Breast Flashcards
what is the standard practice to exclude or diagnose breast cancer
- Clinical assessment (history and examination)
- Imaging (ultrasound or mammography)
- Histology (fine needle aspiration or core biopsy)
Clinical features that may suggest breast cancer
-> Lumps that are hard, irregular, painless or fixed in place
-> Lumps may be tethered to the skin or the chest wall
-> Nipple retraction
-> Skin dimpling or oedema (peau d’orange)
NICE recommendations for a two week wait referral for suspected breast cancer
- Unexplained breast lump in patients aged 30 or above
- Unilateral nipple changes in patients aged 50 or above (discharge, retraction or other changes)
Presentation of a fibroadenoma
- Painless
- Smooth
- Round
- Well circumscribed (well-defined borders)
- Firm
- Mobile (moves freely under the skin and above the chest wall)
- Usually up to 3cm diameter
- NO increased risk of malignancy
What is a fibroadenoma and who does it usually affect
- Benign breast tumours of stromal / epithelial breast duct tissue
- Younger women (20-40) as respond to female hormones
what is the most common cause of breast lumps and who do they usually affect
- Breast cyst
- 30-50 yrs
- Small increased risk of malignancy
Presentation of breast cyst
Smooth
Well-circumscribed
Mobile
Possibly fluctuant
Management of breast cyst
Aspiration
Presentation of fat necrosis
- History of localised trauma causing degeneration and scarring of fat = benign lump
- Painless
- Firm
- Irregular
- Fixed in local structures
- There may be skin dimpling or nipple inversion
Management of fat necrosis
- USS or mammogram and core biopsy to exclude breast cancer
Management of cyclical breast pain
- Wearing a supportive bra
- NSAIDs
- Avoiding caffeine
- Applying heat to the area
- Hormonal treatments (e.g., danazol and tamoxifen) under specialist guidance
Definition of gynaecomastia
- Abnormal amount of breast tissue in males
Possible causes of gynaecomastia
- Hormonal imbalance between oestrogen and androgens
- Hypoprolactinaemia
- Idiopathic
What conditions can cause increased oestrogen and in turn gynaecomastial
- Obesity (aromatase is an enzyme found in adipose tissue that converts androgens to oestrogen)
- Testicular cancer (oestrogen secretion from a Leydig cell tumour)
- Liver cirrhosis and liver failure
- Hyperthyroidism
- Human chorionic gonadotrophin - (hCG) secreting tumour, notably small cell lung cancer
What conditions can reduce testosterone and in turn cause gynaecomastia
- Testosterone deficiency in older age
- Hypothalamus or pituitary conditions that reduce LH and FSH levels (e.g., tumours, radiotherapy or surgery)
- Klinefelter syndrome (XXY sex chromosomes)
- Orchitis (inflammation of the testicles, e.g., infection with mumps)
- Testicular damage (e.g., secondary to trauma or torsion)
What medications can cause gynaecomastia
- Anabolic steroids (raise oestrogen levels)
- Antipsychotics (increase prolactin levels)
- Digoxin (stimulates oestrogen receptors)
- Spironolactone (inhibits testosterone production and blocks testosterone receptors)
- Gonadotrophin-releasing hormone (GnRH) agonists (e.g., goserelin used to treat prostate cancer)
- Opiates (e.g., illicit heroin use)
- Marijuana
- Alcohol
Give 2 treatment options for gynaecomastia
Tamoxifen
Surgery
what disorders can cause hyperprolactinaemia and in turn galactorrhea
-> Idiopathic (no cause can be found)
-> Prolactinomas (hormone-secreting pituitary tumours)
-> Endocrine disorders, particularly hypothyroidism and polycystic ovarian syndrome
-> Medications, particularly dopamine antagonists (i.e., antipsychotic medications)
What AD condition can prolactinomas be associated with
- Multiple endocrine neoplasia (MEN) type 1
what 2 mass effects do macroprolactinomas cause
- Headaches
- Bitemporal haemianopia due to sitting on the optic chiasm
what are the management options of galactorhoea?
- Symptoms : dopamine agonists (bromocriptine/cabergoline)
- Pituitary tumour : trans-sphenoidal surgery
What is mammary duct ectasia ?
Dilation of the large ducts in the breasts
Presentation of mammary duct ectasia
Nipple discharge (cheese like)
Tenderness or pain
Nipple retraction (slit like) or inversion
A breast lump (pressure on the lump may produce nipple discharge)
Who does mammary duct ectasia occur most commonly in?
- Perimenopausal women
- SMOKERS (big RF)
Assessing mammary duct ectasia
Rule out breast cancer with triple assessment
What is often seen on mammogram in mammary duct ectasia but is not specific to it
Microcalcifications
Clear or blood stained nipple discharge
Intraductal papilloma
Common presentation of intraductal papilloma
~ 35-55 yrs old
~ Nipple discharge (clear/blood-stained)
~ Tenderness or pain
~ Palpable kump
Diagnosis of intraductal papilloma
- Triple assessment
- Ductography may be used = “filling defect”
Management of intraductal papilloma
Surgical excisions
Presentation of mastitis
- Breast pain and tenderness (unilateral)
- Erythema in a focal area of breast tissue
- Local warmth and inflammation
- Nipple discharge
- Fever
Management of mastitis
- 1st : conservative = continued breastfeeding, expressing milk.
