Breast Flashcards
What is a breast abscess?
A collection of pus within an area of breast, usually caused by a bacterial infection. This may be a:
-lactational abscess
-non-lactational abscess
What is pus?
Pus is a thick fluid produced by inflammation. It contains dead white blood cells of the immune system and other waste from the fight against the infection. When pus becomes trapped in a specific area and cannot drain, an abscess will form and gradually increase in size.
What is mastitis?
Inflammation of breast tissue, often lactational mastitis, although can be caused by infection. Bacteria can enter at the nipple and back-track into the ducts, causing infection and inflammation.
Risk factors for infective mastitis and breast abscess
Smoking, damage to the nipple (e.g. nipple eczema, candidal indection or piercings) provides bacteria entry. Underlying breast disease can affect the drainage of the breast, predisposing to infection.
What are the most common causative bacteria for breast abscesses?
-staph aureus
-streptococcal species
-enterococcal species
-anaerobic bacteria (such as Bacteriodes species and anaerobic streptococci)
What class of bacteria are staph aureus, streptococcal and enterococcal bacteria?
gram positive
What antibiotic in particular is effective against staph aureus?
Flucloxacillin
Which antibiotics cover anaerobes?
Metronidazole and Co-amoxiclav
Mastitis with infection in the breast tissue presents with breast changes of:
Nipple changes
Purulent nipple discharge (pus from the nipple)
Localised pain
Tenderness
Warmth
Erythema (redness)
Hardening of the skin or breast tissue
Swelling
Fluctuance meaning
being able to move fluid around within the lump using pressure during palpation
key features of a breast abscess
swollen. fluctuant. tender lump within the breast
generalised symptoms of infection
muscle aches, fatigue, fever. signs of sepsis (e.g. tachycardia, raised respiratory rate and confusion)
Management of lactational mastitis
Lactational mastitis caused by blockage of the ducts is managed conservatively, with continued breastfeeding, expressing milk and breast massage. Heat packs, warm showers and simple analgesia can help symptoms. Antibiotics (flucloxacillin or erythromycin/clarithromycin where there is penicillin allergy) are required where infection is suspected or symptoms do not improve.
management of non-lactational mastitis
Analgesia
Antibiotics
Treatment for the underlying cause (e.g., eczema or candidal infection)
Antibiotics for non-lactational mastitis need to be broad-spectrum. The NICE clinical knowledge summaries (last updated January 2021) recommend either:
Co-amoxiclav
Erythromycin/clarithromycin (macrolides) plus metronidazole (to cover anaerobes)
How does mastitis present?
Breast pain and tenderness (unilateral)
Erythema in a focal area of breast tissue
Local warmth and inflammation
Nipple discharge
Fever
What is the first line antibiotic for mastitis?
Flucloxacillin
Most common use of fluconazole?
Serious yeast or fungal infections
Candida infection of the nipple may present with:
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
Candidal infection of the nipple can occur, often after a … This can lead to … , as it causes cracked skin on the nipple that create an entrance for infection. It is associated with oral thrush and candidal nappy rash in the infant.
course of antibiotics
recurrent mastitis
Treatment for candida of the nipple
Topical miconazole 2% after each breastfeed
Treatment for the baby (e.g. miconazole gel or nystatin)
Describe breast cysts
Breast cysts are benign, individual, fluid-filled lumps. They are the most common cause of breast lumps and occur most often between ages 30 and 50, more so in the perimenopausal period. They can be painful and may fluctuate in size over the menstrual cycle.
On examination, breast cysts are:
Smooth
Well-circumscribed
Mobile
Possibly fluctuant
Breasts cysts require further assessment to exclude cancer, with imaging and potentially aspiration or excision. Aspiration can resolve symptoms in patients with pain. Having a breast cyst may slightly increase the risk of breast cancer.
Risk factors for breast cancer
Female (99% of breast cancers)
Increased oestrogen exposure (earlier onset of periods and later menopause)
More dense breast tissue (more glandular tissue)
Obesity
Smoking
Family history (first-degree relatives)
The combined contraceptive pill gives a small increase in the risk of breast cancer, but the risk returns to normal ten years after stopping the pill.
