Breast Flashcards
Define galactorrhea.
Who is it found in?
What is the most common cause?
bilateral, multi-ductal, milky white discharge from the nipples, not associated with pregnancy or lactation
most commonly adult women, also male infants due to maternal oestrogen exposure
hyperprolactinaemia
Causes of hyperprolactinaemic galactorrhoea include:
Idiopathic (40%)
Pituitary adenoma (prolactinoma)
Damage to the pituitary stalk- reduced dopamine inhibition to the pituitary ( surgical resection, multiple sclerosis, sarcoidosis, or TB)
Drug-Induced- SSRIs, anti-psychotics, H2-antagonists
Neurological - neurogenic pathways activated to inhibit dopamine levels ( e.g. varicella zoster or spinal cord injury)
Hypothyroidism- elevated TRH can stimulate prolactin related
Cushing’s disease, Acromegaly, and Addison’s disease
Renal failure or liver failure
Normoprolactinaemic galactorrhoea is less common and is typically idiopathic. How can it be diagnosed?
When all other causes of galactorrhea have been excluded
Normal blood markers and menstruation
What should you include in a hx and examination of galactorrhea? What investigations should you do?
Hx:
Ask about breast lumps, mastalgia and last menstrual period
Features of endocrine disease
Neurological sxs (e.g. headaches, visual disturbances)
Full drug hx
Examination:
Breast examination (often unremarkable)
Check for visual changes
Check for signs of hypothyroidism
Investigations:
b-HCG (preg test)
Serum prolactin levels, TFTs, LFTs, renal function tests
Further endocrine tests (IGF-1, ACTH) if indicated
MRI head with contrast if suspected pit. tumour
Breast imaging if palpable lumps/lymph nodes
What serum prolactin level suggests a prolactinoma (in absence of drug-related cause)?
Prolactin levels >1000 mU/L
Optimal management of galactorrhoea is determined by identifying and treating the underlying cause.
- How should you manage idiopathic normoprolactinaemic galactorrhoea?
- What about patients with non-resolving galactorrhea who are intolerant of medication?
- Often resolves spontaneously
Can trial low-dose dopamine agonist - Bilateral total duct excision is an option
Commonest cause of mastalgia?
cyclical mastalgia - pain associated with the menstrual cycle
bilateral, begins a few days before the beginning of menstruation and subsides at the end
very common
Around a third of mastalgia is non-cyclical pain. What can cause this?
medication- hormonal contraceptives, anti-depressants (e.g. sertraline), antipsychotic drugs (e.g. haloperidol)
extramammary pain - e.g. chest wall pain or shoulder pain.
First line treatment for mastalgia is simple analgesics and reassurance.
A second line agent is Danazol, by what pharmacological action does it exert its effect?
Anti-gonadotrophin
What should you ask in a hx of mastalgia?
Timing and association with menstrual cycle
lumps/skin changes
discharge/galactorrhea
fever
pregnancy and breastfeeding
Does mastalgia in isolation warrant imaging?
Mastalgia in isolation with no other clinical features is not an indication for imaging
The incidence of a breast malignancy associated with a presenting complaint of mastalgia is low
What is the breast triple assessment?
a hospital-based assessment clinic that allows for early and rapid detection of breast cancer
2 week wait referral
comprises of the history + examination, imaging, and histology
A 25yr old lady with a suspicious breast lump is referred to breast clinic for triple assessment. By what imaging modality would be best used as first line? Why?
USS
Ultrasound scanning is more useful in women <35 years and in men in identifying anomalies, due to the density of the breast tissue . This form of imaging is also routinely used during core biopsies.
How is mammography used to assess breast tissue?
Mammography involves compression views of the breast across two views (oblique and craniocaudal), allowing for the detection mass lesions or microcalcifications.
What is the difference between a core biopsy and FNA in assessing suspicious breast lumps?
A core biopsy provides full histology, allowing differentiation between invasive and in-situ carcinoma
FNA only provides cytology
Core biopsies can also generate important information about tumour grading and staging, and have a higher sensitivity and specificity than FNA for detecting breast cancer.
