Breast complaints are usually ____%

__________.

Breast complaints are usually 80%

__Benign_.

???

Contains IgA antibodies that protect against diarrhea,

middle ear infection, lower respiratory track infections, UTI, Neonatal septicemia

Inspect:  Skin of breast & nipple

Palpate: Lymph nodes

Palpate: Entire breast & nipple in sitting

Examine:  Nipple discharge

Mammograms

&

Ultrasounds

What are these:

FNA

Vaccum assisted biopsy

Excisional/Open biopys

Sterotactic/Needle localized biopsy

Cytological Smear/Microscopy

Ductography

MRI

What are these tests for:

Serus Prolactic level

TSH

CT/bone scan of lymphs

CBC, LFT, CXR

HER-2 NU, FISH

What breast study will you do for:

women under 40 yrs of age

women over 40 yrs of age

women under 40 yrs of age:  ULTRASOUND

women over 40 yrs of age:  MAMMOGRAM

Lump

Mass

Nodule

Tumor

This is describing what:

Round & discreet

Defined borders

Smooth, Soft

Freely movable

This is describing what:

Dense & spiculated

Irregular borders

ROCK hard

FIXED

On the Ultrasound how does the mass look for:

Benign

Malignant

Benign:  HOMOGENOUS no internal echoes

Malignant:  IRREGULAR, internal echoes nor uniform

discrete posterior shadows

What are these conditions:

Mastalgia/Mastodynia

Breast discharge

Galactorrhea

Mastitis

Fibrocytic changes

Simple & Complex Breast Cysts

Duct Ectasia

Intraductal Papilloma

Fibroadenoma

This is the most common breast problem in primary care?

Incidence as high as 70%

Which breast pain revolves around menses?

Cyclic

or

Non-cyclic

Cyclic/premenstrual

Resolves after menses

This breast pain is unrelated to menstrual cycle, less common, and women of 40-50 yrs complain?

Cyclic

or

 Non-cyclic

Pregnancy

benign tumor

fibrocystic changes

thrombophlebitis

Cancer

Usually resolves spontaneously

What are these conditions associated with??

Unilateral discharge

Bilateral discharge

Unilateral discharge: 

 CANCER

Bilateral discharge: 

 BENIGN

IDIOPATHIC

PHYSIOLOGICAL

SIDE EFFECT of meds

What is this suggesting:

persistent bilateral milky discharge with ammenorrhea

infertility

visual field loss

What is this?

Milky white or fatty bilateral nipple discharge

Occurs in peripubescent girls

secondary to certain meds

chest wall trauma

endocrine abnormalities

Evaluated with occult blood, prolactin level, & US

Why are prolactin levels elevated,  is it Physiological, Pathological, or Pharmacologic??

Stress

Trauma

surgery

pregnancy

puerpartum

sucking

Why are prolactin levels elevated,  is it Physiological, Pathological, or Pharmacologic??

Acromegaly

Chronic chest wall stimulation

post thoracotomy

Herpes zoster

breast disease

hypothalamic dz

hypothyroidism

cirrhosis

prolactin secreting tumor

renal failure

Why are prolactin levels elevated,  is it Physiological, Pathological, or Pharmacologic??

Amphetamines

Cimetidine

Estrogen

Narcotics

Phenothiazines

TCA

Nicotine

What is this? site of breast

pain

breast tenderness

erythema

local edema

fever chills

Mastitis

Infection of ducts

ABX

Dicloxacillin 500 mg po qid

or

Clindamyacin 300 mg po qid for 7-10 days

YES

with tx, 96% pts respond in 24-48 hrs

Abscess

Need incision & drainage

What are the percentages for nipple discharge in:

breast discharge unrelated to pregnancy & lactation

breast cancer

breast discharge unrelated to pregnancy & lactation

3-10%

breast cancer

2.5-4%

What are the colors of nipple discharge?

Serous

Seroanguinous

Sanguinous

Serous:  Yellow

Seroanguinous:  Straw colored with blood

Sanguinous:  BLOODY 27% indicative of Ca

What do these colors of nipple discharge mean?

milky

purulent

milky:

Prolactin level increased

no breast stimulation for 48-72 hrs b/f blood drawn

often increased in fibroadenoma

purulent:

infection

This type of nipple discharge indicates:

spontaneous

unilateral

persistent

new or occult blood

What are the lab test done for evaluating nipple discharge?

Prolactin level

TSH

Serum human chorionic gonadotropin

Mammogram

ductogram

MRI

Hperprolactinemia

What is this?

