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Gynaecology > Breast > Flashcards

Breast Flashcards

1
Q

What are risk factors for breast cancer?

A 
Alcohol 
Age 
Smoking 
Obesity (only post-menopausal as if pre-menopausal more likely to stop periods) 
oestrogen exposure
Radiation exposure 
Family history- genes (BRAC1 and 2, Tp53, PTEN, STK11, CDH1) 
LCIS - Lobular carcinoma in situ
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2
Q

What causes increased oestrogen exposure?

A

OCP and HRT (exogenous oestrogens)
Early menarche or late menopause (more exposure to oestrogens)
Nulliparity or not breast feeding (no interruption to oestrogen exposure)
Breast density (more adipose tissue means more oestrogen production)

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3
Q

What is ductal carcinoma in situ?

A

pre-invasive disease

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4
Q

what are the two different types of histological cancer and what do they mean?

A

ductal and lobular. Lobular is harder to feel, see and more diffuse

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5
Q

What do grades for cancer mean?

A

how well differentiated the cells are I.e. grade 1 is well differentiated

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6
Q

WHat is the immunophenotype for breast cancer?

A

oestrogen (ER), progesterone (PgR) or HER-2 receptors - determines therapies given

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7
Q

What is the breast cancer screening for BRAC vs non- BRAC?

A

30-50 years annual MRI screen if BRAC gene or similar high risk Fhx

For 47-73 year old every 3 years with mammography

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8
Q

Why is a MRI done for younger women in screening?

A

more dense and glandular breast which are easier to see on MRI

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9
Q

How does a mammograph work?

A

Mammography involves breast compression with a low dose x-ray and look for something “spiky”
Mammography is done in two different planes – cranio-caudal and medio-lateral oblique
Good for detecting DCIS

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10
Q

Name some positives and negatives of breast cancer screening?

A

+ves - True positives and negatives; Decreased mortality

-ves- Test anxiety; Overdiagnosis; False positives and negatives; Costs; XR dose increases risk of cancer slightly

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11
Q

How may breast cancer present?

A 
Lump- hard, irregular, fixed and tethered, painless 
Axillary lympadenopathy 
Ulceration 
Nipple discharge or bleed 
Peau d’orange 
Nipple inversion 
Dimpling 
Tethering 
Mets eg bone fracture or seizure - commonly mets occur in bones, lungs, liver n brain
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12
Q

What is Paget’s disease of the nipple?

A

eczematous change of the nipple due to an underlying malignancy (spreading from duct/lobule onto skin)- Paget’s disease differs from eczema of the nipple in that it involves the nipple primarily and only latterly spreads to the areolar (the opposite occurs in eczema).

90% of such patients will have an invasive carcinoma.

Diagnosis is made by punch biopsy, mammography and ultrasound of the breast.

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13
Q

What are the signs of T4 (locally invasive) cancer?

A
  • Ulceration
  • Peau d’orange, (mammary skin oedema,
  • Inflammatory breast cancer
  • Fixed to chest wall
  • Fixed, matted axillary lymph nodes
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14
Q

What should you ask about and examine in a breast lump hx?

A

Lump- smooth or irregular? Size? Shape? Fixed? Where – use clock face? Symmetry? Soft or hard? Skin changes, nipple changes, lymphadenopathy

HRT, contraception 
Menopause, age 
Menarche age 
Previous mammograms 
Fhx- age diagnosis and who 
Ask about breastfeeding and children if considering mastitis
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15
Q

What are the indiciations for a mammograph?

A

Clinically suspicious lump in patients in >40 years, Residual lump after cyst aspiration, Single duct blood stained nipple discharge, Nipple skin change, National Breast Screening Programme.

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16
Q

What ix should be done for a breast lump in <25 yrs?

A

Histology or cytology only. No imaging if clinically feels benign. Ultrasound if clinically indeterminate or suspicious.

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17
Q

What ix should be done 25-40 years?

A

Breast ultrasound plus histology or cytology: Triple assessment.

18
Q

What ix should be done for >40 yrs?

A

Mammography and ultrasound and either histology or cytology: Triple assessment.

19
Q

What is the gold standard ix for breast lump assessment?

A

core biopsy

20
Q

Describe the difference between the two histology/ cytology ix?

A

Fine needle- assess cells in cytology

Core biopsy- allows further differentiation of the type of cells via histology as bigger tissue sample

21
Q

What is triple assessment?

A

(1) clinical assessment (2) radiological assessment (US/MMG) and (3) pathological assessment (FNA, core biopsy).
Want the 3 in to be in CONCORDANCE

22
Q

What is the surgical mx of breast cancer?

A

Lumpectomy – same as a mastectomy in terms of outcomes unless cancer is multifocal or takes up majority of breast tissue or has spread to skin/lymph nodes

Mastectomy -single/double

Oncoplastics- breast reshaping later

Axillary disease – axillary node clearance

sentinel node biopsy

23
Q

What is axillary node clearance vs sentinel node biopsy?

