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Breast Flashcards

1
Q

3 positions to examine patient in?

A

relaxed with arms by sides
hands on hips
hands behind the head

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2
Q

General inspection of breasts?

A

asymmetry
scars
cosmetic augmentation
tethering, fixation of puckering of overlying skin
nipple eversion/inversion
nipple discharge
skin colour
peau d’orange skin
Paget’s disease of the nipple

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3
Q

What is peau d’orange skin?

A

thickened and dimpled appearance of the skin which may be associated with inflammatory breast cancer

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4
Q

What is Paget’s disease of the nipple?

A

erythematous, scaly rash of the nipple region, resembling eczema
may indicate underlying breast malignancy

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5
Q

Assessing a lump?

A

location
size
shape
consistency
margins
mobile or fixed
tenderness
skin colour
nipple discharge

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6
Q

Triple assessment of breast lump?

A

clinical assessment
imaging
histology

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7
Q

Clinical features of breast lump suggestive of cancer?

A

hard, irregular, painless, fixed in place
tethered to skin or chest wall
nipple retraction
skin oedema and dimpling (peau d’orange)

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8
Q

When to refer for 2 week wait suspected cancer pathway?

A

woman over 30 with unexplained breast lump
woman over 50 with unilateral nipple changes

consider in:
woman over 30 with unexplained axilla lump
skin changes suggestive of breast cancer

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9
Q

What is a fibroadenoma?

A

common benign tumours of stromal or epithelial breast duct tissue

‘breast mouse’

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10
Q

Features of fibroadenoma?

A

more common in younger women (hormone dependent)

painless
smooth
mobile
round
well-circumscribed
firm
usually up to 3cm diameter

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11
Q

What are fibrocystic breast changes?

A

fluctuating changes of the breast with the menstrual cycle due to ducts and lobules of the breast becoming fibrous and cystic in response to female hormones

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12
Q

Symptoms of fibrocystic breast changes?

A

lumpiness
mastalgia
fluctuation of breast size

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13
Q

Mx of fibrocystic breast changes?

A

exclude cancer

wear a supportive bra
NSAIDs
avoid caffeine
applying heat to the area
hormonal treatments under specialist guideline

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14
Q

What are breast cysts?

A

most common cause of breast lumps
benign, individual fluid-filled lumps

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15
Q

Features of breast cysts?

A

most common between 30 and 50

smooth
well-circumscribed
fluctuant
mobile

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16
Q

Mx of breast cysts?

A

exclude cancer
aspiration if painful

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17
Q

What is fat necrosis?

A

benign lump formed by localised degeneration and scarring of fat tissue within the breast, typically in response to trauma

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18
Q

Features of fat necrosis?

A

painless
firm
irregular
fixed in local structures
skin dimpling or nipple inversion may be present

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19
Q

Mx of fat necrosis?

A

exclude cancer (imaging may not be enough to exclude, histology may be necessary)

conservative management typically

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20
Q

What is a lipoma?

A

benign tumour of adipose tissue

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21
Q

Features of a lipoma?

A

soft
painless
mobile
do not cause skin changes

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22
Q

What is a galactocele?

A

breast milk filled cysts when the lactiferous duct is blocked, preventing the gland from draining milk

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23
Q

What is Phyllode’s tumour?

A

rare tumour of the stromal tissue of the breast
large and fast-growing

50% benign, 25% borderline, 25% malignant

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24
Q

Mx of Phyllode’s tumour?

