Breast Masses, Nipple Discharge, and Breast Augmentation

multiple, bilateral, rapid, premenstrual, serous, estrogen, alcohol

Fibrocystic Breasts

• Painful breast masses; often ________ and ________ masses

• _______ fluctuation in mass size is common

• Pain often worsens during ___________ phase

• ______ nipple discharge may also be present

• Most frequent breast lesion

• Occurs most commonly in women 30-50

• _________ hormone is considered a causative factor

• _________ consumption may increase risk, especially in women 18-22 y/o

ultrasound, cystic, phyllodes, mammogram, core, 2

Fibrocystic Breasts → Diagnosis

• Breast __________

  • Can differentiate ______ from solid mass

  • Can reliably distinguish fibroadenoma from carcinoma but not from a _______ tumor

• ________ may be helpful but is often limited d/t radiodensity of breast tissue in young women

• Suspicious lesions should be biopsied via ____ needle biopsy rather than fine-needle aspiration

• Ultrasound + Core Needle Biopsy for solid lesions > _ cm

NSAIDs, gamolenic, pain, E, Danazol, androgenic, Tamoxifen, HRT

Fibrocystic Breasts → Management

• ______ prn

• __________ acid

  • Oil of evening primrose is a natural form of this acid

  • Has been shown to decrease ____ in users

• Vitamin _

• _______ (synthetic androgen)

  • For severe pain - suppresses pituitary gonadotropins

  • Rarely used d/t ________ ADRs (acne, hirsutism, edema)

• _________ reduces some sx but it is not useful in young women d/t side effects, unless it is given to reduce risk of cancer

• Postmenopausal women receiving ___ may stop hormones to reduce pain

surgery, aspiration, fat, caffeine

Fibrocystic Breasts → Management

• _________

  • Total or subcutaneous mastectomy or extensive removal of breast tissue is rarely indicated

• Therapeutic Procedures

  • __________ of a discrete mass suggestive of a cyst is indicated in order to alleviate pain and to confirm the cystic nature of the mass

• Diet

  • Low-___ diet or decreasing dietary fat intake may reduce painful symptoms

  • The role of _______ consumption remains controversial

bra, proliferative, atypical, menopause, HRT

Fibrocystic Breasts → Management

• Patient education

  • Avoid caffeine ???

  • Wear supportive ____ night and day

• Complications

  • Risk of breast cancer in women with _________ or ________ changes in the epithelium or papillomatosis is higher in women in general

• Prognosis

  • Exacerbations of pain, tenderness, and cyst formation may occur at any time until _________

  • After menopause, sx usually subside, except in pts receiving ___

fibroadenoma, fibrocystic, necrosis, abscess, carcinoma, lobular

Breast Masses

• Benign

  • ___________

  • Cyst

  • ________ changes

  • Galactocele

  • Fat _________

  • Breast _________

• Malignant

  • Ductal breast _______

  • _________ carcinoma

  • Mixed ductal/lobular carcinoma

  • Ductal carcinoma in situ

benign, hormonal, round, movable, accidentally, core, excision, proliferative, simple, proliferative, family

Fibroadenoma

• MC _______ tumor in the breast

  • Accounts for half of all breast biopsies

  • MC found in women ages 15-35

• Etiology is unknown, but there is likely a ________ relationship

• ________ or ovoid, rubbery, discrete, relatively ________, nontender mass 1-5 cm

  • Usually discovered __________

  • Can be simple or complex

• Definitive dx can only be confirmed with a ____ biopsy or ________

• Considered a __________ breast lesions, however there is no increased risk of breast cancer in the majority of women with ________ fibroadenomas

  • The risk of subsequent breast cancer is only slightly elevated if there is associated __________ disease or if there is a significant _______ history of breast cancer

glandular, removal, ultrasound, proliferative, calcification, cancer

Fibroadenomas

• Simple

  • Contain ________ and fibrous tissue

  • _______ is not necessary unless it increases in size or becomes painful

  • Can be followed by _________ every 6 months x 2 years

• Complex

  • Contain __________ changes such as sclerosing adenosis, duct epithelial hyperplasia, epithelial ___________, or papillary apocrine changes

  • Associated with slightly increased risk of _______

  • Management is controversial (removal vs conservative)

fibroepithelial, rapidly, multinodular, painless, polylobulated, solid

Phyllodes Tumor

• Uncommon _________ (fibroadenoma-like) breast tumors that grow __________

  • <1% of all breast neoplasms

  • Can be benign or malignant

• On exam → smooth, __________, well-defined, firm, mobile, ___________ mass

• Mammography → Smooth, _____________ mass resembling fibroadenoma

• Ultrasound → _______, hypoechoic, and well circumscribed mass

excision, wide, total, radiation, hormone, lungs

Phyllodes Tumor

• Complete surgical _______ with _____ margins > 1 cm is standard of care

  • If inadequately excised, can recur

  • Because these tumors may be large, ______ mastectomy is sometimes necessary

• If borderline or malignant → adjuvant ________ after complete excision to reduce local recurrence

  • __________ therapy is NOT effective

• Lymph node dissection is not performed

  • The tumor metastasizes to the _______, not the lymph nodes

• Survival rate at 5 years: 60-80%

trauma, surgical, injections, retraction, carcinoma, malignancy, core, excision

Fat Necrosis

• Most commonly occurs as the result of breast ______ or _________ intervention

  • Commonly seen after fat ________ to augment breast size or fill defects after breast surgery

