Breast Flashcards
Selective oEstrogen Receptor Modulators (SERM)
Tamoxifen
It is used in the management of oestrogen receptor-positive breast cancer in PRE-MENOPAUSAL women
Adverse effects
-menstrual disturbance: vaginal bleeding, amenorrhoea
-hot flushes - 3% of patients stop taking tamoxifen due to climacteric side-effects
-venous thromboembolism
-endometrial cancer
Aromatase inhibitors
Anastrozole and letrozole are aromatase inhibitors that reduces peripheral oestrogen synthesis. This is important as aromatisation accounts for the majority of oestrogen production in POSTMENOPAUSAL women and therefore anastrozole is used for ER +ve breast cancer in this group.
Adverse effects
-osteoporosis (NICE recommends a DEXA scan when initiating a patient on aromatase inhibitors)
-hot flushes
-arthralgia, myalgia
-insomnia
Fibroadenoma
Develop from a whole lobule
On examination;
Painless
Smooth
Round
Well circumscribed (well-defined borders)
Firm
Mobile (moves freely under the skin and above the chest wall)
Usually up to 3cm diameter
12% of all breast masses
Over a 2 year period up to 30% will get smaller
No increase in risk of malignancy
If >3cm surgical excision is usual, Phyllodes tumours should be widely excised
NB- fibroadenoma is a solid structure, not cystic (ie. not fluid-filled on USS, and will not fluctuate like a cyst will)
Breast Cyst
The most common breast lump
They can be painful and may fluctuate in size over the menstrual cycle.
On examination, breast cysts are:
Smooth
Well-circumscribed
Mobile
Possibly fluctuant
Small increased risk of breast cancer (especially if younger)
Cysts should be aspirated, those which are blood stained or persistently refill should be biopsied or excised
Breast Cyst
7% of all Western females will present with a breast cyst
Usually presents as a smooth discrete lump (may be fluctuant)
Small increased risk of breast cancer (especially if younger)
Cysts should be aspirated, those which are blood stained or persistently refill should be biopsied or excised
Indications for a mastectomy
Multifocal tumour
Central tumour
Large lesion in small breast
DCIS >4cm
Patient choice
Genetics
Indications for a wide local incision
Solitary lesion
Peripheral tumour
Small lesion in large breast
DCIS <4cm
Patient choice
Risk Factors for breast cancer
BRCA1, BRCA2 genes (40% lifetime risk of breast/ovarian cancer)
1st degree relative premenopausal relative with breast cancer (e.g. mother)
nulliparity, 1st pregnancy > 30 yrs
early menarche, late menopause
combined hormone replacement therapy contraceptive use
past breast cancer
not breastfeeding
ionising radiation
p53 gene mutations
obesity
previous surgery for benign disease
Breast cancer screening
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’.
NB- trans women if they have had feminising hormones for 2 years
Subtypes of breast cancer
Invasive ductal carcinoma
Invasive lobular carcinoma
Ductal carcinoma in situ
Lobular carcinoma in situ
Paget’s disease of the nipple
Inflammatory breast cancer
Invasive ductal carcinoma
The most common type
Invasive lobular carcinoma
The 2nd most common type
May not show up on mammography
Ductal carcinoma in situ
Confined to one area
Microcalcifications
Potential to become invasive
Good prognosis
Women with DCIS are usually followed up with an annual clinic appointment and an annual mammogram for five years
Lobular carcinoma in situ
Asymptomatic and undetectable on mammogram
Usually diagnosed incidentally on breast biopsy
Increased risk of invasive carcinoma
Surgical excision of axillary lymph nodes
USS of axilla prior to surgery- biopsy of any abnormal nodes (can then be cleared during surgery)
If no abnormal nodes detected on USS, a sentinel node biopsy can be performed (deduce whether the sentinel node has cancer cells)
NB- axillary clearance may lead to arm lymphedema and functional arm impairment
Radiotherapy
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
NB- If a woman has been previously treated with radiotherapy, she cannot normally be given radiotherapy again, so if she presents with recurrence then mastectomy is usually offered
Chemotherapy
Cytotoxic therapy may be used either prior to surgery (‘neoadjuvanant’ chemotherapy) 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.
