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!Final Year > Breast > Flashcards

Breast Flashcards

1
Q

What are the 6 types of benign breast disease?

A
  1. Fibroadenoma
  2. Duct ectasia
  3. (Intraductile) papilloma
  4. Breast cyst
  5. Fibrocystic damage
  6. Sclerosing adenosis
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2
Q

What is duct ectasia?

A

Benign breast condition when the mammary ducts become blocked by stagnant secretions causing nipple discharge (+ or - nipple retraction and/ or lump)

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3
Q

What is duct papilloma?

A

Benign breast condition when there is growth of papilloma (epithelial proliferation) in a single duct, usually presents with clear or blood stained discharge originating from a single duct

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4
Q

What is the aetiology of benign ductal disease (ectasia and papilloma)?

A

Occurs in women around the time of menopause
Duct ectasia: the breast ducts shorten and dilate

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5
Q

What are the presenting symptoms of benign ductal disease?

A

Duct ectasia: green/brown/bloody nipple discharge

Papilloma: small lump near nipple, discharge, swelling. May have history of breast discomfort/pain

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6
Q

What are the appropriate investigations for benign ductal disease?

A

Triple assessment:
1. Clinical examination
2. Imaging (mammography and ultrasonography)
3. Needle biopsy (fine needle aspiration- cytology, excision biopsy- histology)

*Ultrasound of the lump would confirm this diagnosis

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7
Q

What is Periductal mastitis?

A

Present at a younger age than duct ectasia but similar features of discharge
May present with features of inflammation, abscess or mammary duct fistula
Strongly associated with smoking- recommend smoking cessation
Usually treated with antibiotics, any abscess with require drainage

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8
Q

What are the features of Mammary duct ectasia?

A

Dilatation of the large breast ducts
Most common around the menopause
May present with a tender lump around the areola +/- a green nipple discharge
If ruptures may cause local inflammation, sometimes referred to as ‘plasma cell mastitis’

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9
Q

What are the features of duct papilloma?

A

Usually present with nipple discharge
Large papillomas may present with a mass
The discharge usually originates from a single duct
No increase risk of malignancy

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10
Q

What is the management of benign ductal disease?

A

Usually no specific treatment needed
Patients with troublesome nipple discharge may be treated by microdochectomy (if young) or total duct excision (if older)

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11
Q

What are the two regions that the breast is composed of?

A

The circular body and the axillary tail

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12
Q

What is the pigmented area of skin surrounding the nipple?

A

Areolae

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13
Q

What is the function of mammary glands?

A

Modified sweat glands, consisting of a series of ducts and secretory lobules
Each lobule consists of many alveoli drained by a single lactiferous duct which converge at the nipple - LACTATION

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14
Q

What is the function of connective tissue stroma?

A

A supporting structure surrounding the glands

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15
Q

What are the three lymph nodes that receive lymph from the breast tissue?

A

Axillary nodes (75%)
Parasternal nodes (20%)
Posterior intercostal nodes (5%)

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16
Q

What does the breast cancer assessment involve?

A

Triple assessment:
1. Clinical examination
2. Imaging-
Mammogram if > 35 years
Ultrasonography if < 35 years - tissue is too dense
3. Needle biopsy (fine needle aspiration- cytology, excision biopsy- histology)

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17
Q

What is a fibroadenoma?

A

BENIGN overgrowth of collagenous mesenchyme of one breast lobule
Benign tumour that consists of glandular and connective tissue

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18
Q

What are the features of a fibroadenoma?

A

A ‘breast mouse’: Mobile, firm and a smooth breast lump
Discrete, non-tender, highly mobile lumps
Develop from a whole lobule
Common in women under the age of 30 years

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19
Q

What is the prognosis of a fibroadenoma?

A

1/3 regress
1/3 stay the same
1/3 get bigger

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20
Q

What are the appropriate investigations for fibroadenoma?

