Breast Flashcards
What positions should the patient sit in when undergoing a breast examination?
- Sitting on side of bed with arms relaxed
- With hands pressed to hips-> tenses chest wall
- With hands behind head
- Palpation performed whilst lying at 45 degrees and hands behind head
What causes peu d’orange?
- Blocked lymphatic drainage-> superficial oedema + thickening
- Dimples-> sweat ducts
- Can be due to inflammatory breast cancer
What is important to look for on breast examination?
Asymmetry, scars, cosmetics, tethering, puckering, nipple eversion/inversion, discharge, erythema
What might be seen on examination in Paget’s disease of the nipple?
- Erythematous scaly rash (like eczema)
- Itchy and inflamed
- Ulcers
How is a breast exam performed?
- 3I’s + ask for chaperone
- Inspection-> sat + relaxed, hands on hips and hands behind head
- Can ask pt to point out abnormality
- Palpate whilst lying at 45 degrees-> 4 quadrants, sub-areola, tail of axilla + axilla
- Assess any lumps-> where, size, shape, consistency, margins, mobile/fixed, tender, skin colour, discharge
- Examine neck-> cervical + supraclavicular LNs
What does the triple assessment consist of?
- Clinical-> history + exam
- Images-> mammogram
- Histology-> biopsy
What is the anatomy of the breast
- Mostly adipose tissue
- Areola + nippe
- Behind nipple-> ducts lead to lobules (where milk produced)
What features might raise suspicion of a breast cancer?
- Hard, irregular, painless, fixed, tethered to skin/chest wall, nipple retraction, peu d’orange
- Axillary lymphadenopathy
What is the 2 week wait referral criteria for breast cancer?
- Age 30+ with unexplained lump
- Age 50+ with unilateral nipple changes
- Consider-> lump in axilla when >30 or skin changes suggestive of BC
What warrants a non-urgent referral for breast cancer?
Unexplained lump when <30
What is a fibroadenoma?
Common + benign stromal/epithelial breast duct tissue tumour-> not usually associated with cancer
What patient demographics do those with fibroadenomas typically have?
Age 20-40
What are the features of a fibroadenoma?
- On exam-> small, mobile, painless, smooth, round, well circumscribed, firm, >3cm
- Respond to oestrogen + progesterone
- Not associated with cancer unless complex or +ve FH
What are fibrocystic breast changes?
- Fibrous + cystic changes to stroma (connective tissues) + ducts + lobules
- Benign
- Respond to hormones-> fluctuate with menstrual cycle
What are the symptoms of fibrocystic breast changes?
- Fluctuant lumps-> within 10 days of menstruation
- Lumpy, painful
How are fibrocystic breast changes managed?
- Exclude cancer
- NSAIDs
- Avoid caffiene
- Heat compresses
- Hormonal-> tamoxifen, danazol
What are breast cysts?
Benign fluid filled lumps
What patient demographics do those with breast cysts typically have?
- Age 30-50
- Perimenopausal
What are the features of breast cysts?
- Smooth, well circumscribed, mobile, can be painful
- Can fluctuate with cycle
- Can slightly increase risk of breast cancer
How are breast cysts managed?
- Assessment
- Aspiration or excision
What is fat necrosis of the breast?
- Benign lump of localised degeneration + scarring of fat tissue-> may be oil cyst
- Doesn’t increase risk of BC
What can trigger fat necrosis of the breast?
trauma, radiotherapy, surgery
What are the examination findings of fat necrosis of the breast?
Painless, firm, irregular, fixed to local tissues, dimpling/nipple inversion
How is fat necrosis of the breast investigated?
- US/mammogram-> looks similar to BC
- May need biopsy
How is fat necrosis of the breast treated?
- Conservative
- Can resolve over time
- Can excise if needed
What is a lipoma?
Benign tumour of adipose tissue-> can be anywhere in the body
What findings will be present in a lipoma?
Soft, painless, mobile lump with no skin changes
How is a lipoma managed?
- Reassurance
- Removal
What is a galactocele?
- Milk filled cysts-> lactiferous duct blocked + prevents draining
- Often when stop breastfeeding
What does a galactocele feel like on examination?
Firm, mobile, painless, beneath areola
How is galactocele managed?
- Usually resolves
- Can drain
- May need antibiotics
What is Phyllodes tumour?
- Rare connective tissue (stromal) tumour-> large and fast growth
- 50% benign, 25% borderline, 25% malignant
What age group usually gets Phyllodes tumour?
Ages 40-50
How is Phyllodes tumour managed?
- Surgery ie wide excision
- Can recur
- Chemotherapy if malignant
What is gynaecomastia?
Enlargement of glandular breast tissue in males
What age group usually gets gynaecomastia?
- Teens
- > 50’s
- Newborns
- Due to circulating male hormones
What causes gynaecomastia?
