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Yr 3 - Core Conditions > Breast > Flashcards

Breast Flashcards

1
Q

What is a breast abscess?

A

A collection of pus within an area of the breast. Infection can either present as simple mastitis or form a breast abscess.

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2
Q

What are the 4 most common pathogens causing breast abscesses

A
  1. Staph aureus (most common)
  2. Streptococcal species
  3. Enterococcal species
  4. Anaerobic species (e.g. Bacteriodes species & anaerobic streptococci)
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3
Q

What are the 2 types of breast abscess?

A
  1. Lactational abscess
  2. Non-lactational abscess
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4
Q

What is a lactational abscess related to?

A

Breastfeeding

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5
Q

What is pus?

A

Pus is a thick fluid produced by inflammation – contains dead WBCs and other waste

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6
Q

How odes an abscess form?

A

When pus becomes trapped in a specific area and cannot drain, an abscess forms and gradually increases in size

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7
Q

Define mastitis

A

Inflammation of breast tissue

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8
Q

What may precede the formation of an abscess?

A

Mastitis

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9
Q

What is a key risk factor for infective mastitis and breast abscesses?

A

Smoking

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10
Q

Why is smoking a risk factor for mastitis?

A

People who smoke have an increased risk of periductal mastitis because substances in cigarette smoke can damage the ducts behind the nipple.

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11
Q

Give some risk factors for breast abscesses

A
  • Smoking
  • Breastfeeding
  • Damage to nipple (e.g. nipple eczema, candida infection or piercings) provides bacteria entry
  • Underlying breast disease (e.g. cancer) can affect the drainage of the breast, predisposing to infection
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12
Q

Why can cancer predispose to breast abscesses?

A

cancer can affect the drainage of the breast, predisposing to infection

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13
Q

Should breastfeeding be stopped in women with mastitis or breast abscesses?

A

No

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14
Q

Why should women with mastitis or breast abscesses continue to breast feed or regularly express breast milk?

A

This is NOT harmful to the baby and is important in helping resolve the mastitis or abscess.

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15
Q

Onset of mastitis/breast abscess?

A

Acute (within a few days)

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16
Q

Describe some breast signs/symptoms seen in mastitis with infection in the breast tissue

A
  • Nipple changes
  • Purulent nipple discharge (pus from nipple)
  • Localised pain (acutely painful)
  • Tenderness
  • Warmth
  • Erythema
  • Hardening of skin or breast tissue
  • Swelling
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17
Q

What key features of a breast lump would suggest its an abscess?

A
  • Swollen
  • Tender
  • Fluctuant
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18
Q

Define fluctuance of a lump

A

being able to move fluid around within the lump using pressure during palpation

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19
Q

Lump in mastitis vs breast abscess?

A

when there is infection WITHOUT an abscess, there can still be hardness of the tissue forming a lump BUT will not be fluctuant (as not filled with fluid)

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20
Q

What makes a breast abscess fluctuant?

A

Fluid

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21
Q

Other signs seen in breast abscess?

A
  • Muscle aches
  • Fatigue
  • Fever
  • Signs of sepsis e.g. tachycardia, raised RR, confusion → sepsis 6
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22
Q

Describe the management plan for lactational mastitis

A

Caused by blockage of ducts → managed conservatively:

  • Continued breastfeeding
  • Expressing milk
  • Breast massage
  • Heat packs, warm showers & simple analgesia to manage symptoms
  • Antibiotics (flucloxacillin or erythromycin/clarithromycin where there is penicillin allergy) – required where infection is suspected or symptoms do not improve
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23
Q

Describe the management plan for non-lactational mastitis

A
  • Analgesia
  • Antibiotics – need to be broad spectrum (co-amoxiclav or erythromycin/clarithromycin + metronidazole)
  • Treatment for underlying cause (e.g. eczema or candida infection)
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24
Q

What Abx are indicated in non-lactational mastitis?

