Breast Disease

Milky discharge; multiple ducts

Discharge that is characteristic with ______________ duct(s), increased prolactin secretion, and potentially caused by
- Pituitary tumor
- Hypothyroidism
- Phenothiazines
- Oral contraceptives

Green/Brown discharge; multiple ducts

Discharge that is characteristic with ______________ duct(s), and is associated with fibrocystic disease

A Single Duct

Bloody discharge that is characteristic with ______________ duct(s), that is unilateral, spontaneous.
� Intraductal papilloma
� Intraductal cancer (rare)
� Associated carcinoma (3.8%)

Breast Cancer
1 in 8 lifetime risk
2nd MCC cancer related death in women
1 in 3000 during pregnancy

MC female malignancy

Inflammatory Breast Cancer

Mimics mastitis - red, swollen, warm, itchy breast, Peau d'orange skin findings, high metastatic rates, Poor Prognosis

Paget Disease of the nipple

Mimics dermatitis - chronic eczematous itchy, scaling rash on the nipples & areola, assoc. Ductal Carcinoma in situ or infiltrating ductal carcinoma
Tx: mastectomy

Angiosarcoma breast cancer

Breast cancer that is extremely rare and is a complication of breast radiation therapy

Ductal Carcinoma in situ (DCIS)

A breast cancer that is confined to the ducts and has not spread into the tissue of the breast. Considered precancerous and curative in the early stage

Invasive Ductal Carcinoma

MC type of Breast Cancer associated with lymphatic METS especially axillary

- Metaplastic
- Micropapillary
- Mixed

Invasive Carcinoma Subtypes that have a poorer prognosis:

Lobular Carcinoma In Situ

Type of breast cancer that is considered precancerous, increased risk of invasive breast cancer, difficult to detect on mammogram, is MC in females 40-50 y/o

Invasive Lobular Carcinoma

2nd MC type of breast cancer, metastasis occurs, and difficult to detect on a mammogram

size & extent of cancer spread
T (size), N (nodes), M (mets)
Stage 0: precancerous, DCIS or LCIS
Stage I-III: within breast/regional lymph nodes
Stage IV: metastatic breast cancer

Staging of breast cancer is based on

how different the cancer cells look from normal ones

Grade of cancer cells is based on...

Human epidermal growth factor receptor 2 (HER2)

has tyrosine kinase activity and is typically more aggressive in breast cancer but should respond to Trastuzumab (Herceptin)


Genetic mutation that is a risk factor associated with breast & ovarian CA

Breast mass - painless, hard, fixed (non-mobile) lump
+/- axillary lymphadenopathy
MC in the Upper Outer Quadrant then areola
Unilateral nipple discharge +/- bloody, purulent or green

Breast Cancer clinical manifestations


A diagnostic method that can detect slow growing masses at least 2 yrs before detectable by palpation

� Dx BRCA prior to clinical findings
� High risk
� Prior cosmetic operations
� Prior to biopsy

Screening indications for a Mammography:

� Mass
� Suspicious breast change
� Primary unknown metastatic cancer

Evaluation indications for a Mammography:

+BRCA patients - No mastectomy

Monitoring indications for a mammography:

Solid or Cystic masses
- recommended initial modality to eval breast masses in women <40 y/o

Ultrasonography is used in conjunction with mammogram for mass +/- Bx as well as evaluation of

? Irregular spiculated mass
? Clustered microcalcifications
? Linear branching calcifications

Diagnosis of Breast Cancer from a Mammogram would show...

? Hypoechoic mass
? Irregular mass
? Internal calcifications
? Enlarged axillary lymph nodes

Diagnosis of Breast Cancer from a Breast Ultrasound would show...

? Heterogeneously enhancing area
? Significant architectural distortion

Diagnosis of Breast Cancer from a Breast MRI would show...

