Breast Flashcards
Things to look for in breast exam
- assymetry
- scars
- implants
- tethering
- nipple eversion/inversion
- nipple discharge
- colour
- peau d’orange
- paget’s disease of the nipple
what is peau d’orange
irregular patch of skin assoc with inflammatory breast cancer
what is paget’s disease of the nipple
erythematous, scaly rash of nipple
how to assess a breast lump
- location
- size
- shape
- consistency
- margins
- mobile or fixed
- tenderness
- skin colour
- nipple discharge
what does assessment of a breast lump entail
triple assessment
- clinical
- imaging
- histology
signs suggestive of breast cancer
- Lumps that are hard, irregular, painless or fixed in place
- tethered lumps
- Nipple retraction
- Skin dimpling or oedema (peau d’orange)
what is fibroadenoma
common benign tumours of stromal/epithelial breast duct tissue
- smooth and mobile
- 20 to 40 yrs
- painless
- well circumscribed
- <3cm
what is fibrocystic breast changes
- response to oestrogen and progesterone to become fibrous and cystic
- benign
- lumpiness
- breast pain/tenderness
- fluctuation of breast size
Mx of fibrocystic breast change
- supportive bra
- NSAIDs
- avoid caffeine
- apply heat to the area
- hormonal treatments (danazol and tamoxifen)
What are breast cysts
- benign individual fluid filled lumps
- 30-50yrs
- smooth, well circumscribed, mobile lump
- possibly fluctuant
what is fat necrosis
benign lump formed by localised degeneration and scarring of fat tissue in the breast
can be assoc with oil cyst
no increased risk of cancer
trigger for fat necrosis
trauma
radiotherapy
surgery
presentation of fat necrosis
painless, firm, irregular, fixed in local structures, dimpling or nipple inversion
what is a lipoma
benign tumours of adipose tissue
soft, painless, mobile, no skin changes
conservative mx
what is a galactocele
- in lactating women after stopping breastfeeding
- breast milk filled cysts that occur when the lactiferous duct is blocked, preventing the gland from draining milk.
- firm, mobile, painless lump, beneath the areola
- benign
- resolve without mx
what is a phyllodes tumour
rare tumours of connective tissue of the breast
40-50 yrs
large and fast growing
benign, borderline or malignant
Mx- surgical removal
what is mastalgia
breast pain
cyclical or non-cyclical
what is cyclical breast pain
- related to hormonal fluctuations
- more common
- bilateral and generalised pain
- heaviness
- aching
what is non-cyclical breast pain
- 40 to 50yrs
- more localised
can be caused by: - medications (contraceptives)
- infection (mastitis)
- pregnancy
what do you need to exclude with mastalgia presentation
- cancer
- infection (mastitis)
- pregnancy
Mx of mastalgia
- supportive bra
- NSAIDs
- avoid caffeine
- heat
- hormonal treatments (danazol and tamoxifen)
what is gynaecomastia
enlargement of the glandular breast tissue in males
causes of gynaecomastia
- prolactinoma
- dopamine antagonists (antipsychotics)
- idiopathic
- physiological
- obesity
- testicular cancer (leydig)
- hyperthyroidism
- hCG secreting tumour
- testosterone deficiency
- Klinefelter’s
- anabolic steroids
- spironolactone
- alcohol, opiates & weed
Mx of gynaecomastia
treat underlying cause
if persistent
- tamoxifen
- surgery
what is galactorrhoea
breast milk production not associated with pregnancy or breastfeeding. Breast milk is produced in response to the hormone prolactin
causes of hyperprolactinaemia
- idiopathic
- prolactinoma
- endocrine disorder: hypothyroidism and PCOS
- antipsychotic meds
other sx assoc with galactorrhoea
Prolactin suppresses gonadotropin-releasing hormone (GnRH) by the hypothalamus, leading to reduced LH and FSH release.
- Menstrual irregularities, particularly amenorrhoea
- Reduced libido
- Erectile dysfunction
- Gynaecomastia
conditions that cause non milk nipple discharge
- Mammary duct ectasia
- Duct papilloma
- Pus from a breast abscess
what is mammary duct ectasia?
benign condition where there is dilation of the large ducts in the breasts
inflammation –> intermitten discharge (white, grey, green)
demographic for mammary duct ectasia
perimenopausal
smoking = RF
presentation of mamary duct ectasia
- Nipple discharge
- Tenderness or pain
- Nipple retraction or inversion
- A breast lump (pressure on the lump may produce nipple discharge)
Mx of mammary duct ectasia
can self resolve
- supportive bra
- warm compress
- abx if infection
-surgical excision of affected duct
what is intraductal papilloma
warty lesion that grows within one of the ducts in the breast. It is the result of the proliferation of epithelial cells.
benign
can be assoc with hyperplasia/ breast cancer
presentation of intraductal papilloma
- 35-55 yrs
- Nipple discharge (clear or blood-stained)
- Tenderness or pain
- A palpable lump
Mx of intraductal papilloma
complete surgical excision
what is lactational mastitis
inflammation of breast tissue and is a common complication of breastfeeding. It can occur with or without associated infection.
causes of mastitis
obstruction
infection (staph A)
presentation of lactational mastitis
- Breast pain and tenderness (unilateral)
- Erythema in a focal area of breast tissue
- Local warmth and inflammation
- Nipple discharge
- Fever
Mx of lactational mastitis
- continue breastfeeding
- heat pack and analgesia
- flucloxacillin for infection
complication of lactational mastitis
breast abscess
what is candida of the nipple
Candidal infection of the nipple can occur, often after a course of antibiotics
presentation of candida of the nipple
- Sore nipples bilaterally, particularly after feeding
- Nipple tenderness and itching
- Cracked, flaky or shiny areola
- Sx in the baby, such as white patches in the mouth and on the tongue (oral thrush), or candidal nappy rash
mx of candida of the nipple
Mother and baby need treatment:
- Topical miconazole 2% to the nipple, after each breastfeed
- Treatment for the baby (e.g., oral miconazole gel or nystatin)
what is a breast asbcess
collection of pus within an area of the breast, usually caused by a bacterial infection. This may be a:
- Lactational abscess
- Non-lactational abscess
what is pus
thick fluid produced by inflammation.
