RN602 Chapter 15 Breast Conditions Review Chapter 15: Breast Conditions Etiology, diagnosis, and treatment of common breast disorders: MASTALGIA
... [Show More] Mastalgia, also called mastodynia or breast pain. M astalgia is classified as: Depends on whether its presence is related to the menstrual cycle. Cyclic: • Most common • Majority of breast pain is cyclic, occurring 1 to 2 weeks prior to menses. Noncyclic: • Less common Etiology: • Mild cyclic mastalgia is considered a normal, physiologic condition caused by the hormonal changes of the menstrual cycle. • Linked to the reproductive cycle, with onset at menarche, monthly cycling, and cessation at menopause. Three hormonally oriented theories have emerged to explain moderate or severe breast pain: 1. Increased estrogen secretion from the ovary 2. Deficient progesterone production 3. Hyperprolactinemia. Mastalgia can also be caused by certain medications, including: • Combined estrogen and progestin contraceptives (i.e., pills, vaginal ring, and transdermal patch) • Hormone therapy (HT) • Antidepressants, digoxin, methyldopa, cimetidine, spironolactone, oxymetholone, and chlorpromazine Diagnosis: Diagnostic imaging is frequently used in the evaluation of breast conditions; information about these tests is provided in Table 15-1. TABLE 15-1 Diagnostic Imaging Tests Test Source of Images Best for Detecting Limitations of Test Mammogram X-rays Calcifications, masses, and architectural Cannot show if mass is solid or cystic; has lower Test Source of Images Best for Detecting Limitations of Test distortion sensitivity in women with dense breast tissue Ultrasound (US) Sound waves Differentiation of solid and cystic masses Typically cannot show calcifications Magnetic resonance imaging (MRI) Magnetic fields, must be enhanced with gadolinium contrast Tissue with increased blood flow such as tumors; high sensitivity and negative predictive value Expensive; limited to specific indications; high rate of false-positive results (lack of specificity) Tomosynthesis X-rays (provide 3-D digital images); use with a standard mammogram Architectural distortion, masses, and calcifications, in dense breast tissue Slight increase in radiation exposure versus standard mammogram, takes twice as long to read Treatment: Nonpharmacologic Therapies • Reassurance is the first-line treatment for mastalgia. • Wearing a supportive and well-fitting bra is frequently, especially with large, heavy breasts. • Reductions in caffeine and dietary fat • Supplementation with vitamins A, B, or E Pharmacologic Therapies • Danazol, tamoxifen, and bromocriptine - all three of these medications offer significant relief • Topical use of diclofenac diethyl ammonium gel (an NSAID), three times daily for 6 month. • Injection of 1 mL of 2% lidocaine and 40 mg of methyl prednisone at the area of maximum tenderness. Other methods: • Modifying the dose or route of HT, which can cause breast pain. • Different contraceptive method or delivery system, such as changing from combined oral contraceptives to a nonoral combined method (i.e., the ring or patch). • Some women report an improvement in mastalgia with use of hormonal contraception. Complementary and Alternative Therapies • Evening primrose oil (EPO) • Agnus castus (also called vitex, chaste tree, or chaste berry) • Isoflavones • Flaxseed bread diet was more effective than omega-3 fatty acid supplementation in reducing cyclical mastalgia NIPPLE DISCHARGE: Nipple discharge can be classified as: 1. Normal lactation 2. Galactorrhea unrelated to childbearing 3. Nonmilky discharge, which is sometimes referred to as pathologic discharge Etiology: Numerous etiologies such as and most common are pregnancy and lactation, galactorrhea, intraductal papilloma, mammary duct ectasia, and cancer. Other reasons: Hyperprolactinemia, which may be caused by pituitary prolactin-secreting tumors, medications, hypothyroidism, stress, trauma, chronic renal failure, hypothalamic lesions, previous thoracotomy, and herpes zoster Diagnosis: Bilateral, milky discharge, perform a pregnancy test. If negative: • Obtain a serum prolactin level & thyroid-stimulating hormone (TSH) measurement ➢ 30 years or older - mammogram and ultrasound should be performed. ➢ Younger than age 30, an ultrasound of the affected breast is recommended and possibly a diagnostic mammogram Treatment: Bromocriptine and cabergoline can be used to treat galactorrhea, but symptoms often recur upon discontinuation of these medications; thus, long-term therapy is usually required • Express