- 2nd : Flucloxacillin (erythromycin if penicllin allergic)
Complication and resultant treatment of mastitis
- Breast abscess
- Incision and drainage
what can cause recurrent mastitis
Candidal infection of the nipple after a course of antibiotics
Presentation of candida of the nipple
- Sore nipples bilaterally, particularly after feeding
- Nipple tenderness and itching
- Cracked, flaky or shiny areola
- Symptoms in the baby, such as white patches in the mouth and on the tongue, or candidal nappy rash
Define a breast abscess
-> Collection of pus within an area of the breast, usually caused by a bacterial infection. May be :
- Lactational abscess
- Non-lactational absces
Key RF for infective mastitis and breast abscess
Smoking
Most common bacterial causes of infective mastitis / breast abscess
- Staphylococcus aureus (the most common)
- Streptococcal species
- Enterococcal species
- Anaerobic bacteria (such as Bacteroides species and anaerobic streptococci)
Presentation of infective mastitis
- Nipple changes
- Purulent nipple discharge (pus from the nipple)
- Localised pain
- Tenderness
- Warmth
- Erythema (redness)
- Hardening of the skin or breast tissue
- Swelling
Key feature suggest breast abscess over infective mastitis
- Swollen, fluctuant, tender lump
Management of non-lactational mastitis
- Analgesia
- Antibiotics (either co-amoxiclav or erythromycin + metronidazole)
T- reatment for the underlying cause (e.g., eczema or candidal infection)
Management of a breast abscess
- Referral to the on-call surgical team in the hospital for management
- Antibiotics
- Ultrasound (confirm the diagnosis and exclude other pathology)
- Drainage (needle aspiration or surgical incision and drainage)
- Microscopy, culture and sensitivities of the drained fluid
RF for breast cancer
- Female
- BRCA1, BRCA2 genes
- Increased oestrogen exposure (earlier onset of periods and later menopause)
- COCP and HRT
- More dense breast tissue (more glandular tissue)
- Obesity
- Smoking
- First-degree premenopausal relative
Explain the genes involved in an increased risk of breast cancer
- BRCA1 on chromosome 17 (70% breast cancer by 80, 50% ovarian cancer)
- BRCA2 on chromosome 13 (60% breast cancer by 80, 20% ovarian cancer)
Give the different types of breast cancer
- Ductal carcinoma in situ
- Invasive ductal carcinoma
- Lobular carcinoma in situ
- Invasive lobular carcino,e
- Pagets disease of nipple
- Inflammatory breast cancer
Explain breast cancer screening in the UK
-> Mammogram every 3 years to women aged 50-70.
How does breast screening differ for higher risk women
- Annual mammogram
- Chemoprevention (Tamoxifen if premenopausal, anastrozole if postmenopausal)
- Risk reducing bilateral mastectomy or bilateral oophorectomy
2 week wait referral for suspected breast cancer
- An unexplained breast lump in patients aged 30 or above
- Unilateral nipple changes in patients aged 50 or above (discharge, retraction or other changes)
Assessment following 2 week wait referral
- Clinical assessment (history and examination)
- Imaging (ultrasound or mammography)
- Biopsy (fine needle aspiration or core biopsy)
Imaging used in breast cancer
- USS = younger women
- Mammograms = older women, better at picking up calcifications
- MRI scans = higher risk women and further assessing features of a tumour
What is done in breast cancer surgery if the initial USS does not show any abnormal nodes ?
Sentinel lymph node biopsy
What 3 types of receptor may be seen in breast cancer ?
- Oestrogen receptors (ER)
- Progesterone receptors (PR)
- Human epidermal growth factor (HER2)
Triple negative breast cancer = no cancer cells express any. of these receptors
what is gene expressing profiling >
- Assessing which genes are present within breast cancer on histology sample
- Done for women with early breast cancers that are ER positive but HER2 & lymph node negative
- Helps guide whether to give additional chemotherapy as predicts the risk of breast cancer recurrence as a distal met
Common breast cancer mets
L : Lungs
L : Liver
B : Bone
B : Brain
Explain the surgical options for breast cancer
- Breast conserving (coupled with radiotherapy)
- Mastectomy
5 common SE of radiotherapy
- General fatigue from the radiation
- Local skin and tissue irritation and swelling
- Fibrosis of breast tissue
- Shrinking of breast tissue
- Long term skin colour changes (usually darker)
3 types of chemotherapy scenarios
- Neoadjuvant therapy – intended to shrink the tumour before surgery
- Adjuvant chemotherapy – given after surgery to reduce recurrence
- Treatment of metastatic or recurrent breast cancer
when can hormone treatment be given for breast cancer ?
- Oestrogen receptor (ER) positive
what are the 2 hormonal treatment options for breast cancer and when are they given ?
1.Tamoxifen for premenopausal women
2. Aromatase inhibitors for postmenopausal women (e.g., letrozole, anastrozole or exemestane)
Method of action of tamoxifen and therefore its SE
- Blocks oestrogen receptor in breast tissue and stimulates them in the uterus and bones
- Helps prevent osteoporosis BUT increases risk of endometrial cancer
Give 3 targeted treatments for women with HER2 positive breast cancer
- Trastuzumab (Herceptin) is a monoclonal antibody that targets the HER2 receptor.
- Pertuzumab (Perjeta) is another monoclonal antibody that targets the HER2 receptor.
- Neratinib (Nerlynx) is a tyrosine kinase inhibitor, reducing the growth of breast cancers.
SE of herceptin
- Can affect heart function and therefore pots require initial and close monitoring of heart function
3 flap reconstruction options following a mastectomy
- Latissmus Dorsi Flap (Pedicled or free flap)
- Transverse Rectus Abdominis Flap (Pedicled or free flap)
- Deep Inferior Epigastric Flap (Free flap)
Difference between pedicled and free flap in breast reconstruction surgery
- Pedicled : keep original blood supply and move tissue under the skin to new location
- Free : cutting away the tissue completely and transplanting to a new location
Risk of TRAM Flap
- Abdominal hern ia due to weakend abdo wall
