Breast Flashcards
State what is involved in a triple assessment of a breast lump
- Clinical assessment (history and examination)
- Imaging
- Ultrasound <35yrs
- Mammogram >35yrs - Histology
- Fine needle aspiration
- Core biopsy
List all the differentials for a breast lump
- Breast cancer
- Fibroadenoma
- Breast cyst
- Fibrocystic breast changes
- Fat necrosis
- Lipoma
- Galactocele
- Phyllodes tumour
Breast cancer - state the following:
- Pain?
- Shape/texture?
- Mobile?
- Well circumscribed?
- Common age groups?
- Additional features?
Pain?
- No
Shape/texture?
- Firm
- Irregular
Mobile?
- Fixed
Well circumscribed?
- No
Common age groups?
- Over age 30
Additional features?
- Nipple retraction
- Skin changes including skin dimpling
Fibroadenoma - state the following:
- Pain?
- Size?
- Shape/texture?
- Mobile?
- Common age groups?
- Increased risk of developing cancer?
Pain?
- No
Size?
- Generally < 3cm
Shape/texture?
- Smooth
- Round
- Fluctuant
Mobile?
- Yes
Common age groups?
- 20-40 years
Increased risk of developing cancer?
- Not usually, unless family history or complex fibroadenoma
Lipoma - state the following:
- Pain?
- Shape/texture?
- Mobile?
- Management
Pain?
- No
Shape/texture?
- Soft
Mobile?
- Yes
Management:
- Conservatively, with reassurance
- Can be removed surgically
Fibrocystic breast changes - state the following:
- Pain?
- Size?
- Shape/texture?
- Mobile?
- Well circumscribed?
- Common age groups?
- Increased risk of developing cancer?
- Additional features?
Pain?
- Yes
Size?
- Fluctuating breast size overall
Shape/texture?
- Generalised lumpiness
Common age groups?
- Menstruating ages
Increased risk of developing cancer?
- Yes
Additional features?
- Features change with menstrual cycle, worst 2 weeks before and resolve during period
Breast cysts - state the following:
- Pain?
- Size?
- Shape/texture?
- Mobile?
- Well circumscribed?
- Common age groups?
- Increased risk of developing cancer?
Pain?
- Yes
Size?
- Fluctuate with menstrual cycle
Shape/texture?
- Smooth
- Fluctuant
Mobile?
- Yes
Common age groups?
- 30-50 years
Increased risk of developing cancer?
- Yes
Fat necrosis - state the following:
- Pain?
- Shape/texture?
- Mobile?
- Increased risk of developing cancer?
- Additional features?
- Management
Pain?
- Yes
Shape/texture?
- Firm
- Irregular
Mobile?
- No
Increased risk of developing cancer?
- No
Additional features?
- May have bruising and erythema
- May have nipple retraction
- May have skin dimpling
Management:
- Needs further investigation for cancer
- May resolve spontaneously over few months
- May require surgical excision
Galactocele - state the following:
- Pain?
- Shape/texture?
- Mobile?
- Common age groups?
- Management
Pain?
- Yes
Shape/texture?
- Firm
Mobile?
- Yes
Common age groups?
- Lactating women
Management:
- May resolve spontaneously
- Can drain with needles
- May require antibiotics if they become infected
Outline the management options for fibrocystic breast changes
- Supportive bra
- NSAIDs for analgesia
- Avoid caffeine
- Apply heat
- Some hormonal treatments
Gynaecomastia - state the following:
- Pathophysiology
- Causes
- Investigations
Pathophysiology:
- Enlargement of glandular breast tissue in males
- Particularly common in adolescents and older men
- May be present transiently in newborns
Causes:
- Generally from imbalance between oestrogens and androgens
- Raised prolactin (including dopamine antagonists)
- Conditions that increase oestrogen
- Conditions that decrease androgens
- Medications e.g. Spironolactone
Investigations:
- Blood tests (depends on suspected cause)
- Imaging e.g. ultrasound, mammogram
Galactorrhoea - state the following:
- Pathophysiology (vague definition)
- Causes
- Investigations
- Management
Pathophysiology:
- Breast milk production, not associated with pregnancy or breastfeeding
Causes:
Hyperprolactinaemia
- Idiopathic
- Prolactinomas
- Endocrine disorders e.g. hypothyroidism, PCOS
- Medications e.g. Dopamine antagonists
- PREGNANCY!