A

Broad spectrum e.g. co-amoxiclav or erythromycin/clarithromycin + metronidazole

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25
Q

Describe the management of a breast abscess

A
  • Referral to on-call surgical team
  • Antibiotics
  • US
  • Drainage (needle aspiration or surgical incision and drainage)
  • MC&S of drained fluid
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26
Q

Define fibrocystic breast changes

A

The connective tissues (stroma), ducts and lobules of the breast respond to the female sex hormones (oestrogen and progesterone), becoming fibrous (irregular and hard) and cystic (fluid-filled). These changes fluctuate with the menstrual cycle.

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27
Q

What drives fibrocystic breast changes?

A

Female sex hormones: oestrogen & progesterone

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28
Q

Who are fibrocystic breast changes common in?

A

Common in women of menstruating age

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29
Q

Prognosis of fibrocystic breast changes?

A

Is a benign (non-cancerous) condition but can vary in severity an affect patient’s quality of life if severe.

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30
Q

When do Fibrocystic Breast Changes tend to appear? When do they tend to resolve?

A

Symptoms usually occur prior to menstruating (within 10 days) and resolve once menstruation begins

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31
Q

How does menopause typically affect fibrocystic breast changes?

A

Symptoms usually improve or resolve after menopause

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32
Q

Breast symptoms seen in fibrocystic breast changes?

A
  • Lumpiness
  • Breast pain or tenderness (mastalgia)
  • Fluctuation of breast size
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33
Q

Management of fibrocystic breast changes?

A

After exclusion of cancer, management involves managing symptoms:

  • Wearing a supportive bra
  • NSAIDs
  • Avoiding caffeine
  • Applying heat to area
  • Hormonal treatments (e.g. danazol and tamoxifen) under specialist guidance
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34
Q

Define a ductal papilloma

A

A warty lesion that grows within one of the milk ducts in the breast.

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35
Q

Is a ductal papilloma associated with cancer?

A

It is a benign tumour but can be associated with atypical hyperplasia or breast cancer.

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36
Q

A ductal papilloma is a proliferation of what cells?

A

Proliferation of epithelial cells that line the ducts.

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37
Q

Presentation of a ductal papilloma?

A

Often asymptomatic – often picked up incidentally on mammograms or ultrasound.

  • Nipple discharge – clear or blood-stained
  • Tenderness or pain
  • Palpable lump
    • Usually found <1cm from nipple
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38
Q

Where is the lump of a ductal papilla located?

A

<1cm from nipple

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39
Q

Describe triple breast assessment

A
  • 1) Clinical assessment (history & examination)
  • 2) Imaging (US, mammography & MRI)
  • 3) Histology (usually by core biopsy or vacuum-assisted biopsy)
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40
Q

Management of ductal papilloma?

A
  • Complete surgical excision is required
  • After removal, tissue is examined for atypical hyperplasia or cancer that may not have been picked up on biopsy
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41
Q

What is the most common benign breast lump?

A

Fibroadenoma

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42
Q

Where does a fibroadenoma arise from?

A

stromal/epithelial breast duct tissue

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43
Q

Who are fibroadenomas typically seen in?

A

Younger women (20-40) i.e. of reproductive age.

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44
Q

Why are fibroadenomas typically seen in younger women?

A

These tumours respond to the female hormones (oestrogen & progesterone) which is why they are more common in younger women and often regress after menopause.

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45
Q

Are fibroadenomas associated with breast cancer?

A

Not cancerous and not usually associated with an increasing risk of developing breast cancer.

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46
Q

Features of a fibroadenoma breast lump

A
  • Small (usually up to 3cm diameter)
  • Mobile within breast tissue (moves freely) – sometimes called a ‘breast mouse’ as they move around within the breast tissue
  • Painless
  • Smooth
  • Round
  • Well circumscribed (well-defined borders)
  • Firm
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47
Q

Give some red flags for a breast lump

A
  • Tethered to skin
  • Nipple discharge (especially bloody)
  • Irregular shape
  • Lymphadenopathy
  • Dimpling of skin
  • Puckering of nipple
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48
Q

Describe the breast lump in fibrocystic change

A

Tender & rubbery

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49
Q

What is a lipoma? Where can they occur?

A

Benign tumours of fat (adipose) tissue. Can occur almost anywhere on the body where there is adipose tissue, including the breasts.

