Common Breast Disorders.docx

**Common Breast Disorders:** - Evaluate breast cancer screening recommendations - Health Promotion-Breast Cancer screening recommendations The U.S. Preventative Services Task Force recommends against teaching breast self-exam; start mammogram at age 40 and do every other year from...

**Common Breast Disorders:** - Evaluate breast cancer screening recommendations - Health Promotion-Breast Cancer screening recommendations The U.S. Preventative Services Task Force recommends against teaching breast self-exam; start mammogram at age 40 and do every other year from 40-74 - Screening in TGD Individuals: For transgender women and transfeminine on hormones start age 50 for individuals who have been on feminizing hormones for more than 5 yrs then screen every 2 years transgender males and transmascular (AFAB): no mastectomy then screen according to guidelines for cisgender females. If mastectomy no evidence for annual chest exam and would get ultrasound or MRI if any concerns. **Mammography:** this is an x-ray of the breast under compression screening is the initial test, total of 4 images taken diagnostic if change is seen and more pictures are taken screening to detect preclinical or early breast cancer; able to detect lesions 2 yrs before they are palpable **Ultrasound:** used to differentiate a cystic from a solid mass **primary diagnostic tool in individuals with breast symptoms \< 30 yrs** aging is a factor because dense glandular tissue is then replaced by fat individual over 30 yrs may do mammography with breast symptoms, especially when mammography is inconclusive. **MRI:** useful in high patients at high risk 1^st^ degree relative with gene mutation (BRCA) history of radiation therapy to the chest hx of breast cancer lifetime risk of breast cancer \>20% have known BRCA1 or BRCA2 recommend yearly (along with mammogram), imaging every 6 months **BRCA Genes:** - Breast cancer genes - Increased risk of breast and/or ovarian cancer with a mutation in one of the BRCA genes and strong family history **Lifetime Average Risk and 5-yr risk: Gail Model** - Age (begins at 35) - Race - Age at the start of menstruation - Age at first live birth of a child - Number of 1^st^ degree relative (mother, sisters, daughters) with breast cancer - Number of previous breast biopsies (whether positive or negative) - Presence of atypical hyperplasia in a biopsy **Breast Anatomy and breast cancer:** - There are 12-20 lobes (lobular tissue) - Each lobe has a collection of secretory cells - Secretory cells drain into milk ducts (5-10 per breast) - Cancer usually arises in lobular or ductal unit of breast - **Breast cancer usually found in the upper outer quadrant of the breast** **Physical Exam:** - Self-breast exam optional - Clinical breast exam performed when patient presents with a specific breast complaint, as part of an overall well person exam in women after age 40 - Remember the breast exam includes examining the axillae and relevant lymph node chains **Concerning Breast Masses:** - Over 2 cm - Immobile - Firm - Skin dimpling - Color changes - Nipple changes **Breast Cancer:** - Erratic cell growth and proliferation in breast tissue - Likelihood of malignancy increases with ageAFAB aged 60-69 years have 1 in 28 risk - Second leading cause of cancer deaths in women **Risk factors for Breast Cancer:** - Age: 80% of breast cancer occurs after 50s - Gender: female 100x more likely than males - Race (white) - Personal history of breast cancer - Higher BMI/ higher body fat % in postmenopausal womenestrogen from adipose tissue - Increased breast tissue density on mammogram - First degree relative with breast cancer (mom, sis, daughter) - Past hx of biopsies for atypical hyperplasia - Combined Oral Contraceptivestemporarily increased, returns to normal 2-5 yrs after d/c - Combined HRT after menopause - Early menarche before age 12 and/or late menopause after age 50 - Nulliparity - Higher bone density - Late age at birth of first child - Alcohol intake (3-6 drinks per week), risk increases with amount consumed - Smoking - Lab evidence of BRCA1 and BRCA2 **What factors decrease breast cancer risk?** - Medical/surgical prevention: mastectomy in high-risk groups; chemoprevention - Breastfeedingevery 12 months of breastfeeding decreases risk by 4.3% - Physical activity - Low fat diet - Inconclusive: mediterranean diet, Vit D, NSAIDs **What factors have NO effect on breast cancer?