Hormone imbalance between oestrogen + androgens
- Idiopathic or physiological-> higher oestrogen in puberty
- Hyperprolactinaemia-> stimulates tissue development
- Obesity-> higher androgen to oestrogen conversion
- Conditions-> testicular cancer, liver disease, hyperthyroid, hCG-secreting tumour
- Reduced testesterone-> older, radiotherapy, surgery, Klienfelter’s, orchitis, testicular damage
- Medications-> anabolic steroids, antipsychotics, digoxin, spironolactone, GnRH, opiates, alcohol
What drugs can cause gynaecomastia?
anabolic steroids, antipsychotics, digoxin, spironolactone, GnRH, opiates, alcohol
Why can hyperprolactinaemia cause gynaecomastia?
- Prolactin stimulates glandular breats tissue development
- Dopamine inhibits so antagonists (antipsychotics) can cause gynaecomastia
Why can obesity cause gynaecomastia?
- Aromatase in adipose converts androgens to oestrogen
- More adipose-> more conversion
How is gynaecomastia investigated?
- Exam-> firm tissue behind areola
- Testicular exam-> TC risk
- Ask about-> sexual dysfunction, lumps, hyperthyroid, medications
- Bloods-> U+Es, LFTs, TFTs, testosterone, sex hormone binding globulin (SHBG), oestrogen, prolactin, LH + FSH, AFP, b-hCG, karyotyping
- Imaging-> breast US, mammogram + biopsy, testicular US, CXR
How is gynaecomastia managed?
- Watchful waiting if healthy
- Stop causative drugs
- Breast clinic-> when unclear or BC suspected
- Tamoxifen-> selective oestrogen receptor modulator
- Surgery
What is galactorrhoea?
- Breast milk production not associated with pregnancy or breastfeeding
- In response to prolactin secretion
When might someone need thorough investigation for gynaecomastia?
If age <30, unexplained + rapid onset
What is the function of prolactin?
- Produced in anterior pituitary + breast/prostate
- Stimulates breast milk production
- Regulates some immune function + metabolism
Why can dopamine antagonists cause galactorrhoea?
- Da blocks prolactin secretion
- Use of DA antagonists (eg antipsychotics)-> raised prolactin
What is the physiology of milk production in pregnancy and breastfeeding?
- Production starts in 2nd + 3rd trimester
- Oestrogen + progesterone inhibit prolactin (in pregnancy)-> rapid drop after birth
- Oxytocin-> stimulates secretion + released after birth
- Tapers off when breastfeeding stops
What can cause galactorrhoea?
Hyperprolactinaemia usually
-Idiopathic, prolactinoma, endocrine (hypothyroid, PCOS), medications (DA antagonists)
What do patients usually present with alongside galactorrhoea and why?
- Menstrual irregularities, reduced libido, erectile dynsfunction, gynaecomastia
- GnRH production from hypothalamus suppressed-> reduced LH + FSH
What is a prolactinoma?
Pituitary gland tumour secreting excess prolactin
What are the types of prolactinoma?
- Microscopic ie <10mm
- Macroscopic ie >10mm
What are the features of prolactinomas?
- gynaecomastia
- galactorrhoea
- bitemporal hemianopia-> pressing on optic chiasm (above pituitary gland)
- headaches
What might cause non-milky breast discharge?
- Mammary duct ectasia
- Duct papilloma
- Pus from breast abscess
What are the investigations for galactorhhoea?
- MRI-> gold std
- Pregnancy test
- Bloods-> prolactin, U+Es, LFTs, TFTs
How is galactorrhoea managed?
- Treat underlying cause
- Dopamine agonists-> bromocriptine or cabergoline, block prolactin secretion, treat symptoms
- -Prolactinoma-> trans-sphenoidal removal
What is mammary duct ectasia?
- Benign dilation of large ducts of breasts
- ‘Ectasia’ = dilation
- No BC risk
How does mammary duct ectasia present?
- Discharge of nipple-> intermittent white/grey/green
- Tenderness, pain, nipple retraction/inversion, lump
- May be incidental finding
How is mammary duct ectasia diagnosed?
- Triple assessment to exclude BC
- Mammogram-> microcalcifications
- Ductography-> mammo’ + contrast
- Discharge cytology
- Ductoscopy
What are the risk factors for mammary duct ectasia?
- Perimenopausal
- Smoking
How is mammary duct ectasia managed?
- May resolve without treatment
- No BC risk
- Symptoms-> warm compress
- Antibiotics if infection
- Surgery-> microdochectomy
What is intraductal papilloma?
- Warty lesion in breast duct due to epithelial cell proliferation
- Benign but can be associated with hyperplasia + BC
How does intraductal papilloma present?
