Breast Flashcards
What is Paget’s disease of the Nipple?
Paget’s disease is an eczematoid change of the nipple associated with an underlying breast malignancy and it is present in 1-2% of patients with breast cancer.
Investigations in Paget’s disease of the nipple?
Diagnosis is made by punch biopsy, mammography and ultrasound of the breast.
Paget’s disease of the nipple vs eczema of the nipple?
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).
What are the non malignant breast diseases? 5
Duct ectasia Periductal mastitis Intraductal papilloma Breast abscess TB
What is duct ectasia?
Duct ectasia is a dilatation and shortening of the terminal breast ducts within 3cm of the nipple. Mammary duct ectasia may be seen in up to 25% of normal female breasts
Duct ectasia is a normal varient of breast involution and is not the same condition as periductal mastitis
What is periductal mastitis?
Periductal mastitis
Present at younger age than duct ectasia
May present with features of inflammation, abscess or mammary duct fistula
Associated with smokers
What is intraductal papilloma?
Intraductal papilloma (rarely a palpable lump)
Growth of papilloma in a single duct
Usually presents with clear or blood stained discharge originating from a single duct
No increase in risk of malignancy
What is breast abscess and how do you treat it?
Breast abscess
Lactational mastitis is common
Infection is usually with Staphylococcus aureus
On examination there is usually a tender fluctuant mass
Treatment is with antibiotics and ultrasound guided aspiration
Overlying skin necrosis is an indication for surgical debridement, which may be complicated by the development of a subsequent mammary duct fistula.
What is debridement?
Debridement is the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue.
What is an indication for surgical debridement in a breast abscess?
Overlying skin necrosis is an indication for surgical debridement, which may be complicated by the development of a subsequent mammary duct fistula.
How many women does mastitis affect?
1 in 10 breast feeding women
What is the first line management for a women with mastitis?
The first-line management of mastitis is to continue breastfeeding.
The BNF advises treating ‘if systemically unwell, if nipple fissure present, if symptoms do not improve after 12-24 hours of effective milk removal or if culture indicates infection’. The first-line antibiotic is flucloxacillin for 10-14 days, reflecting the fact that the most common organism causing infective mastitis is Staphylococcus aureus. Breastfeeding or expressing should continue during treatment.
What is the first line management for a women with mastitis?
The first-line management of mastitis is to continue breastfeeding.
The BNF advises treating ‘if systemically unwell, if nipple fissure present, if symptoms do not improve after 12-24 hours of effective milk removal or if culture indicates infection’.
The first-line antibiotic is flucloxacillin for 10-14 days, reflecting the fact that the most common organism causing infective mastitis is Staphylococcus aureus. Breastfeeding or expressing should continue during treatment.
What is the most common organism that causes infective mastitis?
Staphylococcus aureus
What happens if mastitis is left untreated?
It can develop into a abscess which will need drainage and incision
How does duct ectasia present and at what age?
Patients usually present with nipple discharge, which may be from single or multiple ducts (usually present age >50 years)
The discharge is often thick and green
How do you treat patients with troublesome discharge?
Patients with troublesome nipple discharge may be treated by microdochectomy (if young) or total duct excision (if older).
What is a breast fibroadenoma, how is it managed?
Develop from a whole lobule
Mobile, firm breast lumps
12% of all breast masses
Over a 2 year period up to 30% will get smaller
No increase in risk of malignancy
If >3cm surgical excision is usual,
What is the most common type of breast cancer?
Invasive ductal carcinoma
Some may arise as a result of ductal carcinoma in situ (DCIS)
How are most breast cancers described as?
Most breast cancers arise from duct tissue followed by lobular tissue, described as ductal or lobular carcinoma respectively. These can be further subdivided as to whether the cancer hasn’t spread beyond the local tissue (described as carcinoma-in-situ) or has spread (described as invasive).
What are the 4 main types of breast cancer?
Invasive ductal carcinoma. - Not special type
Invasive lobular carcinoma
Ductal carcinoma in situ (DCIS)
Lobular Carcinoma in situ (LCIS)
What is inflammatory breast cancer?
Inflammatory breast cancer where cancerous cells block the lymph drainage resulting in an inflamed appearance of the breast. This accounts for around 1 in 10,000 cases of breast cancer.
When should you refer people to the breast clinic 2WW?