** - Abortion - IVF - Pesticides - Antioxidants - Tubal ligation - Caffeine intake - Breast implants - Electric blankets - Hair dyes **What are the 2 types of breast cancers?** 1. Invasive: ductal carcinoma arises from the epithelial lining of ducts; lobular originates in the tissue of the lobules; inflammatory breast cancer has a presentation similar to mastitis with the erythema but nontender heavy breast 2. Non-invasive: ductal carcinoma in situ which is confined to the duct **What is paget disease?** - Ulceration of the nipple - The areola may or may not be spared - May indicate underlying ductal carcinoma - These patient will need imaging and breast biopsy done **Breast Cancer Diagnosis:** - Identification of palpable lesion/breast symptoms or abnormal screening mammography - Perform comprehensive breast exam; note skin changes, palpable masses, nipple discharge - Symptoms of metastases: bone pain, arthralgias, cough, jaundice, abdominal pain, headache, visual disturbances, malaise, loss of appetite, weight loss, fever, fatigue - Diagnostic testing: imaging studies and tissue sampling - Breast cancer diagnosis: TNM system, size of tumor, lymph node involvement, metastatic spread **Breast Cancer Treatment:** - Treatment: surgery, chemotherapy, radiation, hormonal therapy (Tamoxifen) - Breast-conserving surgery (lumpectomy/partial mastectomy removes cancer, not breast itself - Chemotherapy: administered after surgery or preoperatively to decrease size of tumor prior to surgery - Radiation therapy: used following breast-sparing surgery - Tumors with hormone receptors: estrogen-blocking drugs or drugs that reduce estrogen are often used to prevent recurrence; typically take for 5-10 yrs after cancer Identify common breast disorders: 1. **Mastalgia (Breast Pain):** - Common breast concern, very common during pregnancy and lactation - Benign over 90% of cases - History: menstrual hx, timing is it cycle vs noncyclic (cyclic is most common and occurs a few days before menstruation; cyclic is almost always benign) - Location: bilateral or unilateral and quadrant location; upper, outer quadrants have denser breast tissue - Medications that can contribute: antidepressants, HRT, hormonal contraceptives, spironolactone, digoxin - Treatment: manage the underlying cause - If benign/no pathological process found: reassure supportive bra (avoid underwire) modify dose or route of hormonal therapy varied data for COCs Danazol: androgen, decreases efficacy of COCs (adverse effects are voice deepening, excessive hair growth and acne) - When would you refer? Unilateral, abnormal physical exam findings, persistent and/or severe 2. **Breast Masses:** - Most breast masses are benign and often cyclical - Malignancy should always be considered - Medical history about other breast symptoms - Perform comprehensive breast exam to assess for skin changes, nipple d/c, lymphadenopathy - Differential diagnoses: fibrocystic changes, cysts, galactocele, infection or abscess, malignancy - Benign Breast Lesions: 1. Non proliferative has no increase risk of CA (simple cysts and galactocele) 2. Proliferative without atypia has small increased risk of CA (fibroadenoma) 3. Proliferative with atypia has substantial increased risk of CA (lobular carcinoma in SITU) - **Diagnostic Evaluation Breast Mass:** if less than 30 years old then do ultrasound if over 30 then do diagnostic mammogram, if mass suspicious for malignancy then add ultrasound refer to surgeon as needed for further evaluation (biopsy or excision) 3. **Fibroadenoma:** - 12% of breast lumps - Peak age is 21-25 yrs old - Often presents with multiple bumps - Description: well defined, unilateral pea or marble-like, painless lump for months or years; can feel rubbery; usually upper outer quadrant - No discharge, retraction, or dimpling - Differential diagnosis: Phyllodes tumor (usually benign), carcinoma - Diagnosis: mammogram or U/S depending on age; a CORE NEEDLE BIOPSY is the definitive diagnosis - Treatment: education and reassurance, serial examinations, any atypical features \>3cm, patient request or significantly enlarging then should remove - Consider excision if new onset in older patient 4. **Fibrocystic Breasts AKA Fibrocystic changes, cystic mastitis, mammary dysplasia** - Outdated term LOL - Range of benign findings in normal