3. Breast lump Flashcards
Symptoms to ask about ?breast disease
Lumps: does the lump fluctuate in size? is it getting bigger? does it fluctuate with menstrual cycle? does the lump move when you press it? any skin changes over where the lump is or elsewhere? any thickening of the skin? any other lumps?
Symmetry change: has there been a change in symmetry? any swelling?
Nipple symptoms: any discharge? colour of discharge? bloody? any skin changes around the nipple such as dry skin? itchy? has the nipple changed shape/inverted?
Pain and temperature: is there any pain in the breast? has it been hot to touch?
History taking breast disease
PC: lumps, nipple change, symmetry, pain and temperature (see other card)
HoPC:
MHx: recent preganancy/breast feeding?
DHx: hormonal contraceptives?
FHx: any family history of breast cancer? were they tested for specific genes?
SHx: SMOKING
go over breast examination cards
What is the triple assessment?
Clinical assessment: symptoms, risk factors, family history particularly age, HRT and medications
Imaging assessment - if <40 USS, if >40 mammogram
Needle biopsy : core biopsy allows you to test for receptors etc as big chunk, fine needle aspiration of lymph nodes allows you to check for malignancy to see if axillary node clearance is indicated.
what are lobules and ducts of the breast?
The lobules are the glands that produce milk.
The ducts are tubes that carry milk to the nipple.
What is the most common overall breast cancer?
Invasive ductal carcinoma (no special type)
breast cancer screening program
The NHS Breast Screening Programme is offered to women between the ages of 50-70 years.
Women are offered a mammogram every 3 years.
After the age of 70 years women may still have mammograms but are ‘encouraged to make their own appointments’.
do people need referred if they have a first degree relative with breast cancer?
If the person concerned only has one first-degree or second-degree relative diagnosed with breast cancer they do NOT need to be referred unless any of the following are present in the family history:
age of diagnosis < 40 years
bilateral breast cancer
male breast cancer
ovarian cancer
Jewish ancestry
sarcoma in a relative younger than age 45 years
glioma or childhood adrenal cortical carcinomas
complicated patterns of multiple cancers at a young age
paternal history of breast cancer (two or more relatives on the father’s side of the family)
or three first-degree or second-degree relatives diagnosed with breast cancer at any age
inheritance of BRCA 1 and BRCA 2
autosomal dominant
2ww referral criteria for breast cancer
aged 30 and over and have an unexplained breast lump with or without pain or
aged 50 and over with any of the following symptoms in one nipple only: discharge, retraction or other changes of concern
consider if:
skin changes that suggest breast cancer or
aged 30 and over with an unexplained lump in the axilla
where does breast cancer metastasise to
L – Lungs
L – Liver
B – Bones
B – Brain
can go anywhere though
when is axillary node clearance indicated?
if lymphadenopathy
if no lymphadenopathy but a postive sentinal node biopsy on first surgery
when is wide local excision indicated?
Solitary lesion
Peripheral tumour
Small lesion in large breast
DCIS < 4cm
when is mastectomy indicated
Multifocal tumour
Central tumour
Large lesion in small breast
DCIS > 4cm
when is radiotherapy indicated for breast cancer? type?
Whole breast radiotherapy is recommended after a woman has had a wide-local excision as this may reduce the risk of recurrence by around two-thirds.
For women who’ve had a mastectomy radiotherapy is offered for T3-T4 tumours and for those with four or more positive axillary nodes
management of estrogen receptor positive breast cancer?
Tamoxifen for premenopausal women
Aromatase inhibitors for postmenopausal women (e.g., letrozole, anastrozole or exemestane)
Pharamcology tamoxifen
Tamoxifen is a selective oestrogen receptor modulator (SERM).
It either blocks or stimulates oestrogen receptors, depending on the site of action.
It blocks oestrogen receptors in breast tissue, and stimulates oestrogen receptors in the uterus and bones.
This means it helps prevent osteoporosis, but it does increase the risk of endometrial cancer.
adverse effects of tamoxifen
menstrual disturbance: vaginal bleeding, amenorrhoea
hot flushes - 3% of patients stop taking tamoxifen due to climacteric side-effects
venous thromboembolism
endometrial cancer
pharmacology aromatase inhibitors such as Anastrozole
Aromatase is an enzyme found in fat (adipose) tissue that converts androgens to oestrogen. After menopause, the action of aromatase in fat tissue is the primary source of oestrogen. Aromatase inhibitors work by blocking the creation of oestrogen in fat tissue
adverse effects of aromatase inhibitors
eg Letrozole. Anastrozole. Exemestane.
osteoporosis
NICE recommends a DEXA scan when initiating a patient on aromatase inhibitors for breast cancer
hot flushes
arthralgia, myalgia
insomnia
what drug is used for HER2 +ve breast cancer?
what i main complication you need to monitor?