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50
Q

Presentation of a lipoma?

A
  • Soft
  • Painless
  • Mobile
  • Does NOT cause skin changes
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51
Q

Management of lipomas?

A
  • Often conservative (reassurance)
  • Can be surgically removed (only if a) rapidly enlarging or b) symptomatic or aesthetic problems)
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52
Q

What is a Phyllodes tumour?

A

Rare tumour of the connective tissue (stroma) i.e. fibroepithelial tumours

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53
Q

What age group do Phyllodes tumours typically affect?

A

Occurring most often between ages 40-50.

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54
Q

Are Phyllodes tumours malignant or benign?

A

Can be benign (50%), borderline (25%) or malignant (25%).

Phyllodes tumours can metastasise.

55
Q

Which 2 features characterise a Phyllodes tumour?

A

Large and fast growing

56
Q

Management of Phyllodes tumour?

A
  • Surgical removal of tumour and surrounding tissue (wide excision)
  • Can reoccur after removal
  • Chemotherapy in malignant/metastatic tumours
57
Q

What is the most common form of cancer in the UK?

A

Breast carcinoma (around 1 in 8 women will develop breast cancer in their lifetime)

58
Q

Give some risk factors for breast carcinoma

A
  • Female (99% of breast cancers)
  • Increased oestrogen exposure (earlier onset of periods and later menopause)
  • More dense breast tissue (more glandular tissue)
  • Obesity
  • Smoking
  • Family history (1st degree relatives)
  • COCP gives small increase in risk of breast cancer, but risk returns to normal 10 years after stopping the pill
  • HRT (particularly combined HRT containing oestrogen & progesterone)
59
Q

Why is obesity a risk factor for breast cancer?

A

Obesity increases oestrogen levels as adipose tissue is the main source of oestrogen biosynthesis

60
Q

Presentation of breast lump in breast carcinoma

A
  • Lumps that are hard, irregular, painless or fixed in palce
  • Lumps may be tethered to the skin or chest wall
  • Nipple retraction
  • Skin dimpling or oedema (peau d’orange)
  • Lymphadenopathy, particularly in the axilla
61
Q

What are BRCA genes?

A

Tumour suppressor genes

62
Q

Mutations in BRCA genes can increase your risk of what cancers?

A

Breast, ovarian, prostate, bowel etc

63
Q

What chromosome is BRCA1 and BRCA2 on?

A

BRCA1 → 17

BRCA2 → 13

64
Q

What is the risk of develop breast & ovarian cancer in those with the BRCA1 mutation?

A

Breast → around 70% will develop breast cancer by age 80

Ovarian → around 50% will develop ovarian cancer

65
Q

What is the risk of develop breast & ovarian cancer in those with the BRCA2 mutation?

A

Breast → Around 60% will develop breast cancer by aged 80

Ovarian → Around 20% will develop ovarian cancer

66
Q

Is a mutation in BRCA1 or BRCA2 a higher risk for breast cancer?

A

BRCA1

67
Q

Breast carcinomas can be divided into 5 main categories. What are these?

A
  1. Carcinoma in situ
  2. Invasive breast cancers
  3. Inflammatory breast cancer
  4. Paget’s disease of the nipple
68
Q

What is the most common type of non-invasive breast malignancy?

A

Ductal carcinoma in situ (DCIS) (20% of all breast cancer diagnoses)

69
Q

What are the 2 types of breast carcinoma in situ?

A
  1. Ductal carcinoma in situ (DCIS)
  2. Lobular carcinoma in situ (LCIS)
70
Q

What is DCIS? What cells?

A

Pre-cancerous or cancerous epithelial cells of the ductal tissue of the breast

71
Q

Can DCIS spread?

A
  • Potential to spread locally over years
  • Potential to become an invasive breast cancer (around 30%)
72
Q

How is DCIS often picked up?

A

Mammogram screning

73
Q

Prognosis of DCIS?

A

Good if fully excised and adjuvant treatment is used

74
Q

Is DCIS or LCIS more common?

A

LCIS

75
Q

What LCIS? Where does it arise from?

A

A pre-cancerous condition of the secretory lobules

76
Q

Who does LCIS typically occur in?