- Usually 35-55 years
- Can be asymptomatic + incidental
- Nipple discharge-> clear or bloody
- Tender lump
How is intraductal papilloma diagnosed?
- Triple assessment
- Ductography-> shows filling defect ie doesn’t fill with contrast
How is intraductal papilloma managed?
- Excision
- Examine for hyperplasia + BC
What is lactational mastitis?
Inflammation of breast tissue due to breastfeeding-> +/- infection
What causes lactational mastitis?
- Obstruction-> milk accumulation
- Infection-> bacteria in nipple backtracks, usually s.aureus
What can prevent lactational mastitis?
Regular milk expression
How does lactational mastitis present?
Pain, erythema, warmth, inflammation, nipple discharge, fever
How is lactational mastitis managed?
- Blockage-> continue to feed + breast massage + analgesia
- Infection-> flucloxacillin/erythromycin, culture + sensitivities, fluconazole if suspect candida
- Continue to breast feed
- Abscess-> rare but may need incision + drainage
Should mums continue to breastfeed in lactational mastitis?
- Yes-> infection won’t harm baby + will clear mastitis
- Express milk to empty if left over or feeds difficult
When does candida of the nipple often occur?
After antibiotics
What are the complications of candida of the nipple?
- Recurrent mastitis due to cracked skin (infection entrance)
- Baby-> oral thrush + candida nappy rash
What are the symptos of candida of the nipple?
- Often bilateral
- Sore, itchy, tender, cracked, flaky areola
- Baby-> white in mouth, nappy rash
How is candida of the nipple managed?
- Topical miconazole after each feed
- Miconazole gel or nystatin for baby
What is a breast abscess?
- Bacterial infection causes collection of pus
- Can be lactational or not
What is the pathophysiology of breast abscess?
- Bacterial infection causes pus collection
- Pus-> inflammation, dead WBCs + waste
- Trapped + can’t drain-> increases + symptoms
What are the risk factors for breast abscess?
- Smoking
- Damage-> eczema, candida, piercings
- Breast disease-> cancer or drainage affected
What bacteria commonly causes breast abscess?
- Staph aureus
- Strep
- Enterococcus
- Anaerobic-> bacteroides, anaerobic strep
How does breast abscess present?
- Over a few days
- Swelling-> painful, tender, warm, erythema, fluctuant
- Nipple changes, discharge, hardened skin/tissue
- Muscle aches, fatigue, fever, sepsis
How is breast abscess managed?
- Depends on if lactational or not
- Diagnosis clinical but can use US + MC&S
- Lactational-> conservative, flucloxacillin
- Non-lactational-> analgesia, treat underlying cause, broad-spectrum ABs (eg co-amoxiclav)
- Refer to surgical for drainage
- Continue breastfeeding
Should patients continue breastfeeding with a breast abscess?
Yes-> not harmful
What is the lifetime risk of developing breast cancer?
1 in 8 women+
What are the risk factors for developing breast cancer?
- Female, obesity, smoking, 1st degree FH, more dense tissue (glandular)
- BRCA 1 + 2 tumour suppression gene mutations
- Increased oestrogen exposure-> earlier periods, later menopause, COCP, HRT
What is the BRCA1 gene and what does it increase the risk of?
- On chromosome 17-> tumour suppressor gene
- 70% get breast cancer by age 80
- Also increases ovarian, bowel + prostate cancer risk
What is the BRCA2 gene and what does it increase the risk of?
- On chromosome 13-> tumour suppressor gene
- 60% get breast cancer by age 80
- Also increases ovarian cancer risk
What is ductal carcinoma in situ (DCIS)?
- Pre- or cancerous epithelial cells of ducts
- Often picked up on screening
- Localised to 1 area but can spread locally over years + become invasive
- Good prognosis
How is ductal carcinoma in situ (DCIS) managed?
- Good prognosis
- Excise + adjuvant treatment
What is lobular carcinoma in situ (LCIS)?
- Pre-cancerous cells in lobules
- Very rarely spreads
- Increases risk of future cancers
What are the symptoms of lobular carcinoma in situ (LCIS)?
- Usually none
- Picked up on screening/biopsy
How is lobular carcinoma in situ (LCIS) managed?
Close monitoring-> 6 monthly exam + yearly mammograms
What is invasive ductal carcinoma NST?
- Cancer of cells from breast ducts
- NST-> no special/specific type eg can be medullary or mucinous
- 80% of all invasive breast cancers
What is the most common type of invasive breast cancers?
Invasive ductal carcinoma NST
How is invasive ductal carcinoma NST investigated?
Mammogram-> visible
What is invasive lobular carcinoma?
- Invasive breast cancer of the lobules
- 10% of invasive BCs
- Not always visible on mammograms
What is inflammatory breast cancer?
- Rare + aggressive-> blocks lymph drainage + causes inflammation
- 1-3% of BCs
- Worse prognosis than others
How does inflammatory breast cancer present?
