breast medicine II vosk exam

most common cause of cyclic breast pain (mastalgia). lesions associate with benign change sin breast skin. “nodular, sensitive breasts”. Thought to be result of hormonal imbalance.

fibrocyctic breast disease

what does progesterone do to the female body during pregnancy

inc breast size early in pregnancy, deep pigmentation nipple/areolar complex, enlarged nipples, areolar widening, inc size of glands.

after delivery of the baby what happens to the mother’s body 

inc oxytocin (let down reflex) and prolactin (milk production) triggers colostrum and breastmilk. 

pt has sx of cyclical breast pain or tenderness, can have bloody brown/green discharge from nipple. discomfort happens most in premenstrual phase. breast exam has movable benign cysts within breast tissue. rubber-like texture. pt has slight discomfort. 

fibrocystic breast changes

how to test for fibrocystic breast dz

triple testing = clinical exam, imaging, and excision biopsy. <35 - sono, >35 - mammo +sono

how to dx fibrocystic breast dz

painful multiple bilateral mobile masses in breast. rapid fluctuation in size of masses. pain and size of cyst inc in premenstrual cycle. most common age is 30-50 yrs.

how to tx fibrocystic breast dz

reassurence, supportive bras, tylenol/NSAIDs, Danazol/Tamoxifen.

common benign neoplasm in women 20 years into puberty (14-35 yrs). earlier in black women than in white. round, firm, discrete, mobile, solitary, non-tender mass 1-5 cm. on upper outer quadrant. aka breast mouse. proliferate in pregnancy b/c of inc hormones. mediator complex subunit 12 (MED12) gene leads to more of this condition.

fibroadenoma

how to diagnose a fibroadenoma

defined solid mass with benign imaging features on US. core needle biopsy and rpt US and breast exam.

how to tx fibroadenoma

no tx bc shrink and disappear over time. indications for surgery if rapidly growing, greater than 2 cm big indicates surgery if pts want or if its growing fast. surgical procedures are lumpectomy/excisional biopsy, cryoablation.

most common cause of breast mass. in women ages 30-50.

breast cyst

how to manage breast cyst

aspirate with needle, get reimaging 4-6 wks later. it can come back or be gone. if cyst has solid components can be malignant

what hs affect the breast

prolactin and oxytocin

why is oxytocin needed for breastfeeding

contracts the cells around the alveoli forcing the milk in the breast out causing letdown. is the happy hormone and can be released by looking at, smiling, or hearing crying of a baby.

prolonged engorgement of milk ducts, with infection from bacterial entry thru breaks in skin. breast flu, having local erythema, pain, swelling, fever, viral flu sx. occurs in first 6 weeks of breast feeding but can occur anytime

lactational mastitis

what bacteria cause mastitis

commonly staph aureus, strep pyogenes, e. coli, bacteriodes species.

what are some risk factors for mastitis

baby doesn’t latch so mammary is overproducing milk but not removing it

tx of mastitis sx

emptying breasts fully, encourage continued breast feeding, pumping, NSAIDs or pain control, warm compress to encourage milk flow, cold compress after feeding to reduce swelling, push it toward lymphatics to drain.

how to tx mastitis after 12-24 hrs sx have not stopped

give abx. dicloxacillin, cephalexin, amox/clav. if PCN allergy give erythromycin. if MRSA then trimethoprim-sulfamethoxazole or clindamycin

if you see a breast abscess in a pt who isn’t lactating that can indicate

inflammatory carcinoma or new onset DM

pt reports sx of breast pain, erythema, warmth, possibly edema/swelling. lactation hx, hx of prior infections, fever, nausea, vom, purulent drainage. this breast d/o is

breast abscess

lactiferous ducts undergo epidermalization where keratin production causes duct be be obstructed, causing what dz

breast abscess.

do you continue to breastfeed if pt has breast abscess

no

how to tx breast abscess

I&D, tx with abx like nafcillin, augmentin, TMP-SMX, clindamycin. NSAIDs for pain control. avoid latching baby to affected breast, continue breast emptying

how to assess for galactorrhea

assess menstrual irregularities, ask about headaches/visual deficit. have pt sit, lean forward, and squeeze areola. discharge can be white/green, bloody = malignancy. get PRL levels, visual field assessment

what are some hypothalamic or pituitary causes of galactorrhea

prolactinomas, non prolactin secreting pituitary tumors

what are some non hypothalamic pituitary causes of galactorrhea

hypothyroidism, meds (risperidone, clozapine, olanzapine, aripiprazole, metoclopramide, domperidone, TCAs, MAOIs, opioids, verapamil). renal failure, chest wall lesions, idiopathic

how to tx galactorrhea

tx the cause. if a pituitary lesion then meds like bromocriptine, cabergoline. tx w dopamine agonists to get sx relief. surgical excision of affected duct. 

what causes pubertal gynecomastia

faster rise in estradiol than rise of test, = imbalance

grade I gyno

small enlargement, no skin excess

grade II gyno

moderate enlargement, no skin excess

grade IIb gynecomastia

moderate enlargement with extra skin

grade III gyno

marked enlargement with extra skin

how to tx gynecomastia

clomiphene, danazol, tamoxifen. grade 1 or IIa can use liposuction and surgical excision. IIb and III have open surgical excision w skin resection

single nontender firm to hard mass with ill definined margins. mammogram abnormal and no palpable mass.

