Breast Flashcards
What is a Fibroadenoma and in which patients are they most common in?
Benign growth of the breast
Proliferations of stromal and epithelial tissue of the duct lobules
Low mallignant potential
Common in women of reproductive age
Describe the findings on examination of a fibroadenoma
Highly mobile
Rubbery on palpation
Less than five cm
Multiple present, bilateral
What is the management of a fibroadenoma?
Reassuarance +/- excision if >3cm (or if patient prefers)
What is a ductal adenoma and which patients is it most common in?
Benign glandular tumour
Most common in older females
How does an adenoma present?
Nodular
Mimics mallignancy
What is an intraductal papilloma and which patients usually present with it?
Benign breast lesion
If multiductal risk of breast cancer
Females age 40-50
How do papillomas present
Larger lesion in the subareolar lesion
Rarely palpable lump
Nipple discharge - may be bloody or clear
Imagining is similar to microadeonma
Management of a papiloma?
Excision and biopsy
If multiple lesions remove
What is a lipoma?
Benign adipose tumour
Low mallignant potential
How does a lipoma present?
Soft
Mobile
Enlarging
What is the management of lipoma?
Removed only if causing symptomatic compressive or asthetic isssids
Reassuarnce
What is a phyllodes tumour and which patients usually present with?
Rare fibroelithelial tumour
Comprised of both stromal and epithelial tumour
Often rapid growing
Occur in older age group
Difficult to clinically and microscopically differentiate from fibroadenomas
What is the management of a Phyllodes Tumour and why?
Excision
1/3 mallignant potential
What features can help differentiate between a benign and mallignant breast lesion?
Benign - Smooth defined borders - Tend to be monile - Multiple lesions Mallignant - Irregular borders - Teathered to skin - Immobile - Other changes such as nipple retraction, dimpling of the skin or axillary lymph node involvement
What does the triple assesment consist of?
Examination Histology (usually core biopsy, FNA if recurrent cystic disease) Imaging - Mammogram >35 years old - Breast ultrasound scan <35 years old
What two views are given in a mammogram?
Oblique
Cranial caudal
When may MRI imaging be useful in breast cancer?
Assesment of lobular breast cancers
Assessing response to neoadjuvant therapy
Why is core biopsy usually better for assesment than FNA?
Differentiates betwee invasive and insitu carcinoma
FNA only provides cytology
What are the values for grading maliignancy overall risk index?
P1-P5
M1-M5/U1-U5
B1-B5
Describe cyclical mastalgia
Usually in luteal phase
Bilateral
Can be caused by HRT
Due to hormonal changes
Causes of non-cyclical mastalgia?
SSRIs
OCP
Antipyschotics
Causes of galactorrhea
Pregnancy
Breast feeding
Maternal oestrogen
Hyperprolactinemia
Pituaitry adenoma
Drug induced (SSRIs, anti-psychotics, H2-antagonists)
Neurological: varicellazoster infection or spinal cord pathology (neurogenic oathwaya are activated to inhibit dopamine levels)
Hypothyroidism (elevated TRH)
Cushings disease, acromegaly, addisons
Renal or liver failure
Damage to the pituitary stalk - sarcoidosis surgical resection, TB, MS
Normoprolactinaemic galactorrhlea is rare
What is Padgets Disease of the breast?
Rare disease of the nipple, 50% of patients with this disease will have an underlying breast cancer.
Features
- Eczema-like rash on the skin of the nipple and areola. This is may be itchy, red, crusty and inflamed.
- Nipple discharge which may be bloody.
- Burning sensation, increased sensitivity or pain
- Nipple changes such as nipple retraction or inverted
- In some cases there may be a palpable breast lump
- There may be a skin ulcer which does not heal
What is fibrocystic disease?
Bilateral nodularity in a younger patient which worsens in relation
to their menstrual cycle.
Under what circimstances should a patient have a urgent referral for the three stop breast assesment clinic?
Any patient aged 30 or over with an unexplained breast lump or aged 50 or over with unilateral nipple changes should be urgently referred (appointment within 2 weeks) for further assessment.
What’s the drug of choice for HER2 receptor positive breast cancer?