Investigations:
- Pregnancy test!!
- Blood tests inclu. serum prolactin, renal, liver and thyroid tests
- MRI scan (first line for pituitary tumours)
Management:
Target underlying cause
- Dopamine agonists e.g. Bromocriptine
- Transsphenoidal removal of pituitary tumour
List 3 hormones that inhibit the production of prolactin (for lactation)
- High oestrogen (high during pregnancy)
- High progesterone (high during pregnancy)
- Dopamine (some medications block this)
State the presentation of galactorrhoea plus additional symptoms they may present with as a result of LH / FSH suppression
Presentation:
- Breast milk production, in the absence of pregnancy or breastfeeding
Additional symptoms:
- Menstrual disturbances
- Low libido
- Erectile dysfunction (males)
- Gynecomastia (males)
Mammary duct ectasia - state the following:
- Pathophysiology
- Main risk factor?
- Presentation
- Investigations
- Management
Pathophysiology:
- Dilation of the large ducts of the beast, with inflammation
- Intermittent discharge from the nipple (white, grey or green)
- Benign condition
Main risk factor:
- Smoking!
- Also common in peri-menopausal women
Presentation:
- Nipple discharge (white, grey or green)
- Pain
- Nipple retraction/inversion
- Breast lump
Investigations:
- First, triple assessment to rule out breast cancer (examination, imaging and biopsy)
- Ductography (contrast mammogram)
- Ductoscopy (small camera into duct)
- Discharge cytology
Management:
- Reassurance (exclude cancer)
- Symptomatic management e.g. warm compress
- Antibiotics if infection
- Surgical excision
Intraductal papilloma - state the following:
- Pathophysiology and common age group
- Presentation
- Investigations
- Management
Pathophysiology:
- Warty lesion within duct of the breast
- Caused by proliferation of epithelial cells
- Commonly occur at 35-55 yrs
Presentation:
- Can be asymptomatic (picked up incidentally)
- Blood stained or clear nipple discharge
- Pain
- Breast lump
Investigations:
- First, triple assessment to rule out breast cancer (examination, imaging and biopsy)
- Ductography (contrast mammogram)
Management:
- Complete surgical excision (check for cancer)
Lactational mastitis - state the following:
- Pathophysiology
- Common organism (if infected)
- Presentation
- Management
Pathophysiology:
- Inflammation of breast tissue
- Complication of breast feeding (with or without infection)
- Either caused by an obstruction in the ducts, or bacteria getting in through the nipple
Common organism (if infected):
- Staphylococcus aureus
Presentation:
- Unilateral breast pain
- Erythema
- Warmth
- Nipple discharge
- Fever
Management:
- Advise to continue breastfeeding
- Conservative e.g. warm compress, analgesia
- Antibiotics if infected
Suggest which antibiotics should be used in lactational mastitis
Flucloxacillin (Erythromycin if penicillin allergy)
Suggest which antibiotic should be used in lactational mastitis if candidal infection is suspected
Fluconazole - but needs to be given to both the baby and mother (otherwise infection will reoccur)
Breast abscess - state the following:
- Pathophysiology
- Risk factors
- Common organism
- Presentation
- Management
Pathophysiology:
- Collection of pus within an area of the breast, commonly a bacterial infection
- Either a lactational (associated with breastfeeding) or non-lactational abscess (unrelated to breastfeeding)
Risk factors:
- Smoking
- Breastfeeding
- Damaged nipple surface
- Underlying breast disease
Common organism:
- Staphylococcus aureus (most common)
Presentation:
- Acute presentation of a swollen, fluctuant tender lump (fluid filled)
- Generalised symptoms of infection e.g. fever