A

axillary node clearance – low reoccurrence and gives prognostic info. But can cause seroma formation and damage to the brachial nerves
sentinel node biopsy where the first node in the chain is identified by a radioisotopes and is then to histology if positive then clearance is done

24
Q

What are indications for a mastectomy vs lumpectomy + conservation?

A

mastectomy:
- pt choice
- large tumour (relative to breast)
- multi-focal
- sub-areolar
- very strong fhx (likely reoccur)
- inflammatory breast cancer

lumpectomy:

  • pt choice
  • uni-focal, primary tumour
  • suitable for radiotherapy
25
Q

What is used for prognosis and staging of breast cancer?

A

TNM staging: T is size, N is lymph nodes and M is mets.

Nottingham prognosis index and PREDICT index

26
Q

What are the non-surgical options for breast cancer? Whta are their indications?

A

Adjuvant therapies
–> have before surgery in locally invasive cancer

adjuvant chemotherapies eg Herceptin (monoclonal Ab) - used in HER-2 postive women

Bisphosphonates for bony mets

Chemo- more indicated if tumour aggressive (high grade) or pt younger.

Radiotherapy- lumpectomy or mastectomy with T3/T4

27
Q

Give examples of adjuvant therapies and when they are clinically indicated

A

Adjuvants are used in oestrogen receptor postive cancers:

eg tamoxifen if pre-menopause
eg aromatase inhibitors if post-menopause

different as different sources of oestrogen in post-menopause

28
Q

Give some SE of chemo and radiotherapy

A

chemo- Can cause alopecia, N+V, ulcers, neutropenic sepsis

radio- can cause skin fibrosis, loss of elasticity and fat necrosis

29
Q

Give some SE of tamoxifen

A

Tamoxifen- causes hot flushing, N+V, PV bleed and slight increase risk in endometrial cancer

30
Q

Give some examples of causes of benign breast lumps

A

fibroadenoma
benign breast change
cyst
papilloma

31
Q

Summarise fibroadenomas

A

25-30 years
Smooth, mobile, non-tender, “breast mouse”
1-3 cm size
Usually biopsy to check - mixture of stromal and glandular tissue (treat with aspirate)

32
Q

Summarise cysts

A

May feel cystic or may feel similar to cancer
Can aspirate
Normally disappear with menopause unless of HRT

33
Q

Summarise benign breast changes

A 
Often tender 
Very common 
Cyclical variation  
Feels like rubbery nodularity 
Management: reassure
34
Q

summarise duct papillomas

A

Lump behind nipple, blood/ clear discharge from nipple - duct papilloma
benign tumour in milk ducts
usually younger than mammary duct ectasia
Multiple ones associated with breast cancer
Triple assess

35
Q

summarise mastitis

A

A tender, red, swollen, and hard area of the breast, usually in a wedge-shaped distribution.
usually UNILAT
May be pyrexia with it
lump DOES NOT fluctuate
usually caused by milk stasis from BREASTFEEDING
commonly caused by s.aureus
Could be inflammatory breast cancer so be careful
give dicloxacillin

36
Q

What is a breast abscess

A

complication of mastitis - so are breastfeeding
collection of pus
A painful, swollen lump in the breast, with redness, heat, and swelling of the overlying skin.
lump FLUCTUATES
fever

37
Q

mx of mastitis?

A

Prescribe an oral antibiotic if the woman has a nipple fissure that is infected, symptoms have not improved (or are worsening) after 12–24 hours despite effective milk removal, and/or breast milk culture is positive.
If breast milk culture results are available, treat with an antibiotic that the organism is sensitive to.
If breast milk culture results are not available:
Treat empirically with flucloxacillin

38
Q

Summarise a galactocele

A 
A galactocele (also called lacteal cyst or milk cyst) is a retention cyst containing milk 
gradual onset
painless, hard
usually breastfeeding
can lead to abscess
39
Q

What is mastalgia?

A

breast pain

likely the result of an underlying benign condition such as fibrocystic breast changes or a single cyst or fibroadenoma.

may be cyclical - will be: Usually starts during the luteal phase of the cycle (within 2 weeks before menses), increases until menstruation begins, and improves after menses.
Is dull, heavy, or aching in nature.
Is usually bilateral.
May be poorly localized and extend to the axilla.

40
Q

How does inflammatory breast cancer present?

A

Inflammatory breast cancer presents with erythema and oedema of the breast, with or without an underlying mass. Sometimes painful.
This type of cancer is less likely to be oestrogen receptor positive and more likely to be HER2 positive than non-inflammatory breast cancers.

41
Q

Describe mammary duct ectasia

A

around menopause, thick green discharge, widening of ducts, nipple inversion

42
Q

Describe fat necrosis

A

Obese, trauma, non-tender lump with bruise over top - fat necrosis (trauma causes fat to release and a cyst form - can aspirate)

Gynaecology (12 decks)

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