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54 Cards in this Set

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Describe the anatomy and physiology of the female breast.
A. Each breast consists of nipple, lobes, ducts, fibrous and fatty tissue.
B. Each breast has 15-20 lobes of glandular tissue.
C. The lobes branch to form 20-40 lobules, which are subdivided into secretory alveoli
D. The alveoli produce milk and other substances, each empties into a lactiferous duct that travels out through the nipple.
E. Behind the nipple the lactiferous ducts enlarge slightly to form small reservoirs called lactiferous sunuses
Mammogram
X-ray used to screen for calcifications, densities, and architectural distortion. Used to screen for breast cancer.
Ultrasound
Ultrasound uses sound waves to differentiate solid versus cystic masses
Magnetic resonance imaging
Uses magnetic fields with or without contrast, used to evaluate tissue with increased blood flow such as tumors.
Fine-needle aspiration biopsy
Tissue for cytologic examination is aspirated with a small needle. It is done for a palpable breast mass or thickening
Stereotactic core needle biopsy
Large bore needle used to obtain cores of tissue for histological examination. Stereotactic mammography is used for localizing the target. Used to assess densities or calcifications seen on mammogram.
Ultrasound-guided core needle biopsy
Large bore needle used to obtain cores of tissue for histological examination. Ultrasound used for localizing and targeting. Done to assess solid lesions seen on ultrasound.
Needle-localized breast biopsy
Use of a wire to localize an occult mammographic anormality prior to excisional biopsy. Done to assess a density or calcification seen on mammogram that can not be effectively core biopsied.
Excisional breast biopsy
Surgical procedure that requires a skin incision. A mass or mammographic abnormality is removed with a surrounding margin of normal appearing tissue. Done to evaluate and treat a palpable breast mass, thickening or skin change.
Differentiate the typical nipple discharge found with mammary duct ectasia, and intraductal papilloma, and galactorrhea.
A. Mammary duct ectasia – bilateral, multiductal, and green, brown, or black in color
B. Intraductal papilloma – uniductal bloody discharge
C. Galactorrhea – Milky nipple discharge in a woman who has not been pregnant or lactated in the past 12 months. Usually bilateral and multiductal. May occur spontaneously or only with breast manipulation.
4. Differentiate the typical examination findings for the following breast masses: fibroadenoma, cyst, lipoma, fat necrosis, hamartoma, galactocele, and malignancy.
A. Fibroadenoma – found in 10% of all women
1. Usually 20-40 years old
2. perhaps result from effect of estrogen on breast tissue
3. Discrete, smooth, round or oval, nontender, mobile
B. Cyst
1. Usually 35-50 years old
2. Fluid filled mass
3. Discrete, tender, mobile
C. Lipoma
1. Usually in later reproductive years
2. Island of fatty tissue
3. Discrete, soft, nontender, may or may not be mobile
D. Fat necrosis
1. result from trauma, usually over 40
2. Ill-defined, firm, nontender, nonmobile
E. Hemartoma
1. Composed of glandular tissue, usually after menopause
2. discrete, nontender, nonmobile, may be nonpalpable with incidental diagnosis on imaging studies
F. Galactocele
1. Milk filled cysts, usually during or after lactation
2. discrete, firm, sometimes tender
G. Malignancy
1.
Describe the assessment and management plan for mastalgia
1. Assessment
1. Determine if it is cyclical or noncyclical and eliminate non breast causes such as muscle pain.
2. Ask about timing, severity, and mitigating factors of pain.
3. Ask about other breast symptoms such as nipple discharge or masses
4. Ask about previous history of breast surgery or disease
5. Ask about menstrual, pregnancy and lactation history
6. Current meds, particularly exogenous hormones
7. Ask about caffeine intake
8. Family history, particularly breast and ovarian cancer
9. Perform comprehensive breast exam
2. Management
1. Once malignancy and non breast causes have been ruled out one can reassure woman and focus on relieving symptoms.
2. supportive bra
3. modifying dose or route of HT or COCs may help
4. danazol, tamoxifen, and bromocriptine rxs for breast pain but all have sig dise effects and pain may return when off meds.
5. NSAIDS oral, injectable or topical
6. evening primrose oil
7. isoflavones
Describe the assessment and management plan for nipple discharge.
1. Discharge that is spontaneous, unilateral, from a single duct, and clear or bloody is more likely to be associated with CA.
