Breast Flashcards
The breast sits on top of what muscle?
Pectoralis major
97% of lymphatic drainage from the breast goes where? 2% goes where?
97% axillary LN
2% internal mammary LN (central)
In what positions should you inspect the breasts?
Arms by side Arms raised Hands on hips Leaning forward Semi-recumbent
What are you looking for on inspection of the breasts?
Symmetry, size, shape, lamp, skin retraction, erythema, also, nipple retraction, dimpling, discharge
What position should the patient be lying in when you palpate their breasts?
Lying flat with hands behind head
When examining a breast lump, which side should you examine first?
Contralateral
What features should you note on examination of a breast lump?
Size, shape, fixity, consistency, fluctuant, pulsatile, temperature, tender
When examining a suspicious breast lump, after examining the breast, what should be examined further for completeness?
Listen to chest
Examine spine, abdo, neuro exam
Benign breast lump:
- smooth or hard
- well or poorly defined
- fixed or moves easily
- assoc skin changes
- painful or painless
- regular or irregular
Smooth rubbery Well defined Moves No skin changes Painful Regular
During a breast lump history, what symptoms could you ask about in a systemic enquiry?
Weight loss, loss of appetite, bone pain, SOB, jaundice, abdo pain, fever, breast trauma
What is the commonest benign breast lesion?
Fibroadenoma
What is fibroadenoma also known as?
Breast mouse
What is the peak age range for fibroadenoma? Painful or painless? Mobile or fixed?
15-25yr
Painless
Mobile
Are all fibroadenomas biopsied?
Only if suspicious on imaging
“Rare benign fibroepithelial tumour with malignant potential, commonest in middle age, excised with clear margins” describes what
Phyllode’s tumour
What organism is commonest in breast abscesses?
S aureus
Fibrocystic breasts:
- uni or bilateral?
- painful or painless?
- what age range?
Uni or bilateral
Painful or painless
Perimenopausal (subsides after menopause)
What is the best preventative measure for duct ectasia?
Smoking cessation
What is the mx of a breast abscess?
Aspirate US guided drainage + ABx
If a breast abscess lasts longer than 2wk what should you do?
Excisional biopsy to exclude inflammatory breast cancer
Halo appearance on mammogram =
Breast cyst
Duct ectasia
- main RF
- what age range?
- presentation?
- uni or bilateral?
- painful or painless
Smoking 40/50s Bilateral Creamy discharge / nipple retraction Red tender lump
What is the management of duct ectasia?
ABx
“Wart like, within duct, PC watery/bloody discharge, not premalignant, Mx excise duct” describes what?
Duct papilloma
What is gynaecomastia?
Increase in breast tissue in males
What drugs can cause gynaecomastia?
Spironolactone, digoxin, cimetidine, cannabis
Testicular tumours can cause gynaecomastia - true or false
True
Which can cause gynaecomastia; cirrhosis or renal disease?
Both can
What drug can be used for the management of gynaecomastia?
Tamoxifen
What is the mechanism of tamoxifen?
Blocks the effects of oestrogen in breast tissue
What carries a higher breast Ca risk, a sister or a mum with a history of breast Ca?
Sister
What is occult disease?
Histologically proven malignant tumours whose primary site cannot be identified
Is Paget’s disease of the nipple invasive/ malignant?
Yes
Breast cancer: which is 80%, which is 20% - lobular or ductal?
80% ductal
20% lobular
Breast cancer is the commonest cancer in females in UK - true or false
True
Paralysis of what nerve is responsible for winged scapula?
Long thoracic nerve
What ages and how often are invited for breast cancer screening?
3 yearly
50 - 74
What test is used for breast cancer screening?
Mammogram
US adjunct if uncertain
From what age are BRCA positive women invited for breast cancer screening? What test is used for them?
From 30yr
MRI
If in primary care you suspect breast cancer what do you prefer them for?
Triple assessment: examination + imaging + tissue biopsy
(imaging = mammo/US/MRI)
(one stop breast clinic)
(using 2 week wait)
What type of biopsy is done for query breast cancer? Is it US guided?
Vacuum assisted core biopsy
All done under US guidance
What classification system is used for breast cancer?
TNM
Breast cancer grading is based on a degree of ______. There are X number grades.
Differentiation
3
Where does breast cancer most commonly metastasise?
4 locations
Bone brain liver lung
Mammogram / US / MRI- which uses ionising radiation?
Mammogram
What does LCIS / DCIS stand for? What separates it from carcinoma?
Lobular carcinoma in situ
Ductal carcinoma in situ
Invasion of the basement membrane
What is the main risk factor for breast cancer?
Estrogen exposure
Which is a risk factor for breast cancer
- early/late menarche
- early/late menopause
- OCP or POP
- breastfeeding or not breastfeeding
- early or later age of 1st pregnancy
- nulliparity or multiparity
- Early menarche
- Late menopause
- OCP (also HRT)
- Not breastfeeding
- Later age 1st pregnancy
- Nulliparity
(think of it as all that fertile time not being protected by pregnancy hormones)
In breast cancer triple assessment, what scan is done in those aged under / over 40 years?
Under 40: US + biopsy
Over 40: US + mammo + biopsy
FNA cytology distinguishes malignant or premalignant - true or false
False
Mammogram sensitivity increases / decreases with age
Increases
due to decreasing fat content
What type of imaging is good for dense fat breasts?
US
US is less sensitive in early cancer - true or false
True
What tumour markers are tested for in breast Ca?
ER
PR
HER2
Are all women with breast Ca checked for BRCA mutations?
I don’t know
80% of breast cancer is positive for
-ER / PR / HER2
ER estrogen receptor
ER is a good prognostic indicator - T or F
True
HER2 is a good prognostic indicator - T or F
False - bad
Mastectomy and breast conservation have the same long-term survival - T or F
True
How many cm margin is left with breast conserving surgery?
1cm
What is the function of radiotherapy in breast cancer?
To decrease local recurrence
In breast cancer, who is offered radiotherapy?
Post WLE or high risk mastectomy
What is the sentinel node?
First lymph-node that drains the tumour
What is the most important prognostic indicator in breast cancer?
Axilla status
What has worst cosmesis in breast construction - immediate or delayed?
Immediate
due to XRT
Immediate and delayed breast construction have the same long-term survival outcomes - T or F
True
In breast cancer Mx, who is given tamoxifen?
ER/PR positive pre-menopausal
In breast cancer Mx, who is given aromatase inhibitors? Give an example of an aromatase inhibitor
ER/PR positive post-menopausal
In breast cancer Mx, who is given Trastuzumab?
HER2+
Letrozole
Define neoadjunct and adjunct
Neoadjunct before surgery
Adjunct after
Is chemotherapy used for ER positive or negative breast Ca
ER negative
Name 2 side effects of tamoxifen
Hot flush
Vaginal dryness
Weight gain
Tamoxifen increases the risk of what cancer?
Endometrial cancer
What do pacemakers, metal clips, claustrophobia and renal failure have in common?
MRI CI
What do telangiectasia, pneumonitis, cardiac event and rib fracture have in common?
Radiotherapy SE
Is BRCA 1 or 2 associated low or high grade cancers?
BRCA 1 high grade
BRCA 2 low grade
What is the ER, HR and HER2 status of BRCA 1 cancers?
Triple negative
What is the ER, HR and HER2 status of BRCA 2 cancers?
ER positive
If sentinel node biopsy is positive - what is the next step?
Node clearance
Is sentinel node biopsy done at the same time as breast conserving surgery or at a later date?
Same time
Is radiotherapy given as after mastectomy?
Only after WLE or after mastectomy if high risk
