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Year 3 Diseases > Breast > Flashcards

Breast Flashcards

1
Q

Define breast cancer and the different types

A

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)

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2
Q

Explain the aetiology/risk factors of breast cancer

A

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
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3
Q

Summarise the epidemiology of breast cancer

A

Most common cancer in women
Peak incidence 40-70 years old
Affects 1 in 9 females in the UK

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4
Q

What are the presenting symptoms of breast cancer?

A 
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

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5
Q

What are the signs on physical examination of breast cancer?

A 
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

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6
Q

What are the appropriate investigations for breast cancer?

A

Triple Assessment

  1. Full, focused breast lump history and examination
  2. USS (<35 years old) or mammography (>35 years old)
  3. 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.

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7
Q

What is the management of breast cancer?

A

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)

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8
Q

Define fibroadenoma

A

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.

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9
Q

Explain the aetiology/risk factors of fibroadenoma

A

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)
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10
Q

Summarise the epidemiology of fibroadenoma

A

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

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11
Q

What are the presenting symptoms of fibroadenoma?

A

Often asymptomatic, incidental finding
Painless, mobile breast lump
Lump may enlarge with increases in oestrogen eg during pregnancy
Slow growing lump

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12
Q

What are the signs on physical examination of fibroadenoma?

A

Smooth, well-demarcated, rubbery, mobile mass

No lymphadenopathy, skin or nipple changes etc

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13
Q

What are the appropriate investigations for fibroadenoma?

A

Triple Assessment:

  1. Clinical - history and examination
  2. USS (<35 years old) OR mammogram (>35 years old)
  3. FNA (if fluid-filled) OR core biopsy (if solid)
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14
Q

What is the management of a fibroadenoma?

A

Usually managed conservatively via active surveillance (most shrink naturally)
Surgery if large, complex or juvenile fibroadenoma
Vacuum Assisted Excision Biopsy

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15
Q

What are the possible complications of fibroadenoma?

A

Recurrence

Complex fibroadenomas may increase the risk of breast cancer

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16
Q

What is the prognosis of fibroadenoma?

A

Good prognosis

17
Q

Define mastitis

A

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).

18
Q

Define breast abscess

A

A localised area of infection with a walled-off collection of pus. It may or may not be associated with mastitis.

19
Q

Explain the aetiology/risk factors of mastitis and breast abscesses?

A

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)
20
Q

Summarise the epidemiology of mastitis/breast abscesses

A

Mastitis occurs in 1-10% of lactating women

Breast abscess occurs in 3-11% of women with mastitis

21
Q

What are the presenting symptoms of mastitis/breast abscesses?

A 
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)
22
Q

What are the signs on physical examination of mastitis/breast cancer?

A 
Warmth/erythema
Firmness
Swelling
Mass
Nipple discharge
Pyrexia

Atypical presentation: nipple inversion/retraction, tender axillary lymph nodes may suggest ipsilateral breast infection

23
Q

What are the appropriate investigations for mastitis/breast abscesses?

A

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

24
Q

What is the management of mastitis/breast abscess?

A

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.

25
Q

What are the possible complications of mastitis/breast abscess?

A

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

26
Q

What is the prognosis of mastitis/breast abscess?

A

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.

27
Q

Define breast cyst and fibrocystic breast changes

A

A benign condition of the breasts resulting in lumpy breasts with fluid filled sacs which fluctuate with hormonal changes of the menstrual cycle

28
Q

Summarise the aetiology and risk factors of breast cysts

A

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
29
Q

Summarise the epidemiology of breast cysts

A

Incidence increases with age

Most common in peri-menopausal women in 40s-50s

30
Q

What are the presenting symptoms of breast cysts?

A

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)

31
Q

What are the signs on physical examination of breast cysts?

A 
Fluctuant lump
Mobile lump
Smooth, well defined lump
Transilluminable lump
Clear nipple discharge
Breast tenderness
Lumpy breasts if multiple cysts
Palpable breast mass
32
Q

What are the appropriate investigations for breast cyst?

A

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

33
Q

Define benign ductal disease - intraductal papilloma and duct ectasia

A

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

34
Q

Summarise the aetiology of intraductal papilloma and duct ectasia

A

Due to changes in hormone levels
May be less common in patients on the OCP
SMOKING is the biggest risk factor for duct ectasia

35
Q

Summarise the epidemiology of intraductal papilloma and duct ectasia

A

Peri-menopausal women

Very common

36
Q

What are the presenting symptoms of intraductal papilloma and duct ectasia?

A

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

37
Q

What are the signs on physical examination of intraductal papilloma and duct ectasia?

A

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

38
Q

What are the appropriate investigations of intraductal papilloma and duct ectasia?

A

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

Year 3 Diseases (23 decks)

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