2. Discharge that occurs with breast manipulation, is bilateral, comes from multiple ducts, and is white, yellow, green, brown or black in color is less likely to be associated with CA.
3. Ask about color of discharge and whether it occurs spontaneously or with manipulation
4. Ask if it is unilateral or bilateral and if it comes from one or more ducts
5. Review meds
6. Ask about other symptoms such as mastalgia or masses
7. Ask about history of breast disease or surgery
8. Symptoms of hypothyroidism, HAs, and visual problems
9. Ask about menstrual, pregnancy and lactational history
10. Family history of breast and ovarian CA
11. Perform comprehensive breast examination
12. Prolactin and TSH levels
2. Management
1. reassure if colostrum or discharge related to fibrocystic beast changes
2. mammary duct ecstasia can be managed expectantly or surgically
3. intraductal papiloma tx with excision
4. for galactorrhea treat underlying cause – surgical removal of tumor, switch meds, treat hypothyroidism. Bromocriptine can be used but has many side effects. Surgery if not able to manage medically and symptoms are severe.
Describe the assessment and management plan for breast masses.
1. Assessment
1. When did she first notice it and has it changed since then?
2. Associated symptoms such as mastalgia or nipple discharge
3. History of breast surgery or disease
4. menstrual, pregnancy and lactational history
5. family history of breast or ovarian CA
6. Comprehensive breast exam
7. If mass is palpable determine size in cm, shape, consisteny, mobility. Determine if it is discrete or ill defined. Tender or nontender. Assess for skin changes, nipple discharge and lymphadenopathy.
8. document location as if on a clock.
9. Imaging can not rule in or out malignancy so a biopsy will be required to determine whether it is solid or cystic, benign or malignant.
2. Management
1. Depends on the type of mass
2. fibroadenoma may not need to be treated but can be excised if growing of painful
3. Asymptomatic cysts need not be treated but FNA can be used for large or painful cysts.
4. Lipoma need only be excised if the clinical exam and tissue sampling are not consistent with lipoma or if there are suspicious findings on mammography or ultrasound.
5. Fat necrosis and hemartomas may need to be excised to be diagnosed but otherwise can be managed expectantly.
6. A galactocele will spontaneously resolved but aspiration can be attempted if it is painful, though it doesn’t always work.
What are the three criteria used for the staging of breast cancer?
A. Primary tumor
B. Regional lymph nodes
C. Distant metastases
Ductal carcinoma in situ (DCIS)
Earliest manifestation of breast CA and involves abnormal cells confined to the ducts. Usually dx due to abnormalities on mammo, rare to find palpable mass.
Lobular carcinoma in situ (LCIS)
Abnormal cells confined to the lobules. It is a noninvasive lesion that does not clearly progress to invasive CA. Often an incidental finding when biopsying another lesion.
Invasive ductal carcinoma
Most common CA. Presents as a discrete solid mass with malignant cells escaping the confines of the duct and infiltrating the breast parenchyma.
Invasive lobular carcinoma
Much less common than invasive ductal carcinoma and may present as a discrete mass, usually in the upper outer quadrant of the breast. The mass may be characterized only as thickening or induration with margins that are ill defined. Increased risk for developing bilateral CA. Associated with unusual spread of metastases including meninges, abdomen, uterine and ovaries.
Paget’s disease
rare form causes eczematous nipple changes as well as erythema, itching and nipple discharge. Usually underlying invasive ductal carcinoma.
Inflammatory breast carcinoma
Most aggressive type of CA. Causes diffuse inflammatory changes of the breast skin with erythema, warmth, skin thickening, and peau d’orange (edema that makes breast skin look like skin of an orange) There may or my not be an underlying invasive malignancy.
What interventions are used to prevent breast cancer in women at high risk for the disease?
A. Tamoxifen and raloxifene
B. Very high risk may choose prophylactic mastectomy
What are the four primary treatment strategies for breast cancer?
A. Surgery
B. Chemotherapy
C. Radiation
D. Hormone manipulation
What known risk factors for breast cancer have been identified?
1. being female
2. advancing age
3. prior personal hx of br CA
4. nulliparity
5. 1st pg p age 30
6. early menarche
7. late menopause
8. family hx, esp first degree relative
9. BRA1 and BRA2 genetic mutation
10. previous breast biopsy revealing atypical, ductal, or lobular hyperplasia
11. ductal or lobular carcinoma in situ
12. exposure to chest radiation
Differentiate the typical nipple discharge found with mammary duct ectasia, and intraductal papilloma, and galactorrhea.
