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Finals Revision > Breast > Flashcards

Breast Flashcards

1
Q

clinical features that suggest.a breast lump is breast cancer

A

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)

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2
Q

When to do a 2 week wait for suspected breast cancer

A

An unexplained breast lump in patients aged 30+

Unilateral nipple changes in patients aged 50+ e.g. discharge, retraction or other changes

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3
Q

When to do a non urgent breast referral for suspected breast cancer

A

unexplained breast lumps in patients under 30 yo

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4
Q

Differentials for breast lumps

A 
Breast cancer
fibroadenoma
Fibrocytic breast changes
Breast cycts
Fat necrosis
Lipoma
Galactocele
Phyllodes tumour
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5
Q

What are fibroadenomas?

A

Common benign tumours of stromal/epithelial breast duct tissue

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6
Q

How do fibroadenomas feel on examination?

A 
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
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7
Q

Ix for fibroadenomas

A

Can do USS and fine needle aspiration if concerned - women at higher risk are those with complex fibroadenomas or a positive family hx

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8
Q

Mx for fibroadenomas

A

Not cancerous and not associated with increased cancer risk

Can follow up with regular check ups

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9
Q

What are fibrocystic breast changes

A

Generalised lumpiness to the breast that are considered a variation of normal and not a disease

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10
Q

Why do fibrocystic breast changes occur?

A

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

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11
Q

When do women get symptoms of fibrocystic breast changes?

A

Typically within 10 days prior to menstruating and resolves once menstruation begins

improve/resolve after menopause

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12
Q

Symptoms of fibrocystic breast changes

A

Lumpiness
Breast pain or tenderness = mastalgia
Fluctuation in breast size

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13
Q

Mx of fibrocystic breast changes

A 
Wear a supportive bra
NSAIDs
Avoid caffeine 
Applying heat to the area
Hormonal treatment e.g. danazol and tamoxifen
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14
Q

What are breast cysts?

A

Benign individual fluid filled lumps
Most common cause of breast lumps
Occur most between 30-50 yo in the perimenopausal period

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15
Q

What do you find on examination of breast cysts?

A 
Painful lump
fluctuate in size over the menstrual cycle
Smooth
Well circumscribed
Mobile
Possibly fluctuant
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16
Q

Ix for breast cysts

A

Need further Ix to exclude breast cancer

USS/mammography + aspiration

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17
Q

Mx for breast cysts

A

Aspiration

Excision

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18
Q

Do breast cysts increase the risk of breast cancer?

A

Yes slightly

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19
Q

What is fat necrosis of the breast?

A

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

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20
Q

What triggers fat necrosis in the breast?

A

Localised trauma
Radiotherapy
Surgery

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21
Q

Pathology of fat necrosis of the breast

A

An inflammatory reaction causes fibrosis and necrosis of fat tissue

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22
Q

Does fat necrosis increase the risk of breast cancer?

A

No

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23
Q

What do you find on examination of fat necrosis of the breast

A 
Painless
Firm
Irregular
Fixed in local structures
Skin dimpling / nipple inversion
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24
Q

Ix for fat necrosis of the breast

A

US/mammogram - similar appearance to breast cancer

Histology - used to exclude breast cancer

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25
Q

Mx for fat necrosis of the breast

A

Exclude breast cancer
Can resolve spontaneously so manage conservatively
Symptoms - surgical excision

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26
Q

What is a lipoma in the breast?

A

Benign tumours of fat (adipose) tissue. Can occur anywhere in the body.

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27
Q

What do you feel on examination of a lipoma in the breast?

A

Soft
Painless
Mobile
Do not cause skin changes

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28
Q

Mx for lipomas in the breast

A

Conservatively
Reassure
Can be surgically removed

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29
Q

What is a galactocele?

A

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

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30
Q

What do you find on examination of a galactocele?