Breast Biopsy
- Fine Needle Aspiration
- Core Needle = preferred
- Lumpectomy (Excisional) +/- Lymph Nodes

Diagnostic method that focuses on the dominant mass found, regardless of absence of mammography findings

Cutaneous candidiasis

Rash that is bright red-orange, with satellite pustules and papules, pruritic. Found underneath the breasts. 10% KOH prep shows hyphae &/or spores


Most common tumor in menstruating women < 25 y/o. Solid, non-cancerous tumor - Single or multiple lesions, Unilateral, Well-circumscribed, Smooth, Round, Rubbery, firm, or hard, Mobile, (~ Painless)

Estrogen stimulation
- puberty, pregnancy, HRT, tumor decrease post-menopausal

A potential cause of development of fibroadenomas


Upon fine needle aspiration, what is most likely the diagnosis if fluid is attained from the procedure?

- Cyst is fluid filled

Upon Breast US, what is most likely the diagnosis if a breast mass is shown to be solid from the procedure?


Upon mammogram, what is most likely the diagnosis if the findings show a mass with smooth round edges and distinct from surrounding tissue?

Phyllodes Tumor

Benign tumor that is very rare. MC in women in late 30's-50's. Typically unilateral. Differs from a fibroadenoma with its sudden increase in size.

Fibrocystic breast disease

Usually multiple, mobile, well demarcated fluid-filled cysts in the breast tissue due to exaggerated response to hormones. Often tender, bilateral with no axillary involvement or nipple discharge. May increase of decrease in size with menstrual hormonal c


Aggravating factors for Fibrocystic breast disease:

intermittent pain
fluctuation in size
several cystic masses

On exam, pt with fibrocystic breast disease will present with:

amber or greenish fluid
disappears with aspiration

When Dx Fibrocystic Breast disease fine-needle aspiration would show ________________.

solid mass
As well as breast US and diagnostic mammogram

When Dx Fibrocystic Breast disease core needle Bx would show ________________.

monthly self breast exam
follow up every 6 months or development of a new mass

Follow up instructions for a pt with fibrocystic breast exam:


Cellulitis of peri-glandular tissue, in a wedge shape, including edema, erythema, warmth, tenderness.
+ lactation
also fever or chills can be associated

Lactational - common in 1st 3 months
Non-infectious - inflammation, non-infx, idiopathic
Subclinical - No clinical S&Sx, elevated Na/K ratio or interlukin in milk

Four types of Mastitis are:

� Tight fitting bra
� One position used
� Poor technique
� Overly fatigued
� Previous episode
� Nipple Piercing
� FB
� Underlying breast condition
� Anatomical breast defect
Staph aureus <<<
Coagulase-negative Staphylococci

Causes of Lactational Mastitis

- Tylenol &/or NSAIDs
- Supportive Care: fluid intake, rest, warm compress
- Breastfeeding: continue, proper latching, fully empty breasts

Treatment on an outpatient basis for mastitis:

- Immunosuppressed
- Toxic appearing
- Hemodynamically unstable
- Rapidly progressive infection
- Failed outpatient treatment

Treatment on an inpatient basis for mastitis for Pts who are

>>>>Dicloxacillin or Clindamycin
>>>>Bactrim, Vancomycin, Mupirocin 2% topical (nipple)

Bacterial cause of mastitis is best treated with these antibiotics...

Nystatin topical (mother) & Nystatin oral (infant)

Fungal cause of mastitis is best treated with these anti-fungal therapy...

6 months

TB cause of mastitis is best treated with the TB therapy for how long...


Granulomatous Mastitis is best treated with

Breast Abscess

Collection of pus in the breast tissue, usually unilateral, in a localized area with erythema, edema, warmth, and tenderness.
(+) lactation
May also have fever/chills, vomiting, drainage (nipple or mass)

- Staph Aureus
- Coagulase-negative Staphylococci
- Polymicrobial
>>> common in 1st 3 months of lactation (blocked milk duct)

Breast abscess usually occurs from these organisms

- Hypoechoic lesion
- Circumscribed
- Irregular
- Ill-defined
- Macrolobulated
- Possible septae

Diagnostic findings on a breast US that would indicate a breast abscess:

- Not MRSA: Dicloxacillin
- MRSA: Clindamycin, Bactrim DS, Vancomycin

Antibiotic treatment for a breast abscess depending on the organism involved is...