A. Mammary duct ectasia – bilateral, multiductal, and green, brown, or black in color
B. Intraductal papilloma – uniductal bloody discharge
C. Galactorrhea – Milky nipple discharge in a woman who has not been pregnant or lactated in the past 12 months. Usually bilateral and multiductal. May occur spontaneously or only with breast manipulation.
4. Differentiate the typical examination findings for the following breast masses: fibroadenoma, cyst, lipoma, fat necrosis, hamartoma, galactocele, and malignancy.
A. Fibroadenoma – found in 10% of all women
1. Usually 20-40 years old
2. perhaps result from effect of estrogen on breast tissue
3. Discrete, smooth, round or oval, nontender, mobile
B. Cyst
1. Usually 35-50 years old
2. Fluid filled mass
3. Discrete, tender, mobile
C. Lipoma
1. Usually in later reproductive years
2. Island of fatty tissue
3. Discrete, soft, nontender, may or may not be mobile
D. Fat necrosis
1. result from trauma, usually over 40
2. Ill-defined, firm, nontender, nonmobile
E. Hemartoma
1. Composed of glandular tissue, usually after menopause
2. discrete, nontender, nonmobile, may be nonpalpable with incidental diagnosis on imaging studies
F. Galactocele
1. Milk filled cysts, usually during or after lactation
2. discrete, firm, sometimes tender
G. Malignancy
1.
Describe the assessment and management plan for mastalgia
1. Assessment
1. Determine if it is cyclical or noncyclical and eliminate non breast causes such as muscle pain.
2. Ask about timing, severity, and mitigating factors of pain.
3. Ask about other breast symptoms such as nipple discharge or masses
4. Ask about previous history of breast surgery or disease
5. Ask about menstrual, pregnancy and lactation history
6. Current meds, particularly exogenous hormones
7. Ask about caffeine intake
8. Family history, particularly breast and ovarian cancer
9. Perform comprehensive breast exam
2. Management
1. Once malignancy and non breast causes have been ruled out one can reassure woman and focus on relieving symptoms.
2. supportive bra
3. modifying dose or route of HT or COCs may help
4. danazol, tamoxifen, and bromocriptine rxs for breast pain but all have sig dise effects and pain may return when off meds.
5. NSAIDS oral, injectable or topical
6. evening primrose oil
7. isoflavones
Describe the assessment and management plan for nipple discharge.
1. Discharge that is spontaneous, unilateral, from a single duct, and clear or bloody is more likely to be associated with CA.
2. Discharge that occurs with breast manipulation, is bilateral, comes from multiple ducts, and is white, yellow, green, brown or black in color is less likely to be associated with CA.
3. Ask about color of discharge and whether it occurs spontaneously or with manipulation
4. Ask if it is unilateral or bilateral and if it comes from one or more ducts
5. Review meds
6. Ask about other symptoms such as mastalgia or masses
7. Ask about history of breast disease or surgery
8. Symptoms of hypothyroidism, HAs, and visual problems
9. Ask about menstrual, pregnancy and lactational history
10. Family history of breast and ovarian CA
11. Perform comprehensive breast examination
12. Prolactin and TSH levels
2. Management
1. reassure if colostrum or discharge related to fibrocystic beast changes
2. mammary duct ecstasia can be managed expectantly or surgically
3. intraductal papiloma tx with excision
4. for galactorrhea treat underlying cause – surgical removal of tumor, switch meds, treat hypothyroidism. Bromocriptine can be used but has many side effects. Surgery if not able to manage medically and symptoms are severe.
Describe the assessment and management plan for breast masses.
1. Assessment
1. When did she first notice it and has it changed since then?
2. Associated symptoms such as mastalgia or nipple discharge
3. History of breast surgery or disease
4. menstrual, pregnancy and lactational history
5. family history of breast or ovarian CA
6. Comprehensive breast exam
7. If mass is palpable determine size in cm, shape, consisteny, mobility. Determine if it is discrete or ill defined. Tender or nontender. Assess for skin changes, nipple discharge and lymphadenopathy.
8. document location as if on a clock.
9. Imaging can not rule in or out malignancy so a biopsy will be required to determine whether it is solid or cystic, benign or malignant.
2. Management
1. Depends on the type of mass
2. fibroadenoma may not need to be treated but can be excised if growing of painful
3. Asymptomatic cysts need not be treated but FNA can be used for large or painful cysts.
4. Lipoma need only be excised if the clinical exam and tissue sampling are not consistent with lipoma or if there are suspicious findings on mammography or ultrasound.