Hormone replacement therapy (HRT) increases the risk of breast cancer, particularly combined HRT (containing both oestrogen and progesterone).
What is the breast cancer gene and where is it?
The BRACA1 gene is on chromosome 17.
The BRACA2 gene is on chromosome 13
Rarer ones: TP53 and PTEN genes
Name some of the different types of breast cancer
-ductal carcinoma in situ (DCIS)
-lobular carcinoma in situ (LCIS)
-invasive ductal carcinoma- NST (no specific type)
-invasive lobular carcinoma
-inflammatory breast cancer
-Paget’s disease of the nipple
What is the most common type of breast cancer
Invasive ductal carcinoma- originate in cells from the breast ducts
-can be seen on mammograms
Describe the NHS breast screening programme
The NHS breast cancer screening program offers a mammogram every 3 years to women aged 50 – 70 years.
Screening aims to detect breast cancer early, which improves outcomes. Roughly 1 in 100 women are diagnosed with breast cancer after going for a mammogram.
There are some potential downsides to screening:
Anxiety and stress
Exposure to radiation, with a very small risk of causing breast cancer
Missing cancer, leading to false reassurance
Unnecessary further tests or treatment where findings would not have otherwise caused harm
Generally, the benefits far outweigh the downsides and breast cancer screening is recommended.
What may be offered to women at high risk of breast cancer?
Chemoprevention may be offered for women at high risk, with:
Tamoxifen if premenopausal
Anastrozole if postmenopausal (except with severe osteoporosis)
Risk-reducing bilateral mastectomy or bilateral oophorectomy (removing the ovaries) is an option for women at high risk. This is suitable for only a small number of women and requires significant counselling and weighing up risks and benefits.
Also: genetic counselling, annual mammogram
Presentation of 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)
Lymphadenopathy, particularly in the axilla
2 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)
-unexplained lump in the axilla in patients 30 or above
-skin changes suggestive of breast cancer
What does triple diagnostic assessment comprise of?
-Used for suspected breast cancer
-Clinical assessment (history and examination)
-Imagine (US or mammography)
-Biopsy (fine needle aspiration or core biopsy)
Do younger or older women generally have more dense breasts with more glandular tissue?
Younger women
When are ultrasound scans useful in suspected breast cancer?
To assess lumps in younger women (e.g. under 30). They are helpful in distinguishing solid lumps (e.g. fibroadenoma or cancer) from cystic (fluid-filled) lumps.
Mammograms are generally more effective in older women. They can pick up …. missed by ultrasound.
calcifications
Describe a sentinel lymph node biopsy
Sentinel node biopsy is performed during breast surgery for cancer. An isotope contrast and a blue dye are injected into the tumour area. The contrast and dye travel through the lymphatics to the first lymph node (the sentinel node). The first node in the drainage of the tumour area shows up blue and on the isotope scanner. A biopsy can be performed on this node, and if cancer cells are found, the lymph nodes can be removed.
Name the 3 types of breast cancer receptors
-oestrogen receptors (ER)
-progesterone receptors (PR)
-human epidermal growth factor (HER2)
What is triple-negative breast cancer?
Triple-negative breast cancer is where the breast cancer cells do not express any of these three receptors. This carries a worse prognosis, as it limits the treatment options for targeting the cancer.
What is gene expression profiling?
Gene expression profiling involves assessing which genes are present within the breast cancer on a histology sample. This helps predict the probability that the breast cancer will reoccur as a distal metastasis (away from the original cancer site) within 10 years.
The NICE guidelines (2018) [DG34] recommend this for women with early breast cancers that are ER positive but HER2 and lymph node negative. It helps guide whether to give additional chemotherapy.
Name the 4 notable locations that breast cancer metastasis occur
2 Ls and 2 Bs
Lungs
Liver
Bones
Brain
What staging system is used in breast cancer?
The TMN system
Describe the investigations of breast cancer
-first step= triple assessment
-lymph node assessment and biopsy
-MRI of the breast and axilla
-liver US for liver metastasis
-CT thorax, abdo and pelvis for metastasis
-isotope bone scan for bony metastasis
-TMN system
What are the surgery options for breast cancer?
