Womens Health Gynecology 2 Exam: Breasts I and II

cyclical mastalgia
- starts in luteal phase and stops at start of menses
- upper outer quadrant, bilateral
- areas if fluid-filled cysts with areas of fibrosis (tender, lumpy, ropy)


tx for mastalgia:
- proper bra fitting, weight reduction, exercise
- SERMS (block ER in breast) tamoxifen, raloxifene
- or danazol
*cant use any of these meds if patient wants to get pregnant while on med or is breast feeding
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cyclical mastalgia
- starts in luteal phase and stops at start of menses
- upper outer quadrant, bilateral
- areas if fluid-filled cysts with areas of fibrosis (tender, lumpy, ropy)


tx for mastalgia:
- proper bra fitting, weight reduction, exercise
- SERMS (block ER in breast) tamoxifen, raloxifene
- or danazol
*cant use any of these meds if patient wants to get pregnant while on med or is breast feeding
A 23 yo patient presents with bilateral breast pain that is localized to the upper outer breasts. She states that the breast pain usually starts a week after her period ends and continues until her menses begins. She expresses tenderness upon palpation and you feel lumpy ropy fibrotic areas. What is this? How can you treat this patient?
cyclical mastalgia - fibrocystic breast changes (areas of fluid filled cysts with areas of fibrosis) - thickening that can be felt in 1 or more breasts (lumpy, ropy, tender)

tx:
- proper bra fitting, weight reduction, exercise
- SERMS (block ER in breast) tamoxifen - endometrial hyperplasia, vaginal bleeding, DVTs, hot flashes
- SERMS (block ER in breast) raloxifene
- or danazol - androgenic effects (wt gain, deep voice, hair growth)

*cant get pregnant with these treatments (or breast feed)
galactorrhea - milky discharge from breasts (non-lactating pts)

cause: hyperprolactinemia
- lactotroph adenoma (endocrine tumor) -check prolactin levels
- meds: phenothiazines, oral contraceptives, TCAs
- hypothyroidism (TSH and FT4 tests) - will have normal prolactin
****always do a pregnancy test!

could also be galactocele but will have palpable mass
during the follicular phase (during period or up to 7 days after) - due to luteal phase being associated with breast tendernessWhen is the best time to preform a breast exam on women?mammograms - detect lesions up to 2 years before they are palpable screening that decreases mortality with breast cancerHow do you screen for breast cancer and how early can this detect potential lesions?mammogram screening (no mass): - 4 images: 2 craniocaudal and 2 mediolateral (2 images per breast) mammogram diagnostic (mass or breast complaint): - do the same as screening + lymph nodes + spot compression/magnified views (diagnostic for breast cancer)If a 50 year old female patient, G2P2, LMP 6 months ago presents for her annual mammogram screening, how many views should you get? What if this patient was presenting due to a plapable breast mass?Abnormal mammogram: - spiculated, high density mass --> most likely breast cancer - sometimes microcalcifications (not pictured)A 44 yo G0P0 patient presents with unilateral nipple discharge. She states that it is a yellowish-bloody fluid that comes from the left breast only. She has no tenderness, or pain otherwise. You initially suspect intraductal papilloma but you palpate a small mass so you are more concerned for cancer. You do a mammogram. What does this show?microcalcifications - abnormalWhat are these findings on a mammogram and are they normal?breast mass in women < 30 = usually do US - tells you if its solid or cystic (anechoic/black = simple cyst, can be drained to relieve symptoms) *also order in women with inconclusive mammogram (if >30 start with mammogram and/or MRI)if a 27 yo patient G1P1 presents with a unilateral breast mass. How do you test to determine the cause?US: - used if mass and < 30 yo (dense breast tissue) to differentiate solid vs cystic (cystic anechoic) MRI: WITH CONTRAST - used with mammogram if women is high risk or has dense breast tissue (usually > 30 + mass) - contrast will show you extra BVs -> cancer has its own blood supply - post-breast cancer diagnosis (FU/staging) FNA: - can use to