BREAST Flashcards
What is mastalgia and how common is it?
Breast pain, over 50% of women suffer at some point
How common is breast cancer?
1 in 8 women, most common in females in UK
On breast examination, give 7 red flag symptoms for breast cancer
Painless lump Skin distortion Bloody nipple discharge Nipple inversion Axillary lymphadenopathy Ulcers Paget's nipple disease
Give risk factors for breast cancer (10)
Increasing age Family history of breast/ovarian cancer (BRCA1/2) Young age at menarche Late menopause Nulliparity Obesity HRT Not breastfeeding Past breast cancer Alcohol
What is the triple assessment test?
Clinical examination
Radiological imaging (mammography, USS)
Pathology (histology, cytology)
What is mammography?
Low dose X rays of the breast, where the breast is compressed between 2 plates to flatten tissue and improve resolution
What is breast screening?
To detect cancer at pre-invasive stage Mammography for all women between 50 and 70 every 3 years After 70 if self organised Under 50 if high risk Trial between 47-73
What is shown on mammogram in ductal carcinoma in situ?
Microcalcification
What is shown on mammogram in carcinoma?
Irregular spiculated mass
When is breast ultrasound used?
When there is a known lesion or suspicious area already identified
How are patients under 25 investigated for breast cancer?
Histology or cytology only, ultrasound if clinically suspicious
How are patients 25-40 investigated?
Breast ultrasound plus histology or cytology
How are patients over 40 investigated?
Mammography and ultrasound and either histology or cytology
When is MRI offered for breast cancer? (3)
Annually between 30-50 if high risk family history for screening
To assess extent of diffuse cancers and lymph node involvements
To assess possible recurrence of breast cancer after treatment
How is tissue diagnosis done in breast cancer? (2)
Fine needle aspiration cytology
Core biopsy
What is fine needle aspiration cytology?
Needle being passed through a lump many times whilst applying suction to the syringe
What is core biopsy?
Needle fired into the lesion to remove a core of tissue, with US guidance
Increased accuracy of diagnosis
What increases breast cancer risk in men? (4)
Age
Family history
Klinefelter’s
Possible use of oestrogens
Disadvantages of breast cancer screening? (4)
Time to attend mammograms
Psychological distress waiting for results
Procedures such as biopsy that are negative
Overdiagnosis - cancer diagnosis that would never have become symptomatic
How much has breast cancer screening reduced mortality by?
15-30%
What is pre-invasive disease in breast cancer?
Ductal carcinoma in situ
Two histological types of invasive breast cancer?
Ductal - invasive ductal carcinoma most common
Lobular - more diffuse
How is breast cancer graded?
1 - well differentiated cells, low mitotic rate
3 - badly differentiated, high mitotic rate
What is the immunophenotype of a breast cancer?
If it is oestrogen receptor, progesterone receptor or HER-2 receptor positibe
What is oestrogen receptor positive cancer?
Expressed on >50%
Good prognosis
Cancer is sensitive to oestrogen which stimulates the tumour
Anti-oestrogens will help
What is progesterone receptor positive cancer?
Indicator of sensitivity to anti-oestrogens
Good prognosis
What is HER-2 receptor positive cancer?
Expressed in 15% Poor prognosis Receptor for epidermal growth factor More aggressive cancer Use trastuzumab
What is triple negative breast cancer?
Cancers which do not express oestrogen receptors, progesterone receptors of HER-2 receptors
Very aggressive
Common in younger patients
Where does breast cancer metastasise to? (4)
Bone, liver, brain, lungs
How is stage 1-2 cancer treated?
Wide local excision surgery or mastectomy (+/- reconstruction) with axillary node sampling/clearance or sentinel node biopsy
Radiotherapy to remaining breast if conserved
Adjuvant chemotherapy
Why is radio/chemotherapy used in breast cancer?
To target micro-metastases and prevent recurrence
May be used to shrink a tumour before surgery
Palliation for mets
When is hormonal therapy used in breast cancer?
All women with oestrogen sensitive breast cancer
What hormonal therapy is used in breast cancer adjuvant to surgery?
Tamoxifen - selective oestrogen receptor modulator - inhibits breast oestrogen receptors
Aromatase inhibitors - prevent peripheral conversion of androgens to oestrogens in post menopausal women
How is Her-2 receptor positive breast cancer treated?
Trastuzumab (herceptin) adjuvant to surgery
How is locally advanced breast cancer treated (stage 3)?
Non surgically - hormonal, chemo/radiotherapy
May be offered surgery depending on response
What is paget’s disease of the nipple?
Eczematous change of the nipple due to an underlying malignancy
How is stage 4 metastatic breast cancer treated?
Endocrine therapy if oestrogen or HER-2 positive
Radiotherapy to reduce pain
Chemotherapy
Bisphosphonates for bones
Name some types of breast reconstructions? (6)
External prosthesis Skin sparing mastectomy Silicone/saline implant Acellular dermal matrix and dermal sling with implant Latissimus dorsi flap +/- implant TRAM flap
Give 4 signs of surgically significant (potential malignancy) nipple discharge
Persistent
Unilateral
Spontaneous
Bloody or clear
What are 3 causes of bloody nipple discharge?
Duct papilloma
Duct ectasia
Invasive/in situ carcinoma
What is duct ectasia?
Lactiferous duct becomes blocked, can cause greenish or bloody discharge
Benign
What is duct papilloma?
Benign warty growth, usually with clear or bloody discharge
What is galactorrhoea?
Milky discharge, may be physiological or due to drugs
What are the two types of breast infection?
Lactational (usually peripheral breast) and non lactational (usually central i.e. duct ectasia)
Treatment of breast infection?
Aspiration
Lactational - flucloxacillin
Non-lactational - flucloxacillin plus metronidazole
How is breast pain classified?
Cyclical or non cyclical
Treatment of cyclical breast pain? (4)
Reassure
Proper bra
Danazol - weak androgen
Tamoxifen - short term
Treatment of non cyclical breast pain?
NSAIDs
Exclude other causes i.e. cardiac, MSK
What is breast nodularity?
Variation of normal - lumpy breasts, often cyclical so should reexamine after period
What is a fibroadenoma?
Common benign mobile lump especially <35yrs
1/3rd shrink, 1/3rd stay the same, 1/3rd enlarge (surgery to remove)
What is a breast cyst?
Abnormal response of part of the breast to hormonal stimulation, common between 40-60
Drain
What is gynaecomastia?
> 2cm lump of breast tissue behind the male nipple
What is pseudogynaecomastia?
Deposition of fat in overweight men
Physiological cause of gynaecomastia?
Imbalance of oestrogen and testosterone
Pathological causes of gynaecomastia? (3)
Drugs - spironolactone, anabolic steroids, oestrogen
Marijuana
Testicular failure or tumours
How is gynaecomastia treated?
Remove cause i.e. drug
Possible excision if embarrassment
If BRCA1/2 gene is present, what is lifetime risk of developing breast cancer?
80%
What is the treatment of women with BRCA1/2 genes?
Prophylactic mastectomy, reduces cancer chance by 90%
