Breast Flashcards
How would you go about investigating a 60 year- old lady who presented to you having found a lump, about 2 cm across, in her left breast?
Triple assessment: 1. History and examination 2. Imaging (mammography) 3. Sampling (FNA or biopsy) Features on history would be pain, duration, growth pattern, associated symptoms etc. Examination would include palpation for size, tenderness, consistency, further lumps. also assess peua dorange, nipple retraction, discharge etc. Ask patient to put hands on hip and head to look for movement of the lump). Determine family history, BRACA1/2 mutation and exposure to oestrogen
What are the risk factors for breast cancer?
Non-modifiable -> BRACA 1/2 gene, FHx, female, age
Modifiable -> oestrogen exposure, smoking, alcohol
Describe the options for adjuvant treatment for breast cancer.
Adjuvant occurs after surgical intervention
Depends on histopathology:
ER, PR treatment, chemotherapy, radiotherapy
What are the surgical options for a small confirmed cancer which is sited laterally in the breast, is not fixed to the skin, deep tissue or nipple?
What are the advantages and disadvantages of the options?
Wide local excision (SN biopsy) -> breast sparing, faster recovery, body image. Higher recurrence rates, need for radiotherapy
Mastectomy -> reduces recurrence. Body image issues, longer recovery, radiotherapy
Discuss with the patient the pros and cons of a wide local excision of the lesion sparing the nipple, and a mastectomy. Give the patient an option. Wide excision more cosmetically pleasing, mastectomy has less of a chance for recurrence. Radiotherapy is often required for both procedures. Discuss the need for a sentinel node biopsy (first draining node) -> especially with wide excision procedure
What are the important differential diagnoses for a breast lump?
Benign -> fibroadenoma, sebaceous cyst, abscess, galactocele, fat necrosis, periductal mastitis
Malignant -> DCIS, LCIS, sarcoma, lymphoma
What is the influence of a patient’s age on the choice of imaging for breast cancer?
Density of the breast tissue. Under 40 requires and U/S 40-55 U/S and mammography 55+ mammography Younger breast tissue is too dense for mammography
A 26 year-old woman presents to the ED with a painful, hot, swollen left breast. She is five weeks post partum with her first child and has been breast feeding successfully. She was prescribed antibiotics for the problem five days ago by her GP but has been getting worse. She has no systemic previous medical history, takes no regular medication. On examination, she is febrile, and has a fluctuant swelling in the left lower quadrant of her left breast with overlying erythema. What is the diagnosis?
What is the treatment?
Diagnosis is breast abscess
treatment is incision and drainage of the abscess. Provide analgesia. Continue breast feeeding. Consider continuation of Abx.
Organism is most likely staph or introduced from newborn
How would you go about investigating a 16 year- old girl who presented to you having found a lump, about 2 cm across, in her left breast?
History and examination
Imaging with USS
FNA or biopsy
What is the most likely organism that might be causing an acute, lactation associated, breast abscess?
Staph aureus.
Most likely due to abrasions and lacerations in the skin around the nipple allowing entry of bacteria. Poor drainage may also allow pathogens introduced by neonate to infect
What is the management of an acute lactation associated breast abscess?
Continue to breastfeed.
Incision and drainage of the abscess.
Analgesia
ABx
A 30 year-old woman presented with a painful lump in her left breast five days after childbirth. This is a photograph of the breast. What is the likely diagnosis and what is the management?
Likely to be breast abscess following lactational mastitis.
Incision and drainage of the abscess. Continue breastfeeding. Abx
A 50 year-old woman is diagnosed with breast cancer. Her surgeon recommends a “lumpectomy” and sentinel node biopsy. The pathology report shows a 20 mm grade 3 ER positive, PR positive, HER-2 negative cancer, without lymphovascular invasion, and a negative sentinel node biopsy.
Q1. Describe three “adjuvant” treatments that would be potentially beneficial to her referring to the aims of each treatment and distinguishing between the aims of adjuvant systemic therapy and adjuvant local therapy.
Radiotherapy -> reduce the size of tumour and prevent recurrence. Indicated in large, poorly differentiated, highly dysplastic tumours, nodal involvement +4, breast conserving therapy
Chemotherapy -> indicated with N1 involvement. Complete this before other adjuvant therapies
Hormonal therapy -> indicated with any ER/PR + cancer
premenopausal (SERM)
postmenopausal (aromatase inhibitor)
A 30 year-old man presents with a 3.2 mm melanoma on his right arm. A wide excision and sentinel node biopsy is performed. One node is removed from the right axilla as part of the sentinel node procedure. It contains a 0.3 mm deposit of melanoma.
Q1. What are the biological arguments for and against proceeding to an axillary clearance?
Axillary clearance should only be performed of there is a +ve node in the area, as there is the risk of micromets. Therefore this patient requires an axillary clearance
Arguments against include greater hospital recovery, increased complications (pain, seroma nerve injury), no health benefit
A 53 year-old man presents with a pearly nodule on his back that has, according to the patient “come up fairly quickly in the last six weeks”. It is bleeding when he rubs it with a towel.
Q1. How should you mange this problem?
Most likely diagnosis is a BCC.
Can either confirm diagnosis with a punch/shave biopsy, and then procede to excision depending on results.
Can excise immediately and get confirmation histology after. Margin should be 3-4mm for non melanoma
A 55 year-old woman presents with a breast lump.
Q1. What assessment process should be used to investigate this woman?
Triple assessment