5. Fat necrosis and hemartomas may need to be excised to be diagnosed but otherwise can be managed expectantly.
6. A galactocele will spontaneously resolved but aspiration can be attempted if it is painful, though it doesn’t always work.
What are the three criteria used for the staging of breast cancer?
A. Primary tumor
B. Regional lymph nodes
C. Distant metastases
Ductal carcinoma in situ (DCIS)
Earliest manifestation of breast CA and involves abnormal cells confined to the ducts. Usually dx due to abnormalities on mammo, rare to find palpable mass.
Lobular carcinoma in situ (LCIS)
Abnormal cells confined to the lobules. It is a noninvasive lesion that does not clearly progress to invasive CA. Often an incidental finding when biopsying another lesion.
Invasive ductal carcinoma
Most common CA. Presents as a discrete solid mass with malignant cells escaping the confines of the duct and infiltrating the breast parenchyma.
Invasive lobular carcinoma
Much less common than invasive ductal carcinoma and may present as a discrete mass, usually in the upper outer quadrant of the breast. The mass may be characterized only as thickening or induration with margins that are ill defined. Increased risk for developing bilateral CA. Associated with unusual spread of metastases including meninges, abdomen, uterine and ovaries.
Paget’s disease
rare form causes eczematous nipple changes as well as erythema, itching and nipple discharge. Usually underlying invasive ductal carcinoma.
Inflammatory breast carcinoma
Most aggressive type of CA. Causes diffuse inflammatory changes of the breast skin with erythema, warmth, skin thickening, and peau d’orange (edema that makes breast skin look like skin of an orange) There may or my not be an underlying invasive malignancy.
What interventions are used to prevent breast cancer in women at high risk for the disease?
A. Tamoxifen and raloxifene
B. Very high risk may choose prophylactic mastectomy
What are the four primary treatment strategies for breast cancer?
A. Surgery
B. Chemotherapy
C. Radiation
D. Hormone manipulation
What known risk factors for breast cancer have been identified?
1. being female
2. advancing age
3. prior personal hx of br CA
4. nulliparity
5. 1st pg p age 30
6. early menarche
7. late menopause
8. family hx, esp first degree relative
9. BRA1 and BRA2 genetic mutation
10. previous breast biopsy revealing atypical, ductal, or lobular hyperplasia
11. ductal or lobular carcinoma in situ
12. exposure to chest radiation
ASC-US
Atypical Squamous cells of Undetermined Significance

This term is used when the squamous cells do not appear completely normal but it is not possible to determine the cause of the atypical cells.
ASC-H
Atypical Squamous Cells cannot excluse HSIL
LSIL
Low-grade squamous intraepithelial neoplasia

Encompases HPV, CIN1 (mild dysplasia): lesion involved the initial 1/3 of the epithelial layer
HSIL
High-grade squamous intraepithelial neoplasia

Encompasses
CIN 2 (moderate dysplasia): Lesion involves 1/3 to 2/3 epithelial layer
CIN 3 (Severe dysplasia): Lesion involves 2/3 to full thickness
Squamous carcinoma
Malignant cells penetrate basement membrane of cervical epithelium and infiltrate supporting tissue.

In advanced cases cancer may spread to adjacent organs such as bladder or rectum, or to distant sites of the body via the blood and lymph.
What is initial management for ASC-US in premenopausal woman?
HPV-DNA if thin prep or wait and retest in 4-6 months or colpo.
What is initial management for ASC-US in postmenopausal woman?
Vag estrogen therapy if evidence of atrophy and no contraindications to estrogen. Otherwise colpo or HPV-DNA testing.
What is the initial management of ASC-H?
Colpo
What is the initial management of AGC in a woman under 35 with regular periods?
Colpo
What is the initial management of AGC with endometrial cells?
Endometrial sampling.
What is initial management of AGC in over 35 or irregular bleding?
colposcopy and endometrial sampling.
What is initial management of LSIL in adolescents?
Colpo triage or HPV-DNA or retest in 6 months.
What is initial management of LSIL in pre-menopausal women?
Colpo
What is initial management of LSIL in post-menopausal women?
estrogen therapy if indicated then repeat cytology 1 weeks after finishing therapy. If not indicated then HPV or repeat cytology in 4-6 months.
What is initial management of HSIL?
Coplo