Aged 30 and over and have an unexplained breast lump with or without pain or
Aged 50 and over with any of the following symptoms in one nipple only: discharge, retraction or other changes of concern
When should you consider a referral to the breast clinic 2WW?
With skin changes that suggest breast cancer or
Aged 30 and over with an unexplained lump in the axilla
What are some genetic risk factors for breast cancer?
Predisposing factors
BRCA1, BRCA2 genes - 40% lifetime risk of breast/ovarian cancer
1st degree relative premenopausal relative with breast cancer (e.g. mother)
What are other risk factors for breast cancer?
Nulliparity, 1st pregnancy > 30 yrs (twice risk of women having 1st child < 25 yrs)
early menarche, late menopause
combined hormone replacement therapy (relative risk increase * 1.023/year of use), combined oral contraceptive use
past breast cancer
not breastfeeding
ionising radiation
When might you not offer surgery to breast cancer patients?
Very elderly, frail woman with metastatic disease who may better be treated with hormonal therapy
What are the two surgeries that can be done for breast cancer?
Wide local excision
Mastectomy
Indications for a wide local excision procedure?
Solitary lesion
Peripheral tumour
Small lesion In a large breast
DCIS < 4cm
Indications for a mastectomy?
Multifocal tumour
Central tumour
Large lesion in a small breast
DCIS > 4cm
When is radiotherapy offered to women for breast cancer?
Whole breast radiotherapy is recommended after a woman has had a wide-local excision as this may reduce the risk of recurrence by around two-thirds. For women who’ve had a mastectomy radiotherapy is offered for T3-T4 tumours and for those with four or more positive axillary nodes
What are 3 important side effects of tamoxifen?
Increased risk of endometrial cancer, venous thromboembolism and menopausal symptoms.
When is hormonal therapy used?
If the tumour is positive for hormone receptors.
When is an axillary node clearance performed for breast cancer?
If there are positive lymph nodes
What is the MoA of Tamoxifen?
Oestrogen receptor antagonist
Which type of breast cancer is more common in younger patients with BRCA1 mutations?
Medullary
What age group of women are routinely screened for breast cancer in the UK?
50-70
How often are women between 40-70 offered breast cancer screening?
3 years
What is the mechanism of action of letrozole?
Aromatase inhibitor
What are the clinical features of Paget’s disease of the breast”
Eczema of the nipple
Itching of the nipple
Lump behind the nipple
Nipple discharge - may be bloody
What modality of imaging if preferred in patients <35 years old in triple assessment of breast lumps?
US
What are the aspects of the breast triple assessment?
Clinical assessment
Imaging
Biopsy
What is the management of fat necrosis?
No management required
What are the lifestyle risk factors for breast cancer?
Obesity
Alcohol
Smoking
What proportion of breast cancer is composed of Phyllodes tumour?
1%
Which receptors are tested in all breast cancers?
Progesterone receptors
Oestrogen receptors
HER2 receptors
Which nerve is most at risk during an axillary node clearance?
Long thoracic nerve
To which lymph nodes does breast cancer most commonly metastasise?
Axillary or cervical
On which chromosome is BRCA1 found?
Ch17
Does BRCA1 or BRCA2 give a high lifetime risk of ovarian cancer?
BRCA1
What is the underlying tumour in Paget’s disease of the breast?
Invasive ductal carcinoma (Ductal carcinoma in situ [possible)
What are the clinical features of fibroadenomas?
Young age of presentation (peaking in early 20s) Firm, non-tender mass Rounded with smooth edges Highly mobile Normally don’t grow beyond 3cm
What is the most common cell type involved in breast tumours?
Ductal
What are some of the examination features of invasive breast cancer?
Irregular, hard lump Tethering to the skin or chest wall Surrounding oedema Peau d’orange skin Skin changes or eczema
What age group is most commonly affected by fibrocystic breast disease?
20-50 years old
What investigation should a patient with suspected fat necrosis of the breast undergoes?
Triple assessment to exclude cancer
Inheritance pattern of BRCA1 and BRCA2?
Autosomal Dominant
What are the possible complications of axillary node clearance?
Lymphoedema
Damage to brachial plexus cords or nerves - particularly long thoracic nerve
Axillary artery/vein injury
Why does Tamoxifen lead to an increased risk of endometrial cancer?
