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Obs & Gynae > Breast > Flashcards

Breast Flashcards

1
Q

What is the breast comprised of?

A
  • Majority is adipose tissue
  • Mammary glands
  • Connective tissue stroma (fatty and fibrous tissue)
  • Pectoral fascia
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2
Q

What is the action of the ducts of the breast?

A

Carry milk from the lobules to the nipples

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3
Q

What is the action of the lobules of the breast?

A

They are the mammary glands that produce milk during pregnancy/ breastfeeding

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4
Q

What does each lobule consist of?

A

Many alveoli drained by a single lactiferous duct

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5
Q

What hormone stimulates the development of breasts?

A

Oestrogen

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6
Q

What is the action of progesterone on the breasts?

A

Stimulates formation of milk glands

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7
Q

Why is lactation inhibited in pregnancy?

A

Progesterone produced in the placenta inteferes with prolactin binding

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8
Q

What is responsible for breast growth in pregnancy?

A

Increased prolactin secretion

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9
Q

What are the steps in breast examination?

A

Get consent/ chaperone/ explain what doing etc
Inspection
Palpation
Assess lump

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10
Q

What are the 3 positions used to inspect the breast?

A

Relaxed with arms by sides
Hands pressed into hip
Hands placed behind head

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11
Q

What are you looking for on inspection of the breast?

A 
Asymmetry
Scars
Cosmetic augmentation
Tethering, fixation or puckering of skin
Nipple eversion/ inversion
Nipple discharge
Skin colour
Paeu d'orange
Paget's disease of the nipple
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12
Q

What is Paeu d’orange?

A

Thickened, oedematous, dimpled skin found with inflammatory breast cancer

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13
Q

What is Paget’s disease of the nipple?

A

Erythematous. scaly rash of the nipple that looks like eczema

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14
Q

How do you palpate the breast?

A

Have them lying at 45 degrees with hand behind head

Use flat of fingers to palpate each quadrant, over the nipple and the axilla

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15
Q

What features should you assess if a lump is found?

A 
Location
Size
Shape
Consistency
Margins
Tethered? 
Tenderness
Skin colour
Nipple discharge
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16
Q

What are the potential causes of breast lumps?

A 
Breast cancer
Fibroadenoma
Fibrocystic changes
Cysts
Fat necrosis
Lipoma
Galactocele
Phyllodes tumur
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17
Q

What are fibroadenomas?

A

Benign tumours of stromal/ epithelial breast duct tissue

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18
Q

How do fibroadenomas usually feel on palpation?

A 
Small (<3cm) 
Smooth
Mobile 
Round
Well circumscribed
Firm
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19
Q

In what age are fibroadenomas the most common?

A

20-40

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20
Q

Why are fibroadenomas more common in younger women?

A

They respond to oestrogen and progesterone, so go after menopause

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21
Q

What are fibrocystic breast changes?

A

When the breasts become fibrous and cystic in response to changes in the menstrual cycle

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22
Q

When do fibrocystic breast changes usually occur and resolve?

A

Usually begin around 10 days before menstruation and then resolve once menstruation begins

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23
Q

How may fibrocystic breast changes present?

A

Lumpiness
Breast pain/ tenderness
Fluctuation of breast size

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24
Q

How can fibrocystic breast changes be managed?

A 
Exclude cancer
Manage symptoms: 
-Supportive bra
-NSAIDs
-Avoid caffeine
-Apply heat to area
-Hormonal treatments
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25
Q

Why do fibrocystic breast changes occur?

A

The connective tissues, ducts and lobules respond to female sex hormones

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26
Q

What are breast cysts?

A

Benign individual fluid filled lumps

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27
Q

What is the most common cause of breast lumps?

A

Cysts

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28
Q

At what age to breast cysts most commonly occur?

A

Between 30 and 50 (in the perimenopausal period)

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29
Q

What are cysts like on examination?

A

Smooth
Well circumscribed
Mobile
May fluctuate with the menstrual cycle

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30
Q

How are breast cysts managed?

A

Need to exclude cancer

Aspiration or excision may resolve symptoms

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31
Q

What is fat necrosis of the breast?

A

When a benign lump forms due to localised degeneration and scarring of fat tissue in the breast

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32
Q

What may cause fat necrosis?

A

Localised trauma
Radiotherapy
Surgery

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33
Q

Why does fat necrosis occur?

A

Trauma causes an inflammatory reaction resulting in fibrosis and necrosis of the fat tissue

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34
Q

What may fat necrosis present on examination?

A 
Painless
Firm
Irregular
Fixed
Skin dimpling/ nipple inversion
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35
Q

How is fat necrosis diagnosed?

