Breast Flashcards
What is meant by mammary duct ectasia? [1]
How does this present? [3]
Dilatation in breast ducts
- There is inflammation in the ducts, leading to intermittent discharge from the nipple.
-. As the ducts shorten and dilate a degree of symmetrical slit like retraction occurs.
Presentation:
* Thick, green discharge
* Nipple retraction or inversion
* Tenderness or pain
**
Ectasia means dilation
Which population does mammary duct ectasia typically present in? [1]
What is another major risk factor? [1]
Perimenopausal women
Smoking is significant RF
How does mammary duct ectasia present on mammogram? [1]
Microcalcifications are a key finding to remember on a mammogram, although they are not specific to mammary duct ectasia.
How do you treat mammary duct ectasia? [1]
Mammary duct ectasia may resolve without any treatment. It is not associated with an increased risk of cancer.
Management depends on the individual patient:
Reassurance after excluding cancer may be all that is required
Symptomatic management of mastalgia (supportive bra and warm compresses)
Antibiotics if infection is suspected or present
Surgical excision of the affected duct (microdochectomy) may be required in problematic cases
Triple assessment of a breast lump is standard practice to exclude or diagnose cancer. This involves: [3]
Clinical features that may suggest breast cancer are: [4]
Clinical assessment (history and examination)
Imaging (ultrasound or mammography)
Histology (fine needle aspiration or core biopsy)
? 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)
The NICE guidelines (updated January 2021) recommend a two week wait referral for suspected breast cancer for [2]
- An unexplained breast lump in patients aged 30 or above
- Unilateral nipple changes in patients aged 50 or above (discharge, retraction or other changes)
NB:
The NICE guidelines recommend also considering a two week wait referral for:
An unexplained lump in the axilla in patients aged 30 or above
Skin changes suggestive of breast cancer
Describe what is meant by firbocystic breast changes [2]
The connective tissues (stroma), ducts and lobules of the breast respond to the female sex hormones (oestrogen and progesterone), becoming fibrous (irregular and hard) and cystic (fluid-filled).
These changes fluctuate with the menstrual cycle.
Fibroadenoma - how / when do you treat? [1]
If >3cm surgical excision is usual, Phyllodes tumours should be widely excised (mastectomy if the lesion is large)
Management of fibrocystic breast changes is to exclude cancer and manage symptoms. Options to manage cyclical breast pain (mastalgia) include: [4]
- Wearing a supportive bra
- Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen
- Avoiding caffeine is commonly recommended
- Applying heat to the area
- Hormonal treatments (e.g., danazol and tamoxifen) under specialist guidance
The most common cause of breast lumps is? [1]
Breast cysts
How do breast cysts present on examination? [4]
Smooth, discreet lump
Mobile
Possibly fluctuant
How do you treat a breast cyst? [2]
- Cysts should be aspirated
- Those which are blood stained or persistently refill should be biopsied or excised
What is fat necrosis? [1]
What is fat necrosis caused by? [1]
Fat necrosis causes a benign lump formed by localised degeneration and scarring of fat tissue in the breast. It may be associated with an oil cyst, containing liquid fat
Fat necrosis is commonly triggered by localised trauma, radiotherapy or surgery, with an inflammatory reaction resulting in fibrosis and necrosis (death) of the fat tissue. It does not increase the risk of breast cancer.
On examination, fat necrosis can be:
[5]
On examination, fat necrosis can be:
- Painless
- Firm
- Irregular
- Fixed in local structures
- There may be skin dimpling or nipple inversion
How do you investigate ?fat necrosis of breast [1]
Imaging and core biopsy
- Ultrasound or mammogram can show a similar appearance to breast cancer. Histology (by fine needle aspiration or core biopsy) may be required to confirm the diagnosis and exclude breast cancer.
[] occur in women that are lactating (producing breast milk), often after stopping breastfeeding
Galactoceles occur in women that are lactating (producing breast milk), often after stopping breastfeeding
Describe what a galactocele is [1]
Where/how do they usually occur? [1]
They are breast milk filled cysts that occur when the lactiferous duct is blocked, preventing the gland from draining milk
They present with a firm, mobile, painless lump, usually beneath the areola.
Where does breast cancer met. to? [4]
Metastasis – 2B2L = brain, bones, lung, liver
Describe what is meant by a phyllodes tumour [1]
Phyllodes tumours are rare tumours of the connective tissue (stroma) of the breast, occurring most often between ages 40 and 50.
They are large and fast-growing. They can be benign (~50%), borderline (~25%) or malignant (~25%).
Malignant phyllodes tumours can metastasise.
How do you treat a phyllodes tumour? [1]
Treatment involves surgical removal of the tumour and the surrounding tissue (“wide excision”). They can reoccur after removal
.
.