Weak endometrial tissue agonist
Which adjunctive drug can be used in HER2 positive breast tumours?
Trastuzumab (otherwise known as Herceptin)
What are the features of fibrocystic breast disease?
Bilateral “lumpy” breasts – more commonly in upper outer quadrant
Breast pain
Symptoms which worsen with the menstrual cycle – normally peaking 1 week before menstruation
What is the peak age of presentation for fibroadenomas?
Early 20s
Weeping, crusting lesion overlying the right nipple, the areolar region is not involved.
Paget’s disease of the nipple
A weeping, crusty lesion such as this is most likely to represent Pagets disease of the nipple (especially since the areolar region is spared). Although no mass lesion is palpable, a proportion of patients will still have an underlying invasive malignancy (hence the lymphadenopathy)
How does fat necrosis present?
More common in obese women with large breasts
May follow trivial or unnoticed trauma
Initial inflammatory response, the lesion is typical firm and round but may develop into a hard, irregular breast lump
Rare and may mimic breast cancer so further investigation is always warranted
How does fibroadenosis present ?
Fibroadenosis (fibrocystic disease, benign mammary dysplasia)
Most common in middle-aged women
‘Lumpy’ breasts which may be painful. Symptoms may worsen prior to menstruation
How does duct papilloma present?
Local areas of epithelial proliferation in large mammary ducts
Hyperplastic lesions rather than malignant or premalignant
May present with blood stained discharge
How does mammary duct ectasia present?
Dilatation of the large breast ducts
Most common around the menopause
May present with a tender lump around the areola +/- a green nipple discharge
If ruptures may cause local inflammation, sometimes referred to as ‘plasma cell mastitis’
An 88-year-old lady presents with a large mass in the upper inner quadrant of her right breast. Investigations confirm an oestrogen receptor positive, invasive ductal carcinoma. She has declined operative treatment.
Endocrine therapy using letrozole
Elderly patients may be managed using endocrine therapy alone. Eventually most will escape hormonal control. In post menopausal women oestrogens are produced by the peripheral aromatization of androgens and aromatase inhibitors are therefore the most popular agent in this age group.
A 74-year-old woman presents with a breast lump. On examination, it has a soft consistency. The lump is removed and sliced apart. Macroscopically there is a grey, gelatinous surface.
Mucinous carcinoma
A 53-year-old woman presents with a bloody nipple discharge. On mammography there is calcification behind the nipple areolar complex. A core biopsy shows background benign change, but cells that show comedo necrosis which have not breached the basement membrane.
DCIS
Comedo necrosis is a feature of high nuclear grade ductal carcinoma in situ. It is has a high risk of being associated with foci of invasion.
Snowstorm sign on US?
Implant rupture
A 45 year old woman presents with a 3cm breast lump. She undergoes a mammogram, biopsy and CT scan for staging. Investigations reveal this to be a single ER+ve, HER2-ve tumour, confined to the breast. What is the next stage of management?
Wide local excision since its less than 4cm and surgery is first line for breast cancer
You can use tamoxifen afterwards since its ER positive
The discharge is bilateral and pale in colour. The volume is small and on examination, there are no masses palpable. She is concerned she has breast cancer. What is the most likely diagnosis?
Hormonal changes
Bilateral, small volumes of discharge is unlikely to be breast cancer
What is the T staging for breast cancer?
The T staging is as follows:
T1 <2cm,
T2 2-5cm,
T3 5+cm,
T4a invades chest wall,
T4b invades skin (includes ulceration or oedema),
T4c invades chest wall and skin,
T4d inflammatory breast cancer.
How does inflammatory breast cancer present and how is it treated?
inflammatory breast cancer (IBC) as evidenced by the typical appearance (progressive, erythema and oedema of the breast in the absence signs of infection such as fever, discharge or elevated WCC and CRP) and an elevated CA 15-3.
It is usually a primary cancer and is managed with neo-adjuvant chemotherapy first-line, followed by total mastectomy +/- radiotherapy.
A 48-year-old lady presents with discomfort in the right breast. On examination she has a discrete soft fluctuant area in the upper outer quadrant of her right breast. A mammogram is performed and a ‘halo sign’ is seen by the radiologist.
Breast cyst
Lesions such as breast cysts compress the underlying fat and produce a radiolucent area (halo sign). If symptomatic these cysts should be aspirated.