What breast lesions can fine needle aspirations be useful for?
cysts
FNA can be used in recurrent cystic disease to provide relief from symptoms and to enable cytology
identify the common benign breast tumour subtypes
Fibroadenoma
Adenoma
Papilloma
Lipoma
Phyllodes Tumours
What are fibroadenomas?
How do they present on examination?
most common benign breast growth that usually occurs in women of a reproductive age
proliferation of stromal and epithelial tissue of the duct lobules
highly mobile lesions - “breast mouse”
well-defined and rubbery on palpation
usually < 5cm diameter
How should confirmed fibroadenomas be managed?
they have a very low malignant potential :
- can be left in situ with routine follow up appointments over a 2 year period
- 30% will get smaller
main indications for excision :
>3cm in diameter or patient preference.
What is a ductal adenoma?
benign glandular tumour, typically occurring in the older female population
nodular lesions mimic malignancy - often escalated to triple assessment
What is an intraductal papilloma?
Where are they found?
How do they present?
benign breast lesion that usually occurs in 40-50yr old women
typically in the subareolar region (usually less than 1cm away from the nipple)
often present with bloody or clear nipple discharge, if large can present as a mass
can appear similar to ductal carcinomas on imaging and therefore usually require biopsy
sometimes excised to ensure no atypical cells or neoplasia
When is risk of breast cancer increased with intraductal papilloma? How is this managed?
Risk of breast cancer is only increased with multi-ductal papilloma
most are treated with microdochectomy
What are breast lipomas?
When may they be removed?
soft and mobile benign adipose tumours
usually asymptomatic, low malignant potential
only removed if causing compressive sxs or aesthetic issues
What are Phyllodes tumours?
rare fibroepithelial tumours comprised of both epithelial and stromal tissue
occur in older age group
often larger and can grow rapidly
How many Phyllodes tumours have malignant potential?
How many benign tumours will recur after excision? How does this affect the management?
1/3 have malignant potential
10% of benign tumours will recur after excision
most Phyllodes tumours should be widely excised (or mastectomy if large)
What is Gynaecomastia?
How often does it progress to breast cancer?
breast tissue development in males due to an imbalanced ratio of oestrogen and androgen activity
1% of cases- usually benign
What causes physiological gynaecomastia?
most commonly occurs in adolescence- delayed testosterone surge relative to oestrogen at puberty
Less commonly occurs in the older population - decreasing testosterone levels with increasing age
Pathological gynaecomastia results from changes in the oestrogen:androgen activity ratio.
What are the 4 main underlying pathologies?
Lack of testosterone :
Klinefelter’s syndrome, androgen insensitivity, testicular atrophy, or renal disease
Increased oestrogen levels:
liver disease, hyperthyroidism, obesity, adrenal tumours, or certain testicular tumours (e.g. Leydig’s cell tumours)
Medication: 25% of cases
e.g. digoxin, metronidazole, spironolactone, chemotherapy, goserelin, antipsychotics, or anabolic steroids
Idiopathic
How does gynaecomastia present on examination?
What must you also examine?
rubbery or firm mass (typically >2cm diameter)
starts from underneath the nipple and spreads outwards over the breast region
must also do a testicular exam, especially in young patients
What is the main differential for gynaecomastia? How can you test for it?
psuedogynaecomastia - adipose tissue in the breast region associated with being overweight
pinching to see if there is an obvious disc of breast tissue present
Tests are only necessary if the cause for gynaecomastia is unknown.
What investigations would you do?
Suspected malignancy - triple assessment
Unknown cause:
U&Es
LFTs
Hormone profile
LH high and testosterone low = testicular failure
LH low and testosterone low = increased oestrogen
LH high and testosterone high = androgen resistance or gonadotrophin-secreting malignancy
In most cases of gynaecomastia, reassurance may be enough. What medical tx is available to alleviate sxs?
Tamoxifen (esp for tenderness)
Mastitis describes inflammation of the breast tissue, both acute or chronic.
How can mastitis be classified?
Mastitis can be classed by lactation status:
Lactational mastitis (more common) :
1/3 of breastfeeding women, more common with 1st baby
usually presents during the first 3 months of breastfeeding or during weaning
associated with cracked nipples and milk stasis
Non-lactational mastitis (less common):
often with other conditions such as duct ectasia (peri-ductal mastitis)
smoking is an important risk factor - damage to the sub-areolar duct walls and predisposing to bacterial infection
How can you confirm a suspected breast abscess?
