Breast Flashcards
RF for breast cancer
FHx, Age, uninterrupted oestrogen exposure Nulliparity 1st pregnancy >30y Early menarche Late menopause HRT, COCP Obesity BRCA genes Not breastfeeding Past Breast Ca 1st degree premenopausal relative with breast ca
Triple assessment
All lumps should undergo triple assessment
Clinical exam
Radiology- USS <35y, mammography + USS >35
Histology/cytology- FNA code biopsy, US guided core biopsy best for new lumps
Differentials for breast pain
Cyclical mastalgia,
Breast cancer
Non-malignant, non-cyclical: Angina Gallstones Lung disease Thoracic outlet syndrome Oestrogen/HRT Tietze’s syndrome- costochondritis + swelling of costal cartilage Bornholm Disease
Causes of nipple discharge
Duct ectasia- green/brown/red, multiple ducts, bilateral
Intraductal papilloma/adenoma/carcinoma- bloody discharge, single duct
Lactation
Breast lump Qs
Previous lumps FHx Pain Nipple discharge Nipple inversion Skin changes Change in size related to menstrual cycle Number of pregnancies First/last/latest period Postnatal Breast feeding Drugs e.g. HRY Consider metastatic disease- weight loss, breathlessness, back pain, abdominal mass
Breast pain Qs
SOCRATES Bilateral/ unilateral Rule out cardiac chest pain History of trauma Masses Related to menstrual cycle
Nipple discharge Qs
Amount
Nature- colour, consistency, blood
Management of nipple discharge
Diagnose cause- mammogram, USS, ductogram
Duct ectasia- smoking cessation reduces discharge from duct ectasia
Microdochectomy/total duct excision
Breast exam general steps
Inspection- size and shape of any masses, overlying surface. Which quadrant, skin involvement- ulceration, dimpling, nipple inversion/discharge
Palpation of breast- confirm size and shape of any lump. Fixed/tethered to skin or underlying structures, fluctuante/compressible/hard? Tender? mobile
Palpation of lymph nodes- metastatic spread, ispilateral/bilateral, fixed
Further examination- abdomen for hepatomegaly, spine for tenderness, lungs (metastatic spread)
Fibroadenoma
Benign overgrowth of collagenous mesenchyme of one breast lobule.
<30y
Firm, smooth, mobile lump
Painless
May be multiple
1/3rd regress, 1/3rd stay the same, 1/3 get bigger
Rx: observation and reassurance. If in doubt- USS +/- FNA. Surgical excision if large >3cm
no increased risk in malignancy
Breast cysts
Common >35y Benign, fluid filled rounded lump Not fixed to surrounding tissue Occasionally painful Rx: diagnosis confirmed on aspiration
Mastitis/breast abscesses
Infection of mammary duct often associated with lactation- usually s.aureus
Abscess presents as painful, hot swelling of breast segment
Rx: ABx. Open incision or percutaneous drainage of abscess
Duct ectasia
Typically around menopause
Ducts became blocked and secretions stagnate
Nipple discharge (green/brown/bloody) +/- nipple retraction +/- lump
Refer for confirmation of diagnosis
Usually no Rx needed
Advise to stop smoking
Fat necrosis
Fibrosis and calcification after injury to breast tissue
Scarring results in a firm lump
Refer for triple assessment
No Rx once diagnosis confirmed
Stages of breast cancer
Stage 1: confined to breast, mobile
Stage 2: growth confined to breast, mobile, lymph nodes in ipsilateral axila
Stage 3: tumour fixed to muscle (but not chest wall), ipsilateral lymph nodes matted and may be fixed, skin involvement larger than tumour
Stage 4: complete fixation of tumour to chest wall, distant metastases
Treatment of breast Ca- local disease
Surgery- removal of tumour by wide local excision or mastectomy +/- breast reconstruction + axillary node sampling/surgical clearance or sentinel node biopsy
Radiotherapy
Chemotherapy
Endocrine agents- aim to reduce oestrogen activity. Used in ER and PR +ve disease. Tamoxifen, aromatase inhibitors, GnRH monologues
Support
Reconstruction
2ww referral guideline
Urgent referral- >30y with unexplained breast lump, >50y with symptoms or change to one nipple
Consider urgent referral if: skin changes, >30y with axillary lump
Consider 2ww if
skin changes that suggest breast cancer
>30y with unexplained lump in axilla
consider non urgent referral
<30 with unexplained breast lump +/- pain
Types of breast cancer: most common
Invasive ductal carcinoma (most common)
Invasive lobular carcinoma
Ductal carcinoma in situ
Lobular carcinoma in situ
indications for mastectomy
Multifocal tumour Central tumour Large lesion in small breast DCIS >4cm Choice
Indications for WLE
Solitary lesion Peripheral tumour Small lesion in large breast DCIS <4cm Choice
Causes of nipple discharge
Physiological
Galactorrhoea- emotional event, drugs
Hyperprolactinaemia- pituitary tumour
Mammary duct ectasia- dilatation breast ducts. thick and green
Carcinoma- blood
Intraductal papilloma- younger patients, blood stained
Fibroadenosis
Middle aged women
‘Lumpy’ breasts which may be painful. Symptoms may worsen prior to menstruation
Paget’s disease of the breast
Intraductal carcinoma associated with reddening and thickening of nipple/areola
May resemble eczema
Diagnosis- punch biopsy, mammography and USS of breast
Treatment of breast cancer
Surgery Radiotherapy Hormone therapy Biological therapy Chemotherapy