A

USS and mammogram may look similar to breast cancer so need histology to rule it out

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36
Q

What are lipomas?

A

Benign tumours of adipose tissue

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37
Q

How do lipomas feel on examination?

A

Soft
Painless
Mobile
Don’t cause skin changes

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38
Q

What are galactoceles?

A

Breast milk filled cysts

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39
Q

Who gets galactoceles?

A

Women who are lactating who stop breastfeeding

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40
Q

How do galactoceles occur?

A

When the lactiferous duct is blocked, preventing the gland from draining milk

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41
Q

How do galactoceles present?

A

Firm, mobile painless lump, usually beneath the areola

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42
Q

How are galactoceles managed?

A

Usually resolve without any treatment but may drain them with a needle

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43
Q

What are phyllodes tumours?

A

Rare tumours of the connective tissue of the breast

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44
Q

What is the most likely cause of a breast lump in a 20 year old?

A

Fibroadenoma

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45
Q

What is the most likely cause of a breast lump in a 30 year old?

A

Localised benign lump

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46
Q

What is the most likely cause of a breast lump in a 60 year old?

A

Breast cancer

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47
Q

What is mastalgia?

A

Breast pain

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48
Q

Is cyclical or non-cyclical breast pain more common?

A

Cyclical

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49
Q

How does cyclical breast pain usually present?

A

Bilateral, generalised pain
Heaviness
Aching

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50
Q

At what age is non-cyclical breast pain more common?

A

In women age 40-50

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51
Q

What may cause non-cyclical breast pain?

A

Medications
Infection
Pregnancy

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52
Q

How can breast pain be investigated?

A

Breast pain diary to look for cyclical breast pain

Exclude cancer, infection and pregnancy

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53
Q

How is mastalgia managed?

A 
Supportive bra
NSAIDs
Avoid caffeine
Apply heat
Hormonal treatment
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54
Q

What is gynaecomastia?

A

The enlargement of the glandular breast tissue in males

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55
Q

In what ages is gynaecomastia most common?

A

Adolescents and older men (>50)

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56
Q

What are the causes of gynaecomastia?

A
  • Idiopathic
  • Hormonal imbalance between oestrogen and androgens (testosterone)
  • Hyperprolactinaemia
  • Medications/ drugs
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57
Q

What is the usual hormonal imbalance that causes gynaecomastia?

A

High oestrogen: Low androgens

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58
Q

What stimulates the breast development in gynaecomastia?

A

Oestrogen

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59
Q

What hormone may also be responsible for gynaecomastia?

A

Prolactin

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60
Q

What may cause hyperprolactaemia in males?

A

Dopamine antagonists (e.g. antipsychotics)

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61
Q

What may cause high oestrogen levels in males?

A 
Physiological during puberty
Obesity
Testicular cancer
Liver cirrhosis
Hyperthyroidism
hCG secreting tumour
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62
Q

What examination should always be performed on a patient presenting with gynaecomastia and why?

A

Testicular examination as 2% of cases are due to a Leydig cell testicular tumour

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63
Q

What conditions that reduce testosterone can cause gynaecomastia?

A 
Older age
Hypothalamus/ pituitary conditions
Klinefelter syndrome
Orchitis
Testicular damage
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64
Q

What medications can cause gynaecomastia?

A 
Anabolic steroids
Antipsychotics
Digoxin
Sprinolactone
GnRH agonists
Opiates
Marijuana
Alcohol
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65
Q

What other condition may present like gynaecomastia?

A

Psuedogynaecomastia: Breast enlargement due to obesity

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66
Q

What will be found on examination of gynaecomastia?

A

Firm tissue behind the areolas

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67
Q

How may gynaecomastia be investigated?

A

Thorough history and examination
Blood tests
Imaging

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68
Q

What is the management of simple gynaecomastia in a healthy adolescent?

A

Watchful waiting

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69
Q

What blood tests may be done in a more complex case of gynaecomastia (eg. > 30 with unexplained rapid onset)?

A 
U&E's 
LFTs
TFTs
Testosterone
Sex hormone-binding globulin
estrogen
Prolactin
LH/ FSH
Alpha-fetoprotein/ beta-hCG (testicular cancer markers)
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70
Q

What imagine may be done for more complex cases of gynaecomastia?

A

Breast USS
Mammogram
Biopsy
Testicular USS

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71
Q

How is gynaecomastia managed?

A

Stop cause (e.g. if cause)
Watch and wait
Tamoxifen/ surgery if problematic

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72
Q

What is galactorrhoea?