How can you manage?
Important complication of surgical management?
USS
prompt empirical antibiotics and US-guided needle therapeutic aspiration
incision and drainage under local if more advanced -can cause formation of a mammary duct fistula (a communication between the skin and a subareolar breast duct)
Breast cysts are epithelial lined fluid filled cavities within the breast tissue, usually requiring no further management and self-resolve.
How can you investigate if there is diagnostic uncertainty?
Potential complications?
Investigations:
mammography - halo shape
USS - definitive diagnosis
persisting, symptomatic, or undeterminable cystic masses may be aspirated - cancer can be excluded if fluid is free of blood or lump disappears
Complications:
2-3 x greater risk of developing breast cancer
fibroadenosis (fibrocystic change) - multiple small cysts and fibrotic areas
How can you manage cyclical pain associated with breast cysts?
high dose gamolenic acid (GLA) or danazol
What is Mammary Duct Ectasia?
How can it be investigated and managed?
dilation and shortening of the major lactiferous ducts
common presentation in peri-menopausal women
often presents with coloured green/yellow nipple discharge, a palpable mass, or nipple retraction (slit-like)
Investigations:
mammography - dilated calcified ducts
histology - multiple plasma cells - plasma cell mastitis
Mx:
conservative or duct excision if unremitting nipple discharge
Fat necrosis of the breast is ischaemic necrosis of fat lobules, associated with trauma in 40% of cases.
How does it present?
How is it investigated?
Management?
usually asymptomatic or presenting as a lump
typically firm initially and may then develop into a hard and irregular lump
less commonly : fluid discharge, skin dimpling, pain and nipple inversion
Investigations:
USS- hyperechoic mass
mammogram - mimics carcinoma
core biopsy is often taken to categorically rule out malignancy
Mx:
analgesia and reassurance
Breast Carcinoma In Situ are neoplasms that are contained within the breast ducts and have not spread into the surrounding breast tissue.
What are the 2 types?
Which is more likely to progress to an invasive malignancy?
Ductal Carcinoma In Situ (DCIS) (more common) and Lobular Carcinoma In Situ (LCIS)
LCIS
What is DCIS?
5 major types?
How does it present?
Tx?
most common type of non-invasive breast malignancy (20% of breast cancer)
malignancy of the ductal tissue that is contained within the basement membrane
comedo, cribriform, micropapillary, papillary, and solid (most lesions are mixed)
Picked up on screening - microcalcifications seen on mammography
Tx is surgical excision
What is LCIS?
How does it present?
Tx?
Lobular Carcinoma in Situ (LCIS) is a non-invasive lesion of the secretory lobules of the breast that is contained within the basement membrane
usually diagnosed before menopause
asymptomatic - incidental finding during biopsy of the breast
Management is dependent on extent of disease:
- Low grade LCIS - monitoring
- Bilateral prophylactic mastectomy can be potentially indicated if individuals possess the BRCA1 or BRCA2 genes
Invasive carcinoma of the breast can be classified into:
Invasive ductal carcinoma (70-80%)
Invasive lobular carcinoma (5-10%)
Other subtypes, such as medullary carcinoma, invasive micropapillary carcinoma, or metaplastic carcinoma
Invasive ductal carcinoma (IDC) is the most common type of breast carcinoma. How does it present on microscopy?
nests and cords of tumour cells with associated gland formation
Invasive lobular carcinoma (ILC) is the second most common type of breast cancer and is more common in older women. What is it characterised by?
diffuse (stromal) pattern of spread - makes detection more difficult
by the time of diagnosis, tumours can often be large
Risk factors for invasive breast cancer?
Female sex and increasing age
Family history - BRAC1 / 2
Exposure to unopposed oestrogens -early menarche, late menopause, nulliparity, and 5 years + use of HRT
PMH of benign breast disease
Obesity, alcohol and smoking
How may breast cancer present if symptomatic?
breast or axillary lump
asymmetry or swelling
abnormal nipple discharge / nipple retraction
skin changes (peau d’orange or Paget’s-like nipple changes)
mastalgia
What clinicopathological staging system is widely used for primary breast cancer prognosis?
