Breast Flashcards
clinical features that suggest.a breast lump is breast cancer
Lumps that are hard, irregular, painless or fixed in place
Lumps may be tethered to the skin or the chest wall
Nipple retraction
Skin dimpling or oedema (peau d’orange)
When to do a 2 week wait for suspected breast cancer
An unexplained breast lump in patients aged 30+
Unilateral nipple changes in patients aged 50+ e.g. discharge, retraction or other changes
When to do a non urgent breast referral for suspected breast cancer
unexplained breast lumps in patients under 30 yo
Differentials for breast lumps
Breast cancer fibroadenoma Fibrocytic breast changes Breast cycts Fat necrosis Lipoma Galactocele Phyllodes tumour
What are fibroadenomas?
Common benign tumours of stromal/epithelial breast duct tissue
How do fibroadenomas feel on examination?
Small (usually <3cm) and mobile Breast mouse = move around within the breast tissue, move freely under the skin and above the chest wall Painless Smooth Round Well circumscribed Firm
Ix for fibroadenomas
Can do USS and fine needle aspiration if concerned - women at higher risk are those with complex fibroadenomas or a positive family hx
Mx for fibroadenomas
Not cancerous and not associated with increased cancer risk
Can follow up with regular check ups
What are fibrocystic breast changes
Generalised lumpiness to the breast that are considered a variation of normal and not a disease
Why do fibrocystic breast changes occur?
The stroma, ducts and lobules of the breast respond to oestrogen and progesterone, becoming fibrous (irregular & hard) and cystic (fluid filled) - fluctuates with the menstrual cycle
When do women get symptoms of fibrocystic breast changes?
Typically within 10 days prior to menstruating and resolves once menstruation begins
improve/resolve after menopause
Symptoms of fibrocystic breast changes
Lumpiness
Breast pain or tenderness = mastalgia
Fluctuation in breast size
Mx of fibrocystic breast changes
Wear a supportive bra NSAIDs Avoid caffeine Applying heat to the area Hormonal treatment e.g. danazol and tamoxifen
What are breast cysts?
Benign individual fluid filled lumps
Most common cause of breast lumps
Occur most between 30-50 yo in the perimenopausal period
What do you find on examination of breast cysts?
Painful lump fluctuate in size over the menstrual cycle Smooth Well circumscribed Mobile Possibly fluctuant
Ix for breast cysts
Need further Ix to exclude breast cancer
USS/mammography + aspiration
Mx for breast cysts
Aspiration
Excision
Do breast cysts increase the risk of breast cancer?
Yes slightly
What is fat necrosis of the breast?
A benign lump formed by localised degeneration and scarring of fat tissue in the breast.
Can be associated with an oil cyst containing liquid fat
What triggers fat necrosis in the breast?
Localised trauma
Radiotherapy
Surgery
Pathology of fat necrosis of the breast
An inflammatory reaction causes fibrosis and necrosis of fat tissue
Does fat necrosis increase the risk of breast cancer?
No
What do you find on examination of fat necrosis of the breast
Painless Firm Irregular Fixed in local structures Skin dimpling / nipple inversion
Ix for fat necrosis of the breast
US/mammogram - similar appearance to breast cancer
Histology - used to exclude breast cancer
Mx for fat necrosis of the breast
Exclude breast cancer
Can resolve spontaneously so manage conservatively
Symptoms - surgical excision
What is a lipoma in the breast?
Benign tumours of fat (adipose) tissue. Can occur anywhere in the body.
What do you feel on examination of a lipoma in the breast?
Soft
Painless
Mobile
Do not cause skin changes
Mx for lipomas in the breast
Conservatively
Reassure
Can be surgically removed
What is a galactocele?
Occur in women who are lactating, often after stopping breast feeding
They are milk filled cysts that occur when the lactiferous duct is blocked, preventing the gland from draining milk
What do you find on examination of a galactocele?
Firm
Mobile
Painless
Beneath areola usually
Mx for galactocele
Benign - usually resolve without treatment
can drain them with a needle
Rarely become infected = abx
What is a phyllodes tumour?
Rare tumour of the connective tissue (stroma) of the breast
Occurs most commonly between 40-50 yo
Large and fast growing
Are phyllodes tumours benign or malignant?
benign (~50%),
borderline (~25%)
malignant (~25%) - can metastasise
Mx of phyllodes tumours
Wide excision
Can reoccur after removal
Malignant/mets = chemotherapy
How can mastalgia be classified?