A

Breast milk production not associated with pregnancy or breastfeeding

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73
Q

What stimulates the production of breast milk?

A

Prolactin

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74
Q

Where is prolactin produced?

A

Anterior pituitary gland

and some in breast and prostate

75
Q

What blocks the secretion of prolactin?

A

Dopamine

76
Q

What stimulates breast milk excretion?

A

Oxytocin

77
Q

What are the key causes of hyperprolactinaemia?

A

Idiopathic
Prolactinomas
Endocrine disorders
Medications (dopamine antagonists)

78
Q

What does prolactin supress?

A

GnRH release from the hypothalamus

79
Q

What can hyperprolactinamia also present with and why?

A 
It suppresses GnRH and therefore LH/ FSH so may present with: 
Menstrual irregularities
Reduced libido
Erectile dysfunction
Gynaecomastia
80
Q

What are prolactinomas?

A

Tumours of the pituitary gland that secrete excessive prolactin

81
Q

Other than galactorrhoea, how may prolactinomas present?

A

Headaches

Bitemporal hemianopia

82
Q

What conditions can cause non-milk nipple discharge?

A

Mammary duct ectasia
Duct papilloma
Pus from breast abscess

83
Q

What investigations should be done for galactorrhoea?

A 
Pregnancy test
Blood tests: 
-Serum prolactin
-Renal profile
-LFTs
-TFTs
MRI for pituitary tumour
84
Q

How is galactorrhoea managed?

A

Depends on underlying cause:

  • Dopamine agonists for hyperprolactinaemia
  • Trans-sphenoidal removal or pituitary tumour
85
Q

What is mammary duct ectasia?

A

Benign condition where there is inflammation and dilation of the large ducts in the breasts

86
Q

In which women is mammary duct ectasia most common?

A

Perimenopausal women

87
Q

What is the most significant risk factor in mammary duct ectasia?

A

Smoking

88
Q

How may mammary duct ectasia present?

A

Nipple discharge (intermittend, may be white, grey or green)
Tenderness/ pain
Nipple retraction/ inversion
Breast lump

89
Q

How is mammary duct ectasia diagnosed?

A

Exclude breast cancer (triple assessment)
Ductography
Nipple discharge cytology
Ductoscopy

90
Q

What is the key mammogram finding with mammary duct ectasia?

A

Microcalcifications

91
Q

How is mammary duct ectasia managed?

A

May resolve with no treatment
Symptomatic management
If problematic, may require surgical excision

92
Q

What is an intraductal papilloma?

A

Warty lesion that grows within a breast duct

93
Q

What is an intraductal papilloma the result of?

A

Proliferation of epithelial cells

94
Q

What is the typical presentation of intraductal papilloma?

A

Often asymptomatic
Clear/ blood-stained nipple discharge
Tenderness/ pain
Palpable lump

95
Q

Between what ages are intraductal papillomas most common?

A

35-55

96
Q

How are intraductal papilloma diagnosed?

A

Triple assessment

Ductography

97
Q

What is ductography?

A

Injecting contrast into the abnormal duct and performing mammograms to visualise it

98
Q

How are intraductal papilloma managed?

A

Complete surgical excision

99
Q

What is mastitis?

A

Inflammation of the breast tissue

100
Q

What causes mastitis?

A
  • Obstruction in the ducts with accumulation of milk

- Infection cause by bacteria entering nipple

101
Q

When is mastitis most common?

A

Common complication of breastfeeding

102
Q

What is the most common bacterial cause of mastitis?

A

Staph. aureus

103
Q

How does mastitis present?

A 
Breast pain/ tenderness
Erythema
Local warmth/ inflammation
Nipple discharge
Fever
104
Q

How is mastitis managed if it is caused by duct blockage?

A

Conservative:

  • Continued breastfeeding
  • Expressing milk
  • Breast massage
  • Heat packs
  • Warm showers
  • Simple analgesia
105
Q

How is mastitis managed when it is caused by infection/ conservative management is not working?

A

Flucloxacillin

Send milk sample for culture and sensitivities

106
Q

Should women keep breastfeeding even if they have infection?

A

Yes- won’t harm baby and will help clear mastitis

107
Q

What may occur after a course of antibiotics?

A

Candida of the nipple

108
Q

What can candida of the nipple cause and why?

A

Recurrent mastitis as it causes cracked skin on the nipple that allows entrance for infection

109
Q

What is a breast abscess?

A

A collection of pus within an area of the breast

110
Q

What usually causes breast abscesses?

A

Bacterial infection

111
Q

What are the two types of breast abscess?

A

Lactational abscess

Non-lactational abscess

112
Q

What does pus contain?