early findings of breast cancer

skin/nipple retraction, axillary lymphadenopathy, breast enlargement, redness, edema, fixation of mass to skin, peau d’orange.

later findings of breast cancer

ulcers, supraclavicular lymphadenopathy, arm edema, bone, lung, liver, brain, other distant metastases

late findings of breast cancer

most common cancer in women

breast cancer.

how does heredity affect risk of breast ca

primary relative doubles risk. risk inc as affected relative age dec. BRCA 1 & BRCA 2 gene accounts for 5% breast ca

risk factors of breast ca NAACP

nulliparity, age at menarche <12, age at menopause >55, cancer of breast in self or primary relative, pregnancy of first child >30

hwo to stage breast cancer

TNM system. tumor size, clinical assessment of axillary nodes, presence/absence of distant mets.

what is TNM system

basis of staging breast ca

how to diagnose breast ca

abnormal mammo, less often bc of palpable mass.

what tests do you run to dx breast ca

bilateral mammo, breast US, CBC, LFTs, Alk phos

pt presents with palpable painless mass. pt has occasional breast pain, nipple discharge, erosion, retraction, enlargement or itching of nipple. redness, hardness, enlargement of the breast. they also complain of bone, arm, and lung pain. pt shows abnl breast size/contour, nipple retraction, edema, redness, retraction of nipple. 

breast cancer with suspected metastesis

signs of advanced carcinoma

edema, redness, nodularity or ulcers of skin, large primary tumor >5cm, fixed to chest wall, enlargement/shrinkage, or retraction of breast. axillary and supraclavicular LAD. 

eczematoid eruption and ulcer arises from nipple and can spread to areola. associated with underlying carcinoma. mass may be palpable. pain, itching, burning with bloody discharge and nipple retraction. pathognomonic intraepithelial adenocarcinoma or paget cells within epidermis of nip

paget’s disease of breast

how to tx paget’s disease

mastectomy

aggressive but rare form of ca. diffuse, brawny edema of skin of breast with erysipeloid border. usually no palpable mass. looks similar to fungal infection. inflammation caused by blocked dermal lymphatics by tumor emboli = lymphedema.

inflammatory carcinoma

how to tx inflammatory carcinoma

chemo, surgery/radiation. usually radical mastectomy is rec’d

how to tx breast ca in pregnancy

modified radical mastectomy, systemic chemo, potential termination of pregnancy with the risk of harm to fetus.

mammograms can spot non palpable ca for how many years before theyre palpable

2 years prior

cytology is

exam of nipple discharge or cyst fluid. mammo and biopsy needed if fluid is bloody

what is a method of biopsy that can determine if a ca is invasive or non invasive,

FNA biopsy

what labwork should be given as initial evaluation of possible breast ca

CBC, BMP, LFT, b-hCG.

what labs can indicate distant metastatic dz

alk phos or LFTs. hypercalcemia seen in advanced or metastatic

single best screening tool for early detection of breast ca

mammography

sensitivity and specificity of mammogram is

70-90%, specificity >90%

annual mammos start at what age

40. if genetic predisposition then beginning at 25

BRCA1 and BRCA2 are associated with what malignancies

breast, ovarian, colon, prostate, and pancreatic.

ER/PR negative tumors are treated how 

systemic chemo bc endocrine therapy does nothing

if a node negative tumor has estrogen receptors what does that mean for its likelihood to recur

less likely to recur in comparison to ER poor tumors INITIALLY. long erm ER + tumors more likely to metastasize to bone tissue and organs than ER- which are more likely to spread to liver, lung, and brain

these drugs are known to have significant improvements in overall survival in pts with HER2 gene

trastuzumab, lapatinib

what is the most common type of breast ca

invasive ductal

what is a radical mastectomy

radical removal of breast, pectoral muscles, axillary lymph nodes. modified mastectomy preserves the pectoralis muscle. radical isn’t used as much bc we want to preserve tissue

what is a modified radical mastectomy

removal of breast, pec major fascia, and eval selective lymph nodes.

what is breast conservation therapy

a lumpectomy, axillary evaluation, and post op irradiation. no difference in relapse when compared to a mastectomy

what is axillary evaluation

removal of ca in axilary lymph. can result in nerve damage and lymphadema. sentinel node biopsy is alternative bc if it is pos for metastatic dz then they do formal dissection. 

what is hormonal therapy

used for all women whos breast ca expresses hs receptors. tamoxifen helps ER+ tumors. anastrozole helps postmenopausal women with early stage breast ca. hi risk of MSK d/o, OP, and cardiac events.

how does cytotoxic chemotherapy help breast ca

eliminate any hidden microscopic metastesis. standard of care for pts with ER- tumors

how often should a pt with breast ca follow up

for life, to detect recurrences and second primaries. PE 3-6 mo for first 3 yrs, then every 6-12 mo until yr 5, then anually. annual mammograms.

what is a complication of breast ca tx

edema of the arm, happens bc of lymph disruption.

are hormone negative tumors more or less recurrent

more

are hormone positive tumors more or less recurrent

less

Transverse rectus abdominis myocutaneous (TRAM) or deep inferior epigastric perforator flap (DIEP) are examples of what procedure

breast reconstruction