A

Firm
Mobile
Painless
Beneath areola usually

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31
Q

Mx for galactocele

A

Benign - usually resolve without treatment
can drain them with a needle

Rarely become infected = abx

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32
Q

What is a phyllodes tumour?

A

Rare tumour of the connective tissue (stroma) of the breast

Occurs most commonly between 40-50 yo

Large and fast growing

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33
Q

Are phyllodes tumours benign or malignant?

A

benign (~50%),
borderline (~25%)
malignant (~25%) - can metastasise

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34
Q

Mx of phyllodes tumours

A

Wide excision
Can reoccur after removal
Malignant/mets = chemotherapy

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35
Q

How can mastalgia be classified?

A

Cyclical - occurring at specific times of the menstrual cycle (more common)

Non-cyclical - unrelated to menstrual cycle

36
Q

What is gynaecomastia?

A

the enlargement of the glandular breast tissue in males

37
Q

Causes of gynaecomastia

A

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
38
Q

what examinations should you do in a man presenting with gynaecomastia?

A

Testicular examination
Liver examination
Thyroid examination

39
Q

Where is prolactin produced?

A

anterior pituitary gland

40
Q

What is galactorrhea?

A

Breast milk production not associated with pregnancy or breast feeding. Breast milk is produced in response to prolactin.

41
Q

Causes of hyperprolactinaemia that can cause galactorrhea

A 
Idiopathic
Prolactinomas
Hypothyroidism 
Polycystic ovarian syndrome
Antipsychotic medications
42
Q

How can hyperprolactinaemia present?

A 
Galactorrhoea
Menstrual irregularities - amenorrhoea 
Reduced libido 
Erectile dysfunction 
Gynaecomastia
43
Q

What are prolactinomas and what are they associated with?

A

Tumours of the pituitary galnd
Secrete excessive prolactin
Associated with multiple endocrine neoplasia type 1 (MEN) - autosomal dominant condition

44
Q

Symptoms of prolactinomas

A

Headaches

Bitemporal hemianopia due to compression of the optic chiasm

45
Q

Conditions that cause discharge from the nipples that is not milk

A

Mammary duct ectasia
Duct papilloma
Pus from breast abscess

46
Q

Ix for galactorrhea

A 
Pregnancy test
Serum prolactin 
Renal function 
LFTs
TFTs
MRI brain - pituitary tumour
47
Q

Mx of galactorrhea

A

dopamine agonists to block prolactin secretion = bromocriptine / cabergoline

Trans-sphenoidal surgical removal of pituitary tumour

48
Q

Causes/risk factors for breast cancer

A 
-	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
49
Q

Protective factors for breast cancer

A

Breast feeding

50
Q

What type of cancer is breast cancer?

A

Adenocarcinoma

51
Q

How can breast cancers be classified molecularly?

A

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

52
Q

Common sites breast cancers metastasise to

A

Lungs
Liver
Bone
Brain

53
Q

What is the screening programme for breast cancer?

A

Every 3 yrs from 47-73
Craniocaudal and oblique views of breast on mammography
Reduced breast Ca deaths by 25%
10% false negative rate

54
Q

What is included in the triple assessment of a breast lump?

A

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

55
Q

What is the staging for breast cancer?

A

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

56
Q

Mx for breast cancer

A
  1. Wide local excision + radiotherapy
    a. Same survival as with mastectomy but WLE has higher recurrence rates
  2. Mastectomy
    a. Done for large tumours
    b. Multifocal or central tumours
    c. Nipple involvement
    d. Patient choice
  3. Sentinel node biopsy
  4. Chemotherapy
  5. Oestrogen receptor positive tumours - tamoxifen for premenopausal women & anastrozole/letrozole for post menopausal women
57
Q

Complications for breast surgery

A
  • Haematoma
  • Seroma
  • Frozen shoulder
  • Long thoracic nerve palsy
  • Lymphoedema
  • Upper inner arm numbness – intercostobrachial nerve injury
58
Q

What is a sentinel node biopsy?