A

wide excision of the tumour
chemotherapy in malignant or metastatic tumours

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25
Two types of mastalgia?
cyclical non-cyclical
26
Features of cyclical breast pain?
typically occurs 2 weeks before menstruation (luteal period) bilateral and generalised pain heaviness aching
27
Causes of non-cyclical breast pain?
idiopathic medications (contraceptives) infection pregnancy referred from: costochondritis post-herpetic neuralgia
28
Diagnosis of mastalgia?
breast pain diary exclude: cancer mastitis pregnancy
29
Mx of cyclical breast pain?
wear a supportive bra NSAIDs heat to the area avoid caffeine hormonal treatment under specialist guidance
30
What is gynaecomastia?
enlargement of the glandular breast tissues in males
31
Causes of gynaecomastia?
idiopathic, medications, raised oestrogen, raised prolactin, decreased testosterone raised oestrogen levels: obesity testicular cancer (Leydig cell tumour) liver cirrhosis liver failure hyperthyroidism hCG secreting tumour (SCLC) raised prolactin levels: dopamine antagonists (antipsychotics) prolactinoma reduced testosterone levels: older age hypothalamus or pituitary causes Klinefelter orchitis testicular damage medications: anabolic steroids antipsychotics digoxin spironolactone GnRH analogues opiates marijuana alcohol
32
Medications that cause gynaecomastia?
steroids (incr. oestrogen) antipsychotics (incr. prolactin) digoxin (stimulates oestrogen receptors) spironolactone (decr. testosterone) GnRH opiates marijuana alcohol
33
Assessment of gynaecomastia?
distinguish from pseudogynaecomastia due to obesity establish cause: meds testicular exam signs of chronic liver disease signs of testosterone deficiency signs of hyperthyroidism
34
Investigations in gynaecomastia?
not always necessary U&Es LFTs TFTs testosterone SHBG prolactin LH and FSH oestrogen b-hCG karyotyping (47XXY) breast US mammogram biopsy testicular US CXR
35
Mx of gynaecomastia?
treat underlying cause conservative mx tamoxifen surgery
36
What is galactorrhoea?
breast milk production not associated with pregnancy or breast-feeding
37
What hormones are responsible for breast milk?
prolactin stimulates breast milk production oxytocin stimulates breast milk secretion dopamine, oestrogen and progesterone inhibit prolactin
38
Causes of hyperprolactinaemia?
idiopathic prolactinoma hypothyroidism PCOS medications (dopamine antagonists)
39
Presentation of hyperprolactinaemia?
galactorrhoea amenorrhoea reduced libido erectile dysfunction gynaecomastia
40
What are prolactinomas?
tumours of the pituitary gland that secrete excessive prolactin microprolactinoma (<10mm) macroprolactinoma (>10mm)
41
Association with prolactinoma?
MEN 1
42
Adverse effects of macroadenomas of the pituitary?
headache bitemporal hemianopia
43
Investigations for galactorrhoea?
pregnancy test serum prolactin U&Es LFTs TFTs MRI brain
44
Mx of galactorrhoea?
treat underlying cause dopamine agonists (bromocriptine, cabergoline) to treat symptoms of hyperprolactinaemia trans-sphenoidal removal of pituitary adenoma
45
What is mammary duct ectasia?
dilation of the large ducts in the breast, with inflammation leading to intermittent nipple discharge
46
RFs for mammary duct ectasia?
perimenopausal women smoking
47
Presentation of mammary duct ectasia?
nipple discharge (white, grey, green) tenderness or pain nipple retraction or inversion breast lump pressure on lump may cause nipple discharge
48
Diagnosis of mammary duct ectasia?
exclude breast cancer (triple assessment) microcalcifications on mammogram (not specific to duct ectasia) ductography nipple discharge cytology ductoscopy
49
Mx of mammary duct ectasia?
may resolve without treatment, does not have any association with cancer reassurance symptomatic management of mastalgia antibiotics if infection surgical excision of the affected duct in problematic cases
50
What is an intraductal papilloma?
warty lesion that grows within the ducts of the breast due to proliferation of epithelial cells benign tumours but can be associated with atypical hyperplasia and cancer
51
Presentation of intraductal papillomas?
35-55 most common clear or blood-stained nipple discharge tenderness or pain palpable lump
52
Diagnosis of intraductal papilloma?
triple assessment ductography ('filling defect')
53
Mx of intraductal papilloma?
complete surgical excision examination for atypical hyperplasia that was not picked up on biopsy
54
What is lactational mastitis?
inflammation of the breast with or without infection common complication of breast-feeding
55
Causes of lactation mastitis?
obstruction and accumulation of milk infection (staph aureus most common)
56
Presentation of mastitis?
unilateral pain and tenderness erythema in focal area local warmth and inflammation nipple discharge fever
57
Mx of lactational mastitis?
due to obstruction: conservative continue breastfeeding breast massage heat packs, warm showers, simple analgesia due to infection: antibiotics (flucloxacillin first-line) encourage to keep breast feeding if feeding difficult, express milk
58
Complication of lactational mastitis?
breast abscess
59
What is candida of the nipple?
fungal infection of the nipple that occurs after a course of antibiotics leads to recurrent mastitis typically presents with oral thrush and candida nappy rash in the infant
60
Mx of candida of the nipple?
topical miconazole 2% to each nipple after breastfeeding miconazole or nystatin for the baby
61
What is a breast abscess?