Describe the difference between cyclical and non-cyclical breast pain
Cyclical breast pain:
- is more common and is related to hormonal fluctuations during the menstrual cycle.
- The pain typically occurs during the two weeks BEFORE menstruation (the luteal phase) and settles during the menstrual period.
- There may be other symptoms of premenstrual syndrome, such as low mood, bloating, fatigue or headaches.
Non-Cyclical Breast Pain:
- Non-cyclical breast pain is more common in women aged 40 – 50 years
- It is more likely to be localised than cyclical breast pain. Often no cause is found. However, it may be caused by: Medications (e.g., hormonal contraceptive medications); Infection (e.g., mastitis); Pregnancy
Diagnosis:
A [] can help diagnose cyclical breast pain.
The three main things to exclude when someone presents with breast pain are:
Diagnosis
A breast pain diary can help diagnose cyclical breast pain.
The three main things to exclude when someone presents with breast pain are:
* Cancer (perform a thorough history and examination)
* Infection (mastitis)
* Pregnancy (perform a pregnancy test)
Describe what is meant by an intraductal papilloma [1]
- An intraductal papilloma is a warty lesion that grows within one of the ducts in the breast.
- It is the result of the proliferation of epithelial cells.
- The typical presentation is with clear or blood-stained nipple discharge.
Describe the presentation of an intraductal papilloma [4]
Intraductal papillomas are often asymptomatic. They may be picked up incidentally on mammograms or ultrasound.
They may present with:
- Nipple discharge (clear or blood-stained)
- Tenderness or pain
- A palpable lump
Describe how you investigate an intraductal papilloma [2]
Patients require triple assessment with:
* Clinical assessment (history and examination)
* Imaging (ultrasound, mammography and MRI)
* Histology (usually by core biopsy or vacuum-assisted biopsy)
Microdochectomy
- Ductography may also be used. This involves injecting contrast into the abnormal duct and performing mammograms to visualise that duct. The papilloma will be seen as an area that does not fill with contrast (a “filling defect”).
Which is the most common type of breast cancer
Invasive ductal carcinoma.
Invasive lobular carcinoma
Ductal carcinoma-in-situ (DCIS)
Lobular carcinoma-in-situ (LCIS)
Which is the most common type of breast cancer
Invasive ductal carcinoma.
- This is the most common type of breast cancer. To complicate matters further this has recently been renamed ‘No Special Type (NST)’. In contrast, lobular carcinoma and other rarer types of breast cancer are classified as ‘Special Type’
Invasive lobular carcinoma
Ductal carcinoma-in-situ (DCIS)
Lobular carcinoma-in-situ (LCIS)
Describe what is meant by Paget’s disease of the nipple [1]
Paget’s disease of the nipple is an eczematoid change of the nipple associated with an underlying breast malignancy and it is present in 1-2% of patients with breast cancer
- In half of these patients, it is associated with an underlying mass lesion and 90% of such patients will have an invasive carcinoma.
- 30% of patients without a mass lesion will still be found to have an underlying carcinoma. The remainder will have carcinoma in situ.
Describe the features of breast cancer [5]
- Breast lump: typically painless. Classically described as fixed, hard
- Breast skin changes
- Bloody nipple discharge
- Inverted nipple
- Axillary mass
- Skin dimpling or oedema (peau d’orange)
Describe the different types of surgery [2] for breast cancer and why they might be given to patients,
Give the reasons you would choose one / other [4]
Women either have a wide-local excision or a mastectomy:
- Around two-thirds of tumours can be removed with a wide-local excision.
Chemoprevention of breast cancer can occur with which drugs for: premenopausal [1] and post-menopausal [1]
What is the one pathological state that is a CI for post-menopausal women? [1]
Chemoprevention may be offered for women at high risk, with:
* Tamoxifen if premenopausal
* Anastrozole if postmenopausal (except with severe osteoporosis)
Which surgeries can be provided for high risk breast cancer patients [2]]
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.
When is radiotherapy offered for breast cancer? [1]
- Whole breast radiotherapy is recommended after a woman has had a wide-local excision as this may reduce the risk of recurrence by around two-thirds.
- For women who’ve had a mastectomy radiotherapy is offered for T3-T4 tumours and for those with four or more positive axillary node
Which are the three breast cancer receptors? [3]
- Oestrogen receptors (ER)
- Progesterone receptors (PR)
- Human epidermal growth factor (HER2)
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.
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 which breast cancers? [1]
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.
TOM TIP: What do you need to remember about a patient with breast cancer who has had axillary clearance (if they were re-emitted) [1]
TOM TIP: It is important to remember that you should avoid taking blood or putting a cannula in the 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.
