ≥ 55

When should women with a family history of breast cancer in a first degree relative start screening?

At age 40 or 10 years prior to the diagnosis of the relative, whichever comes sooner

When should annual screenings begin for BRCA positive individuals?

Age 25 w/ breast MRI

Routine mammography is generally not recommended in who?

Women under 30

What should be performed in any woman older 30 with a palpable lump or thickening?

Diagnostic mammogram +/- U/S

What type of mammogram?

• remains gold standard

• breast compressed bt 2 clear plastic plates

• uses 2 XRs from above and side to create 2D image

2D digital mammogram

What type of mammogram?

• digital breast tomosynthesis

• several images taken from multiple angles to render 3D image

• detects cancer better and reduces risk of false positive results in dense breast tissue

3D digital mammogram

Which is better to distinguish between solid and cystic lesions, U/S or mammogram?

U/S

Screening mammography is not recommended postpartum in a woman until when?

Menses resumes

What kind of mammography can be done in a lactating woman?

Diagnostic (if needed), risk false negative

What is breast imaging reporting and data system (BI-RADS)?

Scale that radiologists use to categorize mammograms

What is BI-RAD category 1?

Normal

What is BI-RAD category II?

Benign appearing abnormality

What is BI-RAD category III?

Probably benign, possibly malignant

What is BI-RAD category IV?

Suspicious for malignancy

What is BI-RAD category V?

Malignant until proven otherwise

What is BI-RAD category O?

insufficient imaging information to allow for complete evaluation

When is recommended if screening mammogram shows abnormalities?

additional views via diagnostic mammogram +/- U/S or MRI

What is cone compression view?

Compress great tissue selectively over abnormal area to differentiate superimposed breast tissue from true abnormality

What is magnification view?

Further characterize masses w/ micro calcifications

How does a cyst appear on U/S?

Round or oval with smooth walks and dark / anechoic center

How does a solid mass appear on u/s?

Solid mass is echoic - reflects waves

Why can breast U/S not be used alone for screening?

Can vail to visualize palpable abnormality since lesion is isodense (same density) with surrounding tissue 🧛🏻‍♂️🍷

What does dense breast tissue indicate?

Individual has greater amount of fibroglandular tissue; often detected by breast imaging

How are U/S helpful in breast cancer screening?

Distinguish cystic from solid mass

What increases the risk of missed lesions on screening mammograms alone?

Dense breast tissue

How is dense breast tissue categorized?

A-D based on mammographic appearance

What is recommended for dense breast tissue?

Whole breast 3D U/S as screening adjunct to mammogram, sometimes MRI

What category breast density?

• almost all fatty tissue

A

What category breast density?

• scattered areas of dense glandular and fibrous tissue (white areas on mammogram)

B

What category breast density?

• herterogenously dense

• hard to see small masses in/around tissue

C

What category breast density?

• extremely dense

• harder to see masses / other findings that appear white

D

What might have higher sensitivity for cancer than mammography?

MRI

Cancer enhances ____ while benign lesions enhance ______

Rapidly ; slowly or not at all

When is MRI indicated as annual screening?

Inc risk of breast CA (BRCA mutation, first degree relative w/ BRCA, life time risk ≥20%) and pre/post breast treatment

When is the best time to do an MRI?

Post menstrual cycle- greater sensitivity in luteal phase

When is the best time to do a mammogram?

1-2 weeks after period

What is engorgement of vascular & ductal systems due to heightened response to reproductive hormones, anatomic factors, fatty acid imbalance, medication use, and breast size?

Mastalgia / mastodynia

What is the MC pathologic cause of nipple discharge?

Intraductal papilloma

What is intraductal papilloma?

Benign wart like growth in the milk duct that causes serosanguinous discharge

What kind of nipple discharge is MC?

Physiologic (galactorrhea)

How would benign nipple discharge appear on PE?

B/L (MC), clear to milky dc but can also be yellow, green, brown, or gray

How would nipple discharge suspicious of malignancy appear on PE?

U/L (MC), serous, serosanguinous or bloody discharge & associated with overlying skin changes (dimpling, peau de orange), nipple inversion, asymmetry, axillary LAD

What is common in 3rd trimester of pregnancy and lactation due to breast tissue hypervascularity?

Bloody nipple discharge

What are most cancers that produce nipple discharge?

In situ & can be seen on mammogram (repeat imaging x 6-12 mos)

What is inflammation of the glandular breast tissue?

Mastitis

Who is mastitis MC in?

Lactating women, esp in first 3 mos nursing (usually from staph aureus overgrowth in milk)

What is the MC type of mastitis in non lactational women?

Periductal mastitis (MC in smokers or cracked nipples in runners)

What is the MCC of an abscess formation within the fat / parenchymal tissue of the breast?

Staph aureus

Who are breast abscess MC in?

Breastfeeding females

What are ssx of breast abscess?

