Bewbs (.)(.) (Womens notes) Flashcards
What is a fibroadenoma?
Benign tumours of the stromal/epithelial breast duct tissue
What is the typical examination of fibroadenomas?
Painless, smooth, round, well circumscribed, firm, mobile (‘Chest mouse’), usually up to 3cm
What population are fibroadenomas more common in and why?
Younger women, as they respond to female hormones
When is surgical excisions of fibroadenomas typically done?
When they are >3cm
What is fibrocystic breast changes?
Considered a normal variation of normal; the breast tissue respond to the female sex hormones (oestrogen and progesterone), becoming fibrous and cystic. Due to changes in the menstrual cycle
What factor affects the symptoms of fibrocystic breast changes?
Where a woman is in her menstrual cycle
What are the symptoms of fibrocystic breast changes?
Lumpiness, breast pain or tenderness, fluctuation of breast sizes
What hormonal treatments may be considered in severe cyclical breast pain?
Hormonal treatments: danazol and tamoxifen
What age range are breast cysts most common in?
The perimenopausal period (between 30 and 50)
How do breast cysts typically present?
Smooth discrete lump, may be fluctuant
What is the management of breast cysts?
Further assessment to exclude cancer, and may need aspiration
What is the common trigger of fat necrosis in the breast?
Trauma, radiotherapy or surgery
What is the pathophysiology of fat necrosis?
Benign lump due to localised degeneration and scarring of fat tissue in the breast
What is the findings of fat necrosis on examination?
Painless, firm, irregular, fixed in local structures, skin simpling/nipple inversion
What must be excluded in fat necrosis and why?
Breast cancer: symptoms can be similar and they can appear similar on US or mammogram. Histology is required
What are the findings of a breast lipoma?
Soft, painless, mobile, do not cause skin changes
What are galactoceles?
They occur in women who are lactating, and often stop after breastfeeding. They are due to milk ducts being blocked.
How do galactoceles present?
Firm, mobile painless, lump usually beneath the areola
What are phyllodes tumours?
Tumours of the connective tissue (stroma) of the breast
What are the categories of phyllodes tumours?
Benign, borderline, malignant
What is the treatment for phyllodes tumours?
Wide excision, mastectomy if large lesion
What is triple assessment in breast cancer?
Clinical assessment (hx and exam), imaging (mammography or US), histology (fine needle or core biopsy)
What are features that suggest a breast lump is cancerous?
Hard, irregular, painless, fixed in place. Lumps may be tethered to the skin or chest wall. Nipple retraction, skin dimpling or oedema (peau d’orange)
When should women be referred for two week wait with breast lumos?
- unexplained breast lump in patients 30 and above
- unilateral nipple changes in 50 and above
- unexplained lump in the axilla
- skin changes suggestive of breast cancer
What is mastalgia?
Breast pain
What is the common cancer in the UK?
Breast cancer
What are risk factors for breast cancer development?
Female, more oestrogen exposure, obesity, more dense breast tissue, smoking, diabetes, FHx, HRT, COCP (small), DCIS
Where is the BRCA1 gene?
Chromosome 17
What percentage of people develop breast and ovarian cancer with the BRCA1 gene?
70% develop breast cancer by 80, and 50% ovarian cancer
What percentage of people develop breast and ovarian cancer with the BRCA2 gene?
60% of people develop breast cancer by 80, 20% ovarian cancer
What is the most common type of breast cancer?
Invasive ductal carcinomas
What are indications for mx?
Multifocal, central tumour, large lesions, DCIS >4cm, patient choice
What are indications for WLE?
Solitary lesions, peripheral tumour, small lesion in large breast, DCIS <4cm, patient choice
What is DCIS?
Pre-cancerous or cancerous epithelial cells of the breast ducts, localised to a single area, often picked up on mammograms. Can become full invasive breast cancer
What is Paget’s disease of the nipple?
Eczematoid change of the nipple associated with underlying breast malignancy. Nearly all patients have malignancy
What causes inflammatory breast cancer?
When cancerous cells block the lymph drainage, resulting in an inflamed appearance of the breast
How does Paget’s disease present?
Erythematous, scaly rash. Indicates breast cancer involving the nipple
What ages is breast screening offered between?
50 and 70
How frequently is breast screening offered?
Every 3 years
What are ‘high risk patients’ in breast cancer?
First degree relative with breast cancer under 40 years, first degree male relative with breast cancer, first degree relative with bilateral breast cancer under 50 years, two first degree relatives with breast cancer
What is offered for women with increased risk of breast cancer?
Annual mammograms. Potential chemoprevention (tamoxifen or anastrozole), or risk reducing bilateral mastectory or bilateral oopherectomy
What imaging is done for potential breast cancer in younger women and why?