Management:
- Depends on whether lactational or non-lactational mastitis
- Lactational mastitis = conversative management, may need antibiotics (Flucloxacillin)
- Non-lactational mastitis = conversative management, may need broad-spectrum antibiotics (Co-Amoxiclav)
Abscess:
- Ultrasound
- Drainage
- Antibiotics / MCS
Outline some risk factors for breast cancer
- Female gender
- Smoking
- Family history
- Obesity
- HRT
- Oral contraceptive
- Prolonged lifetime oestrogen exposure
- Previous breast cancer
- More dense breast tissue (more glandular)
Outline the main gene mutations associated with breast cancer
BRCA - tumour supressor genes:
BRCA-1 on chromosome 17
BRCA-2 on chromosome 13
Outline the 6 main types of breast cancer
Ductal carcinoma in-situ
Lobular carcinoma in-situ
Invasive ductal carcinoma
Invasive lobular carcinoma
Inflammatory breast cancer
Paget’s disease
Ductal carcinoma in-situ - state the following:
- Type of cell affected
- Localised or widespread?
- Presentation?
- Detectable on mammogram?
- Potential to spread?
- Prognosis?
Type of cell affected?
- Epithelial cells of the breast ducts
Localised or widespread?
- Localised to single area
Presentation?
- Often picked up incidentally on mammogram
Detectable on mammogram?
- Yes
Potential to spread?
- May spread, around 30%
Prognosis?
- Good, if fully excised with adjuvant treatment
Lobular carcinoma in-situ - state the following:
- Outline?
- Presentation?
- Detectable on mammogram?
- Potential to spread?
- Management?
Outline?
- Precancerous condition typically in pre-menopausal women
Presentation?
- Often asymptomatic, usually diagnosed incidentally during a breast biopsy
Detectable on mammogram?
- No
Potential to spread?
- May spread, around 30%
Management?
- Close monitoring
Invasive ductal carcinoma - state the following:
- Type of cell affected?
- Detectable on mammogram?
Type of cell affected?
- Cells of the breast ducts
Detectable on mammogram?
- Yes
Invasive lobular carcinoma - state the following:
- Type of cell affected?
- Detectable on mammogram?
Type of cell affected?
- Cells of the breast lobules
Detectable on mammogram?
- Not always
Inflammatory breast cancer - state the following:
- Presentation?
- Prognosis?
Presentation?
- Presents similarly to mastitis or breast abscess
- However, does not respond to antibiotics
Prognosis?
- Often worse than other types of breast cancer
Describe the presentation of Paget’s disease of the nipple
- Eczema appearance
- Erythematous, scaly rash
State the current breast cancer screening programme
3 yearly mammograms for women ages 50-70 years
Outline the negatives of the breast cancer screening programme
- Unnecessary stress and anxiety and additional testing
- Missing cancer, leading to false reassurance
- Exposure to radiation (mammogram is x-ray)
Outline some presenting features of breast cancer
- Lump
- Lymphadenopathy (especially in axilla)
- Skin changes e.g. dimpling
- Nipple changes e.g. retraction or discharge
Outline the triple assessment for breast cancer investigation
- History and examination
- Imaging
- Ultrasound if <35 years
- Mammogram if >35 years - Biopsy
- Fine needle aspiration
- Core biopsy
State the 3 receptors that can be targeted in breast cancer hormonal treatment
- Oestrogen receptor
- Progesterone receptor
- HER2 (human epidermal growth factor) receptor
State the common sites of metastasis for breast cancer
LLBB
Lungs
Liver
Brain
Bones
Suggest some indications for when to prescribe antibiotics in mastitis
- Patient is systemically unwell
- Not improving on breastfeeding alone (within 12-24 hours)
- Nipple fissures are present
- Positive culture
