Breast Flashcards
Triple assessment
- Clinical history and examination
- Imaging - mammography or USS
- Biopsy - Core biopsy, FNAC
RF for breast cancer
Early menarche Late menopause Obesity FHx Alcohol 1st child after 30 yo `
Scoring
M1 - normal ( for FNAC C1 - inadequate) M2 - benign M3 - uncertain probably benign M4 - Uncertain probably malignant M5 - Malignant
Advantages of mammography
Visualise in 2 planes
Less user dependent
Helps plan mx
When is USS done first line?
Pt younger than 35 yo as breast tissue more dense
Other imaging modalities
MRI - when boundaries are hard to establish or if pt has implant
CT - mets
PET scan - bone mets
Liver USS - mets
FNAC limitations
Cannot grade
Cannot see if invasive or in situ
Only a few cells
When in FNAC used
Lymph nodes
History features
Onset Skin or nipple changes Trauma Age of menopause and menarche Parity and age at first pregnancy Systemic symptoms - FLAWS FHx
Presentation
Lump Painless Nipple retraction Nipple disharge Skin changes - peau d'orange and rash Breast distortion Swelling
Breast eczema
Areola involvement normally sparring nipple or nipple presents later
Paget’s disease of breast
Rash of nipple spreads to areolar or areolar spared
Topical steroids do not work
Lobules
milk producing gland - epties via ductules into lactiferous ducts
Fibroadenoma presentation
Benign Mobile and smooth Non tender 'Breast mouse' Prevalent in the younger population - under 30 yo
Breast cyst
Benign - distended involuted lobules
Smooth, fluid filled
Sometimes painful
May be visible
Halo shape on mammography
Sebaceous cyst
Has punctum
Confined to skin
Breast abscess
Often secondary to mastitis
More common in breast feeding female
Swollen, tender and red breast Fluctuant mass Systemic symptoms such as fever Foul smelling \+/- pus
RF for breast abscess
DM
Smoking
Piercing
Recent pregnancy - breast feeding
Phyllodes tumour
Large, non tender and mobile
1/3rd progress to malignancy
40+ yo
Tendency to reoccur
Fibrocystic changes
Multiple lumps bilaterally Thickening of breast tissue Firm and ropy May be painful Usually pre-menopausal and cyclical
- does not increase risk of CA but may mask
Fat necrosis
History of trauma in obese women
Palpable lump
Older to middle-aged women
USS - Hyperechoic mass
Breast cancer common type
Invasive ductal carcinoma
Ductal carcinoma presentation
Hard, fixed, irregular and painless lump
Nipple inversion
Dimpling of skin, peau d’orange, skin tethering
Breast screening
For 47 - 73 yo every 3 years
Mammography
Breast conservation surgery
Wide local excision
Axillary investigation
Sentinal node biopsy
if +ve - axillary clearance
Receptors and treatment
ER+ve - Tamoxifen - SERM
HER2 +ve - Herceptin (trastuzumab) - monoclonal antibody
Post menopausal - aromatase inhibitor - anastrozole
Risk stratification tool
Nottingham Blood Richardson
Guidance for 2ww referral
- aged 30+ with unexplained breast lump with to without pain
- aged 50+ with unilateral nipple discharge, retraction or other symptoms of concern
Consider if:
- skin changes that suggest breast cancer
- aged 30+ with an unexplained lump in axilla
Mammary duct ectasia
Dilation of large breast ducts
Common around menopause
Presentation: Tender lump around areolar Nipple discharge - thick and green/black RF - smoking Possible nipple inversion
Ix:
Mammography - dilated calcified ducts
Biopsy - multiple plasma cells
Mx - Conservative or duct excision
Medication causing gynaecomastia
Spironolactone
Metronidazole
Intraductal papilloma
Benign
Wart-like lump in the milk duct
Clear or bloody spontaneous discharge
Breast abscess mx
Refer urgently for general surgery - USS needle asperation
Mastitis mx
Continue breastfeeding using affected breast
If systemic features, nipple fissure or symptoms do not improve after 12 hrs - flucloxacillin - 10 - 14 days
Types of breast tumour
Invasive ductal carcinoma Invasive lobular carcinoma Ductal carcinoma in situ Lobular carcinoma in situ Phyllodes tumour
BRCA 1 and 2 gene location
BRCA 1 - Chromosome 17
BRCA 2 - Chromosome 13
Common sites of breast metastasis
Lung
Liver
Bones
Brain
Side effects of axillary clearance
Arm lymphoedema
When to do a mastectomy
DCIS - 4+ cm
Central
Multifocal
Large lesion in small breast
Before starting anastrozole what test is organised
DEXA scan for osteoporosis
Ductal carcinoma in situ presentation an tx
Bloody nipple discharge
Mammography - calcification behind nipple areolar complex
Histology - comedo necrosis not breached basement membrane
Tx:
- Wide local excision
Complication of free TRAM flap reconstructive surgery
Muscle taken from rectus abdominis therefore can get abdominal hernia
Herceptin delivery
Every 3 weeks for 1 year following initial treatment
- close monitoring of heart
- contraindicated in women with HF
S/E - diarrhoea, breast pain and headaches
Radiotherapy
Adjuvant therapy after WLE with clear margins in the affected breast only
Surgical complications
• Haematoma, seroma • Frozen shoulder • Long-thoracic nerve palsy - winged scapula • Lymphoedema • Upper inner arm numbness - Intercostobrachial nerve injury
Tamoxifen
SERM
- antagonises breast and uterus ER
- Agonist for endometrial ER - Increases endometrial CA risk and can cause menopausal symptoms
Supportive treatment
- Bone pain: DXT (deep xray therapy), bisphosphonates, analgesia
- Brain: occasional surgery, DXT, steroids
- Lymphoedema: decongestion, compression
Lat dorsi myocutaneous flap
Usually if implant
Types of mastalgia
Cyclical:
- bilateral
- associated with menstrual cycle
- NSAIDs if not breastfeeding
- Danazol - anti - gonadotropin
Non cyclical:
- hormone contraceptives
- antidepressants
- antipsychotics
Extramammary pain:
- Shoulder or chest cause
Mx of lobular carcinoma in situ
Low grade - monitor
BRCA1/2 - bilateral prophylactic mastectomy
Invasive ductal carcinoma clinical features
Breast lump Asymmetry Swelling Abnormal nipple discharge Nipple retraction Skin changes (dimpling/peau d’orange, or Paget’s-like changes) Mastalgia Palpable lump in the axilla.