Nottingham Prognostic Index (NPI)
It is calculated by:
(Size x 0.2) + Nodal Status + Grade
All breast malignancies are checked for their expression of which receptors?
Oestrogen Receptor (ER), Progesterone Receptor (PR), and Human Epidermal growth factor Receptor (HER2)
determines suitability of targeted adjuvant therapies (including endocrine and monoclonal antibody therapies)
tumours that are negative for all three receptors are associated with a poorer prognosis
What breast cancer screening is currently available in the UK?
NHS breast cancer screening programme currently invites women aged 50-71yrs to have a mammogram every three years
What is Paget’s disease of the nipple?
How can it be differentiated from eczema?
persistent roughening, scaling, ulcerating or eczematous change to the nipple
vast majority of Paget’s (85-88%) will also have an underlying neoplasm
Paget’s always affects the nipple and only involves the areola as a secondary event, whilst eczema nearly always only involves the areola and spares the nipple
How can Paget’s disease of the nipple be investigated?
What is the first line management ?
Investigations:
punch biopsy, mammography and ultrasound of the breast
Mx:
operative, if possible - in all cases the nipple and areola will need to be removed
In cases associated with an underlying malignancy, radiotherapy may be necessary
Breast conserving treatment is only suitable for individuals with localised operable disease and no evidence of metastatic disease.
What is the most common breast conserving tx?
A Wide Local Excision (WLE) - excision of the tumour, a 1cm margin of macroscopically normal tissue is taken along with the malignancy
only suitable for focal smaller cancers
A mastectomy removes all the tissue of the affected breast. When would it be indicated?
multifocal disease
high tumour:breast tissue ratio
disease recurrence
patient choice
Axillary surgery is most commonly performed alongside WLE and mastectomies, in order to assess nodal status and remove any nodal disease.
What is a sentinel node biopsy?
removing first lymph nodes into which the tumour drains
nodes are identified by injecting a blue dye with associated radioisotope into the peri-areolar skin
radioactivity detection and / or visual assessment (blue nodes) can identify the sentinel nodes, which can be removed and sent for histological analysis
Axillary node clearance involves removing all nodes in the axilla. What are the complications of this procedure?
paraesthesia, seroma formation, and lymphoedema in the upper limb
A risk-reducing mastectomy is an operation to remove healthy breast tissue in order to reduce the risk of developing breast cancer.
What patient factors confer high risk of developing breast cancer?
A strong family history of breast or ovarian cancer
Testing positive for genetic mutations, such as BRCA1 or BRCA2, PTEN, or TP53 mutations
Previous history of breast cancer
can refer patients to a genetic counsellor to discuss options
Hormone treatments provide the biggest contributor in medical management to improved survival in breast cancer.
What options are available?
(explain how they work, suitable patients and ADRs)
Tamoxifen:
blockade of oestrogen receptors
pre-menopausal patients
increases risk of VTE operatively
increases risk of endometrial cancer
Aromatase inhibitors:
Examples: Anastrozole, Letrozole, or Exemestane
inhibit the action of aromatase, which normally converts androgens into oestrogens
post-menopausal patients as adjuvant therapy
increases risk of osteoporosis - DEXA scan before starting
Immunotherapy:
may be used in patients whose cancers express specific growth factor receptors
Herceptin for HER-2 +ve malignancies
Risk of cardiotoxicity
What surgical reconstructive techniques are available in the oncoplastic treatment of breast malignancy?
therapeutic mammoplasty:
WLE combined with a breast reduction technique
nipple and areola preserved
flap formation
How does the presence/absence of axillary lymphadenopathy determine surgical management of breast cancer?
women with no palpable axillary lymphadenopathy at presentation:
pre-operative axillary USS before primary surgery
if +ve then they should have a sentinel node biopsy to assess the nodal burden
in patients with clinically palpable lymphadenopathy:
axillary node clearance is indicated at primary surgery
this may lead to arm lymphoedema and functional arm impairment
What factors favour Mastectomy V Wide Local Excision of breast cancer?