Painful, warm, erythematous swelling w/ fluctuant mass that is non mobile

What is the tx for breast abscess?

Abx, bromocriptine if related to lactation, I&D, refer for bx if inflammation does not respond quickly (suspicion for inflammatory carcinoma)

What are breast that contain multiple fluid filled cysts that are due to an exaggerated response to hormones, often worse in luteal phase and abates after menopause?

Fibrocystoic breasts

Are fibrocystotic breasts a disease state?

No

What is the MC benign breast disorder?

Fibrocystotic breasts

Who are Fibrocystotic breasts MC in?

30-50 y/o

what are ssx of fibrocystotic breasts?

Smooth, round, mobile & well demarcated masses commonly B/L & MC in upper outer quadrant

Tender, worsens w/ cyclical menses

No axillary involvement or nipple discharge

How are fibrocystotic breasts dx?

Usually clinical Hx & CBE, U/S w/ diagnostic mammogram if > 30, breast FNA bx/aspiration, excisional bx

What are treatment options for fibrocystotic breasts?

Lifestyle- correct fitting bra w/o underwire, dietary changes

Vit A, B & E**; +/- primrose oil

NSAIDs, OTC analgesics, warm/cool compresses

Low dose combo BC

Aspiration or excision of symptomatic cyst

What is the 2nd MC breast disorder?

Fibroadenoma

When is fibroadenoma MC?

late teens to early 20s

What is a benign breast tumor made of glandular and fibrous tissue that is normally influence and may regress after menopause?

Fibroadenoma

Where are fibroadenomas MC?

Upper outer quadrant

What are sx of fibroadenomas?

Smooth circumscribed firm, nontender, mobile rubber mass in upper outer quadrant

Gradually grow without fluctuation w/ menstruation

Can inc size w/ pregnancy

No axillary involvement or nipple discharge

How are fibroadenomas dx?

Hx & CBE, mammogram, US if under 30, breast bx if suspicious or collagen arranged in swirls

What is the treatment for fibroadenoma?

Self limiting, observation, lifestyle mods, excision for cosmetic or if bothersome

What is the most commonly occurring non-epithelial (not in ducts or glands) neoplasm of the breast that arise from stromal or CT, ~15% are malignant?

Phyllodes tumor

When does phyllodes tumor MC present?

In 50s

What are sx of phyllodes tumors?

Smooth, sharply demarcated texture and freely mobile, tend to be large, can have local LN mets (rare)

What is a malignancy primarily of the milk ducts or lobules (epithelial cells)?

Breast cancer

What is the MC non skin malignancy in women and 2nd MCC of cancer related death?

Breast cancer

What are RF for breast cancer?

BRCA 1 & 2 mutations, fhx 1st degree relative, age > 65, caucasian, higher number of menstrual cycles, prolonged exposure to unopposed estrogen, increasing age

The following RF are seen for what condition?

• Menarche before 12

• late menopause

• nulliparity and never breast feeding

• first pregnancy over 35

• prolonged exposure ot unopposed estrogen (obesity, HRT, insulin resistance, PCOS)

Breast cancer

How does breast CA in young women present?

Bad prognosis & worse grade, bigger tumor, more + node, more likely to be genetic

Where are most breast cancers located?

Upper outer quadrant (most epithelial cells)

What type of breast cancer?

• arise from epithelial components - cells that line ducts, lobules, and make milk

• can be in situ or invasive

Carcinoma

What type of breast cancer?

• arise from CT, non epithelial origin

• phyllodes tumore, angiosarcoma

• < 1 % BCs

Sarcoma

What type of early breast cancer is confined to the inside of the ductal system & usually treated more aggressively?

Ductal carcinoma in situ (DCIS)

What is the MC type of breast cancer?

Iinfiltrating ductal carcinoma (IDC)

What type of breast cancer?

• invasive carcinoma in milk ducts

• appear as stellate /star like (worse prognosis) or well circumscribed (rounded) areas on mammograms

Infiltrating ductal carcinoma (ICD)

What type of breast cancer?

• In the lobules

• usually appears as subtle thickening in upper outer quadrant of breast

• often positive for estrogen and progesterone receptors → responds well to hormone therapy

• MC CIS

Lobular infiltrating carcinoma (ILC)

What is the typical course of hormone positive tumors?

Slower course & more responsive to hormone therapy (hormones are the stimulus for tumor growth)

What tumors express human epidermal growth factor receptor and are more aggressive?

HER2 + / neu-positive

How does a cancerous breast mass present?

Painless, hard, fixed breast lump MC in upper outer quadrant ± axillary LAD

The following sx are seen with what condition?

• changes in breast size or contour. changes in nipples- inversion, puckering

• U/L nipple dc- bloody, purulent, green

• asymmetric redness, ulceration, dimpling, skin thickening

Breast cancer