breast tissue undergoing the usual cyclical physiologic changes - Hormones fluctuation - Typically bilateral - Will often have tenderness with palpation; no supraclavicular or axillary lymphadenopathy or overlying skin changes - Image/biopsy if not sure - Simple or complex cyst: could be carcinoma or fibroadenoma; a complex cyst has something other than clear fluid inside it - Diagnosis: ultrasound or ultrasound biopsy; if it's a complex cyst pt would require a core biopsy to rule out malignancy - Treatment: education and reassurance 5. Nipple discharge - Pregnancy and lactation most common - Galactorrhea: milky nipple discharge in past 12 months typically bilateral and multiductal because it's usually a hormone problem result of hyperprolactinemia and not breast pathology headaches and visual changes we're concerned for a pituitary tumor can cause menstrual disturbances due to increase in prolactin levels can lead to amenorrhea or oligomenorrhea assess medication hx and marijuana use Paget: consider this because this can also cause nipple discharge - Non-milky discharge: intraductal papilloma/mammary duct ectasia this is the most common causes of non-milky nipple discharge (not cancerous) - Cancer-related nipple discharge: 5-12% of breast cancers spontaneous (without any manipulation) and bloody accompanied by mass or abnormal mammogram person over 50 yrs old **Nipple discharge history:** - Duration and color of nipple discharge - Pregnant vs non - Bilateral vs unilateral - Singular vs multiple ducts - Menstrual cycle - Occurs spontaneously or only with manipulation - Review medications/substances: CHCs, HRT, antiemetics, antipsychotics, antidepressants, cocaine, stimulants, marijuana - Note other breast symptoms like masses - **Unilateral, spontaneous, single duct, clear or bloody discharge HIGH CONCERN FOR CANCER** - White/yellow/green/brown, multiple ducts, bilateral, w/ manipulation thinking BENIGN - Mammography/ultrasound to biopsy - Check prolactin levels to see if it's hormonal or caused by a pituitary tumor - Normal findings and imaging do a duct exploration - Abnormal imaging want to excise lesion w discharging duct - Physiologic, not treatment needed and compression not recommended - Hyperprolactinemia need to look for cause i.e. pituitary tumors 6. **Gynecomastia** - Benign proliferation of glandular tissue of male breast - Common in infancy, puberty, and in middle-aged to older males - 60-90% of male babies due to maternal estrogen and transient "mini-puberty" usually lasts 2-3 weeks - 4-69% during puberty usually at tanner stage 3; usually lasts 18 months - A result of increased estrogen production or decreased androgen production - Risk factor: obesity (b/c the fat producing estrogen) - Palpable breast tissue that extends outside the area under the nipple - Typically bilateral but can be unilateral or asymmetric enlargement - Pain is common in adolescents - Tenderness and nipple sensitivity from rubbing against shirt - Glandular tissue that is centrally located, symmetrical in shape, usually bilateral, and tender to palpation (early on) - Pseudogynecomastia: an increase in breast fat; diffuse breast enlargement without subareolar glandular tissue; fingers will not meet resistance until the nipple - Breast cancer: typically unilateral, nontender, fixed masses; found eccentric to nipple areolar complex. Associated sx: skin dimpling, nipple discharge, regional lymphadenopathy. - Take detailed history: include symptoms of liver and kidney dz, hyperthyroidism and hypogonadism in ROS - PE: in addition to breast exam to testicular exam and abdominal exam to check for mass (adrenocortical carcinoma) - Middle-aged and older adults consider AM total testosterone - Recent onset, painful/tender, or \>4 cm with no apparent cause need to do serum hCG, LH, testosterone, and estradiol with increased hCG and decreased LH think testicular or extragonadal germ cell tumor with increase estradiol plus decreased LH think testicular or adrenal tumor - If suspecting breast CA then to mammogram or U/S with possible surgery referral - Treatment: treat the underlying condition; refer to endocrinologist if suspecting hyperthyroidism or hypogonadism - If there is no identifiable cause then can give tamoxifen for up to 3 months after observation - Remember no surgery in kids/adolescents until adult testicular size has been reached