look at fluids/cysts, if it is bloody when you aspirate you must send to cytology - cant distinguish invasive/non-invasive cancers Core-Needle Aspiration: - large solid massses for hormones or growth factors (immunohistologic staining) or tumor reoccurance risk (tumor analysis)What can be used to differentiate solid vs cystic masses? What can be used if the women is over 30 years old & is high risk for breast cancer or has dense breast tissue? What can be used for post-breast cancer diagnosis such as FU and staging? What can be used to analyze large, solid masses for hormones and growth factors or tumor reoccurrence risk? What can be used to analyze fluids?diagnostic mammogram + US - if solid/fixed (or unsure if fluid/solid, more than 1) Fine needle aspiration - if determined it is cyst/fluid filled (mobile) SEE ALGORITHM NOTES diagnostic mammogram: - 4 images: 2 craniocaudal and 2 mediolateral (2 images per breast) - lymph nodes + spot compression/magnified views (diagnostic for breast cancer)If a 30 yo patient presents with a suspicious breast mass, and you are not sure if the mass is solid or fluid-filled, what should you do? What if the mass is determined to be fluid-filled?FU in 4-6 weeks - if reoccurs do DMUS diagnostic mammogram: - 4 images: 2 craniocaudal and 2 mediolateral (2 images per breast) - lymph nodes + spot compression/magnified views (diagnostic for breast cancer)A 30 yo patient presents with a unilateral breast mass. You have determined that the mass is mobile and not fixed so you do FNA. If the fluid is straw colored or clear and the mass disappears what should you do next?DMUS - diagnostic mammogram and USA 34 yo patient presents with a unilateral breast mass. You have determined that the mass is mobile and not fixed so you do FNA. If the fluid is straw colored or clear, but the mass persists what should you do next?send to cytology and do DMUS diagnostic mammogram: - 4 images: 2 craniocaudal and 2 mediolateral (2 images per breast) - lymph nodes + spot compression/magnified views (diagnostic for breast cancer)A 34 yo patient presents with a unilateral breast mass. You have determined that the mass is mobile and not fixed so you do FNA. If the fluid is bloody, what do you do next?do DMUS diagnostic mammogram: - 4 images: 2 craniocaudal and 2 mediolateral (2 images per breast) - lymph nodes + spot compression/magnified views (diagnostic for breast cancer)A 30 yo patient presents with a unilateral breast mass. You have determined that the mass is mobile and not fixed so you do FNA. No fluid comes out with aspiration. What do you do next?complex cyst with internal echos - anechoic/echoic +/- multiple areas do US guided FNA and excisional biopsyA 30 yo patient presents with a unilateral breast mass. You cant determine whether the mass is mobile or fixed so you do a DMUS. The ultrasound shows multiple anechoic and echoic areas (black and white areas) What do you do next?core needle biopsy + excisional biopsyA 30 yo patient presents with a unilateral breast mass. You determine the mass is fixed and firm so you do DMUS. The US shows a large echoic area (white area). What do you do next?do core needle biopsy and excisional biopsy core needle because echoic/white so solid (would do FNA if anechoic)A 30 yo patient presents with a breast mass. You determine the mass is fixed and firm so you do DMUS. The US shows multiple echoic areas (white areas). What do you do next?simple cyst - if symptoms do FNA - if no symptoms FU mammogram in futureA 30 yo patient presents with a unilateral breast mass. You determine the mass is fixed and firm so you do DMUS. The US shows one anechoic area (black). What do you do next?send for surgical consult or FU in 2/3 monthsA 30 yo patient presents with a unilateral breast mass. You determine the mass is fixed and firm so you do DMUS. The US comes back normal. What do you do next?non-proliferative mass/lesions: - no increase in number of cells and no atypical cells (cell growth is not new or unexpected) - not associated with increased risk for cancer and can be due to blockages or hormones proliferative mass/lesions: - increase in number of cells but cells themselves are normal (no