  • Also occurs after breast surgery, segmental resection, radiation therapy, or postmastectomy flap reconstruction

• Breast mass often associated with skin or nipple _________

• Usually indistinguishable from ________, even with imaging studies

  • Mimics _________, but isn’t

• ____ needle biopsy usually needed for diagnosis

• _________ not necessary → mass gradually disappears

  • No increased risk of subsequent breast cancer

hyperprolactinemia, hypothyroidism, birth control

Galactorrhea

• Milky discharge can be caused by:

  • _____________ → obtain serum prolactin levels for pituitary tumor

  • TSH to exclude ____________

  • Antipsychotics

    • Other medication: ______ _________

  • Pregnancy/Postpartum

benign papilloma, 50, cytologic, mammogram

Discharge Characteristics → Bloody

• Most likely from ________ _________ in the duct

• Can be cancer

  • Especially > __ years

  • ___________ examination may identify malignancy → negative cyto does not r/o cancer

• Order ____________ or ultrasound

fibrocystic, ectasia, intraductal papilloma, fibrocystic, removed, abscess

Discharge Characteristics

• Serous

  • Benign ___________ disease

  • Duct __________

  • Can be __________ _____________

    • Intraductal CA very rarely

• Green or Brown

  • Often d/t ___________ breasts

    • Mass detected should be ___________

• Purulent

  • Subareolar ____________

lining, clear, bloody, multiple, solitary

Intraductal Benign Papilloma

• Benign → a papillary growth of the _________ of the breast duct

• Nipple discharge can range from ______ to grossly ________

• May be solitary or multiple

  • Risk of breast cancer may be higher in ________ lesions than __________ lesions

blocked, fluid, widens, perimenopausal, asymptomatic, biopsy, sticky, tender, inward, hard

Duct Ectasia

• Benign → Milk duct becomes ________ → _______ build-up

• Duct _________ and its walls thicken

• Most often occurs in women of __________ age (45-55), can happen after menopause

• Often ____________ → detected via __________ done for another breast problem

• May cause a nipple discharge → often _______ and thick

• The nipple may be pulled _________

  • Sometimes scar tissue around the abnormal duct causes a _____ lump that may be confused with cancer

ultrasound, biopsy, does not, warm, antibiotics, surgery

Duct Ectasia

• _____________ and/or mammogram

• If there is a lump → _________ to r/o cancer

• Duct ectasia ____ ____ increase breast cancer risk

• Sometimes improves without treatment

  • _____ compresses and _____________ are helpful

• Resistant cases

  • Abnormal duct may need to be removed with ________

scarring, 12, firmness, distortion, painful, capsule

Augmented Breasts → Capsule Contraction/Scarring

• Fibrous tissue / __________ forms around the implant

• Most develop within __ months after surgery

• Causes a ________ and __________ of the breast that can be _________

• Sometimes requires removal of the implant and surrounding __________

removed, inflammation, capsulectomy, observation

Augmented Breasts → Implant Rupture

• Ruptured silicone gel implants should be ____________ d/t the possibility of the gel material causing _____________ and other tissue reactions

  • If rupture is suspected or known, a ____________ is typically performed to remove the gel material from the breast pocket

• Close ____________ is an option for those patients who do not wish to have a ruptured implant removed or exchanged due to cost or current overall satisfaction with their breasts

s aureus, bimodal, 6, 6, 6, fever, drainage, pain, healing, migration

Augmented Breasts → Implant Infection

• Most due to gram-positive pathogens → coagulase-negative staphylococci, Cutibacterium species, _ _________, and streptococci

• ____________ presentation

  • During the acute postop period ( _ days to _ weeks after surgery) OR late onset (> _ months after surgery)

• Acute infections → _______, breast pain, erythema, and __________

• Subacute infections → chronic _____, persistent drainage, failed _________ of the incision site, or ____________ of the implant

bactrim, vancomycin, systemic, necrotic, replace

Augmented Breasts → Implant Infection Treatment

• Mild superficial cellulitis → ________, clindamycin, or doxycycline + amoxicillin

• Extensive cellulitis and/or deep infections → ___________

• Surgical intervention for pts with ________ signs of infection and extensive cellulitis, or drainage from a wound that connects to the implant, purulent drainage from US-guided aspiration, threatened implant exposure, or wound breakdown

  • The intent of surgery is to drain purulent fluid, resect _______ tissue, and explore the condition of the pocket to determine if it would be possible to immediately ________ an implant

anaplastic large cell lymphoma, squamous cell carcinoma, mammography, radiation

Augmented Breasts → Cancer

• New studies are showing increased incidence (but still RARE)

  • BIA-ALCL (breast implant-associated ___________ _______ ____ ____________)

  • BIA-SCC (breast implant-associated ____________ ____ __________)

• Women with augmentation can still develop breast cancer

• Detection in patients with implants may be more difficult because _______________ is less able to detect early lesions

• If a cancer develops in a patient with implants, it should be treated in the same manner as in women without implants

  • ___________ of the augmented breast often results in marked capsular contracture

systemic, arthralgia, rash, removal, reconstruction

Breast Implant Illness (BII)

• Refers to __________ symptoms (fatigue, __________, brain fog, ______, etc.) reported only in individuals with breast implants (saline or silicone)

• Symptoms often improve after implant __________ (explanation) in some patients, though mechanisms remain unclear

• It’s not specific to augmentation vs ____________, but rather to any implanted breast device