Breast Flashcards
Define breast cancer and the different types
Malignancy of breast tissue.
Ductal carcinoma in situ - confined to ducts and has not invaded the basement membrane; potential precursor for invasive ductal carcinoma.
Invasive ductal carcinoma - this is the most common form
Invasive lobular carcinoma
Paget’s disease of the breast - Paget’s cells in epidermis of nipple. Involved in DCIS or invasive ductal carcinoma
Phyllodes tumour - fast growing tumour of periductal stromal and epithelial cells; can be benign, borderline or malignant, premenopausal (40-50 years)
Explain the aetiology/risk factors of breast cancer
Combination of genetics (BRCA-1 and BRCA-2 genes) and environmental factors
Risk Factors: Increasing age Radiation Alcohol Smoking Gender (Female) Family history of breast or ovarian cancer (if <40yrs then very significant) Obesity
Prolonged exposure to oestrogen: Nulliparity (not having kids) Late Age at 1st Pregnancy Early menarche Late menopause No breastfeeding Combined Oral Contraceptive Pill >5 years HRT
Summarise the epidemiology of breast cancer
Most common cancer in women
Peak incidence 40-70 years old
Affects 1 in 9 females in the UK
What are the presenting symptoms of breast cancer?
New nipple inversion Nipple discharge (may be bloody) Nipple ulceration Skin changes eg peau d'orange New breast lump/swelling - usually painless Change in breast size or shape Axillary lump
Symptoms of malignancy: bone pain, weight loss
DCIS: asymptomatic and itching
What are the signs on physical examination of breast cancer?
Lump in the breast - firm, irregular borders, fixed to surrounding structures eg chest wall Peau d'orange Erythema of tissue Skin tethering Skin ulceration Nipple inversion Nipple discharge (DCIS)
Paget’s disease of the nipple: eczema-like hardening of the skin on the nipple (usually caused by Ductal Carcinoma in situ infiltrating the nipple)
Signs of metastases:
Spinal tenderness
Cervical or axillary lymphadenopathy
Hepatomegaly
What are the appropriate investigations for breast cancer?
Triple Assessment
- Full, focused breast lump history and examination
- USS (<35 years old) or mammography (>35 years old)
- Fine Needle Aspiration (fluid filled) or core biopsy (solid)
Sentinel Lymph Node Biopsy:
Radioactive tracer is injected into the tumour
Scan identifies the sentinel lymph node (first lymph node draining the cancer)
This node is then biopsied to check the extend of spread
Staging (primarily metastases to bone, lung, regional lymph nodes, liver and brain):
CXR
Liver ultrasound
CT (brain/thorax)
Bloods: FBC, U&Es, calcium, bone profile, LFTs, ESR
Cancer antigen CA 15-3 is used to monitor response to cancer treatment and recurrence.
What is the management of breast cancer?
Depends on Stage & Grade
Surgical with adjuvant or neoadjuvant chemotherapy or radiotherapy: Lumpectomy Wide local excision Masectomy Sentinal node removal Axillary clearance -> lymphoedema
Hormone therapy:
Tamoxifen – oestrogen antagonist (ER +ve tumours)
Trastuzumab (Herceptin) – anti-Her-2 receptor (HER +ve tumours)
Define fibroadenoma
A benign, smooth, well-circumscribed, mobile tumour formed of mixed fibrous and glandular tissue usually found in young women which moves in response to the menstrual cycle.
It arises from stromal and epithelial tissue.
Explain the aetiology/risk factors of fibroadenoma
Aetiology is unknown
Development is thought to be hormonally related (increased sensitivity to oestrogen)
Risk Factors: < 40 years old PMH of benign breast disease Medication: OCP/HRT Obesity History of fibroadenomas Early reproductive age (15-25 years)
Summarise the epidemiology of fibroadenoma
Most common in early reproductive years (< 40 years old)
Most common cause of breast lump in females <30
Multiple or large fibroadenomas are more common in Afro-Caribbean women
1/3 regress; 1/3 stay the same; 1/3 get bigger
What are the presenting symptoms of fibroadenoma?
Often asymptomatic, incidental finding
Painless, mobile breast lump
Lump may enlarge with increases in oestrogen eg during pregnancy
Slow growing lump
What are the signs on physical examination of fibroadenoma?
Smooth, well-demarcated, rubbery, mobile mass
No lymphadenopathy, skin or nipple changes etc
What are the appropriate investigations for fibroadenoma?
Triple Assessment:
- Clinical - history and examination
- USS (<35 years old) OR mammogram (>35 years old)
- FNA (if fluid-filled) OR core biopsy (if solid)
What is the management of a fibroadenoma?
Usually managed conservatively via active surveillance (most shrink naturally)
Surgery if large, complex or juvenile fibroadenoma
Vacuum Assisted Excision Biopsy
What are the possible complications of fibroadenoma?
Recurrence
Complex fibroadenomas may increase the risk of breast cancer
What is the prognosis of fibroadenoma?
Good prognosis
Define mastitis
Mastitis is inflammation of the breast with or without infection.
Mastitis with infection may be lactational (puerperal) or non-lactational (e.g. duct ectasia).
Non-infectious mastitis includes idiopathic granulomatous inflammation and other inflammatory conditions (e.g. foreign body reaction).
Define breast abscess
A localised area of infection with a walled-off collection of pus. It may or may not be associated with mastitis.
Explain the aetiology/risk factors of mastitis and breast abscesses?
Infectious mastitis and breast abscess are usually caused by bacteria colonising the skin - MOST COMMONLY STAPH AUREUS.
Streptococcus pyogenes and Staphylococcus epidermis can also be causative
Non-infectious mastitis may result from underlying duct ectasia or foreign material (eg nipple piercing, breast implant, or silicone).