colostrum during pregnancy should be reassured that the discharge is benign and advised that avoiding nipple stimulation will generally lead to resolution of the discharge. Galactorrhea unrelated to pregnancy or lactation depends on the etiology. • If caused by pituitary tumors may be treated surgically, • Discontinuing a medication that causes galactorrhea • Treating hypothyroidism if it is present may resolve the discharge. BENIGN BREAST MASSES:/Breast mass types and diagnostic studies: TABLE 15-2 Features of Benign Breast Masses Type of Mass Typical Physical Examination Findings Tissue Sampling Findings Fibroadenoma Discrete, smooth, round or oval, nontender, mobile Ductal epithelium, dense stroma, numerous elongated nuclei without fat Cyst Discrete, tender, mobile; size may fluctuate with the menstrual cycle Cyst fluid and inflammation Lipoma Discrete, soft, nontender; may or may not be mobile Fatty tissue Fat necrosis Ill defined, firm, nontender, nonmobile Necrotic fat with inflammation Phyllodes tumor Discrete, firm, round, mobile, findings similar to a fibroadenoma, but mass is usually larger; may observe stretching of skin due to rapid tumor growth Stromal hypercellularity with glandular and ductal elements Hamartoma Discrete, nontender, nonmobile; may be nonpalpable with incidental diagnosis on imaging studies Glandular tissue, fat, and fibrous connective tissue Galactocele Discrete, firm, sometimes tender Fat globules Diagnosis: • Physical examination suggests a palpable area of concern • Ultrasound if the woman is younger than age 30, • Diagnostic mammogram with or without an ultrasound if she is 30 years or older. BREAST CANCER TABLE 15-4 TNM Classification of Breast Cancers Primary Tumor (T) TX Primary tumor cannot be assessed T0 No evidence of primary tumor Tis Carcinoma in situ: ductal carcinoma in situ, lobular carcinoma in situ, or Paget’s disease of the nipple with no associated invasive carcinoma or carcinoma in situ (Paget’s disease with a tumor is classified according to tumor size) T1 Tumor 2 cm or smaller in greatest dimension (may be subdivided into T1mi, T1a, T1b, and T1c, depending on the exact size of the tumor) T2 Tumor larger than 2 cm but not larger than 5 cm in greatest dimension T3 Tumor larger than 5 cm in greatest dimension T4 Tumor of any size with direct extension to the chest wall (T4a), skin (T4b), or both (T4c); inflammatory carcinoma (T4d) Regional Lymph Nodes (N) NX Regional lymph nodes cannot be assessed (e.g., previously removed) N0 No regional lymph node metastases N1 Metastases in movable ipsilateral axillary node(s) N2 Metastases in ipsilateral axillary lymph nodes that are clinically fixed or matted (N2a), or in clinically detected (by imaging studies or clinical examination) ipsilateral internal mammary nodes in the absence of clinically evident axillary lymph node metastases (N2b) N3 Metastases in ipsilateral infraclavicular lymph node(s) with or without axillary lymph node involvement (N3a), or in clinically detected (by imaging studies or clinical examination) apparent ipsilateral internal mammary lymph node(s) with clinically evident axillary lymph node metastasis (N3b), or metastases in ipsilateral supraclavicular lymph node(s) with or without axillary or internal mammary lymph node involvement (N3c) Distant Metastases (M) M0 No clinical or radiographic evidence of distant metastases M1 Distant detectable metastases Breast cancer risk factors: Pg. 368 BOX 15-1: Risk Factors for Breast Cancer • Female • Advancing age • Personal history of invasive breast cancer, ductal carcinoma in situ, or lobular carcinoma in situ • Family history of invasive breast cancer, ductal carcinoma in situ, or lobular carcinoma in situ, especially in first-degree relatives • Inherited detrimental genetic mutations • Biopsy-confirmed proliferative breast lesions with atypia • Dense breast tissue on mammogram • High-dose radiation to chest, especially during puberty or young adulthood • Menarche before age 12 years • Menopause at age 55 years or older • Nulliparity • First full-term pregnancy after age 30 years • Current use of combined oral contraceptives (likely due to detection bias of regular screening) • Use of combined estrogen– progestogen hormone therapy after menopause • Weight gain leading to overweight or obese status after age 18 years • Physical inactivity • Consumption of one or more alcoholic beverages per day • Jewish ancestry (Ashkenazi) • Place of birth (North America and Northern Europe versus Asia and Africa Show Less [Show Less]