Trastuzumab, a monoclonal antibody
What drug is used for oestrogen receptive breast cancers in post-menopausal women?
Trastuzumab
What drug is used for oestrogen receptive breast cancers in pre-menopausal women?
Tamoxifen
What is the first line treatment of infective mastitis?
Flucloxacillin
How does late menopause affect the risk of breast cancer?
Increases
How does early menarche affect the risk of breast cancer?
Increases?
What is seen in DCIS on USS?
Multiple calcifications
What is seen in a breast cyst on USS?
Halo sign
What commonly perscribed drug class can cause mastalgia?
SSRIs
Hormonal contraceptives
Antipsychotic drugs like haloperidol
What age ranges are invited to breast cancer screening and how often?
50-70 every three years
What is the single most prognostic factor for breast cancer?
Nodal status
What classification is used to classify breast cancer?
Bloom Richardson
What is Paget’s disease of the nipple?
Features of Paget’s includes itching or redness of nipple/areola, flaking and thickened skin and ulceration, which is often painful and sensitive. The nipple may also be flattened and have a yellow/bloody discharge. Nearly all those with Paget’s disease of the breast will have an underlying malignancy.
Lactational mastitis?
First few months of breast feeding or weaning
Cracked nipples milk stasis
Encourage breast feeding
Analgesia
Systemically unwell nipple fissure or no improvement - abx - flucloxacillin to cover staph aureus
Periductal mastitis more common in those with duct entasis
Smoking. If risk factor
Analgesia and abx - flucloxacillin
What medication can be given in a patient who wants to stop breast feeding to stop lactation?
Cabergoline (dopamine agonist)
When might a punctum be seen in the breast (small hole)
Abscess
Give abx and USS guided FNA or incision and drainage if advanced
What will be seen on mammogram of a breast with fibrocystic changes
Halo sign on mammogram
Causes of galactorrhea?
Hyperprolactinaemia Drug induced - SSRIs antipsychotics H2 antagonists Acromegaly Hypothyroidism Pituitary adenoma Pregnancy test Idiopathic
Duct ectasia
Dilation and shortening or major lactiferous ducts
Menopausal women
Green and a yellow discharge
Palpable mass and may cause nipple inversion or retraction
Usually conservative may need abx, some pts treated surgically
What is radical scar
Proliferating breast lesion that can mimic breast cancer on mamorgram
Mx of gynaecomastia
Treat underlying condition
Tamoxifen
Surgery
Which conditions that can cause increased oestrogen and therefore gynaecomastia
Hyperthyroidism
Liver disease
Obesity
Adrenal tumours
Medications that can cause gynaecomastia?
digoxin, Metronidozole, spironolactone, finesteride, chemo, anti-psychotics
Which pts have a fibroadenoma biopsied?
Over 25
Most common breast cancer
DCIS and Carcinoma insitu
How does DCIS and carcinoma insitu appear on mammogram
Multiple calcifications looks like a city
Where is papilloma found
Sub areolar region
BLOODY DISCHARGE
Eczema vs pagets
Eczema is nipple sparing
Why do you need to do a punch biopsy in Paget’s disease?
97% of these patients will have underlying neoplasms either in situ or invasive disease
Types of hormonal breast cancer
Oestrogen receptor positive
Her 2 receptor positive
What do pre menopausal patients with breast cancer receive
Tamoxifen
What are post menopausal women with breast cancer given
Anastrozole
Tamoxifen side effects
VTE
endometrial
Hot flushes
Menstursl disturbance
Herceptin most serious side effect
Cardio toxicity
Anastrozole side effects?
Osteoporosis
What hormone treatment is given to patients with HER 2 receptor positive breast cancer
Biologicals
Herceptin
Indications for wide local incisions in breast cancer surgical management?
Solitary lesion
Peripheral lesion
Small lesion in a large breast
DCIS<4 cm
Indications for mastectomy in management of breast cancer?
Multifocal tumour
Focal tumour
Large lesion in small breast
DCIS >4 cm
Drugs that can cause gynaecomastia?
DISCO Digoxin Isoniazid Cimetidine (H2RA) Spironolactone Oestrogens