A

Occurs typically in pre-menopausal women (90%)

77
Q

How is LCIS often picked up?

A
  • Often asymptomatic** and **undetectable on a mammogram
  • Usually diagnosed incidentally on a breast biopsy
78
Q

Prognosis of LCIS?

A

Higher risk of invasive malignancy in the future (around 30%)

79
Q

Management of LCIS?

A

Often close monitoring (e.g. 6 monthly examination and yearly mammograms)

80
Q

What defines an invasive cancer?

A

Has invaded the basement membrane

81
Q

What are the 2 types of invasive breast cancer?

A
  1. Invasive ductal carcinoma
  2. Invasive lobular carcinoma
82
Q

Give some subtypes of invasive ductal carcinomas

A

Tubular, cribiform, papillary, mucinous/colloid, medullary (have distinct patterns of growth)

83
Q

Where do invasive ductal carcinomas originate?

A

Originate in cells from the breast ducts

84
Q

What is the most common type of invasive breast cancer?

A

Invasive ductal carcinoma

85
Q

How are invasive ductal carcinomas often picked up?

A

Can be seen on mammograms

86
Q

Who are invasive lobular carcinomas normally seen in?

A

Much more common in older women

87
Q

Where do invasive lobular carcinomas arise from?

A

Originate in cells from breast lobules

88
Q

How are invasive ductal carcinomas often picked up?

A

Not always visible on mammograms

  • Diffuse spread makes detection more difficult
  • Tumours often quite large by the time they’re detected
89
Q

What is inflammatory breast cancer?

A

Cancer cells block lymph vessels in skin of breast, causing breast to appear swollen and red or inflamed.

90
Q

What age group is inflammatory breast cancer typically seen in?

A

Younger women (<40 y/o)

91
Q

What does inflammatory breast cancer present similarly to?

A

Presents similar to a breast abscess or mastitis → swollen, warm, tender breast with pitting skin (peau d’orange)

BUT does not respond to Abx

92
Q

What type of cancer does peau d’orange of the breast indicate?

A

Inflammatory breast cancer

93
Q

Prognosis of inflammatory breast cancer?

A
  • Worse than other breast cancers as tends to be more aggressive and spread more quickly
  • Typically at a locally advanced stage when 1st diagnosed
  • 1/3 cases have already metastasised
94
Q

What is Paget’s disease of the breast?

A

A rare condition associated with breast cancer

95
Q

Is Paget’s disease of the breast related to Paget’s disease of the bone?

A

No

96
Q

Presentation of Paget’s disease of the breast?

A
  • Looks like eczema of nipple/areolar
  • Erythematous, scaly rash
97
Q

What may Paget’s disease of the nipple indicate?

A

May represent DCIS or invasive breast cancer

98
Q

Who is offered mammograms and how often?

A

Women aged 50-70 y/o every 3 years

99
Q

What is the aim of mammograms?

A

Detect breast cancer early – roughly 1 in 100 women are diagnosed with breast cancer after going for a mammogram

100
Q

Disadvantages of breast cancer screening?

A
  • Anxiety & stress
  • Exposure to radiation, with very small risk of causing breast cancer
  • Missing cancer – false reassurance
  • Unnecessary further tests or treatment where findings would not have otherwise caused harm

Generally, the benefits far outweigh the downsides and screening IS recommended

101
Q

Genetic testing for breast cancer can be performed in high risk patients. What must happen first?

A

Genetic counselling & pre-test counselling to discuss benefits and drawbacks of genetic testing .g. implications for family members and offspring.

102
Q

Give some management options for high risk breast cancer patients

A
  1. Annual mammogram screening (as opposed to every 3 years)
  2. Chemoprevention
  3. Bilateral mastectomy or bilateral oophorectomy → significant counselling required
103
Q

What is the pharmacological agent for chemoprevention of breast cancer in premenopausal women?

A

Tamoxifen

104
Q

What is the pharmacological agent for chemoprevention of breast cancer in postmenopausal women?

A

Anastrozole

105
Q

What is the main contraindication for anastrozole?