Risk factors: Smoking Age >30 years old Lactation/breast-feeding Nipple injury/broken skin (eczema) Previous mastitis or breast abscess Prolonged mastitis can lead to breast abscess Nipple piercing/foreign body Skin infection Immunosuppresion Milk stasis (inadequate drainage, blocked ducts, milk oversupply, external pressure on the breast, infrequent feeding, or rapid weaning)
Summarise the epidemiology of mastitis/breast abscesses
Mastitis occurs in 1-10% of lactating women
Breast abscess occurs in 3-11% of women with mastitis
What are the presenting symptoms of mastitis/breast abscesses?
Flu-like symptoms Malaise Myalgia Fever Breast pain (sharp, shooting with breast feeding) Decreased milk outflow Warm, firm, tender, red breast swelling Purulent nipple discharge (pus-containing)
What are the signs on physical examination of mastitis/breast cancer?
Warmth/erythema Firmness Swelling Mass Nipple discharge Pyrexia
Atypical presentation: nipple inversion/retraction, tender axillary lymph nodes may suggest ipsilateral breast infection
What are the appropriate investigations for mastitis/breast abscesses?
Breast USS - abscess will show up as hypoechoic
Diagnostic needle aspiration drainage - purulent fluid suggests breast abscess
Fine needle aspiration
Nipple discharge cytology
Milk, aspirate, discharge or biopsy tissue - culture and sensitivity
Histopathological examination of biopsy tissue
What is the management of mastitis/breast abscess?
If negative culture and signs and symptoms have been present form less than 12-24 hours:
Effective milk removal (breast feeding 8-12 times a day, breast pumping, massage)
Supportive care (breastfeeding advice, analgesia)
Advice: increase fluids, warm and/or cold compress, bed rest
Severe/prolonged symptoms or systemic:
Empiric antibiotic therapy (flucloxacillin orally 4x a day)
Antifungal therapy for nipple candidiasis (for mother and infant)
Surgical intervention to drain abscess:
Needle aspiration with local anaesthesia with or without ultrasound guidance. Daily aspiration for 5-7 days may be necessary.
What are the possible complications of mastitis/breast abscess?
Cessation of breastfeeding
Breast abscess can be a complication of mastitis
Sepsis - due to bacteraemia in very young or immunosuppressed patients
Scarring
Functional mastectomy - breast unable to effectively lactate due to tissue destruction from infection
Necrotising fasciitis in childhood may be initiated by mastitis
Extra-mammary skin infection
Mammary fistula
What is the prognosis of mastitis/breast abscess?
With prompt, appropriate treatment, most breast infections will resolve without serious complications.
Mastitis resolves after 2-3 days of appropriate antibiotic therapy in most patients.
Lactational abscesses are easier to treat.
Most patients with breast infection can continue to breast feed.
Define breast cyst and fibrocystic breast changes
A benign condition of the breasts resulting in lumpy breasts with fluid filled sacs which fluctuate with hormonal changes of the menstrual cycle
Summarise the aetiology and risk factors of breast cysts
Fluctuates dependent on menstrual cycle as they are related to reproductive and hormonal factors
Risk factors: Nulliparity Late menopause Combined oral contraceptive pill Obesity Later age at first childbirth
Summarise the epidemiology of breast cysts
Incidence increases with age
Most common in peri-menopausal women in 40s-50s
What are the presenting symptoms of breast cysts?
Lumpy breasts
Breast lumps often in upper outer quadrant
Breast pain associated with menstrual cycle
Clear nipple discharge
Increased size of lump and breast tenderness during period (cyclical breast pain)
What are the signs on physical examination of breast cysts?
Fluctuant lump Mobile lump Smooth, well defined lump Transilluminable lump Clear nipple discharge Breast tenderness Lumpy breasts if multiple cysts Palpable breast mass
What are the appropriate investigations for breast cyst?
Mammography >35years old: dense breasts, circumscribed density
Breast Ultrasound <35 years old: breast cysts, solid mass
Cyst Aspiration (symptomatic women): should be clear/straw coloured. If bloody fluid, cytology required)
Breast Biopsy - indicated for solid masses to differentiate fibrocystic breasts and malignancy
Define benign ductal disease - intraductal papilloma and duct ectasia
Intraductal papilloma - small benign papillary tumour in lactiferous duct, causing bloody or serous nipple discharge. Can lead to ductal ectasia then breast cancer
Breast duct ectasia - dilatation of milk ducts due to blockage with ductal secretions
Summarise the aetiology of intraductal papilloma and duct ectasia
Due to changes in hormone levels
May be less common in patients on the OCP
SMOKING is the biggest risk factor for duct ectasia
Summarise the epidemiology of intraductal papilloma and duct ectasia
Peri-menopausal women
Very common
What are the presenting symptoms of intraductal papilloma and duct ectasia?
History of breast pain or discomfort - may be cyclical
Intraductal papilloma:
Serous or bloody nipple discharge
Often absence of lump
Duct ectasia:
Subareolar tender mass
Thick yellow/green nipple discharge
What are the signs on physical examination of intraductal papilloma and duct ectasia?
Subareolar mass
Focal or diffuse nodularity of breast
Duct Ectasia - causes thick yellow/green discharge
Features of malignancy will be ABSENT in benign breast disease: Dimpling, Peau d’orange, Enlarged axillary lymph nodes
What are the appropriate investigations of intraductal papilloma and duct ectasia?
Mammography (two-view) - intraductal papilloma may not be visualised as too small
USS in patients < 35 years
Fine Needle Aspiration (sent for cytological analysis)
Excision Biopsy: sent for histological analysis