Trastuzumab (Herceptin)
a monoclonal antibody that targets the HER2 receptor. It may be used in patients with HER2 positive breast cancer. Notably, it can affect heart function; therefore, initial and close monitoring of heart function is required.
Pertuzumab (Perjeta)
Neratinib (Nerlynx)
when is ‘neoadjuvanant’ chemotherapy used?
to downstage a primary lesion or after surgery depending on the stage of the tumour, for example, if there is axillary node disease - FEC-D is used in this situation.
A key reason for considering neo-adjuvant chemotherapy in breast cancer is to try to downsize the tumour before surgery and allow breast conserving surgery rather than mastectomy
what is peau d’orange linked to
inflammatory breast cancer
Looks like eczema of the nipple/areolar, spreads from nipple to areola
Erythematous, scaly rash
pagets disease of the nipple
associated with an underlying breast malignancy
what are phyllodes tumours
Phyllodes tumours are rare tumours of the connective tissue (stroma) of the breast, occurring most often between ages 40 and 50. They are large and fast-growing. They can be benign (~50%), borderline (~25%) or malignant (~25%). Malignant phyllodes tumours can metastasise.
blood supply of lattismus muscle ?
the thoracodorsal artery, and branch of the subscapular artery
Young patient with firm mobile mass
fibroadenoma
Soft, fluctuant swelling perimenopause
cyst
recurrent infection/abscess in smoker
periductal mastitis
nipple retraction and occasionally creamy nipple discharge
might be brown-green discharge
duct ectasia
Bloody discharge with no lump
Intraductal papilloma
obese/large breasts, following trauma Initial inflammatory response, the lesion is typical firm and round but may develop into a hard, irregular breast lump
fat necrosis
management of fibroadenoma
If greater than 4cm - core biopsy to exclude a phyllodes tumour.
10% will increase in size, 30% regress and the remainder stay the same. This does not apply during pregnancy and lactation when they may increase in size substantially and subsequently sequester milk.
Management:
If want excision - circumareolar incision. Smaller lesions may be removed using a mammotom
‘halo appearance’ on mammography.
cyst
what type of scan helps confirm a cyst
USS - fluid filled
first line management of mastitis
- continue breastfeeding
- If unwell etc. - flucloxacillin for 10-14 days
treatment of periductal mastitis
co-amoxiclav
Pathophysiology duct ectasia
Duct ectasia is a dilatation and shortening of the terminal breast ducts within 3cm of the nipple. It is common and the incidence increases with age. Associated with smoking
management of duct ectasia
Patients with troublesome nipple discharge may be treated by microdochectomy (if young) or total duct excision (if older).
Lumpiness
Breast pain or tenderness (mastalgia)
Fluctuation of breast size
fibrocystic breast change
management fibrocystic breast change
Options to manage cyclical breast pain (mastalgia) include:
Wearing a supportive bra
Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen
Avoiding caffeine is commonly recommended
Applying heat to the area
Hormonal treatments (e.g., danazol and tamoxifen) under specialist guidance
breastfeeding lady firm, mobile, painless lump, usually beneath the areola
galactocele
management galactcele
They are benign and usually resolve without any treatment. It is possible to drain them with a needle. Rarely, they can become infected and require antibiotics.
gynaecomastia drug causes
spironolactone
anabolic steroids
How to describe physical examination impression
Physical examination impression:
P1 = normal
P2 = benign
P3 = uncertain
P4 = suspicious
P5 = malignant
How to describe mammogram impression
Mammogram:
M1 = normal
M2= benign
M3 = uncertain
M4 = suspicious
M5 = malignant
whata re the three types of receptors breast cancer may have?
There are three types of receptors:
Oestrogen receptors (ER)
Progesterone receptors (PR)
Human epidermal growth factor (HER2)
what is ductal carcinoma in situ?
Pre-cancerous or cancerous epithelial cells of the breast ducts
Localised to a single area
Often picked up by mammogram screening
Potential to spread locally over years
Potential to become an invasive breast cancer (around 30%)
Good prognosis if full excised and adjuvant treatment is used
what is lobular carcinoma in situ?
A pre-cancerous condition occurring typically in pre-menopausal women
Usually asymptomatic and undetectable on a mammogram
Usually diagnosed incidentally on a breast biopsy
Represents an increased risk of invasive breast cancer in the future (around 30%)
Often managed with close monitoring (e.g., 6 monthly examination and yearly mammograms)
what is invasice ductal carcinoma NST? what does NST mean?
NST means no special/specific type, where it is not more specifically classified (e.g., medullary or mucinous)
Also known as invasive breast carcinoma of no special/specific type (NST)
Originate in cells from the breast ducts
80% of invasive breast cancers fall into this category
Can be seen on mammograms
what is invasive lobular carcinoma
Around 10% of invasive breast cancers
Originate in cells from the breast lobules
Not always visible on mammograms
what is inflammatory breast cancer? what is the pathophysiology of the inflammation?