atypia) - increased risk of cancer (~2x) proliferative mass/lesions with atypia: - increase in cell number + atypia (malignant cells replace normal epithelium but basement membrane is intact) - increased risk for invasive cancer (3-5x) (not cancer bc BM intact)What is the difference between proliferative, nonproliferative, and proliferative with atypia masses/lesions?cysts - no increase in cell #/no abnormal cells - fluid-filled round mass (single or clustered) may be painful if enlarging & will show abnormal mammogram (anechoic area(s)), may palpate mass but should be mobile *PE is not enough to determine if cyst is benign (must do FNA to determine next steps)What is the most common non-proliferative lesion? Describe this.galactocele - common in women who are pregnant or breast feeding (often after breastfeeding stops) - dx/tx: FNA (can do US but dont do mammogram in lactating women because milk blocks image)A 25 yo patient G1P1, who is currently breast feeding presents with complains of a unilateral mass and you determine that this mass is mostly mobile. You decide to do FNA which shows a milky-fluid. What is this?galactocele: - milk-filled cyst common in pregnant women or breastfeeding (often after stops breast feeding) - dx/tx: FNA (may do US but dont do mammogram in lactating women) US will show anechoic areas - most common benign lesions in lactating womenWhat is a galactocele? How is it treated?normal fibrocystic breast changes - lobes dilate and form cysts of various sizes (mobile) - may feel ropy/firm fibroadenoma: - round, firm, rubbery, and slightly mobile (solid on US) Do a FNA: - no fluid - likely fibroadenoma (will be solid on US, confirmed with core needle biopsy) - straw-colored/green - normal fibrocystic changesIf a 22 yo patient complains of a palpable mass. You determine that this mass is round, firm but mobile. How would you determine whether this mass is a fibroadenoma or normal fibrocystic breast changes?Breast Abscess (Non-proliferative): - TX: drain with I&D or FNA if not at the surface (if signs of infection: fever and erythema - give dicloxicillin) *if patient doesnt recover with tx suspect inflamatory breast cancer (any breast infections/including abscess) rare to occur in non-lactating women, but if it does it often reoccursA 34 yo G1P1, currently breastfeeding patient presents to the clinic with complaints of a breast mass. You are able to palpate this mass and determine that it is mobile. You also notice the patient has a slight fever and some mild erythema around the mass. What is this and how do you treat it? What if the patient does not recover with treatment?if a patient with a breast infection (fever, erythema, etc) does not respond to treatment ***especially with axillary lymphadenopathyWhen should you suspect inflammatory breast cancer?Breast abscess (non-proliferative) -palpable mass (mobile) that may or may not have signs of infection (fever or inflammation) - tx: I&D or FNA (dicloxicillin too if infections signs) - rare to occur in non-lactating women, but if it does it often reoccursWhat is a breast abscess?Lipomas & fat necrosis (non-proliferative): - benign, mobile mass - may or may not cause nipple retractions - may or may not cause tenderness - will have no fluid drained with FNA and will have normal mammogram and US cause: trauma and surgery tx: usually self-limiting but if doesnt resolve after several weeks do a biopsyWhat are lipomas?Lipoma (non-proliferative): - benign, mobile mass (appears anywhere on body) - may or may not cause nipple retractions - may or may not cause tenderness cause: trauma and surgery tx: usually self-limiting but if doesnt resolve after several weeks do a biopsyA patient presents to your clinic with complains of a mass on her axillary region. She recently underwent cosmetic breast surgery. You notice slight retractions of the skin with no tenderness. You determine that it is mobile so you do FNA. No fluid is drained so you do a DMUS. The mammogram and US appear normal. What do you suspect and why?Fibroadenomas (proliferative) - round, firm, rubbery, relatively mobile mass - solid on imaging (US) tx: no exision need once you determine it is fibroadenoma