Non-milky

Duct ectasia

Non-puerperal mastitis

Intraductal papilloma

Breast cancer

Milky or galactorrhea

Breast stimulation

Breast implants or postreduction

Chest wall irritation

Medication

Hypothyroidism

Pituitary adenoma

Present with:

 multiple bilateral achy, tender, or painful lumpy breast tissue

??

What is this:

Glandular and lack discreteness from surrounding breast tissue

Intensity of sx intensifies pre-menstrually (luteal phase)

What is this:

Pain often bilateral and extends into axilla, shoulder or arm

Aggravated by caffeine intake

reduction of caffeinated drinks, food, chocolate

 supportive bra

Evening primrose oil

What is this:

Highest frequency of breast lumps

Common in women 35-50 yrs age

Typically round or elliptical, soft, fluctuant, or mobile

Upper outer quadrant

Vary in size through out menstrual cycle

with imaging

Mammogram or US

Observe vs. Referral to breast surgeon if bothersome for excision

Usually single, nontender, rubbery, firm, encapsulated, ovoid or lobular mass

Freely movable

Does not vary in size with menstrual cycle

Found commonly in women in 20s

Multiple and bilateral 25% of time

Found mostly in upper outer quadrant

Only by a BIOPSY

observe vs referral to breast surgeon if bothersome for excision

Etiology unclear but felt to be caused by cellular debris and lipid containing substances that obstruct subareolar duct (inflammatory response)

??

What condition is this??

Symptoms include nipple discharge that is straw colored, green or brown, subareolar swelling, burning, nipple itching

Evaluation:   occult blood, Prolactin level, ultrasound

Treatment:   refer for surgical removal

What is this:

Small usually nonpalpable benign tumor located in mammary duct

Most common benign lesion to cause  spontaneous serous or serosanguinous nipple discharge

Usually unilateral

Usually occurs in women 35-55 year old

???

Intraductal Papilloma

Eval:  Occult blood, Prolactin level, US

Tx:  Refer to surgeon for removal

Classic:

Single lump, hard, non-tender,immobile, irregular borders

Most frequent in upper outer quadrant

Eventually affix to skin, ligaments, chest wall, & metastasize to other organs 

1%

Rare

Entire breast swollen

Axillary lymphadenopathy 

Rapidly progressing disease

???

Unilateral

Well demarcated

Erythematous

Scaly plaque on nipple & areola

??

Paget's Diseas of nipple

Superficial manifestation of underlying ductal carcinoma

1-3% of Breast Ca

1 in 8 lifetime risk

Peak age at diagnosis 45-65,

 with 75% occurring over age of 50m70% invasive;

 invasive ductal more common than lobular (96-97% vs. 3-4%)

Early menarche

Late menopause

Nulliparity or first pregnancy after 35

Prior history of breast cancer

Obesity

Excess alcohol use

Family history

BRCA carriers have risks for breast and ovarian cancer, usually early onset

90 % of women with breast cancer have NO family history

How do you protect against breast Ca with:

???

exercise

dietary soy

weight control

Tamoxofin as prophylaxis in high risk women

When are mammograms recommended:

age 40

Clinical breast exams for:

age 20-30

age 40+

Age 40:  mammograms yearly

CBE:

20-30s every 3 years

40+ yearly

Breast Ca Detection methods for:

Women at high risk (greater than 20% lifetime risk):

Moderately increased risk (15% to 20% lifetime risk):

 Yearly MRI screening:

Women at high risk (greater than 20% lifetime risk):

 MRI & mammogram every year

Moderately increased risk (15% to 20% lifetime risk):

Talk w/ MD about the benefits and limitations of adding MRI screening to their yearly mammogram.

 Yearly MRI screening:

Not recommended for lifetime risk of breast ca  less than 15%.

What is this?

Assesses breast cancer risk:

  1. ethnicity

  2. age at first menses

  3. age  at first pregnancy

  4. number of first degree relatives with

      breast cancer

  5. number of previous breast biopsies

  6. number of breast biopsies with positive

      hyperplasia 

Tamoxifen

Evista

Prophylactic mastectomy

What is this??

Lumpectomy (simple lumpectomy)

Mastectomy (radical vs. modified)

Radiation Therapy

Chemotherapy

Hormonal Therapy

Does this warrant a referral??

Suspicious breast lumps

non-milky d/c

nipple lesions

abn mammograms/US

After dx & tx:

 PE indicated every 3 months for 1st 5 yrs  & thereafter yearly

Regular follow-up visits include chest x-ray and LFT’s

Yearly mammogram, Address physical/ psychosocial-body image,libido, sexuality

??????