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Benign Breast Disease
Fibrocystic disease includes:
- Papillomatosis
- Sclerosing adenosis
- Epithelial hyperplasia
- Ductal hyperplasia
- Lobular hyperplasia
- *Risk of cancer with ATYPICAL ductal or lobular hyperplasia
- *Tx: remove suspicious areas
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Sclerosing adenosis
Cluster of calcifications on mammogam without mass or pain; can look like breast CA
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Intraductal papilloma
- Most common cause of bloody discharge from nipple
- Not premalignant
- Dx: contrast ductogram
- Tx: resection (subareolar resection can by curative)
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Fibroadenoma
- Most common in adolescents and young women
- 10% are multiple
- Change with menstrual cycle/enlarge with pregnancy
- Giant >5cm
- Path: fibrous tissue compressing epithelial cells
- Mamm: coarse calcifications
- <30 yo
- Exam: 'feel benign' (firm, rubbery, rolls, not fixed)
- US or mamm
- FNA or core needle bx
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Nipple discharge
- Most is benign
- Dx: BL mamm
- Green: fibrocystic
- Bloody: intraductal papilloma, ductal CA
- Serous: CA
- *tx: excisional biopsy
- Spontaneous: CA
- *dx: biopsy
- Nonspontaneous: ...
- *+/- excisional biopsy
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Diffuse papillomatosis
- Multiple ducts of both breasts
- Mamm: swiss cheese
- Increase risk of CA with diffuse type (40%)
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DCIS
- Malignant cells of ductal epithelium without invasion of basement membrane
- 50-60% will get cancer in the ipsilateral breast if not removed
- *5-10% get cancer in contralateral breast
- Premalignant
- Clinically not palpable
- Mamm: cluster of calcifications
- 2-3mm margin with excision
- Solid
- Cribiform
- Papillary
- Comedo
- *most aggressive, likely to recur
- *tx: simple mastectomy
- Tx: lumpectomy and XRT, +/- tamoxifen
- *Simple mastectomy: high grade (comedo, multicentric, multifocal), large tumor, unable to get good margins, no ALND
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LCIS
- 40% get cancer of either breast
- *likely ductal CA (70%)
- *5% have synchronous breast CA
- No calcifications, not palpable
- Premenopausal
- Do not need negative margins with excision
- Tx: nothing, tamoxifen, or bilateral subcutaneous mastectomy without ALND
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Breast CA Risk
- Risk 1/8 or 12%
- 4-5% in women with no risk factors
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Symptomatic breast mass workup
- <30 yo:
- US
- *If solid: FNA
- *If FNA nondiagnostic: excisional biopsy
- 30-50yo:
- BL mamms
- FNA
- Excisional biopsy if FNA nondiagnostic
- >50yo
- BL mamms
- Excisional or core needle biopsy
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Breast cyst fluid
- Bloody: cyst excisional biopsy
- Clear and recurs: excisional biopsy
- Complex: excisional biopsy
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Mammogram
- 90% sensitivity and specificity
- Sensitivity increases with age
- >5mm to be detected
- Suspicious lesions need needle loc and excisional or core needle biopsy
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Screening
- Mamm every 2-3 years after age 40, yearly after 50
- High risk screen: mamm 10 years before youngest age of diagnosis of breast CA in first-degree relative
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BIRADS
- 1: Negative: Routine screening
- 2: Benign: Routine screening
- 3: Probably benign: Short-interval follow-up
- *6mo
- 4: Suspicious abnormality: Definite probability of malignancy, consider biopsy
- 5: Highly suggestive of malignancy: High probability of cancer, appropriate action needs to be taken
- *Image guided core biopsy, needle loc and excision
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Node levels
- I: lateral to pectoralis minor
- II: beneath to pectoralis minor
- III: medial to pectoralis minor
Rotter's: between the pec major and minor
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Prognostic staging factors
- Node status is the most important
- Other: tumor size, grade, progesterone and estrogen receptor status
- 30% of nonpalpable nodes are positive at surgery
- 0+: 75% 5 yr survival
- 1-3+: 60% "
- 4-10+: 40% "
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