Cyclical - occurring at specific times of the menstrual cycle (more common)
Non-cyclical - unrelated to menstrual cycle
What is gynaecomastia?
the enlargement of the glandular breast tissue in males
Causes of gynaecomastia
Idiopathic
Increase in oestrogen -
- Obesity
- Testicular cancer - oestrogen secreted by Leydig cell tumour
- Liver cirrhosis / liver failure
- Hyperthyroidism
- HCG secreting tumour - SCLC
Reduced testosterone -
- Older age
- Hypothalamus / pituitary conditions that reduce FSH and LH e.g. tumours/radiotherapy
- Klinefelter syndrome
- Orchitis
- Testicular damage
Medications -
- Antipsychotics (increase prolactin levels)
- Anabolic steroids (raise oestrogen levels)
- Digoxin
- Spironolactone (inhibits testosterone production & blocks testosterone receptors)
- GnRH agonists e.g. goserelin for prostate ca
- Opiates
- Marijuana
- Alcohol
what examinations should you do in a man presenting with gynaecomastia?
Testicular examination
Liver examination
Thyroid examination
Where is prolactin produced?
anterior pituitary gland
What is galactorrhea?
Breast milk production not associated with pregnancy or breast feeding. Breast milk is produced in response to prolactin.
Causes of hyperprolactinaemia that can cause galactorrhea
Idiopathic Prolactinomas Hypothyroidism Polycystic ovarian syndrome Antipsychotic medications
How can hyperprolactinaemia present?
Galactorrhoea Menstrual irregularities - amenorrhoea Reduced libido Erectile dysfunction Gynaecomastia
What are prolactinomas and what are they associated with?
Tumours of the pituitary galnd
Secrete excessive prolactin
Associated with multiple endocrine neoplasia type 1 (MEN) - autosomal dominant condition
Symptoms of prolactinomas
Headaches
Bitemporal hemianopia due to compression of the optic chiasm
Conditions that cause discharge from the nipples that is not milk
Mammary duct ectasia
Duct papilloma
Pus from breast abscess
Ix for galactorrhea
Pregnancy test Serum prolactin Renal function LFTs TFTs MRI brain - pituitary tumour
Mx of galactorrhea
dopamine agonists to block prolactin secretion = bromocriptine / cabergoline
Trans-sphenoidal surgical removal of pituitary tumour
Causes/risk factors for breast cancer
- Oestrogen exposure o Early menarche, late menopause o HRT / OCP o First child >35 yo o Obesity
- Advanced age
- Genetic predisposition (BRCA1/BRCA2)
o 10% of breast Ca is familial
o BRCA1 – 17q – 80% breast Ca, 40% ovarian Ca
o BRCA2 – 13q – 80% breast Ca - Proliferative breast disease with atypia
- Previous breast Ca
Protective factors for breast cancer
Breast feeding
What type of cancer is breast cancer?
Adenocarcinoma
How can breast cancers be classified molecularly?
Breast cancers can be classified based on their expression of certain hormone receptors & genes that have significance for management & prognosis:
1) hormone receptor status - oestrogen or progesterone receptors. Use anti-oestrogen/progesterone treatment.
2) HER2 status - human epidermal growth factor 2 - higher grade & more aggressive cancers - mx with transtuzumab
Common sites breast cancers metastasise to
Lungs
Liver
Bone
Brain
What is the screening programme for breast cancer?
Every 3 yrs from 47-73
Craniocaudal and oblique views of breast on mammography
Reduced breast Ca deaths by 25%
10% false negative rate
What is included in the triple assessment of a breast lump?
1 History and clinical examination
2 Radiology
• <35 yo = US
• >35 yo = US + mammography
3 Pathology
• Solid lump = core needle biopsy
• Cystic lump = fine needle aspiration
• High suspicion of malignancy = excisional biopsy / wire localised biopsy
What is the staging for breast cancer?