A

severe osteoporosis

106
Q

What is the NICE criteria for a 2 week wait referral for suspected breast cancer?

A
  • Unexplained breast lump in patients aged 30 and above
  • Unilateral nipple changes in patients aged 50 and above e.g. discharge, retraction or other changes
  • Unexplained lump in axilla in patients aged 30 and above
  • Skin changes suggestive of breast cancer
107
Q

What imaging modality is used for breast cancer assessment in younger women (<30)? Why?

A

Ultrasound as more dense breasts (more glandular tissue)

108
Q

What imaging modality is used for breast cancer assessment in older women (<30)?

A

Mammogram

109
Q

What can mammograms pick up that may be missed by US?

A

Calcifications

110
Q

What is US of the breast useful in differentiating?

A

Helpful in distinguishing solid lumps (e.g. fibroadenoma or cancer) from cystic lumps (fluid-filled)

111
Q

What imaging may be recommended after a mammogram?

A

MRI

112
Q

What staging system is used in breast cancer?

A

TNM

113
Q

What are the 4 most common sites for breast cancer to metastasise to?

A
  1. Bone (hypercalcaemia)
  2. Lungs
  3. Liver
  4. Brain
114
Q

What are the 3 types of breast cancer receptors?

A
  1. Oestrogen (ER)
  2. Progesterone (PR)
  3. Human epidermal growth factor (HER2)
115
Q

What is triple negative breast cancer?

A

Triple-negative breast cancer is where the breast cancer cells do NOT express ANY of these three receptors (ER, PR, HER2)

116
Q

Prognosis of triple negative breast cancer?

A

This carries a worse prognosis as it limits treatment options.

117
Q

Give some management options for breast cancer

A
  1. Surgery
  2. Radiotherapy
  3. Chemotherapy
  4. Hormone therapy
118
Q

What biopsy is typically done prior to breast cancer surgery?

A

Sentinel node biopsy to assess if there has been any lymphatic spread

119
Q

What is the 1st line pharmacological option for hormone therapy in ER-positive breast cancer in premenopausal women?

A

Tamoxifen

120
Q

What class of drug are indicated in hormone therapy in ER-positive breast cancer in premenopausal women?

A

Aromatase inhibitors (e.g. letrozole, anastrozole, exemestane)

121
Q

What is the 1st line pharmacological option for hormone therapy in HER2-positive breast cancer in premenopausal women?

A

Trastuzumab (Herceptin) → immunotherapy (monoclonal antibody)

122
Q

Give the 2 fist line pharmacological options in oestrogen-receptor positive breast cancers

A
  1. Tamoxifen
  2. Aromatase inhibitors
123
Q

Who is tamoxifen indicated in?

A

Oestrogen-receptor positive breast cancer in pre-menopausal women

124
Q

Who are aromatase inhibitors indicated in?

A

Post-menopausal women

125
Q

Give some examples of aromatase inhibitors

A

Anastrozole, letrozole, exemestane

126
Q

What is aromatase? Function?

A

Aromatase in an enzyme found in fat (adipose) tissue that converts androgens to oestrogen in post-menopausal women – after menopause, the action of aromatase in fat tissue is the primary source of oestrogen

127
Q

After menopause, what is the primary source of oestrogen in women?

A

Action of aromatase converted androgens to oestrogen in fat tissue

128
Q

Mechanism of aromatase inhibitors?

A

Aromatase inhibitors block the creation of oestrogen in fat tissue

129
Q

What is the 1st line pharmacological option for hormone therapy in HER2-positive breast cancer in premenopausal women?

A

Trastuzumab

130
Q

What is another name for Trastuzumab?

A

Herceptin

131
Q

What class of drug is Trastuzumab?

A

Monoclonal antibody (immunotherapy)

132
Q

Mechanism of Trastuzumab (Herceptin)?

A

Cell signalling inhibitor:

1) Blocking HER-2 activating ligand from binding
2) Activating the body’s own immune response against these cells

133
Q

Main side effect of Trastuzumab (Herceptin)?

A

Can affect heart function (cardiotoxicity) so initial & close monitoring of heart function is required.

Yr 3 - Core Conditions (33 decks)

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