Presents similarly to a breast abscess or mastitis
Swollen, warm, tender breast with pitting skin (peau d’orange)
Does not respond to antibiotics
Worse prognosis than other breast cancers
Pathophysiology
Cancerous cells block the lymph drainage resulting in an inflamed appearance of the breast. This accounts for around 1 in 10,000 cases of breast cancer.
what is pagets disease of the nipple?
Looks like eczema of the nipple/areolar
Erythematous, scaly rash
Indicates breast cancer involving the nipple
May represent DCIS or invasive breast cancer
Requires biopsy, staging and treatment, as with any other invasive breast cancer
how does pagets disease differ from normal eczema of the nipple?
Paget’s disease involves the nipple primarily and only latterly spreads to the areolar
(the opposite occurs in eczema).
options for reconstruction
MASTECTOMY
- Immediate reconstruction, done at the time of the mastectomy
- Delayed reconstruction, which can be delayed for months or years after the initial mastectomy
- Breast implants (inserting a synthetic implant)
- Flap reconstruction (using tissue from another part of the body to reconstruct the breast eg lattismus dorsi flap
BREAST-CONSERVING
- may not be necessary
- Partial reconstruction (using a flap or fat tissue to fill the gap)
- Reduction and reshaping (removing tissue and reshaping both breasts to match)
when should a fibroadenoma be biopsied
A size of greater than 4cm attracts a recommendation for core biopsy to exclude a phyllodes tumour.
natural history of fibroadenoma
The natural history of fibroadenomas is that 10% will increase in size, 30% regress and the remainder stay the same.
pathophysiology fibroadenoma
Under the age of 25 years the breast is usually classified as undergoing development. Lobular units are being formed and a dense stroma is formed within the breast tissue. This may result in the development of fibroadenomas.
management of cysts
Symptomatic cysts may be aspirated and following aspiration the breast re-examined to ensure that the lump has gone.
most common organism causing infective mastitis
Staphylococcus aureus
complication mastitis
If left untreated, mastitis may develop into a breast abscess. This generally requires incision and drainage.
advice breastfeeding/expressing if on flucloxacillin for mastitis
Breastfeeding or expressing should continue during treatment.
what breast diseases are associated with smoking
periductal mastitis and abscesses
duct ectasia
fat necrosis pathophysiology
Fat necrosis causes a benign lump formed by localised degeneration and scarring of fat tissue in the breast. It may be associated with an oil cyst, containing liquid fat. Fat necrosis is commonly triggered by localised trauma, radiotherapy or surgery, with an inflammatory reaction resulting in fibrosis and necrosis (death) of the fat tissue. It does not increase the risk of breast cancer.
how might you need to distinguish between breast cancer and fat necrosis
Ultrasound or mammogram can show a similar appearance to breast cancer. Histology (by fine needle aspiration or core biopsy) may be required to confirm the diagnosis and exclude breast cancer.
management fat necrosis
After excluding breast cancer, fat necrosis is usually treated conservatively. It may resolve spontaneously with time. Surgical excision may be used if required for symptoms.
pathophysiology fibrocystic breast change
The connective tissues (stroma), ducts and lobules of the breast respond to the female sex hormones (oestrogen and progesterone), becoming fibrous (irregular and hard) and cystic (fluid-filled). These changes fluctuate with the menstrual cycle.
how does symptoms of fibrocystic breast change fluctuate with the menstrual cycle
Symptoms often occur prior to menstruating (within 10 days) and resolve once menstruation begins. Symptoms usually improve or resolve after menopause.
lipomas on examination
Soft
Painless
Mobile
Do not cause skin changes
what are lipomas
Lipomas are benign tumours of fat (adipose) tissue. They can occur almost anywhere on the body where there is adipose tissue, including the breasts
management lipoma
They are typically treated conservatively with reassurance. Alternatively, they can be surgically removed.
pathophysiology galactocele
Galactoceles occur in women that are lactating (producing breast milk), often after stopping breastfeeding. They are breast milk filled cysts that occur when the lactiferous duct is blocked, preventing the gland from draining milk. They present with a firm, mobile, painless lump, usually beneath the areola. They are benign and usually resolve without any treatment. It is possible to drain them with a needle. Rarely, they can become infected and require antibiotics.
How should you manage a pt w breast cancer with no palpable axillary lymphadenopathy. A pre-operative ultrasound of the axillary nodes comes back negative
Sentinal node biopsy during surgery
Conplication of axillary node clearance
Functional arm impairment
An axillary node clearance can cause functional arm impairment from either the lymphedema (which causes swelling and limited range of motion) or nerve damage given the proximal nature of the nerves that run from the axilla to the lymph nodes being dissected. The specific nerves in question include the long thoracic nerve, axillary nerve, musculocutaneous nerve and radial nerve
how to know what to do about axilla with +ve sential node biopsy
In patients with breast cancer undergoing breast conserving surgery with adjuvant radiotherapy if, at sentinel node biopsy, less than 3 involved nodes are found then no further management of the axilla is required