It contains dead white blood cells of the immune system and other waste from the fight against the infection
causes of breast abscess
- Staph A (MC)
- Streptococcal species
- Enterococcal species
- Anaerobic bacteria (such as Bacteroides species and anaerobic streptococci)
presentation of breast abscess
- acute
- Nipple changes
- Purulent nipple discharge
- Localised pain
- Tenderness
- Warmth
- Erythema
- Hardening of the skin or breast tissue
- Swelling
- swollen fluctuant tender lump
- fever
Mx of breast abscess
analgesia
abx
incision and drainage
MC&S of fluid
most common cancer in the UK
breast
RFs for breast cancer
- increased oestrogen exposure
- obesity
- smoking
- FH
- female
- more dense breast tissue
- COCP
- HRT
genes involved with breast cancer
BRCA 1(chr17) and 2 (chr13)
also increases ovarian cancer more BRCA1. BRCA2 prostate cancer risk
types of breast cancer
- ductal carcinoma in situ
- lobular carcinoma in situ
- invasive ductal carcinoma
- invasive lobular carcinoma
- inflammatory breast cancer
- paget’s disease of the nipple
- medullary
- mucinous
- tubular
describe DCIS
- Pre-cancerous or cancerous epithelial cells of the breast ducts
- Localised to a single area
- Often picked up by mammogram screening
- Potential to spread locally over years
- Potential to become an invasive breast cancer (around 30%)
- Good prognosis if full excised and adjuvant treatment is used
describe LCIS
- A pre-cancerous condition occurring typically in pre-menopausal women
- Usually asymptomatic and undetectable on a mammogram
- Usually diagnosed incidentally on a breast biopsy
- Represents an increased risk of invasive breast cancer in the future (around 30%)
- Often managed with close monitoring (e.g., 6 monthly examination and yearly mammograms)
describe invasive ductal carcinoma
- Originate in cells from the breast ducts
- 80% of invasive breast cancers fall into this category
- Can be seen on mammograms
Describe invasive lobular carcinomas
- Around 10% of invasive breast cancers
- Originate in cells from the breast lobules
- Not always visible on mammograms
describe inflammatory breast cancer
- 1-3% of breast cancers
- Presents similarly to a breast abscess or mastitis
- Swollen, warm, tender breast with pitting skin (peau d’orange)
- Does not respond to antibiotics
- Worse prognosis than other breast cancers
describe paget’s disease of the nipple
- Looks like eczema of the nipple/areolar
- Erythematous, scaly rash
- Indicates breast cancer involving the nipple
- May represent DCIS or invasive breast cancer
- Requires biopsy, staging and treatment, as with any other invasive breast cancer
what is breast cancer screening
mammogram every 3 years 50-70yrs
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
referral criteria for suspected breast cancer
- An unexplained breast lump in patients aged 30 or above
- Unilateral nipple changes in patients aged 50 or above (discharge, retraction or other changes)
- An unexplained lump in the axilla in patients aged 30 or above
- Skin changes suggestive of breast cancer
breast imaging modalities
- USS in <40s
- mammograms >40
breast cancer receptors
- 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.
most common sites of metastasis in breast cancer
2Ls and 2Bs
- L: lungs
- L: liver
- B: bones
- B: brain
Mx of breast cancer
- surgery (mastectomy or breast-conserving +radiotherapy)
hormone treatments for breast cancer
ER positive
- tamoxifen for premenopausal
- aromatase inhibitors (post menopausal)
Mechanism of aromatase inhibitors
Reducing peripheral synthesis of oestrogen
Mechanism of selective oestrogen receptor modulators (tamoxifen)
Partial antagonism of the oestrogen receptor
mx for HER2 positive BC
Herceptin (trastuzumab)
Perjet
NERATINIB
when don’t you use monoclonal antibodies
HER2 negative
which hormonal therapy is used for oestrogen receptor positive breast cancer
Tamoxifen- premenopausal (TAMPON)
Anastrazole- postmenopausal (ANCIENT)
inheritance pattern of BRCA gene
autosomal dominant, therefore children have 50% chance of inheritance so do siblings
People who get called for earlier breast screening
- one 1st degree female relative diagnosed <40 y/o or
one 1st degree male relative with breast cancer at any age, or
one 1st degree relative with bilateral breast cancer where the first primary was diagnosed <50 years - two 1st degree relatives, or one 1st degree + one 2nd degree relative, with breast cancer at any age
- one 1st degree or 2nd degree relative diagnosed with breast cancer at any age and one 1st/2nd degree relative with ovarian cancer at any age (one of these should be a first-degree relative)
- three 1st/2nd degree relatives with breast cancer at any age