Mastectomy V Wide Local Excision
Multifocal tumour V Solitary lesion
Central tumour V Peripheral tumour
Large lesion in small breast V Small lesion in large breast
DCIS > 4cm V DCIS < 4cm
What radiotherapy is offered after wide local excision?
After mastectomy?
WLE = always whole breast radiotherapy as this may reduce the risk of recurrence by around two-thirds
Mastectomy = radiotherapy is offered for T3-T4 tumours and for those with 4+ positive axillary nodes
Who can Trastuzumab (Herceptin) not be used in?
Patients with heart disorders
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer if they are:
aged 30 + and have an unexplained breast lump with or without pain
or
aged 50 + with any of the following symptoms in one nipple only: discharge, retraction or other changes of concern
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer in people:
with skin changes that suggest breast cancer or
aged 30 and over with an unexplained lump in the axilla
Who should you consider non urgent referral to breast clinic for?
people aged under 30 with an unexplained breast lump with or without pain
commonest cause of blood stained nipple discharge in younger women?
Intraductal papilloma
Rarely associated with a palpable mass
Requires an USS and possibly galactogram
When are FEC-D and FEC chemotherapy used?
FECD: when node +ve
FEC: node -ve but requires chemotherapy
Common causative organism of breast abscesses?
Finding on examination?
Staphylococcus aureus
On examination there is usually a tender fluctuant mass
What does the ‘snowstorm’ sign on ultrasound of axillary lymph nodes indicate?
extracapsular breast implant rupture
due to leakage of silicone, which then drains via the lymphatic system
the first-line management of mastitis is to continue breastfeeding with simple analgesia/warm compresses. When would you treat medically?
if systemically unwell, if nipple fissure present, if symptoms do not improve after 12-24 hours of effective milk removal of if culture indicates infection
oral flucloaxcillin 10-14 days
What is fibroadenosis (fibrocystic disease, benign mammary dysplasia)?
Most common in middle-aged women
‘Lumpy’ breasts which may be painful. Symptoms may worsen prior to menstruation
What is the chance of siblings and children of BRCA1 carrier to also have the gene?
50/50
The presence of positive axillary lymph nodes and residual tumour at resection margins post-mastectomy are both indications for what tx?
adjuvant ipsilateral chest wall and regional lymph node radiotherapy
progressive erythema and oedema of the breast in the absence signs of infection such as fever, discharge or elevated WCC and CRP suggests what?
inflammatory breast cancer (IBC)- rare but rapidly progressive breast cancer caused by obstruction of lymph drainage
managed with neo-adjuvant chemotherapy first-line, followed by total mastectomy +/- radiotherapy.
Key things to do at the start of a breast exam besides intro and consent?
Position the patient at 45 degrees
Ensure a chaperone is present during the examination (family members not appropriate)
Ask the patient to remove their clothing to expose their chest, from above the waist
Provide a blanket for the patient to cover themselves when not required to expose the breasts
What is involved in the inspection part of a breast examination?
Check for any obvious scars or masses present
Look for any skin changes or ulceration (erythema, puckering, or peau d’orange )
Look for any nipple changes (nipple discharge or inversion)
inspect axillae for obvious masses
Repeat examination with hands on head and hands on hips to accentuate any asymmetry
What is involved in the palpation part of a breast examination?
Ask the patient to place both hands behind their head
Examine each quadrant of the breast in turn, including the axillary tail
Using a flat hand, press the breast against the underlying chest wall, rolling the underlying tissue
If you palpate lumps :
note their position, size, shape, consistency, overlying skin changes, and mobility
examine their fixity to pectoralis muscles by asking the patient to push against your hand with their hand outstretched
Examine both axilla in turn
Palpate for any lymphadenopathy
5 sets of axillary lymph nodes are present: apical, anterior, central, posterior, and medial
assess for potential metastasis:
Palpate the spine for tenderness
Palpate the abdomen for hepatomegaly
Percuss and auscultate the lungs for lung masses
Further investigations following breast examination?
Mammography and / or ultrasound, if necessary
Biopsy (core needle or fine needle aspirate), if necessary