Hormonal therapy
Tamoxifen is still used in pre- and peri-menopausal women.
In post-menopausal women, aromatase inhibitors such as anastrozole and letrozole are used
Biological therapy
Trastuzumab (Herceptin) for tumours that are HER2 positive.
NB- Trastuzumab cannot be used in patients with a history of heart disorders (may want to do echo first)
Fibrocystic breast disease
Most common in middle-aged women
Lumpiness
Breast pain or tenderness (mastalgia)
Fluctuation of breast size
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.
NB- rule out cancer, supportive bra, NSAIDs, avoid caffeine
Mammary duct ectasia
Dilatation of the large breast ducts
Most common around the menopause
Associated with smoking
May present with a tender lump around the areola +/- a green nipple discharge
If ruptures may cause local inflammation, sometimes referred to as ‘plasma cell mastitis’
Duct papilloma
Local areas of epithelial proliferation in large mammary ducts
Hyperplastic lesions rather than malignant or premalignant
May present with wartery, blood stained discharge, lump, tenderness
NB- surgical excision
Fat necrosis
More common in obese women with large breasts
May follow trivial or unnoticed trauma
Initial inflammatory response, the lesion is typical firm and round but may develop into a hard, irregular breast lump
Rare and may mimic breast cancer so further investigation is always warranted
Breast abscess
More common in lactating women (and smokers)
Swollen, fluctuant, hot and tender lump (very painful)
Management- ultrasound-guided drainage (MSC of drained fluid) with ABX coverfibro
Cyclical mastalgia
Benign cyclical mastalgia is a common cause of breast pain in younger females.
It varies in intensity according to the phase of the menstrual cycle
NB- different to fibrocystic breasts
Women should be advised to wear a supportive bra
Conservative treatments include standard oral and topical analgesia
Causes of nipple discharge
Normal physiology
Galactorrhoea (drugs, emotions)
Hyperprolactinoma
Carcinoma
Mammary duct ectasia
Intraductal papilloma
NB- assessment of nipple discharge;
Examine breast and determine whether there is mass lesion present
All mass lesions should undergo Triple assessment.
Reporting of breast investigations
Where a mass lesion is suspected or investigations are requested these are prefixed using a system that denotes the investigation type e.g. M for mammography, followed by a numerical code as shown below:
1 No abnormality
2 Abnormality with benign features
3 Indeterminate probably benign
4 Indeterminate probably malignant
5 Malignant
Enhanced breast screening for high risk patients
Annual MRI and mammogram from the age of 40
NB- no screening necessary if a woman has had bilateral risk-reducing mastectomy
Investigations for a breast lump
2 week wait referral
Triple assessment- clinical exam, imaging (inc. axilla), and USS guided core biopsy with histology
Bloods- look at calcium and ALP (metastases)
Before surgery- baseline bloods
During surgery- sentinel node biopsy
Management of breast cancer
- Referral to breast specialist (2 weeks if cancer suspected)
- MDT to discuss options (surgical, chemo, radiotherapy)- use of the PREDICT tool (estimate breast cancer survival and the benefits of hormone therapy, chemotherapy)
- Macmillan cancer support, breast cancer specialist nurse etc.
HER2 +ve cancers
HER2-positive cancers demonstrate a more aggressive tumour growth and higher recurrence rates and therefore are associated with a poor prognosis
Grading cancer
1-3
Grade 1 breast cancers are slower growing and have a better prognosis. Grade 3 breast cancers are faster growing and are more likely to recur after treatment, so they are associated with a worse prognosis
USS or mammogram guided biopsy for calcifications
• The calcifications can’t be seen on ultrasound so the biopsy would need to be guided stereotactically (by mammogram)
Lymphoedema
Massage techniques to manually drain the lymphatic system (manual lymphatic drainage)
Compression bandages
Specific lymphoedema exercises to improve lymph drainage
Weight loss if overweight
Good skin care
NB- it is important to remember that you should avoid taking blood or putting a cannula in the arm on the side of previous breast cancer removal surgery. This is because there is a higher risk of complications and infection due to the impaired lymphatic drainage on that side.