- Similar to mastitis/abscess + peau d’orange
- No response to antibiotics
What is paget’s disease of the nipple?
Breast cancer involving the nipple-> DCIS or invasive
How is paget’s disease of the nipple managed?
- Biopsy + staging
- Treat accordingly
What are some of the rarer types of breast cancer?
- Medullary
- Mucinous
- Tubular
Who is eligible for the breast cancer screening programme (low risk)?
50-70 year old women
How often are women called for the breast cancer screening programme (low risk)?
Every 3 years
What are some positives to the breast cancer screening programme?
- Detect early + improve outcomes
- 1/100 diagnosed after screening
What are some negatives to the breast cancer screening programme?
Anxiety, radiation exposure, missing cancer + false reassurance, unnecessary further tests
Who meets the criteria for being high risk for breast cancer?
- 1st degree FH of BC under 40 years
- 1st degree male relative with BC
- 1st degree relative with bilateral BC diagnosed age <50
- 2 1st degree relatives with BC (any age)
How are patients who are ‘high risk’ for breast cancer screened + managed?
- Genetic counselling
- Annual mammogram-> often from 30+
- Chemoprevention-> tamoxifen or anastrozole
- Bilateral mastectomy
- Bilateral oophrectomy
What imaging might be used when investigating breast cancer?
- US-> <30’s as more dense tissue
- Mammograms-> older + pick up calcifications
- MRI-> when high risk
When are lymph node assessments offered during breast cancer assessments?
- After diagnosis
- Offered US of axilla + US-guided biopsy
- May get sentinel LN biopsy during surgery
What is a sentinel lymph node biopsy?
- Performed during BC surgery-> when US not show anything
- Isotope contrast + blue dye injected into tumour
- Travels to 1st LN as where tumour drains to
- Biopsy
- If cancer then can remove
What receptors can be targetted in breast cancer treatment if the tumour is positive for these?
- Oestrogen (ER)
- Progesterone (PR)
- Human epidermal growth factor (HER2)
What is triple negative breast cancer?
Doesn’t respond to hormone treatments for ER, PR or HER2 receptors-> worst prognosis
What is gene expression profiling?
- Assessment of which genes are present within BC
- Predicts risk of recurrence in distal mets within 10 years
- Decide whether or not to give chemo
- When to give-> early BC that’s ER +ve (but HER2 and LN -ve)
Where does breast cancer commonly metastasise to?
2Ls 2Bs-> lungs, liver, bones, brain
How is breast cancer assessed and staged?
- Triple assessment
- LN assessment + biopsy
- MRI of breast + axilla
- Liver US for mets
- CT-TAP
- Isotope scan for bony mets
- TNM system used
- MDT-> discuss tests + treatment decisions
What are the surgical options for breast cancer?
- Wide local excision + radiotherapy-> breast-conserving
- Mastectomy +/- immediate or delayed reconstruction
- Axillary clearance-> when LN cancer found, risk of lymphoedema
When is radiotherapy given in breast cancer and how?
- After breast-conserving surgery
- To reduce recurrence risk
- Eg every day for 3 weeks
- High dose from multiple angles
What are the potential side effects after radiotherapy for breast cancer?
Fatigue, local skin/tissue irritation, fibrosis + breast shrinking, long term skin colour change
When is chemotherapy used in breast cancer?
- Neoadjuvant-> shrink tumour before surgery
- Adjuvant-> after to reduce recurrence
- To treat mets or reccurent BC
What hormone treatments are available for ER +ve breast cancer?
- Tamoxifen (selective ER modulator)-> premenopausal women, blocks receptors in breast and stimulates in uterus + bones
- Anastrozole (aromatase inhibitors)-> blocks conversion of androgens to oestrogen, usually post-menopausal
- Fulvestrant-> ER downregulator
- GnRH agonists
- Ovarian surgery
- Usually give for 5-10 years
How does tamoxifen work?
- Selective ER modulator
- Blocks receptors in breast and stimulates in uterus + bones
- Can prevent osteoporosis
What are the risks associated with tamoxifen?
Increases risk of endometrial cancer
What targetted treatments are available for HER2 +ve breast cancer?
- Herceptin (trastuzumab)-> monoclonal antibody
- Perjeta (pertuzumab)-> used alongside Herceptin
- Nerlynx-> tyrosine kinase inhibitor
How are breast cancer patients followed up post-treatment?
- Yearly mammograms for 5 years at least
- Individual written care plan-> review dates, advice on recurrence, support
What are the options for reconstructive breast surgery?
- Immediate or delayed
- Partial-> flap or fat tissue eg latissimus dorsi or transverse rectus abdominis
- Reduction + reshaping
- Implants-> minimal scarring but SE’s (harden, leakage etc)