- Needle Aspiration
- Incision and drainage
- Percutaneous catheter drainage
- Duct excision

Surgical Intervention for a breast abscess is...

Breast CA (60-85%)
Ovarian CA (15-40%)

Genetic testing in a 45 y/o female shows the presence of mutations BRAC1 & BRCA2. This Pt has an increase risk of what malignancies?

Fibrocystic breast disease

A 28 y/o female complaining of multiple painful breast lumps developing of the past several months. They enlarge and shrink in size during the month. During the physical exam you find multiple bilateral soft, painful breast masses with no erythema, skin c

Monitor for now; no further intervention

A 26 y/o Pt has just been diagnosed with a fibroadenoma via Bx. What is the next step in your medical management?


A patient comes to your clinic stating that she has noticed skin changes over her right breast. During the physical examination, you note that her skin has a swollen, pitted surface. What is the most likely diagnosis?

D. 26 y/o who is breast feeding

Which of the following patients is most likely to develop mastitis?
A. 18 y/o female with fibrocystic dz
B. 58 y/o woman with remote history of breast CA
C. 44 y/o female with gynecomastia
D. 26 y/o who is breast feeding

A. increase caffeine intake

Which of the following is NOT usually recommended in the management of fibrocystic changes of the breasts?
A. increase caffeine intake
B. restrict foods containing methylxanthine
C. use mild diuretics intermittently
D. take Danazol regularly

D. 40
ACOG: annually >/= 40 y/o

According to the latest guidelines from the American Congress of Obstetricians and Gynecologists (ACOG), at what age should women start having annual mammograms?
A. 55
B. 30
C. 50
D. 40

B. Breast CA - Peau d'orange

A 45 year-old woman is a new patient. She has not been to a doctor in several years but does not have any specific complaints today. During your physical exam, you notice that her right breast has an area that appears like the texture of an orange peel. W

recommended initial modality to evaluate breast masses in women < 40 y/o

A 17 y/o woman with an ill-defined, mobile, 1cm cyst of the R breast. Which of the following is the best diagnostic approach?
A. Mammography
D. Excisions Bx
E. Thermographic exam
F. Bilateral mastectomy

A. Mammography

A 60 y/o woman with 1.7cm, mobile L breast mass. Which of the following is the best diagnostic approach?
A. Mammography
D. Excisions Bx
E. Thermographic exam
F. Bilateral mastectomy


A 52 y/o woman with bilateral saline breast implants? Which of the following is the best diagnostic approach?
A. Mammography
D. Excisions Bx
E. Thermographic exam
F. Bilateral mastectomy

A. Mammography only

Which of the following imaging modalities has been shown to be cost-effective in screening for breast cancer?
A. Mammography only
B. Mammography and US
C. Mammography and CT
D. Mammography and thermography

B. No increased risks

Which of the following describes the radiation risk with modern mammography given once annually?
A. Increased risk for thyroid CA
B. No increased risks
C. Increased risk for lung CA
D. Increased risk of skin CA in chest area

D. One option is a core tissue Bx by stereotactic means

A 55 y/o women has several coarse calcifications found on mammography that are suspicious for BRCA. No FH BRCA and no palpable mass. Which of the following is the most accurate statement?
A. Best Dx method is FNA
B. The lesion is definitely CA
C. Because

A. Mammography

A 50 y/o woman with no breast masses whose mother died of breast cancer. Which of the following is the best diagnostic approach?
A. Mammography
D. Excisions Bx
E. Thermographic exam
F. Bilateral mastectomy