What are the two first line treatments for oestrogen receptor positive breast cancers? [2]
Tamoxifen for premenopausal women
Aromatase inhibitors for postmenopausal women (e.g., letrozole, anastrozole or exemestane)
Which of the following is an aromatase inihibitor
Tamoxifen
Fulvestrant
Anastrozole
Leuprorelin
Trastuzumab
Pertuzumab
Which of the following is an aromatase inihibitor
Tamoxifen
Fulvestrant
Anastrozole
Leuprorelin
Trastuzumab
Pertuzumab
Which of the following is a selective oestrogen receptor modulator (SERM)
Tamoxifen
Fulvestrant
Anastrozole
Leuprorelin
Trastuzumab
Pertuzumab
Which of the following is a selective oestrogen receptor modulator (SERM)
Tamoxifen
Fulvestrant
Anastrozole
Leuprorelin
Trastuzumab
Pertuzumab
Which of the following is a selective oestrogen receptor downregulato
Tamoxifen
Fulvestrant
Anastrozole
Leuprorelin
Trastuzumab
Pertuzumab
Which of the following is a selective oestrogen receptor downregulato
Tamoxifen
Fulvestrant
Anastrozole
Leuprorelin
Trastuzumab
Pertuzumab
Which of the following targets the HER2 receptor [2]
Tamoxifen
Fulvestrant
Anastrozole
Leuprorelin
Trastuzumab
Pertuzumab
Which of the following targets the HER2 receptor
Tamoxifen
Fulvestrant
Anastrozole
Leuprorelin
Trastuzumab
Pertuzumab
Name three HER2 receptor drugs [3]
Trastuzumab (Herceptin) is a monoclonal antibody that targets the HER2 receptor. It may be used in patients with HER2 positive breast cancer. Notably, it can affect heart function; therefore, initial and close monitoring of heart function is required.
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).
Neratinib (Nerlynx) is a tyrosine kinase inhibitor, reducing the growth of breast cancers. It may be used in patients with HER2 positive breast cancer.
Tamoxifen increases the risk of which cancer? [1]
Why? [1] / Describe the MoA
increase the risk of endometrial cancer:
- 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.
Name three aromatase inhibitors [3]
Describe their MoA [1]
Letrozole, anastrozole or exemestane
Aromatase inhibitors work by blocking the creation of oestrogen in fat tissue.
It can be caused by bacterial infection, blocked milk ducts, or a combination of both. breast pain, swelling, redness, and warmth, as well as fever and flu-like symptoms in severe cases.
refers to which breast pathology?
Mastitis
most common organism causing infective mastitis is []
most common organism causing infective mastitis is Staphylococcus aureus
What is the treatment plan for mastitis?
the first-line management of mastitis is to continue breastfeeding.
simple measures
* analgesia
* warm compresses
the first-line antibiotic is oral flucloxacillin for 10-14 day
What is a complication of infectious mastitis [1]
Breast abscesses
- The infective organism is most commonly Staphylococcus aureus , and up to 50-60% of such cases have been reported to involve methicillin-resistant Staphylococcus aureus (MRSA)
Non-lactational breast abscesses may be caused by []
Non-lactational breast abscesses may be caused by duct ectasia, which is a thickening and widening of the mild duct generally seen in women aged 45-55, and that can cause mastitis and subsequent infection.
Describe the treatment regime for breast abscesses [3]
3Describe how you treat Paget’s disease of the nipple [4]
Surgery: The mainstay of treatment for Paget’s disease of the nipple is surgical. There are two primary surgical options:
* Breast-Conserving Surgery (BCS): It involves the excision of the nipple-areola complex and a margin of healthy tissue. Typically followed by radiation therapy or
* Mastectomy: recommended when an invasive or in situ carcinoma in the breast parenchyma is present, separate from the nipple-areola complex, or in the case of multifocal disease.
Systemic Therapy
- Patients with ER-positive tumours should be offered adjuvant hormonal therapy. HER2-positive tumours may benefit from targeted therapy with trastuzumab.
Prior to breast surgery for cancer, what do you investigate for as it determines management?
presence/absence of axillary lymphadenopathy determines management:
women with no palpable axillary lymphadenopathy at presentation:
- should have a pre-operative axillary ultrasound before their primary surgery
- if negative then they should have a sentinel node biopsy to assess the nodal burden
in patients with breast cancer who present with clinically palpable lymphadenopathy:
- axillary node clearance is indicated at primary surgery
-
Anastrozole is an aromatase inhibitor used for the treatment of oestrogen receptor-positive breast cancer in postmenopausal women
Name a significant risk of using this drug [1]
Patients taking these medications are at an increased risk of osteoporosis.
NB: tamoxifen causes amenorrhoea, endometrial cancer, vaginal bleeding and venous thromboembolism
In the UK, all women are offered breast cancer screening with mammography every [] years between the ages of 50 and 70 years.