via biopsyWhat is the most common benign neoplasm that occurs in young women within 20 years of puberty?fibroadenoma: proliferative - usually occurs in late teens/early 20s (masses < 30 usually do US) - round, firm, rubbery and slightly mobile (will be solid on US) - core needle biopsy will confirm this dx so no need to do excisionA 18 yo patient presents to your clinic with complains of a palpable round mass. You note that it is firm, rubbery, and somewhat mobile. You do a FNA which shows no fluid. You then decide to do a DMUS and the US shows an echoic/white area. If the core needle biopsy determines that this is _______, you dont need to do excisional biopsy.epithelial hyperplasia (proliferative) - found on mammogram (gray or white areas) - no palpable mass - biopsy shows more than 2 cell layers with proliferation but normal cellsA 45 yo patient comes in for a regular screening mammogram. The mammogram shows abnormal gray-white areas so you decide to do a core needle biopsy. The biopsy shows proliferation of cells with no atypia and shows 3 cell layers. What is this and why?Sclerosing Adenosis - increased fibrosis within the expanded lobule with distorsion and compression of the epithelium - abnormal mammogram - proliferative cells that are normalA 45 yo patient comes in for a regular screening mammogram. The mammogram shows abnormal gray-white areas so you decide to do a core needle biopsy. The biopsy shows proliferation of cells with no atypia. Overall you note increased fibrosis within the expanded lobule with compression of the epithelium. What is this?complex sclerosing lesion (radial scar) - proliferative - tubules entrapped in densely hyalinated stroma surrounded by radiating areas of the epithelium - abnormal mammogram - proliferative cells that are normal mimics invasive carcinomaA 45 yo patient comes in for a regular screening mammogram. The mammogram shows abnormal gray-white areas so you decide to do a core needle biopsy. The biopsy shows proliferation of cells with no atypia. Overall you note tubules entrapped in densely hyalinated stroma surrounded by radiating areas of the epithelium. What is this and what does it mimic?intraductal papilloma (proliferative) - unilateral nipple discharge, multiple or single non-palpable massWhat is the most common cause of pathological nipple discharge (serous, blood, or serosaguineuous)?intraductal papilloma (proliferative) - unilateral serous (yellow), blood, or serosaguineuous nipple discharge - usually found on mammogram and requires needle biopsy to confirm (may or may not do surgical excision)Explain what intraductal papillomas are, and what the treatment and diagnosis is.lobular circinoma in situ (LCIS) - proliferative with atypia - usually no symptoms, detected on regular mammogram screening - shows increase in cell number IN LOBULES + atypical cells (basement membrane remains intact so it cannot metastasize) management: annual mammogram, biannual breast exams, stop hormonal therapy (CHC, MHT) may give tamoxifen (SERM) to prevent invasive breast cancer Tx: core needle biopsy followed by excisional biopsyWhat is lobular carcinoma in situ? How is it diagnosed and treated?ductal carcinoma in situ (DCIS): - no symptoms, detected on regular mammogram screening - shows increase in cell number IN DUCTS + atypical cells (basement membrane remains intact so it cannot metastasize) tx: core needle biopsy followed by excisional biopsy management: annual mammogram, biannual breast exams, stop hormonal therapy (CHC, MHT), may give tamoxifen (SERM) to prevent invasive breast cancer ***increased risk for invasive cancer or reoccuranceWhat is ductal carcinoma in situ? How is it diagnosed and treated? How are these patients managed?DCIS: - detected on mammogram screen (no sx) - proliferative w/ atypia of duct (DCIS) or lobe (LCIS) (BM intact) - tx: core needle biopsy followed with excisional biopsy (may give patient tamoxifen to prevent long term invasive cancer) must stop CHC or MHT therapy - management: yearly mammograms and biannual breast exams DCIS has increased risk for invasive or reoccuring cancershow are carcinoma in situs diagnosed and treated?breast cancer - age: 50+ - ethnicity: whiteThis is the most common malignancy and the second leading cause of cancer-related death among women in the US. What age/ethnicity is most commonly affected by this?