Breast Flashcards
Differentials for nipple discharge
Physiological
Galactorrhoea
Hyperprolactinaemia
Mammary duct ectasia
Carcinoma
Intraductal papilloma
Common causes of breast pain
Cyclical pain = hormonal changes
Non-cyclical = medication (hormonal contraceptives), infection (mastitis), pregnancy
Management for cyclical breast pain
Wear supportive bra
Simple analgesia (NSAIDs)
Avoid caffeine
Apply heat to area
Hormonal Tx = danazol, tamoxifen
Risk factors for breast cancer
- Lobular Carcinoma In Situ
- Late first childbirth (>35)
- Alcohol consumption
- ADH
- HRT for greater than 5 years
- COCP (returns to normal 10 yrs after stopping pill)
- Obesity (post menopausal)
- BRCA 1 and 2
What is the screening programme for breast cancer?
Mammography (XR)
o MRI screening for BRCA gene carriers from age 30
o Offered every 3 years to women aged 50-70
Presentation of breast cancer
- Fixed, hard, irregular non-tender lump
- Nipple discharge
- Nipple indrawing
- Nipple inversion
- Skin tethering
- Skin dimpling or oedema
- Lymphadenopathy (particularly in axilla)
What are the different types of breast cancer?
- Ductal carcinoma in situ (DCIS)
- Lobular carcinoma in situ (LCIS)
- Invasive ductal carcinoma (no special type) = most common
- Invasive lobular carcinoma
- Inflammatory breast cancer
- Paget’s disease of nipple = Eczematoid change of nipple, starts at nipple and spreads to areola
Investigations for breast cancer
- Mammography (older women) or USS (younger women)
- MRI scanning = Women at higher risk of developing breast cancer
- Core biopsy or fine needle aspiration
- Lymph node assessment
What is the 2WW referral criteria for breast cancer?
- Unexplained breast lump if aged 30+
- Unilateral nipple changes in patients aged 50+
- Consider for unexplained lump in axilla if aged 30+
- Consider for skin changes suggestive of cancer
- Non-urgent referral for lumps if aged <30
Surgical management options for breast cancer
o Breast conservation + whole breast radiotherapy = solitary lesion, peripheral, small lesion in large breast, <4cm
o Mastectomy = multifocal, central, large lesion in small breast, >4cm
o Axillary clearance
What are the pharmacological options for breast cancer?
Chemotherapy
o Neoadjuvant therapy = shrink tumour before surgery
o Adjuvant therapy = after surgery to reduce recurrence
Hormone treatment given for (5-10 years) Oestrogen receptor +ve
o 1st line = tamoxifen (premenopausal women)
o Aromatase inhibitors (letrozole) for postmenopausal women
Biological therapy
o Trastuzumab (Herceptin) = targets HER2 receptor
o Pertuzumab (Perjeta) = HER2 receptor
o Neratinib (nerlynx)
When is radiotherapy given in breast cancer?
o Whole breast radiotherapy recommended after a woman has had wide-local excision
o For mastectomy, RT offered for T3-T4 tumours and those with 4+ positive axillary nodes
What follow up is given for women treated with breast cancer?
Surveillance mammograms yearly for 5 years
Where does breast cancer metastase to?
Lungs, liver, bones, brain (2L and 2B)
Complication of breast surgery
Chronic lymphoedema
Axillary web syndrome
Brachial plexus injury
What are the side effects of radiotherapy?
o General fatigue
o Local skin and tissue irritation and swelling
o Fibrosis of breast tissue
o Shrinking of breast tissue
o Long term skin colour changes
How does a fibroadenoma present?
- Painless, Smooth, Round, firm, mobile lump
- Well circumscribed
- Usually up to 3cm
- More common in younger women (20-40)
Management for a fibroadenoma
> 3cm = surgical excision
What is a breast cyst?
benign, individual fluid-filled lump
How does a breast cyst present?
- Painful and fluctuate in size over menstrual cycle
- Smooth
- Well-circumscribed
- Mobile
- Possibly fluctuant
What is Fat necrosis in the breast?
benign lump formed by localised degeneration and scarring of fat tissue in breast
What can trigger fat necrosis?
Localised trauma
Radiotherapy
Surgery
How does fat necrosis present?
- Painless, firm, irregular lump
- Fixed in local structures
- Skin dimpling or nipple inversion
How does a lipoma present?
- Soft, painless, mobile lump
- Do not cause skin changes
What are the differentials of a breast lump?
Breast cancer
Fibroadenoma
Breast cyst
Fat necrosis
Lipoma
What are the risk factors for a breast abscess?
Smoking
Damage to nipple = nipple eczema, candida infection, piercings
Underlying breast disease
What are the causes of a breast abscess/mastitis?
- Staph. Aureus
- Streptococcus
- Enterococcal
- Anaerobic bacteria
How dose a breast abscess/mastitis present?
- Acute onset (few days)
- Swollen, fluctuant, tender lump
- Nipple changes
- Purulent nipple discharge
- Localised pain
- Warmth
- Erythema
- Hardening of skin or breast tissue
What is the management of lactational mastitis
o Continue breastfeeding and expressing milk
o Breast massage
o Heat packs, warm showers
o Single analgesia
o Abx (flucloxacillin or erythromycin for 10-14 days) = infection suspected or symptoms not improve
What is the management of non-lactational mastitis
o Analgesia
o Abx (co-amoxiclav or erythromycin + metronidazole)
o Treatment of underlying cause
What is the treatment of a breast abscess?
o Referral to on-call surgical team
o Abx
o US
o Drainage = needle aspiration or surgical incision and drainage
o MCS of drained fluid
Adverse affects of tamoxifen
menstrual disturbance: vaginal bleeding, amenorrhoea
hot flushes - 3% of patients stop taking tamoxifen due to climacteric side-effects
venous thromboembolism
endometrial cancer
Adverse affects of aromatase inhibitors (letrozole and anastrozole)
osteoporosis = NICE recommends a DEXA scan when initiating a patient on aromatase inhibitors for breast cancer
hot flushes
arthralgia, myalgia
insomnia