-Breast-conserving surgery (e.g. wide local excision), usually coupled with radiotherapy.
-Mastectomy (removal of the whole breast), potentially with immediate or delayed breast reconstruction.
-Axillary clearance- removal of the axillary lymph nodes is offered to patients where cancer cells are found in nodes. However, this increases the risk of chronic lymphoedema in that arm.
What is chronic lymphoedema?
-Chronic lymphoedema is a chronic condition caused by impaired lymphatic drainage of an area.
-Can occur in an entire arm after breast cancer surgery on that side, with removal of the axillary lymph nodes in the armpit.
-As the lymphatic system plays an important role in the immune system, areas of lymphoedema are prone to infection.
Why is it important to not insert a cannula or take blood in an arm on the side of previous breast cancer removal surgery?
This is because there is a higher risk of complications and infection due to the impaired lymphatic drainage on that side.
Function of the lymphatic system?
-Responsible for draining excess fluid from the tissues.
-Role in immune system
What are common radiotherapy side effects?
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)
Patients with oestrogen-receptor positive breast cancer are given treatment that disrupts the oestrogen stimulating the breast cancer.
The two main first-line options for this are:
-Tamoxifen for premenopausal women
-Aromatase inhibitors for postmenopausal women (e.g., letrozole, anastrozole or exemestane)
How does Tamoxifen work?
-Tamoxifen is a selective oestrogen receptor modulator (SERM).
-It either blocks or stimulates oestrogen receptors, depending on the site of action.
-It blocks oestrogen receptors in breast tissue, and stimulates oestrogen receptors in the uterus and bones.
-This means it helps prevent osteoporosis, but it does increase the risk of endometrial cancer.
How long are tamoxifen and aromatase inhibitor given for and who are they given to?
5-10 years to women with oestrogen-receptor positive breast cancer.
How does aromatase work?
-Aromatase is an enzyme found in fat (adipose) tissue that converts androgens to oestrogen.
-After menopause, the action of aromatase in fat tissue is the primary source of oestrogen.
-Aromatase inhibitors work by blocking the creation of oestrogen in fat tissue.
Other than tamoxifen and aromatase, what are the other options for women with oestrogen-receptor positive breast cancer?
-Fulvestrant (selective oestrogen receptor down regulator)
-GnRH agonists (e.g. goserelin or leuprorelin)
-Ovarian surgery
What is an agonist and antagonist?
An agonist is a drug that binds to the receptor, producing a similar response to the intended chemical and receptor.
An antagonist is a drug that binds to the receptor either on the primary site, or on another site, which all together stops the receptor from producing a response.
What receptor does Trastuzumab (Herceptin) target?
HER2 receptor
What is Trastuzumab?
Trastuzumab (Herceptin) is a monoclonal antibody that targets the HER2 receptor.
It may be used in patients with HER2 positive breast cancer.
It can affect heart function; therefore, initial and close monitoring of heart function is required.
What is Neratinib (Nerlynx)?
Neratinib (Nerlynx) is a tyrosine kinase inhibitor, reducing the growth of breast cancers. It may be used in patients with HER2 positive breast cancer.
What is Pertuzumab (Perjeta)?
Pertuzumab (Perjeta) is another monoclonal antibody that targets the HER2 receptor. It may be used in patients with HER2 positive breast cancer. This is used in combination with trastuzumab (Herceptin).
What are the different types of breast reconstructive surgery?
-Partial reconstruction
-Reduction and reshaping
-Breast implants
-Flap reconstruction (using tissue from another part of the body)
-Latissimus dorsi flap
-Transverse rectus abdominis flap (TRAM flap)- risk of abdominal hernia due to weakened abdominal wall
-Deep inferior epigastric perforator flap (DIEP Flap)- the deep inferior epigastric artery is attached to the internal mammary artery and vein.
What is pedicled and free flap in reconstructive tissue?
“Pedicled” refers to keeping the original blood supply and moving the tissue under the skin to a new location.
“Free flap” refers to cutting the tissue away completely and transplanting it to a new location.