Ultrasound in younger women, for those with denser breasts
When is MRI used in breast cancer assessment?
Screening in women with high risk of breast cancer, and further assess size and features
How is the lymph nodes assessed in breast cancer?
Ultrasound of the axilla and ultrasound guided biopsy. SLNB can be done in surgery
Where is breast cancer most likely to spread to?
2Ls and 2Bs: lungs, liver, bones, brain
What is a potentially complication of axillary clearance?
Chronic lymphoedema
What is the possible management of chronic lymphoedema?
Massage techniques, compression bandages, weight loss
What are potential s/e of radiotherapy in women with breast cancer?
Fatigue, local skin and tissue irritation and swelling, fibrosis of breast tissue, shrinkage of breast tissue, longer term colour changes
What is the hormone treatment of patients with ER+ve breast cancer?
Tamoxifen in premenopausal, and aromatase inhibitors in post menopausal women (letrozole, anastrozole)
How does tamoxifen work?
Selective oestrogen receptor modulator. It blocks/stimulates oestrogen receptors depending on the site: blocks in the breast, stimulates in uterus and bone
How does aromatase inhibitors work?
Blocks the conversion of androgens to oestrogen in post menopausal women
What is the screening follow up in patients who have had breast cancer?
Surveillance mammograms yearly for 5 years
What is the management of a woman with breast cancer who has no palpable axillary lymphadenopathy at presentation?
Pre operative ultrasound; if this is negative, SLNB
What is the management of patients who present with clinically palpable lymphadenopathy?
ALNC
When is radiotherapy recommended?
When a woman has had a WLE
What biological therapy is used in HER2 positive cancers?
Herceptin (trastuzumab)
When is herceptin C/I?
Patients with a hx of heart disorders
What are s/e of tamoxifen?
Menstrual disturbance, hot flushes, VTE, endometrial cancer
What scan should be done when a patient is started in letrozole/anastrozole?
DEXA: due to increased risk of osteoporosis
What is the likely diagnosis in a woman over 40 with lumpy, painful breasts before menstruation?
Fibroadenosis (fibrocystic disease)
What is mammary ductal ectasia?
Dilation of the large ducts of the breast, which causes inflammation of the ducts and discharge
What population is mammary duct ectasia most common in?
Perimenopausal women
What is a significant risk factor for mammary duct ectasia?
Smoking
What is the assessment of ductal ectasia?
Triple (assessment, imaging, biopsy)
What is duct papilloma?
A warty lesion that growth in the ducts of the breasts due to proliferation of epithelial cells
What is the typical presentation of intraductal papilloma?
Clear or blood stained nipple discharge. No lump
Other than triple assessment, what investigations can be done for ductal ectasia + ductal papilloma?
Ductography: injecting contrast into the abnormal duct and performing mammograms to visualise the duct
What is the tx of intraductal papillomas, and what must be checked?
Intraductal papillomas require complete surgical excision. After removal, the tissue is examined for atypical hyperplasia or cancer that may not have been picked up on the biopsy.
What is galactorrhoea?
Breast milk production not associated with pregnancy or breast feeding
What drugs can cause galactorrhoea and why?
Dopamine antagonists (eg, antispychotics). Due to dopamin blocking the secretion of prolactin
What drugs can cause prolactin secretion and galactorrhoea?
Dopamine agonists (e.g., bromocriptine or cabergoline)
What hormone stimulates breast milk production?
Oxytocin
What hyperprolactinaemia also present with and why?
Menstrual irregularities, reduced libido, erectile dysfunction, gynaecomastia. Due to prolactin suppressing GnRH, reduces LH + FSH
What genetic condition are prolactinomas associated with?
Multiple endocrine neoplasia (MEN) type 1
What are differential causes of nipple discharge?
Galactorrhoea, hyperprolactinaemia, mammary duct ectasia, carcinoma, intraductal papilloma
What investigations should all patients with nipple discharge get?
Triple assessment
What is mastitis?
Inflammation of the breast tissue associated with breast feeding
What are the features of mastitis?
Painful, tender, red hot breast, fever, general malaise
What is the first line management of mastitis?
Continue breast feeding
When should mastitis be treated with abx?
If systemically unwell, nipple fissure present, symptoms not improving, or if culture indicates infection
What is the first line abx for mastitis?
Oral flucloxacillin for 10 days (s.aureus most common cause)
What is the difference between duct ectasia and periductal mastitis?
Duct ectasia is a normal varient of breast involution, and is seen in many older women. Periductal mastitis is in younger women, associated with smoking, and treated with abx
What is the most common cause of breast abscess?
S.aureus
What is the treatment of breast abscess?
Abx, US guided aspiration, surgical debridement if necessary