A

Dead white blood cells and other waste leftover from immune response

113
Q

How does an abscess form?

A

When pus becomes trapped in a specific area and cannot drain

114
Q

What are the most common bacteria that cause breast abscesses?

A

Staph. aureus
Streptococcal species
Enterococcal species
Anaerobic bacteria

115
Q

How do breast abscesses present?

A

Acute onset
Swollen, fluctuant tender lump
Generalised symptoms of infection

116
Q

What does fluctuance mean?

A

Able to move fluid around within the lump on palpation

117
Q

How are abscesses diagnosed?

A

History/ examination

118
Q

What is the management for breast abscesses?

A 
Treat mastitis (antibiotics) 
Refer to surgical team
USS
Drainage
Microscopy, culture and sensitivities of drained fluid
119
Q

What is the most common cancer in the UK?

A

Breast cancer

120
Q

How many women will develop breast cancer in their lifetime?

A

1 in 8

121
Q

What are the risk factors for developing breast cancer?

A 
Female
Increased oestrogen exposure
More dense breast tissue
Obesity
Smoking 
Family history
COCP
HRT
122
Q

What genes increase the risk of breast cancer?

A

BRCA genes

123
Q

What is BRCA?

A

Breast Cancer gene- tumour suppressor genes

124
Q

On which chromosome is the BRCA1 gene?

A

Chromosome 17

125
Q

On which chromosome is the BRCA2 gene?

A

Chromosome 13

126
Q

What are the different types of breast cancer?

A 
Ductal carcinoma in situ
Lobular carcinoma in situ
Invasive ductal carcinoma
Invasive lobular carcinomas
Inflammatory breast cancer
127
Q

What is the most common type of breast cancer?

A

Invasive ductal carcinoma (NST)

128
Q

What is a DCIS?

A

Ductual carcinoma in situ= cancerous/ pre-cancerous epithelial cells in the breast ducts, usually localised to a single area

129
Q

What is LCIS?

A

Lobular carcinoma in situ= pre-cancerous condition found incidentally on breast biopsy

130
Q

What does NST stand for?

A

No special/ specific type

131
Q

What percentage of breast cancers are invasive ductal carcinomas of no specific type?

A

80%

132
Q

How do inflammatory breast cancers present?

A

Similarly to breast abscess or mastitis

paue d’orange

133
Q

Between what ages does breast cancer screening occur and how often?

A

Every 3 years for women age 50-70

134
Q

What are the potential downsides to screening/

A

Anxiety
Exposure to raditation
False negatives/ positives
Unecessary further tests/ treatments

135
Q

What patients are classified as higher risk for breast cancer?

A

First degree relative with breast cancer (<40/ male/ bilateral)
Two first-degree relatives

136
Q

What may be offered to women at increased risk?

A

Annual mammogram
Chemoprevention
Risk reducing bilateral mastectomy or oophorectomy

137
Q

What clinical features may suggest breast cancer?

A

Hard, irregular, painless or fixed lumps
Nipple retraction
Peau d’orange
Lymphadenopathy

138
Q

What would trigger a 2WW referral for breast cancer?

A

Unexplained breast lump >30

Unilateral nipple changes >50

139
Q

What diagnostic assessment is used for breast cancer?

A

Triple assessment:

  1. Clinical assessment
  2. Imaging
  3. Biopsy
140
Q

What does the clinical assessment component of the triple assessment involve?

A

Examination and history

141
Q

What imaging is done during the triple assessment in younger women?

A

USS

142
Q

What imaging is done during triple assessment for older women?

A

Mammograms

143
Q

Why do older and younger women have different breast imaging?

A

Breast tissue is much more dense in younger women so it is hard to distinguish lumps with mammograms

144
Q

When might MRI be used in breast cancer?

A

To screen women at higher risk

To further assess the size/ features of a tumour

145
Q

What else should be assessed when a woman is diagnosed with breast cancer?

A

Lymph nodes

146
Q

How are the lymph nodes assessed?

A

USS of axilla and ultrasound-guided biopsy of any abnormal nodes

147
Q

What may be done during breast cancer surgery to look for abnormal nodes?

A

Sentinel lymph node biopsy

148
Q

What is a sentinel lymph node biopsy?

A

When an isotope contrast and blue dye are injected into the tumour area. These travel through the lymphatics to the sentinel lymph node which will show up blue and then a biopsy can be performed or they can be moved

149
Q

What is a sentinel lymph node?

A

The first lymph node draining a cancer

150
Q

What are the 3 types of breast cancer receptors?

A

Oestrogen receptors
Progesterone receptors
Human epidermal growth factor

151
Q

Why are the receptors found on tumours important on breast cancer?

