Breast Disease Flashcards

Breast Disease Overview

Anatomy of the Breast and Axilla

• Borders of the Breast:

  • Superior: Clavicle

  • Medial: Lateral edge of the sternum

  • Inferior: Inframammary fold

  • Lateral: Medial edge of the latissimus dorsi

• Borders of the Axilla:

  • Superior: Axillary vein

  • Deep: Serratus anterior muscle

  • Posterior: Subscapularis muscle

  • Inferior: Meeting of the latissimus dorsi and chest wall forming a triangular structure

• Nerves at Risk:

  • Long thoracic nerve: Injury results in winged scapula

  • Thoracodorsal nerve: Injury results in weakness of should ADduction

• Axillary Lymph Node Levels:

  • Level I: Lateral to the pectoralis minor

  • Level II: Posterior to the pectoralis minor

  • Level III: Medial to the pectoralis minor

  • During axillary node dissection for breast cancer, levels I and II should be removed, but it's not necessary to extend to level III.

History and Physical Exam (H&P) for Breast Disease

• Symptoms:

  • Inquire about any symptoms that prompted the visit

  • Masses: Note any changes in size, consistency, or cyclical nature related to the menstrual cycle

  • Nipple changes: including discharge or retraction

  • Skin changes: erythema, dimpling, etc

• Risk Factors:

  • Age of first menarche and menopause

  • Age of first live birth

  • Breastfeeding history

  • Family history: Including breast, gynecologic, and ovarian cancers

  • Prior mammograms and biopsies: including results

  • Oral contraceptive use

  • Fertility treatments

  • Hormone replacement therapy

    • Estrogen exposure is a risk factor for breast cancer. Factors such as early menarche, late menopause, and hormone replacement therapy increase estrogen exposure, while multiple pregnancies and breastfeeding decrease exposure.

• Risk Assessment Models

  • Gail Model: Used to calculate lifetime risk of breast cancer.

• Physical Exam:

  • Perform both seated and supine

  • Inspection: Assess symmetry, skin changes, and nipple changes

  • Palpation: Systematically palpate for lumps or bumps, noting location, size, distance from the nipple, and quadrant.

  • Axillary exam: Always include axillary nodes; also consider supraclavicular and inframammary nodes.

Breast Imaging

• Screening Mammography:

  • Standard Views: Craniocaudal (CC) and Mediolateral Oblique (MLO)

  • Guidelines: Start at age 40 for average-risk women; repeat annually

• High-Risk Patients:

  • >20% lifetime risk (Gail model) or BRCA mutation: Annual MRI and mammogram, staggered every six months

• Diagnostic Mammography:

  • Used for further investigation of abnormalities, with additional compression and magnification views

• Concordance:

  • Ensure agreement between imaging, physical exam, and biopsy results; discordance may indicate sampling error and the need for repeat or excisional biopsy.

• BI-RADS (Breast Imaging Reporting and Data System):

  • 0: Technical limitation, needs repetition

  • 1: Negative, no findings

  • 2: Benign findings

  • 3: Probably benign, short interval follow-up (6 months or less)

  • 4: Suspicious, biopsy required

  • 5: Very suspicious/probably malignant, biopsy required

  • 6: Known malignancy (post-biopsy, pre-excision)

Benign Breast Diseases

Infection

• Symptoms: Pain, erythema, swelling

• Association: Often related to lactation, common during breastfeeding, especially after the first child

• Mastitis vs. Abscess:

  • Mastitis: Cellulitis-like, red, painful skin infection

  • Abscess: Fluid or purulent collection in addition to skin changes

• Workup for Suspected Abscess: Ultrasound to detect fluid collection if no palpable fluctuation.

• Common Bacteria: Staph aureus and streptococci

• Treatment:

  • Early antibiotics (e.g., Augmentin), avoiding tetracyclines or Cipro

  • Supportive measures for mastitis: Compresses, supportive bras

    • Can continue breastfeeding.

  • Breast Abscesses: Aspiration preferred over incision and drainage (I&D) to minimize scarring; repeat aspiration if recurrence. I&D is indicated if aspiration fails.

Nipple Discharge

• Benign Features: Bilateral, milky, cyclical (hormonally related); green discharge (fibrocystic disease).

• Concerning Features: Bloody or serous, unilateral, spontaneous, non-lactational, persistent. Requires workup with mammogram and ultrasound to rule out cancer

• Intraductal Papilloma:

  • Most common cause of bloody nipple discharge

  • Treatment: Excision, often requiring localization via ductography

Fibroadenomas

• Characteristics: Benign, common in adolescents and young women, painless, slow-growing, rubbery, well-circumscribed, palpable mass.

• Imaging: Ultrasound is preferred over mammogram due to dense breast tissue in younger patients. Findings are described as well circumscribed, regular borders.

• Diagnosis: Ultrasound-guided biopsy is required to confirm.

• Treatment: Excision if symptomatic, growing, or >3 cm.

Phyllodes Tumors

• Characteristics: Fibroepithelial tumor, grows larger than fibroadenomas, occurs in older adults. Histology shows leaf-like pattern, cleft-like spaces, hypercellular stroma.