- age 50+ (white) - first degree relative with breast or ovarian cancer - BRCA 1/2 (women < 40 with breast cancer should have genetic test) - more periods: early start of period or late menopause, had first kid at 30+, never breastfed - alcohol use (2-4 drinks a week) - oral contraceptives (recent or long term) - ashkenazi jew prevention: - bold above - mammograms, genetic testing for BRCA, breast cancer prophylaxisWhat are the risks for breast cancer? what are ways to help prevent this?pagets disease (breast cancer) - itching, burning, pain - usually starts around the nippleWhat is this and what symptoms does it cause?1. invasive/infiltrative ductal carcinoma - most common 2. Invasive lobular carcinoma - usually more than 1 tumor and bilateral 3. Pagets Disease - pain, itching, burning and starts around nipple 4. inflammatory breast cancer - swelling/edema of breast with demarcated, raised border - may mimic mastitisWhat is the most common type of breast cancer? What type of breast cancer usually has more than 1 tumor and is bilateral?1. invasive/infiltrative ductal carcinoma - most common 2. Invasive lobular carcinoma - usually more than 1 tumor and bilateral 3. Pagets Disease - pain, itching, burning -starts around nipple 4. inflammatory breast cancer - swelling/edema of breast with demarcated, raised border - may mimic mastitisWhat type of breast cancer causes pain, itching, and burning and starts around the nipple? What type causes edema/swelling of the breast with a demarcated, raised border that can mimic mastitis?inflammatory breast cancer especially if axillary lymphadenopathy, may cause inflammationA patient complaining of breast swelling with well-demarcated raised border likely has what?Stage 1: - tumor has increased in size only (not to other areas) Stage 2A: - tumor increased in size and lymph nodes are involved but not axillary lymph nodes Stage 2B: - tumor increased in size and has axillary lymph node involvement Stage 3: - tumor has spread to local/neighboring areas of body or breast Stage 4: (metastatic) - tumor has spread to non-local areas of the bodyWhat stage of cancer does a patient have if: - tumor increased in size and lymph nodes are involved but not axillary lymph nodes - tumor has increased in size but not to other areas - tumor increased in size and has axillary lymph node involvement - tumor has spread to non-local areas of the body - tumor has spread to local/neighboring areas of body or breast1. PR and ER receptors are positive = positively affects prognosis (can turn off and on receptors) 2. Her2/Neu gene = negatively affects prognosis (cant control growth)How does the following affect breast cancer prognosis: - ER receptors - PR receptors - Her2/neu geneworst prognosis 1. ER receptors inactive/neg (cant turn on/off) 2. PR receptors inactive/neg (cant turn on/off) 3. Her2/Neu gene present (cant control growth)What is triple negative breast cancer?1. lumpectomy (breast conservation therapy) + lymph node biopsy - often combined with radiation - CI: pregnancy or multicentric breast cancer (more than 1 quadrant) OR 2. mastectomy - often combined with radiation in later stages + Chemo therapy + SERMS (tamoxifen) - turns of ER/PR receptors (5yr) +/- aromatase inhibitors (letrozole or anasterazole) - if ER positive +/- trastuzumab - if HER 2 positive **Treatment from breast cancer may cause lymphedema of the armWhat is the treatment for people with breast cancer? What if they are ER positive? What if they are HER2 positive? What may breast cancer treatment cause?Most recurrences of breast cancer occur within 5 years of primary therapy. (why you use tamoxifen for 5 years after surgery) Often metastasizes to: - bone (back pain) - liver (jaundice, AST/ALT increases) - Lungs (chronic persistant cough) travels via lymph (usually same side of axilla) and diagnosed with imagingMost recurrences of breast cancer occur within ____ years of primary therapy. Where does breast cancer often metastasize to and how does it get there?