A

Breast examination = Firm, smooth and mobile under the skin = ‘breast mouse’
If diagnostic uncertainty = refer for USS +/- fine needle aspiration
Imaging with ultrasound:
- Well-circumscribed, round to ovoid or macro lobular mass
- Generally uniform hypoechogenicity

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21
Q

What is the management plan for a patient with fibroadenoma?

A

In young females with small fibroadenomas (<3cm on imaging) = watchful waiting without biopsy
If >3cm = Surgical excision is usual, core biopsy may be recommended to exclude a phyllodes tumour

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22
Q

What are the features of Sclerosing adenosis, (radial scars and complex sclerosing lesions)?

A

Usually presents as a breast lump or breast pain
Causes mammographic changes which may mimic carcinoma
Cause distortion of the distal lobular unit, without hyperplasia (complex lesions will show hyperplasia)
Considered a disorder of involution, no increase in malignancy risk

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23
Q

What is the management of Sclerosing adenosis?

A

Lesions should be biopsied, excision is not mandatory

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24
Q

What are the features of fat necrosis?

A

Occurs after a traumatic injury to breast tissue
Trauma (which may be minor) -> leads to fibrosis and calcification which presents as immobile firm lumps at the area of injury
May also be bruising around the area
Physical features can mimic carcinoma

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25
Q

What is the management of fat necrosis?

A

No treatment is required once diagnosis is confirmed following a triple assessment

26
Q

What is a breast cyst?

A

Common (7% of all Western females will present with a breast cyst)
Usually presents as a smooth discrete lump (may be fluctuant)
Small increased risk of breast cancer (especially if younger)

27
Q

What are the features of a breast cyst?

A

Painful (as compared to non-tender fibroadenomas)
Fluid filled
Round
Mobile on examination- do not adhere to surrounding tissue
May be fluctuant

28
Q

What is the management plan for a breast cyst?

A

Imaging: ‘Halo’ appearance on mammography
Cysts should be aspirated, those which are blood stained or persistently refill should be biopsied or excised

29
Q

What is mastitis?

A

Inflammation of the breast with or without infection

30
Q

What are breast abscesses?

A

A breast abscess is a localised area of infection with a walled-off collection of pus
It may or may not be associated with mastitis (as a complication)

31
Q

What are the two types of mastitis with infection?

A

Lactational (puerperal)
Non-lactational (e.g. duct ectasia)

32
Q

What is the aetiology for mastitis/ breast abscesses?

A

Lactational mastitis is common
Infection is usually Staphylococcus aureus

33
Q

What are the features of mastitis/ breast abscesses?

A

Tender, fluctuant mass
Painful immobile subcutaneous lumps tethered to the overlying skin
Rubor (erythema) and calor (warm) of the involved area of skin compared to surrounding skin
Patient may also have a fever/ flu like symptoms

34
Q

What are the appropriate investigations for mastitis/breast abscesses?

A

Ultrasound: hypoechoic lesion (abscess), may be well circumscribed, irregular, or ill defined
Diagnostic ultrasound guided needle aspiration

35
Q

What is the management for mastitis/breast abscesses?

A

First line management = continue breastfeeding
Treatment only if:
- systemically unwell
- if nipple fissure present
- if symptoms do not improve after 12-24 hours of effective milk removal
- if culture indicates infection
First line = flucloxacillin for 10-14 days (breastfeeding should continue)
If left untreated, mastitis may develop into a breast abscess: generally requires incision and drainage

36
Q

What are the complications of mastitis/breast abscesses?

A

Breast abscesses (less than 10% of patients with mastitis)
Cessation of breastfeeding (most patients can continue to breastfeed)
Sepsis
Scarring (recurrent infections)
Functional mastectomy (breast that is unable to effectively lactate as a complication of prior tissue destruction from infection or treatment)

37
Q

What is fine needle aspiration?

A

A type of biopsy procedure where a thin needle is inserted into an area of abnormal-appearing tissue or body fluid

38
Q

What are the indications for fine needle aspiration?

