Breast Flashcards
What is the breast triple assessment?
- History and Examination
- Imaging (Mammography or US if <35 years old or male)
- Histology (core biopsy as full histopathology)
Why is a core biopsy taken for breast lesions not FNA?
Higher specificity and sensitivity than FNA
Allows full histology so can differentiate between in-situ/invasive carcinoma so can stage but FNA is only cytology
If woman has recurrent cystic disease she can have FNA for symptom relief and cytology
What is the aetiology for galactorrhoea?
Hyperprolactinaemia: (see image)
- Normoprolactinaemic galactorrhoea: diagnosis of exclusion. idiopathic and can be reassured and observed
What hormones control lactation?
TRH and Oestrogen stimulate Prolactin production
Dopamine inhibits prolactin production
Prolactin made by anterior pituitary gland
What investigations are done when a woman presents with galactorrhea?
- Exclude pregnancy if of reproductive age with B-hCG
- Serum prolactin levels (if >1000mU/L in the absence of a drug cause then suggests prolactinoma)
Check TFTs, LFTs, U+E’s
If suspect pituitary tumour e.g PRL>1000 MRI with contrast
If breast lump or lymph nodes then breast imaging
How is galactorrhoea managed?
- Pituitary tumour: dopamine agonist (e.g Cabergoline and Bromocriptine) and referral for possible transphenoidal surgery
Idiopathic normoprolactinaemic galactorrhoea: usually resolves spontaneously but can give low dose dopamine agonist
Intolerant to medication galactorrhoea: bilateral total duct excision
What are the different classifications of mastalgia?
- Cyclical: affects both breasts due to hormonal changes. often starts few days before menstruation and subsides at the end. also women on HRT get this
- Non-cyclical: unrelated to menstrual cycle e.g hormonal contraceptives, anti-depressants (sertraline) or antipsychotics (haloperidol).
- Extra mammary: chest wall or shoulder pain
How is mastalgia investigated and managed?
Ix
If no other symptoms no imaging
Pregnancy test
Mx
1st: Reassurance and Pain control: firm bra in day and soft bra at night, oral ibuprofen/paracetamol or topical NSAIDs
2nd: Refer to specialist if above doesn’t work and give Danazol (anti-gonadotrophin agent) but has severe s/e of nausea, dizziness and weight gain
How does mastitis present, what causes it and how is it managed?
Inflammation of the breast tissue, can be acute or chronic. Often due to infection by S.Aureus
Features: tenderness, swelling, induration, erythema, need to check area for abscess formation
Management:
1st Line: Continue breast feeding and analgesics
2nd Line: If systemically unwell or not improved in 24-48 hrs then flucloxacillin
3rd Line: I+D
How do breast abscesses due to mastitis present and how are they managed?
A collection of pus within the breast lined with granulation tissue usually due to acute mastitis
Features: tender, fluctuant, erythematous masses, sometimes with a puncutum. Systemic symptoms like fever and lethargy
Ix: US if diagnosis in doubt
Mx: prompt empirical antibiotics and US-guided needle therapeutic aspiration. if advanced may need I+D under local anaesthetic
What is a complication of draining a non-lactational abscess?
Formation of a mammary duct fistula (a communication between the skin and a subareolar breast duct)
Treated by fistulectomy and antibiotics but can recur
How do breast cysts present and how are they investigated and managed?
Epithelial lined fluid-filled cavities, which form when lobules become distended due to blockage, usually in the perimenopausal age group
Features: distinct smooth masses that can be tender and in both breasts
Ix: halo shape on mammography and diagnosed by US
Mx: often self-resolve so reassure but if large can aspirate
What is mammary duct ectasia, how does it present and how is it investigated and managed?
Dilation and shortening of the major lactiferous duct usually in perimenopausal women
Features: coloured green/yellow nipple discharge (if blood stained needs triple assessment), a palpable mass, or nipple retraction.
Ix: Mammography with calcified dilated ducts and no other signs of malignancy. Can take biopsy which will show multiple plasma cells
Mx: Conservatively if malignancy can be excluded by radiology. If recurring nipple discharge then duct excision
How does fat necrosis of the breast present and how is it investigated and managed?
Acute inflammatory response leading to ischaemic necrosis of fat lobules. Often due to either blunt trauma or previous breast surgery/radiological intervention
Features: usually asymptomatic or painless lump. If acute inflammatory response continues then chronic fibrotic change can occur forming solid irregular lump
Ix: Positive traumatic history and/or hyperechoic mass on US. Look like malignancy on mammogram if fibrotic lesion so core biopsy
Mx: Self limiting so reassure and analgesic
What is the pathophysiology of gynacomastia
Physiological: in adolescence due to the delay in testosterone surge to oestrogen in puberty and in elderly as testosterone declines
Pathological: due to changes in oestrogen:androgen ratio (see image)
How is gynaecomastia investigated?
Tests only necessary if cause unknown. Check LFTs and U+E’s then if these are normal take hormone profile of LH and testosterone
If malignancy suspected then triple assessment
How is gynaecomastia managed after investigations?
Treat underlying cause
Reassurance
Tamoxifen can be given to alleviate tenderness
If fibrotic changes then surgery is only option if other medical treatments failed
what type of histology is common in breast cancer
ductal - most common
lobular
What are some risk factors for developing breast cancer?
Female
Age (risk doubles every 10 years after menopause)
BRCA1/2 (tumour suppressor genes)
FHx in first degree relative
Previous benign disease
Obesity
Alcohol
Early menarche and Late menopause
Nulliparous women or first child over 30
COCP/HRT
What are some visible changes to the breast that can cause a woman to seek medical advice as she is concerned about breast cancer
Lump in breast or axilla
Asymmetry
Swelling (all or part of breast)
Abnormal nipple discharge
Nipple retraction
Skin changes (dimpling/peau d’orange, or Paget’s-like changes)
Mastalgia
What is involved in the NHS Breast Screening Programme?
Woman are invited to have a mammogram every 3 years from 50-70.
Any abnormalities will be sent for triple assessment
What is Paget’s disease of the nipple and how does it present?
Presents as a roughening, reddening, and slight ulceration of the nipple and often has underlying neoplasm
Itching or redness in the nipple and/or areola with flaking and thickened skin. Often painful and sensitive. Can also be flattened
Paget’s disease can often be mistaken for dermatitis/eczema. How can you tell the difference between the two?
Paget’s always involves the nipple but eczema often only affects the areola and spares the nipple
How is Paget’s disease of the nipple investigated and managed?
Ix:
Biopsy (often whole nipple removed for histology)
Breast and Axilla exam, Mammogram, US, MRI breast
Mx:
Surgery: nipple and areola removed
If underlying malignancy needs radiotherapy
