Breast Flashcards
What is the triple assessment?
Hospital-based assessment clinic that allows for the early and rapid detection of breast cancer
1) History and examination
2) Imaging – mammography & ultrasound (more useful in women <35 years and in men)
3) Histology – biopsy is required of any suspicious mass or lesion
What is galactorrhoea?
Defined as copious, bilateral, multi-ductal, milky discharge, not associated with pregnancy or lactation
Occurs almost exclusively in females and most commonly in adults
List causes of galactorrhoea
Hyperprolactinaemia – idiopathic, pituitary adenoma, drug-induced, neurological, hypothyroidism, renal failure/liver failure, damage to the pituitary stalk
Normoprolactinaemic – less common & typically idiopathic
List investigations for galactorrhoea
Essential to exclude pregnancy in all females within the reproductive age range
Should have serum prolactin levels checked, TFTs, LFTs + U&Es
Pituitary tumour is suspected – MRI head with contrast
Describe the management for galactorrhoea
Identifying and treating the underlying cause
Confirmed pituitary tumours – dopamine agonist therapy & referred to neurosurgery for potential trans-sphenoidal surgery
List types of benign breast tumours
Fibroadenoma
Adenoma
Papilloma
Lipoma
Phyllodes tumours
Describe a fibroadenoma
Most common benign growth in the breast & usually occurs in women of a reproductive age
Proliferations of stromal and epithelial tissue of the duct lobules
Examination – highly mobile lesions that are well-defined and rubbery, multiple & bilateral
Very low malignant potential & can be left in situ with routine follow up appointments
Describe an adenoma
Ductal adenoma is a benign glandular tumour, typically occurring in the older female population
Lesions are nodular & can easily mimic malignancy -> most cases will undergo escalation for triple assessment
Describe a papilloma
Intraductal papillomas are benign breast lesions that occur in females in 40-50 years (typically in subareolar region)
Symptoms: bloody/clear nipple discharge, mass
Usually require biopsy and same cases may be excised to ensure no atypical cells/neoplasia are present
Describe a lipoma
Soft and mobile benign adipose tumour
Low malignant potential – usually only removed if they are enlarging or causing aesthetic issues
Describe Phyllodes tumours
Rare fibroepithelial tumours
Commonly larger, occur in an older age group & comprised of both epithelial and stromal tissue
1/3 have malignant potential & 10% will recur after excision -> should be widely excised
What is gynaecomastia?
Condition by which males develop breast tissue due to an imbalanced ratio of oestrogen and androgen activity
Usually benign disease but breast cancer can develop in about 1% of cases
Describe the pathophysiology of gynaecomastia
Physiological gynaecomastia – adolescence (delayed testosterone surge relative to oestrogen), older population (decreasing testosterone levels)
Pathological gynaecomastia:
1) Lack of testosterone
2) Increased oestrogen levels
3) Medication
4) Idiopathic
What is mastitis?
Inflammation of the breast tissue
Most common cause is from infection (staph aureus), but occasionally be granulomatous
Describe the classification of mastitis
1) Lactational mastitis – presents during the first 3 months of breastfeeding/during weaning
a. Cracked nipples & milk stasis
b. More common with first child
2) Non-lactational mastitis – especially in women with other conditions such as duct ectasia
a. Tobacco smoking is important risk factor -> damage to sub-areolar duct walls & predisposing to bacterial infection
Describe the management of mastitis
Systemic abx therapy and simple analgesics
Lactational mastitis – continued milk drainage/feeding is recommended
What is a breast abscess and its management?
Collection of pus within the breast lined with granulation tissue, most commonly developing from acute mastitis
Confirmed via an ultrasound scan
Initial phase – often fully reversible with prompt empirical abx and US-guided needle therapeutic aspiration
Important complication of drainage – mammary duct fistula
Describe breast cysts
Epithelial lined fluid-filled cavities
Usually in the perimenopausal age group
Present singularly or with multiple lumps & appear as distinct smooth masses
Describe investigations and management of breast cysts
Can be identified by their typical halo shape on mammography & definitively diagnosed using USS
Aspiration – cancer may be excluded if the fluid is free of blood/lump disappears
Management – self-resolving
2% of patients with cysts have carcinoma at presentation & patients with cysts have 2-3 times greater risk of developing breast cancer in the future
Describe mammary duct ectasia
Dilation and shortening of the major lactiferous ducts
Common presentation in peri-menopausal women
Presents with coloured nipple discharge, palpable mass or nipple retraction
Describe investigations and management of mammary duct ectasia
Identified by mammography by dilated calcified ducts without any other features of malignancy
Biopsy – multiple plasma cells on histology
Managed conservatively
What is fat necrosis?
Common condition caused by an acute inflammatory response in the breast -> ischaemic necrosis of fat lobules
Often referred to as traumatic fat necrosis due to its association with trauma
Usually asymptomatic or presenting as a lump
Describe investigations and management of fat necrosis
May be suggested by positive traumatic history and/or hyperechoic mass on USS
Core biopsy is often taken to categorically rule out malignancy
Self-limiting & only requires analgesia and reassurance
Describe a ductal carcinoma in situ
Most common type of non-invasive breast malignancy
Malignancy of the ductal tissue of the breast that is contained within the basement membrane
Often detected during screening – suspicious microcalcifications, subsequently confirmed on biopsy
Any should be treated with surgical excision
Describe a lobular carcinoma in situ
Non-invasive lesion of secretory lobules of the breast that is contained within the basement membrane
Usually diagnosed as an incidental finding during biopsy of the breast
Management depends on the grade:
- Low grade: treated by monitoring rather that excision
- Bilateral prophylactic mastectomy can be potentially indicated if individuals possess the BRCA1/BRCA2 genes
List different types of invasive breast cancers
Invasive ductal carcinoma
Invasive lobular carcinoma
Others – medullary carcinoma, invasive micropapillary carcinoma or metaplastic carcinoma
List risk factors for invasive breast cancer
Female
Increasing age
Family history of breast cancer
Exposure to unopposed oestrogen – early menarche, late menopause, nulliparity & long term HRT
Previous benign breast disease
Obesity
Alcohol & smoking
List clinical features of invasive breast cancer
Symptomatically/asymptomatically via screening
Breast or axillary lump
Asymmetry
Swelling
Abnormal nipple discharge
Nipple retraction
Skin changes
Mastalgia
Describe the investigations and management for invasive breast cancer
Gold standard for diagnosis is triple assessment
Management determined by a MDT
Treatment options include surgery, radiotherapy, chemotherapy, hormonal therapy and/or antibody therapy
What is Paget’s disease on the nipple?
Persistent roughening, scaling, ulcerating or eczematous change to the nipple
Vast majority of Paget’s will also have an underlying neoplasm
Describe the clinical presentation of Paget’s disease of the nipple
Itching or redness in the nipple and/or areola
Flaking and thickened skin on/around the nipple
Area often painful and sensitive
Describe the investigations and management for Paget’s disease of the nipple
Biopsy needed to confirm diagnosis
First line management is operative – nipple and areola will need to be removed
In cases associated with underlying malignancy, radiotherapy may also be necessary