A
  • 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
59
Q

USS appearance of extra capsular breast implant rupture

A

Snowstorm sign

60
Q

What is mammary duct ectasia?

A

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)

61
Q

Who gets mammary duct ectasia?

A

perimenopausal women

smokers

62
Q

Presentation of mammary duct ectasia

A

nipple discharge - white, grey, green
tenderness or pain
Nipple retraction/inversion
A breast lump - pressure on the lump may produce nipple discharge

63
Q

Diagnosis of mammary duct ectasia

A

Triple assessment

Mammogram = MICROCALCFICIATIONS

Ductography - contrast injected into abnormal duct & mammograms performed to visualise duct
Nipple discharge cytology
Ductoscopy - endoscope into duct

64
Q

Mx of mammary duct ectasia

A

Resolves without tx
Not associated with increased cancer risk

problematic cases - surgical excision of duct (microdochectomy)

65
Q

What is an intraductal papilloma?

A

a warty lesion that grows within one of the ducts in the breast - result of the proliferation of epithelial cells

66
Q

Do intraductal papillomas increase the risk of breast cancer?

A

they are benign tumours that are associated with atypical hyperplasia / breast cancer

67
Q

Presentation of intraductal papillomas

A 
occur between 35-55 yo mostly 
clear/blood stained nipple discharge 
tenderness/pain
a palpable lump 
asymptomatic - found on mammogram
68
Q

Diagnosis of intraductal papillomas

A

Triple assessment

duct-graphs - insect contrast dye into duct and do mammography to visualise duct - when an area doesn’t fill with contrast

69
Q

Mx of intraductal papillomas

A

need complete surgical excision

histology of tissues removed afterwards to look for atypical hyperplasia/cancer

70
Q

What is mastitis?

A

inflammation of breast tissue that is a common complication of breast feeding.

Can occur with or without associated infection

71
Q

Pathology of mastitis

A

obstruction in the ducts and accumulation of milk

or can be caused by infection

72
Q

Most common infective organism seen in mastitis

A

staph aureus

73
Q

Presentation of mastitis

A 
breast pain/tenderness unilaterally
erythema in a focal area of breast tissue
local warmth and inflammation 
nipple discharge
fever
74
Q

Mx of mastitis

A 
continue breastfeeding
express milk
breast massage
heat packs
warm showers
simple analgesia

infection suspected = flucloxacillin and keep breast feeding

75
Q

complication of mastitis

A

breast abscess

76
Q

what is candida of the nipple and what causes it?

A

candidal infection of the nipple after a course of abx

77
Q

complications of candida of the nipple

A

recurrent mastitis
oral thrush in the infant
candidal nappy rash in the infant

78
Q

presentation of candida of the nipple

A

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

79
Q

tx of candida of the nipple

A

mother & baby need tx

topical miconazole 2% to nipple after every breastfeed

baby - miconazole gel or nystatin

80
Q

What is a breast abscess?

A

a collection of pus within an area of the breast, usually caused by a bacterial infection.

81
Q

2 types of breast abscess

A

lactational

non-lactational

82
Q

risk factors for breast abscess

A 
smoking 
mastitis
breast feeding 
damage to the nipple - eczema, candidal infection, piercings 
underlying breast disease e.g. cancer
83
Q

Causative bacteria of breast abscesses

A

most common = staph aureus

strep
enterococcal

84
Q

symptoms of breast abscess

A 
a swollen, fluctuant, tender lump within the breast
muscle aches
fatigue
fever
signs of sepsis
85
Q

mx of breast abscess

A 
referral to on call surgical team
antibiotics
USS
Drainage - needle aspiration or surgical incision and drainage 
MC&S of drained fluid

keep breastfeeding

86
Q

what is Mondor’s disease of the breast?

A

Mondor’s disease of the breast is a localised thrombophlebitis of a breast vein.

Finals Revision (18 decks)

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