A

They can guide treatment

152
Q

What is triple-negative breast cancer?

A

Where the breast cancer cells do not express any of the three breast cancer receptors

153
Q

What is gene expression profiling?

A

Assessing which genes are present in breast cancer on a histological sample

154
Q

What are the most common metastasis of breast cancer?

A 
(2L 2B)
Lungs
Liver
Bones 
Brain
(can spread anywhere)
155
Q

How is breast cancer staged?

A

Triple assessment
Lymph node assessment/ biopsy
MRI
Liver USS/ CT thorax, abdomen or pelvis, bone isotope

156
Q

What system is used to stage breast cancer?

A

TNM

Tumour, nodes, metastasis

157
Q

What are the treatment options for breast cancer?

A 
Surgery
Radiotherapy
Chemotherapy
Hormone treatment
Targeted treatments
158
Q

What are the two options for breast cancer surgery?

A

Breast-conserving surgery
Mastectomy
(axillary clearance)

159
Q

What is breast-conserving surgery also called?

A

Lumpectomy/ wide local excision

160
Q

What is lymphoedema?

A

Chronic condition caused by impaired lymphatic drainage

161
Q

When is lymphoedema common?

A

After axillary clearance during breast cancer surgery

162
Q

What causes Lymphoedema?

A

The lymphatic system is usually responsible for draining excess fluid from the tissues, so when the lymphatic system is impaired, the tissues become swollen with excess protein-rich fluid

163
Q

What are the complications of axillary clearance?

A

Lymphoedema

Increased infection in area

164
Q

What treatments can be used to manage Lymphoedema?

A

Massage techniques
Compression bandages
Exercises to improve lymph drainage
Weight loss

165
Q

When is radiotherapy usually used in breast cancer?

A

In patients with breast-conserving surgery to reduce risk of recurrence

166
Q

How is radiotherapy given in breast cancer?

A

High dose radiation given from multiple angles on a targeted area.
Usually have a course after surgery (e.g. every day for 3 weeks)

167
Q

What are the common radiotherapy side effects?

A 
General fatigue
Local skin/ tissue irritation and swelling
FIbrosis
Shrinking
Skin colour changes
168
Q

What are the three uses of chemotherapy in breast cancer?

A

Neoadjuvant
Adjuvant
As treatment

169
Q

What is neoadjuvant therapy?

A

Treatment given as the first step to shrink the tumour before surgery

170
Q

What is adjuvant therapy?

A

Treatment given after surgery to reduce recurrence

171
Q

When can hormone treatment be used in breast cancer?

A

When patients have oestrogen-receptor positive breast cancer they can be given treatment that disrupts the oestrogen stimulating the breast cancer

172
Q

What are the two options for hormone treatment in breast cancer?

A 
Tamoxifen (premenopausal) 
Aromatase inhibitors (postmenopausal
173
Q

What is the action of tamoxifen?

A

Selective oestrogen receptor modulator that blocks oestrogen receptors in breast tissue

174
Q

What is the action of aromatase inhibitors?

A

Aromatase is an enzyme found in adipose tissue that converts androgens to oestrogen. After menopause it is the primary source of oestrogen so inhibitors work bu blocking the creation of oestrogen.

175
Q

For how long after oestrogen-receptor positive breast cancer is diagnosed should hormone treatment be given?

A

5-10 years

176
Q

What targeted treatments can be used in breast cancer?

A

Trastuzumab/Pertuzumab= monoclonal antibodies that targets HER2 receptor

177
Q

What follow up do women treated for breast cancer get?

A

Surveillance mammograms yearly for 5 years.

178
Q

What reconstructive options is offered to women having a mastectomy?

A

Immediate reconstruction
Delayed reconstruction
Reconstruction
Reduction and reshaping

179
Q

What is partial reconstruction?

A

Using a flap or fat tissue to fill the gap left after breast-conserving surgery

180
Q

What is reduction and reshaping?

A

Removing tissue and reshaping both breasts to match after breast-conserving surgery

181
Q

What are the options for reconstructing the breast after mastectomy?

A

Breast implants

Flap reconstruction

182
Q

What are the options of tissue that can be used in flap reconstruction surgery?

A

Portion of the latissimus dorsi and associated skin and fat
Transverse rectus abdominis
Deep inferior epigastric perforator

183
Q

What does pedicled refer to?

A

Keeping the original blood supply and moving the tissue under the skin to a new location

184
Q

What does ‘free flap’ refer to?

A

Cutting the tissue away completely and transplanting to a new location

Obs & Gynae (4 decks)

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