A

Removes some fluid or cells from a breast lesion (a cyst, lump, sore or swelling) with a fine needle used in cytology, microscopy and sensitivity to help make a diagnosis

39
Q

What are the possible complications for fine needle aspiration?

A

Minimal bleeding and bruising, especially on anticoagulation or anti-platelet medication- can result in a haematoma
Infection at the biopsy site is rare
Rare complication is pneumothorax

40
Q

What is breast cancer?

A

A malignancy originating in the breast(s) and nodal basins

41
Q

What are some of the predisposing factors for breast cancer?

A
  1. BRCA1, BRCA2 genes - 40% lifetime risk of breast/ovarian cancer
  2. 1st degree relative premenopausal relative with breast cancer (e.g. mother)
  3. Nulliparity, 1st pregnancy > 30 yrs (twice risk of women having 1st child < 25 yrs)
  4. Oestrogen exposure: early menarche, late menopause
  5. COCP: (relative risk increase * 1.023/year of use), combined oral contraceptive use
  6. Past breast cancer
  7. Not breastfeeding
  8. Ionising radiation
  9. p53 gene mutations
  10. Obesity
42
Q

What is the epidemiology of breast cancer?

A

Breast cancer is the most common female malignancy
It is most commonly diagnosed in middle-aged or older women (median age at diagnosis is 62 years)
Women are affected 100x more than men

43
Q

What are the presenting symptoms of breast cancer?

A

Breast mass (does not have to be a new mass)
Nipple discharge
Skin thickening
Retraction of the nipple

44
Q

What are the signs of breast cancer on physical examination?

A

History of breast mass: tenderness, change in size or character (in relation to menstrual cycle)
Nipple discharge: bloody is more classically associated with neoplasm
Overlying skin changes: Peau d’orange (dimpling of the skin), erythema, ulceration, retraction of nipple (Paget’s?)
Axillary lymphadenopathy: nodal involvement increases in proportion to the size of the tumour

45
Q

What are the appropriate investigations for breast cancer?

A

Triple assessment:
1. Clinical examination
2. Imaging: an irregular spiculated mass, clustered microcalcifications, and linear branching calcifications
3. Core (needle) biopsy: histological findings confirming an invasive ductal carcinoma, invasive lobular carcinoma, medullary carcinoma, mucinous carcinoma, or metaplastic carcinoma

46
Q

What are the different types of breast cancer?

A

Most breast cancers arise from duct tissue followed by lobular tissue, described as ductal or lobular carcinoma respectively
These can be further subdivided as to whether the cancer hasn’t spread beyond the local tissue (described as carcinoma-in-situ) or has spread (described as invasive)
1. Invasive ductal carcinoma (‘No Special Type (NST)’) = MOST COMMON
2. Invasive lobular carcinoma
3. Ductal carcinoma-in-situ (DCIS)
4. Lobular carcinoma-in-situ (LCIS)

47
Q

What is Paget’s disease of the nipple?

A

An eczematoid change of the nipple associated with an underlying breast malignancy (retraction of the nipple)
Present in 1-2% of patients with breast cancer
In half of these patients, it is associated with an underlying mass lesion and 90% of such patients will have an invasive carcinoma
30% of patients without a mass lesion will still be found to have an underlying carcinoma
The remainder will have carcinoma in situ

48
Q

What is the referral pathway for breast cancer?

A

2WW if:
1. Aged 30 and over and have an unexplained breast lump with or without pain or
2. Aged 50 and over with any of the following symptoms in one nipple only: discharge, retraction or other changes of concern
Consider 2WW if:
1. Skin changes that suggest breast cancer or
2. Aged 30 and over with an unexplained lump in the axilla
Non-urgent referral if: under 30 with an unexplained breast lump with or without pain

49
Q

What are the management options for breast cancer?

A

Depends on the staging, tumour type and patient background
Ultimately patient’s choice!
Options include:
Surgery
Radiotherapy
Hormone therapy
Biological therapy
Chemotherapy

50
Q

What surgical options are available for breast cancer?