Common breast radiotherapy side effects
General fatigue from the radiation
Local skin and tissue irritation and swelling
Fibrosis of breast tissue
Shrinking of breast tissue
Long term skin colour changes (usually darker)
Lipoma
Benign tumours of adipose tissue
Soft
Painless
Mobile
Do not cause skin changes
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.
Phyllodes tumour
They are large and fast-growing. They can be benign (~50%), borderline (~25%) or malignant (~25%). Malignant phyllodes tumours can metastasise.
Surgical removal (chemo if malignant)
Non cyclical mastalgia
more common in women aged 40 – 50 years. It is more likely to be localised than cyclical breast pain. Often no cause is found. However, it may be caused by:
Medications (e.g., hormonal contraceptive medications)
Infection (e.g., mastitis)
Pregnancy
The pain may not originate in the breast but instead come from:
The chest wall (e.g., costochondritis)
The skin (e.g., shingles or post-herpetic neuralgia)
Gynaecomastia- Increased oestrogen
Obesity (aromatase is an enzyme found in adipose tissue that converts androgens to oestrogen)
Testicular cancer (oestrogen secretion from a Leydig cell tumour)
Liver cirrhosis and liver failure
Hyperthyroidism
Human chorionic gonadotrophin (hCG) secreting tumour, notably small cell lung cancer
Gynaecomastia- reduced testosterone
Testosterone deficiency in older age
Hypothalamus or pituitary conditions that reduce LH and FSH levels (e.g., tumours (PROLACTINOMA- the high prolactin reduces the LH/FSH), radiotherapy or surgery)
Klinefelter syndrome (XXY sex chromosomes)
Orchitis (inflammation of the testicles, e.g., infection with mumps)
Testicular damage (e.g., secondary to trauma or torsion)
Gynaecomastia- drug causes
D-digoxin
I-isoniazid
S-spironolactone
C-cimitidine
O-oestrogen
K-ketoconazole
DISCO King
Management of gynaecomastia
Increased oestrogen- tamoxifen
Otherwise, surgery
Investigations for gynaecomastia
Bedside- testicular examination,
Bloods- FBC UE LFT TFT hormones eg. testosterone oestrogen LH FSH prolactin AFP (testicular cancer)
Imaging- breast USS, testicular USS, mammogram, biopsy
NB- need to exclude cancer (even in men)
Galactorrhoea
refers to breast milk production not associated with pregnancy or breastfeeding
There is a long list of causes of hyperprolactinaemia, but the key causes to remember are:
Idiopathic (no cause can be found)
Prolactinomas (hormone-secreting pituitary tumours)
Endocrine disorders, particularly hypothyroidism and polycystic ovarian syndrome
Medications, particularly dopamine antagonists (i.e., antipsychotic medications)
Prolactin suppresses gonadotropin-releasing hormone (GnRH) by the hypothalamus, leading to reduced LH and FSH release. Therefore, hyperprolactinaemia can also present with:
Menstrual irregularities, particularly amenorrhoea (absent periods)
Reduced libido (low sex drive)
Erectile dysfunction (in men)
Gynaecomastia (in men)
Investigations and management of galactorrhoea
A pregnancy test is essential in women with childbearing potential presenting with breast milk production.
Blood tests include:
Serum prolactin
Renal profile (U&Es)
Liver function tests (LFTs)
TFT’s
Management;
Dopamine agonists (e.g., bromocriptine or cabergoline) can be used to treat the symptoms
Trans-sphenoidal surgical removal of the pituitary tumour is the definitive treatment of a prolactinoma.
Mastitis
Mastitis can be caused by an obstruction in the ducts or and infection (Staphylococcus aureus)
Mastitis presents with:
Breast pain and tenderness (unilateral)
Erythema in a focal area of breast tissue
Local warmth and inflammation
Nipple discharge
Fever
Management- continue breastfeeding (affected breast), flucloxacillin, drainage of any abscesses that form
Chemotherapy used in breast cancer
Node +ve disease: FEC-D
Node -ve disease: FEC
Trans women and breast cancer screening
A person assigned male at birth who has been taking feminising hormones for longer than 2 years can have breast screening