collection of pus within an area of the breast, typically caused by a bacterial infection
62
Types of breast abscesses?
lactational non-lactational
63
RFs for breast abscesses?
breast feeding mastitis smoking damage to the nipple underlying breast disease
64
Causes of breast abscess?
staph aureus most common streptococcal enterococcal anaerobic bacteria
65
Presentation of breast abscess?
swollen, fluctuant, tender lump nipple changes purulent nipple discharge pain tenderness warmth erythema hardening of skin and tissue swelling systemic symptoms
66
Mx of breast abscess?
antibiotics US incision and drainage microscopy, c&s of drained fluid continue breast feeding
67
Risk factors for breast cancer?
female gender BRCA 1 and BRCA 2 gene mutations TP53 gene mutations prior chest wall radiation FHx lifetime oestrogen exposure (early menarche, late menopause, nulliparity, no breastfeeding) smoking obesity COCP combined HRT
68
Types of breast cancer?
DCIS LCIS Invasive ductal carcinoma Invasive lobar carcinoma Inflammatory breast cancer Paget's disease of the nipple medullary mucinous tubular
69
What is DCIS?
ductal carcinoma in situ pre-cancerous or cancerous epithelial cells in the breast ducts localised to a single area
70
Prognosis of DCIS?
around 30% become IDC potential to spread locally good prognosis if fully excised and adjuvant radiation used
71
What is LCIS?
lobar carcinoma in situ pre-cancerous condition occurring in pre-menopausal women
72
Prognosis of LCIS?
represents increased risk of breast cancer in the future monitored 6 monthly with exams and yearly mammograms
73
What is invasive ductal carcinoma?
aka no specific type 80% of invasive breast cancers can be seen on mammograms
74
What is invasive lobular carcinoma?
originate in cells from breast lobular tissue 10% of invasive breast cancer not always visible on mammograms
75
What is inflammatory breast cancer?
1-3% presents similarly to mastitis or breast abscess worst prognosis
76
Downsides to breast screening?
anxiety and stress radiation exposure false negatives unnecessary tests and treatments
77
Screening for breast cancer?
mammogram every 2 years from 50-70
78
High-risk FHx for breast cancer?
1st degree relative with breast ca <40 1st degree male relative with breast ca 1st degree relative with bilateral breast ca <50 2 1st degree relatives with breast ca
79
Mx of high-risk patients?
genetic counselling annual mammogram (30 onwards) chemoprevention (tamoxifen if pre-menopause, anastrozole if post-menopause) bilateral mastectomy and oophorectomy
80
Presentation of breast cancer?
hard, irregular, fixed lump lumps tethered to skin or chest wall nipple retraction skin dimpling or oedema (peau d'orange) lymphadenopathy (axilla NB!!!!!!!)
81
Imaging options for breast cancer?
US in under 30 years (if palpable lump, distinguish between solid and cyst) mammogram in older women (calcifications) MRIs for further assessment US axilla sentinel lymph node biopsy
82
Breast cancer receptors?
ER PR HER2 triple negative breast cancer carries the worst prognosis as limits treatment options
83
Common sites of metastases in breast cancer?
lung liver brain bone
84
Surgery options in breast cancer?
breast-conserving surgery + radiation mastectomy axillary clearance
85
Hormonal treatment in ER positive breast cancer?
tamoxifen (selective oestrogen receptor modulator) in pre- and peri-menopausal women anastrozole (aromatase inhibitor) in post-menopausal women
86
Side Effects of tamoxifen?
increased risk of endometrial cancer increased risk of VTE protective against osteoporosis
87
Side Effects of anastrozole?
osteoporosis
88
Targeted treatment of HER2+ breast cancer?
trastuzumab (Herceptin) Pertuzumab Neratinib
89
Reconstructive surgery options?
immediate reconstructive (at time of mastectomy) delayed reconstructive
90
Reconstructive surgery following breast-conserving surgery?
may not be necessary partial reconstruction (flap or fat tissue to fill the gap) reduction and reconstruction
91
Reconstructive surgery following mastectomy?
breast implants flap reconstruction (latissimus dorsi, transverse rectus abdominus, deep inferior epigastric perforator)
92
Indications for mastectomy?
patient preference large tumour in small breast multifocal, multicentric disease inability to achieve clear margins (2 tries) in breast recurrence after WLE and radiation (can't have radiation again) inability to have radiation
93
Indications for axillary node clearance?
node positive at presentation sentinel lymph node positive
94
Complications of axillary node clearance?
lymphoedema winging of scapula (long thoracic nerve damage) paraesthesia of upper arm (intercostobrachial nerve) damage to thoracodorsal nerve (latissimus dorsi -> extension, rotation and adduction of arm)
95
When is breast conserving surgery suitable?
2mm clear margin suitable for radiotherapy impalpable lesions can be localised (magnet, wire)
96
DCIS vs LCIS malignant change?
DCIS precursor to malignancy in ipsilateral breast LCIS not pre-malignant but may be lead to malignancy in either breast
97
How do mammograms work?
2 views of breasts - oblique and lateral mass, microcalcifications, spiculations suspicious not effective in higher density breasts (younger women)
98
Poor prognostic factors in breast cancer?
size bilateral LN involvement distal metastases triple negative high grade inflammatory breast cancer TP53 mutations
99
4 areas to examine in the breast?
4 quadrants subareolar space tail of spence axilla

Surgery (10 decks)

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