A

Vast majority will be offered surgery
Mastectomy and wide local excision (2/3rds can be WLE)
Prior to surgery: presence/absence of axillary lymphadenopathy?
- if positive then they should have a sentinel node biopsy to assess the nodal burden
- if clinically palpable lymphadenopathy, axillary node clearance is indicated at primary surgery (this may lead to arm lymphedema and functional arm impairment)

51
Q

What are the indications for a mastectomy and wide local excision?

A

Mastectomy:
Multifocal tumour
Central tumour
Large lesion in small breast
DCIS > 4cm

WLE:
Solitary lesion
Peripheral tumour
Small lesion in large breast
DCIS < 4cm

52
Q

What should all women be offered if they have surgical management of breast cancer?

A

Regardless of type of surgical treatment, all women should be offered breast reconstruction to achieve a cosmetically suitable result

53
Q

What radiotherapy options are available for breast cancer?

A

WLE: Whole breast radiotherapy is recommended after WLE (may reduce the risk of recurrence by around two-thirds)
Mastectomy: radiotherapy is offered for T3-T4 tumours and for those with four or more positive axillary nodes

54
Q

What hormonal therapy options are available for breast cancer?

A

Adjuvant hormonal therapy is offered if tumours are positive for hormone receptors
Tamoxifen is still used in pre- and peri-menopausal women
In post-menopausal women, aromatase inhibitors such as anastrozole are used for this purpose (aromatisation accounts for the majority of oestrogen production in post-menopausal women and therefore anastrozole is used for ER +ve breast cancer in this group)
*Important side-effects of tamoxifen include an increased risk of endometrial cancer, VTE and menopausal symptoms

55
Q

What chemotherapy options are available for breast cancer?

A

Cytotoxic therapy may be used either prior to surgery (‘neoadjuvanant’ chemotherapy) to downstage a primary lesion
Or
After surgery depending on the stage of the tumour e.g. if there is axillary node disease - FEC-D is used in this situation (5-fluorouracil, epirubicin, cyclophosphamide and docetaxel)

56
Q

What biological therapies are available for breast cancer?

A

The most common type of biological therapy is trastuzumab (Herceptin)
It is only useful in the 20-25% of tumours that are HER2 positive.
*Trastuzumab cannot be used in patients with a history of heart disorders

57
Q

What is the breast cancer screening pathway?

A

Mammogram offered to women between the ages of 50-70 years every 3 years
> 70 years women may still have mammograms but are ‘encouraged to make their own appointments’

58
Q

What is a mastectomy?

A

Surgical option for breast cancer
Must check the presence/absence of axillary lymphadenopathy
Indicated for:
- Multifocal and/or central tumours
- Large lesions in a small breast
- DCIS > 4cm
Should be offered reconstruction surgery
Radiotherapy is offered for T3-T4 tumours and for those with four or more positive axillary nodes

59
Q

What needs to be check prior to surgical management of breast cancer?

A

The presence/absence of axillary lymphadenopathy
1. Women with no palpable axillary lymphadenopathy at presentation → need a pre-operative axillary ultrasound before their primary surgery
1a. If positive → Sentinel node biopsy
2. Women who present with clinically palpable lymphadenopathy → axillary node clearance is indicated at primary surgery

60
Q

What are the complications of axillary node clearance in breast cancer management?

A

Arm lymphoedema and functional arm impairment

61
Q

What is a sentinel node biopsy?

A

A diagnostic procedure to test if cancer has spread beyond the original tumour (test to find the first lymph node it would spread to)

62
Q

When is wide local excision preferred over mastectomy in the management of breast cancer?

A
  1. Solitary lesions
  2. Peripheral tumour
  3. Small lesion in a large breast
  4. DCIS < 4cm
    Around 2/3rds of tumours can be treated with a WLE, offer breast reconstruction
    Whole breast radiotherapy is recommended after to reduce recurrence by 2/3rds

!Final Year (26 decks)

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