• Diagnosis: Core needle biopsy cannot determine if the tumor is benign or malignant. Diagnosis require excision.

• Treatment: Excision with wider margins than fibroadenomas. No axillary surgery is needed.

• Metastasis: Ten percent can be malignant and spread hematogenously, commonly to the lungs.

Malignant Breast Disease

Paget's Disease of the Breast

• Presentation: Eczematous, scaly, red, or ulcerated bloody changes around the nipple; often mistaken for a skin rash.

• Etiology: Malignant cells in the skin of the nipple.

• Workup: Diagnostic mammography, ultrasound; MRI if initial imaging is negative.

• Treatment: Treat the underlying malignancy (DCIS vs. invasive cancer), with excision of the nipple-areolar complex during surgery.

Ductal Carcinoma In Situ (DCIS)

• Description: Malignant cells confined to the duct lumen (stage 0 breast cancer).

• Progression: Premalignant, 50% progress to invasive cancer.

• Presentation: Usually presents as calcifications on screening mammogram.

• Diagnosis: Core biopsy is essential for diagnosis and hormone receptor testing.

• Treatment: Lumpectomy followed by radiation (standard) or mastectomy (for diffuse, multi-quadrant DCIS or contraindication to radiation).

  • Lumpecteomy requires 2mm negative margins

• Axillary Surgery: Sentinel lymph node biopsy is not needed, as DCIS does not invade lymphatics.

• Adjuvant Therapy: Endocrine therapy (e.g., Tamoxifen) is recommended if ER/PR positive.

Lobular Carcinoma In Situ (LCIS)

• Characteristics: Usually found incidentally, less associated with calcifications or masses, considered a marker of increased breast cancer risk (1% per year per breast).

• Risk Implication: Increases the risk for both breasts, ductal carcinoma likely to come back.

• Treatment: Complete excision to rule out other pathologies (e.g., DCIS), adjuvant endocrine therapy (prevention measure), high-risk screening, or prophylactic mastectomy in select cases.

Invasive Breast Cancer

• Types: Ductal carcinoma (more common) and lobular carcinoma.

• Staging: Based on TNM (Tumor, Node, Metastasis) system.

  • T1: Small tumors (≤2 cm).

  • T2: Tumors between 2cm and 5cm

  • T3: >5cm

  • T4: invading other structures (like pec)

  • N: Nodes assessed via axillary exam.

  • M: Distant metastases.

• Workup: Physical exam (lymph nodes), diagnostic mammogram, ultrasound, core needle biopsy (grade, receptor status, HER2 status).

Inflammatory Breast Cancer

• Presentation: Peau d'orange (skin erythema, dimpling, and thickening) due to dermal lymphatic invasion.

• Diagnosis: Clinical diagnosis based on peau d'orange and swelling, confirmed by skin punch biopsy.

• Imaging: Mammogram and ultrasound are primary; MRI is sometimes used in high-risk patients.

• Treatment: Neoadjuvant chemotherapy, modified radical mastectomy (mastectomy with complete axillary lymph node dissection), and adjuvant radiation.

Surgical Options for Invasive Breast Cancer

• Breast-Conserving Therapy (Lumpectomy/Partial Mastectomy):

  • Excision of the tumor with a rim of normal tissue (no tumor on ink at margins).

  • Almost always includes radiation to reduce recurrence.

• Mastectomy:

  • Complete removal of all breast tissue.

  • Radiation may not always be required.

  • Often combined with reconstruction modalities (tissue expander followed by implant or flap, e.g., DIEP flap).

• Both options have the same overall survival rates; mastectomy has a slightly lower recurrence rate.

Axillary Surgery for Invasive Breast Cancer

• Sentinel Lymph Node Biopsy:

  • For clinically node-negative patients.

  • Uses radioactive tracer and blue dye to identify and excise the first draining lymph nodes.

  • Excise any palpable, blue, or hot nodes (uptaking >10% of maximum).

• Axillary Lymph Node Dissection:

  • For inflammatory breast cancer or clinically node-positive patients.

  • Removal of all level I and II lymph nodes.

  • Indicated if nodes remain positive after neoadjuvant therapy or if sentinel lymph node biopsy is not feasible.

Systemic Treatments

• Chemotherapy:

  • Can be given neoadjuvant (before surgery) or adjuvant (after surgery).

  • Neoadjuvant chemotherapy is used for large tumors, clinically node-positive disease, skin/chest wall involvement, and aggressive histologies (triple-negative or HER2-positive).

  • HER2-positive cancers require HER2-directed targeted therapy (trastuzumab, pertuzumab).

  • Adjuvant chemotherapy may be indicated based on genomic risk factors (Oncotype DX score).

• Radiation:

  • Local treatment to reduce recurrence after lumpectomy or mastectomy (depending on pathology).

• Endocrine Therapy:

  • Selective Estrogen Receptor Modulators (SERMs): Tamoxifen for premenopausal, ER/PR-positive tumors, or chemo-prevention (LCIS).

  • Aromatase Inhibitors (Letrozole, Anastrazole): For postmenopausal patients.

  • Side effects: Hot flashes, joint pains, osteopenia (monitor with DEXA scans).

  • Goal: Administer endocrine therapy for approximately five years.