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Physician Assistant Exam: Problems of the Breast

From infection to malignancy, many medical problems can affect the breast. For the Physician Assistant Exam, you will need to know about some breast-related medical conditions and their evaluation and management.

Blocked milk ducts: Mastitis

Mastitis is a bacterial infection in the milk ducts. The most common cause is Staphylococcus aureus. Other bacteria, including Streptococcus, can also cause mastitis. The most significant risk factor is breastfeeding. Women who are immunocompromised are also at significant risk of developing mastitis.

You obtain the culture via a sample of breast milk. For a simple infection, treatment is a first-generation cephalosporin. Other medication classes can include penicillin or macrolide antibiotics. The treatment of a breast abscess includes incision and drainage (I&D) of the abscess plus the use of antibiotics.

If left untreated, a possible complication is abscess formation. Determining whether you’re dealing with a simple infection or an abscess can be difficult. In that case, you may need an ultrasound to make the diagnosis.

Milk Leaks: Control prolactin to treat galactorrhea

Galactorrhea is the leaking of breast milk in someone who isn’t postpartum. The most common cause of galactorrhea is increased secretion of prolactin. For PANCE questions concerning the cause of galactorrhea, the answer is a pituitary tumor or prolactinoma until proven otherwise.

Profound hypothyroidism can also cause this condition, but that’s not as common as an elevated prolactin level. The prolactin level is the first test you order for anyone with galactorrhea.

The treatment of galactorrhea is treating the prolactinoma. Depending on the size of the prolactinoma, treatment options include just careful monitoring; the use of dopamine agonists, including bromocriptine, which inhibits the production of prolactin; and/or surgical and radiation treatments.

Man boobs: Gynecomastia

Gynecomastia is the one breast-related condition that affects men rather than women. To use the vernacular, it means the development of “man boobs.” Medically, this means the enlargement of the breast due to a glandular hyperplasia of the breast cells.

In addition to testosterone, all men have estrogen in their bodies. These hormones normally exist in a homeostatic balance, so men typically don’t develop the man boob. But the body can convert testosterone into estradiol, and whenever the body makes less testosterone with more estradiol, you have the perfect setup for gynecomastia.

Liver failure and alcohol abuse are two big causes of gynecomastia. Any conditions that can affect testosterone production and cause hypogonadism can increase the risk for gynecomastia. Mumps can cause orchitis; causing the orchitis to increase the risk of developing hypogonadism, which also increases the risk of developing gynecomastia.

The fibros

Fibroadenoma and fibrocystic breast disease are two separate conditions, but they’re both benign.

Fibroadenoma

Fibroadenomas are benign breast lumps that occur in young women, usually in their early 20s. The lumps are painless and freely movable. The first step is to do a breast examination, then order imaging studies. Options include a mammogram and ultrasound.

The ultrasound may be recommended first because the mammogram is unreliable because a younger woman’s breasts have more fatty tissue. Confirmation that the mass isn’t breast cancer is a core biopsy, not a fine needle aspiration. Surgery usually isn’t required.

Fibrocystic breast disease

Fibrocystic breast disease usually occurs in women in their late 30s and 40s. With fibrocystic breast disease, the main complaint is that one or both breasts hurt. Usually both breasts are affected.

The diagnosis is first suggested by a breast examination, palpating breast lumps. That can be painful. An imaging study such as a mammogram may be ordered, but diagnosis is the breast biopsy.

Which one of the following would be recommended for treating fibrocystic breast disease?

(A) Morphine
(B) Not wearing a bra for a short period of time
(C) Caffeine products
(D) Yearly ultrasounds
(E) Ibuprofen

The correct answer is Choice (E). Fibrocystic breast disease can be painful, and ibuprofen has a role in helping with the pain.

Beat breast cancer

The top two causes of death for women are heart disease and breast cancer. Risk factors for breast cancer include a family history, usually in a first-degree relative. Others factors are older age, nulliparity, early menarche, late menopause, obesity and bottle-feeding. Other risk factors include a sedentary lifestyle and excessive alcohol intake.

Another risk factor is testing positive for the breast cancer genes, breast cancer type 1 susceptibility protein (BRCA1) or BRCA2. This also increases the risk of ovarian cancer.

Here are the screening guidelines for breast cancer:

  • Women between the ages of 50 to 74 should have a mammogram at least every 2 years.

  • Having a screening before the age of 50 is a decision between a patient and her medical professional. They assess the woman’s risk factors and family history. The American Cancer Society endorses mammogram screening beginning at age 40.

Finding a breast lump on clinical breast exam or seeing a lump on a mammogram suggests the diagnosis. You’re looking for changes in size and shape. Dimpling, peau d’orange, and nipple retraction are signs of a possible malignancy. The breast should be separated into quadrants, and each should be palpated carefully. Examining the axillary area for the presence of lymphadenopathy is mandatory.

If the mammogram confirms a mass, sometimes an ultrasound can confirm whether the mass is cystic or solid. The standard of care is a breast biopsy to determine the type of abnormality.

Here’s a brief review of types of breast cancer:

  • Infiltrating ductal carcinoma: Infiltrating ductal carcinoma is the most common type of invasive breast cancer, accounting for more than 70 percent of all breast malignancies. It usually doesn’t have a great prognosis.

  • Lobular carcinoma: This form usually occurs in the upper outer quadrant of the breast and often responds to hormonal treatment.

  • Ductal carcinoma in situ (DCIS): This is the most common cause of noninvasive breast cancer.

The treatment of breast cancer is multifactorial. For ductal carcinoma in situ, the treatment is usually lumpectomy plus radiation. For the others, it’s often mastectomy with concomitant chemotherapy and radiation.

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