In the UK, all women are offered breast cancer screening with mammography every 3 years between the ages of 50 and 70 years.
An obese woman presents with an irregular lump on the lateral aspect of her right breast associated with skin tethering. Biopsy excludes a malignant cause.
Suggest? [1]
Fat necrosis (the trauma can occur unnoticed)
A 41-year-old woman presents with a two-month history of an irregular fixed lump in her left breast.
Suggests? [1]
The combination of a persistent lump spanning at least one menstrual cycle and the irregularity point to a diagnosis of cancer.
A 56-year-old woman has recently been diagnosed with breast cancer. She attends an appointment with her consultant to discuss the potential treatment options. She has a solitary lesion in the upper outer quadrant of her right breast which is 2.5cm in diameter. Her cancer is staged as T2 N1 M0.
What management option is this patient most likely to be offered?
- Neoadjuvant FEC chemotherapy followed by a right-sided mastectomy
- Neoadjuvant FEC chemotherapy followed by a wide local excision
- Neoadjuvant FEC-D chemotherapy followed by a wide local excision and whole breast radiotherapy
- Right-sided mastectomy followed by FEC-D chemotherapy
- Right-sided mastectomy followed by whole breast radiotherapy
- Neoadjuvant FEC chemotherapy followed by a wide local excision
- Neoadjuvant FEC-D chemotherapy followed by a wide local excision and whole breast radiotherapy
- Right-sided mastectomy followed by FEC-D chemotherapy
- Right-sided mastectomy followed by whole breast radiotherapy
What four factors determine if a breast cancer surgery is a mastectomy? [4]
Multifocal tumour
Central tumour
Large lesion in small breast
DCIS > 4cm
What four factors determine if a breast cancer surgery is a wide local excision? [4]
DCIS < 4cm
Peripheral tumour
Solitary lesion
Small lesion in large breast
Describe what causes inflammatory breast cancer [1]
Describe the presentation of inflammatory breast cancer [1]
IBC is a rare but rapidly progressive form of breast cancer caused by obstruction of lymph drainage causing erythema and oedema
progressive erythema and oedema of the breast in the absence signs of infection such as fever, discharge or elevated WCC and CRP) and an elevated CA 15-3.
How do you treat inflammatory breast cancer? [3]
neo-adjuvant chemotherapy first-line, followed by total mastectomy +/- radiotherapy.
A 58-year-old undergoes a triple assessment after finding a lump in the right upper lateral quadrant of her breast. Her last menstrual period was 8 years ago, she has never used any hormonal contraceptives or hormone replacement therapy and has no other past medical history.
A biopsy shows the presence of ductal carcinoma in situ that is progesterone receptor-negative, HER2-negative, and oestrogen receptor-positive. She is offered a lumpectomy with adjuvant radiotherapy and endocrine therapy.
What is the mechanism of action of the most likely drug she will be given?
Complete oestrogen receptor antagonism
GnRH receptor agonism
GnRH receptor antagonism
Inhibition of peripheral oestrogen synthesis
Partial oestrogen receptor antagonism
tamoxifen
Inhibition of peripheral oestrogen synthesis
Tamoxifen works by which MoA? [1]
Complete oestrogen receptor antagonism
GnRH receptor agonism
GnRH receptor antagonism
Inhibition of peripheral oestrogen synthesis
Partial oestrogen receptor antagonism
Tamoxifen works by which MoA? [1]
Complete oestrogen receptor antagonism
GnRH receptor agonism
GnRH receptor antagonism
Inhibition of peripheral oestrogen synthesis
Partial oestrogen receptor antagonism
Periductal mastitis is common in smokers and may present with recurrent infections.
Treatment is with [].
Periductal mastitis is common in smokers and may present with recurrent infections. Treatment is with co-amoxiclav
A 20-year-old lady presents with a mobile lump in the upper outer aspect of her right breast. On examination she has a firm mobile mass in the upper outer quadrant of her right breast.
Fibroadenoma
Which of the following is associated with a halo sign on mammography
Breast cyst
Duct ectasia
Atypical ductal hyperplasia
Fibroadenoma95
Which of the following is associated with a halo sign on mammography
Breast cyst
Duct ectasia
Atypical ductal hyperplasia
Fibroadenoma
[] is recommended after a woman has had a wide-local excision as this may reduce the risk of recurrence by around two-thirds
Whole breast radiotherapy is recommended after a woman has had a wide-local excision as this may reduce the risk of recurrence by around two-thirds
Which drug do you use for perimenopausal women?
Anastrozole
Enoxaparin
Goserelin
Tamoxifen
Trastuzumab
Which drug do you use for perimenopausal women?
Anastrozole
Enoxaparin
Goserelin
Tamoxifen
Trastuzumab