Stage 1 = confined to breast, mobile, no lymph node involvement
Stage 2 = stage 1 + nodes in ipsilateral axilla
Stage 3 = Stage 2 + fixation to muscle (not chest wall). Lymph nodes matted and fixed, large skin involvement
Stage 4 = Complete fixation to chest wall + mets
Mx for breast cancer
- Wide local excision + radiotherapy
a. Same survival as with mastectomy but WLE has higher recurrence rates - Mastectomy
a. Done for large tumours
b. Multifocal or central tumours
c. Nipple involvement
d. Patient choice - Sentinel node biopsy
- Chemotherapy
- Oestrogen receptor positive tumours - tamoxifen for premenopausal women & anastrozole/letrozole for post menopausal women
Complications for breast surgery
- Haematoma
- Seroma
- Frozen shoulder
- Long thoracic nerve palsy
- Lymphoedema
- Upper inner arm numbness – intercostobrachial nerve injury
What is a sentinel node biopsy?
- Gold standard
- Blue dye / radiocolloid injected into tumour, this drains to the sentinel node (the first lymph node that a section of breast drains to
- Visual inspection / gamma probe during surgery to identify sentinel node
- Sentinel node is removed and sent for frozen section
- If the node is negative, there’s no need for further dissection
- If the sentinel node is positive = axillary clearance / radiotherapy
USS appearance of extra capsular breast implant rupture
Snowstorm sign
What is mammary duct ectasia?
a benign condition where there is dilation of the large ducts in the breasts.
There is inflammation in the ducts = intermittent discharge from the nipple (white, grey or green)
Who gets mammary duct ectasia?
perimenopausal women
smokers
Presentation of mammary duct ectasia
nipple discharge - white, grey, green
tenderness or pain
Nipple retraction/inversion
A breast lump - pressure on the lump may produce nipple discharge
Diagnosis of mammary duct ectasia
Triple assessment
Mammogram = MICROCALCFICIATIONS
Ductography - contrast injected into abnormal duct & mammograms performed to visualise duct
Nipple discharge cytology
Ductoscopy - endoscope into duct
Mx of mammary duct ectasia
Resolves without tx
Not associated with increased cancer risk
problematic cases - surgical excision of duct (microdochectomy)
What is an intraductal papilloma?
a warty lesion that grows within one of the ducts in the breast - result of the proliferation of epithelial cells
Do intraductal papillomas increase the risk of breast cancer?
they are benign tumours that are associated with atypical hyperplasia / breast cancer
Presentation of intraductal papillomas
occur between 35-55 yo mostly clear/blood stained nipple discharge tenderness/pain a palpable lump asymptomatic - found on mammogram
Diagnosis of intraductal papillomas
Triple assessment
duct-graphs - insect contrast dye into duct and do mammography to visualise duct - when an area doesn’t fill with contrast
Mx of intraductal papillomas
need complete surgical excision
histology of tissues removed afterwards to look for atypical hyperplasia/cancer
What is mastitis?
inflammation of breast tissue that is a common complication of breast feeding.
Can occur with or without associated infection
Pathology of mastitis
obstruction in the ducts and accumulation of milk
or can be caused by infection
Most common infective organism seen in mastitis
staph aureus
Presentation of mastitis
breast pain/tenderness unilaterally erythema in a focal area of breast tissue local warmth and inflammation nipple discharge fever
Mx of mastitis
continue breastfeeding express milk breast massage heat packs warm showers simple analgesia
infection suspected = flucloxacillin and keep breast feeding
complication of mastitis
breast abscess
what is candida of the nipple and what causes it?
candidal infection of the nipple after a course of abx
complications of candida of the nipple
recurrent mastitis
oral thrush in the infant
candidal nappy rash in the infant
presentation of candida of the nipple
sore nipples bilaterally particularly after feeding
nipple itching
cracked flaky or shiny areola
symptoms in the baby - white patches in the mouth & on the tongue or candidal nappy rash
tx of candida of the nipple
mother & baby need tx
topical miconazole 2% to nipple after every breastfeed
baby - miconazole gel or nystatin
What is a breast abscess?
a collection of pus within an area of the breast, usually caused by a bacterial infection.
2 types of breast abscess
lactational
non-lactational
risk factors for breast abscess
smoking mastitis breast feeding damage to the nipple - eczema, candidal infection, piercings underlying breast disease e.g. cancer
Causative bacteria of breast abscesses
most common = staph aureus
strep
enterococcal
symptoms of breast abscess
a swollen, fluctuant, tender lump within the breast muscle aches fatigue fever signs of sepsis
mx of breast abscess
referral to on call surgical team antibiotics USS Drainage - needle aspiration or surgical incision and drainage MC&S of drained fluid
keep breastfeeding
what is Mondor’s disease of the breast?
Mondor’s disease of the breast is a localised thrombophlebitis of a breast vein.
