Breast Flashcards
What is the breast triple assessment?
A hospital-based assessment clinic that allows for the early and rapid detection of cancer.
Components:
History/examination
Investigation
Histology
Imaging in the triple assessment?
Mammography
Ultrasound scanning
What is the scoring system in the triple assessment?
Exam score starts with P, imagine score starts with M or U, and histology score starts with B.
There is then a number that denotes the result of each component. 1 = Normal 2 = Benign 3 = Uncertain/likely benign 4 = Suspicious of malignancy 5 = Malignant
So e.g.
P1/M1/B1 would be a normal finding
When to use mammography or ultrasound?
Ultrasound is more useful in women <35 and in men.
What is mastitis?
Inflammation of the breast tissue, usually due to infection (s. aureus)
How can we classify mastitis?
Lactational mastitis (more common) Non-lactational mastitis
What are the clinical features of mastitis?
Tenderness
Swelling
Induration
Erythema
How do you manage mastitis?
Simple analgesics
Abx
If lactational, continued milk drainage/feeding is recommended
What is a breast abscess?
A collection of pus within the breast lined granulation tissue, most commonly developing from acute mastitis
How does a breast abscess present?
A tender fluctuant and erythematous mass, with potentially a punctum present
They can also have systemic symptoms, including:
Fever
Lethargy
How can we diagnose a breast abscess?
Ultrasound
How do we manage breast abscesses?
Initial phase - prompt empirical abx and US guided needle therapeutic aspiration
Advanced - incision and drainage under local anaesthetic
Complications of a breast abscess?
If non-lactational, it can cause formation of a mammary duct fistula (communication between the skin and subareolar breast duct)
What is a breast cyst?
An epithelial lined fluid-filled cavity which occurs when lobules become distended due to blockage, usually in the perimenopausal age group
Features of a breast cyst?
Can be singular or with multiple lumps
May affect one or both breasts
On palpation they appear as distinct smooth masses
How can we investigate a breast cyst?
Mammography - halo shape
Ultrasound
Aspiration (freehand or with US) and cytology
Management of a breast cyst?
No treatment, they self resolve
Larger cysts can be aspirated for aesthetic reasons
Does previous cysts affect your likelihood to have cancer in the future?
Yes. Patients with cysts are 2-3 times more likely to develop breast cancer in the future
What is mammary duct ectasia?
Dilation and shortening of the major lactiferous ducts
How does mammary duct ectasia present?
Yellow/green nipple discharge
Palpable mass
Nipple retraction
How do we investigate mammary duct ectasia?
Mammography - dilated, calcified ducts seen with no features of malignancy
How do we manage mammary duct ectasia?
Conservatively
Unremitting nipple discharge can be managed with duct excision
What is fat necrosis?
A common condition caused by an acute inflammatory response in the breast, leading to ischaemic necrosis of fat lobules
Often associated with trauma
Fat necrosis clinical features
Asymptomatic
Lump Fluid discharge Skin dimpling Pain Nipple inversion
If the inflammation persists, can cause a chronic fibrotic change leading to a solid irregular lump
Investigating fat necrosis
A hyperechoic mass on ultrasound
If they’re more developed they often feel a bit more irregular and as a result are more suspicious of cancer. Core biopsy will often be taken to rule out malignancy
Management of fat necrosis
Self-limiting
Analgesia
Reassurance
What is a fibroadenoma?
The most common benign growth. They are proliferations of stromal and epithelial tissue of duct lobules
Usually found in women of reproductive age
What are the examination findings of a fibroadenoma?
Highly defined Mobile Rubbery Less than 5cm usually They can be multiple and bilateral
Management of fibroadenoma
Left in situ with routine follow up appointments
Main indications for excision are >3cm in diameter or patient preference
What is a ductal adenoma?
A benign glandular tumour that typically occurs in the older female population
What are the features of a ductal adenoma?
Nodular
Mimic malignancy
Management of ductal adenoma?
As they are nodular and mimic malignancy, most cases undergo triple assessment
What is an intraductal papilloma?
A benign breast lesion that usually occurs in women in their 40/50s, mostly in the subareolar region
How does an intraductal papilloma present?
Clear or bloody nipple discharge
Sometimes as a mass
How do we treat intraductal papillomas?
As they can appear similar to a ductal carcinoma on imaging, they usually require biopsy
If multi-ductal papilloma, microdochectomy
What is a lipoma?
A soft and mobile benign adipose tumour
We don’t usually remove, but can if it’s causing symptomatic compression/aesthetic reasons
What are Phyllodes tumours?
These are rare fibroepithelial tumours composed of both epithelial and stromal tissue
What are the features of Phyllodes tumours?
Older age
Rapid growth
Often difficult to differentiate from fibroadenomas
Are Phyllodes tumours malignant?
10% have malignant potential
As a result they are usually widely excised (or mastectomy)
What causes gynaecomastia?
An imbalanced ratio of oestrogen and androgen activity
What are physiological causes of gynaecomastia?
Delayed testosterone surge relative to oestrogen during puberty
Older age - secondary to decreasing testosterone levels w/age
What are pathological gynaecomastia causes?
Lack of testosterone: Klinefelter's Androgen insensitivity Testicular atrophy Renal disease
Increased oestrogen levels: Liver disease Hyperthyroid Obesity Adrenal tumours Leydig cell tumours
Medication: Digoxin Metronidazole Spironolactone Chemo Anabolic steroids Antipsychotics
Idiopathic
Examination findings in gynaecomastia?
Rubbery/firm mass (>2cm in diameter) starting from underneath the nipple and expanding outward
Differentials of gynaecomastia?
Pseudogynaecomastia (basically they’re overweight)
Investigations in gynaecomastia?
To investigate the cause
If expecting malignancy, triple assessment
If unknown cause - check liver/renal function and hormone profile
Hormone profile results interpretation (gynaecomastia)?
LH high + low testosterone - testicular failure
LH low and testosterone low - increased ostrogen
LH high and testosterone high - androgen resistance or gonadotrophin secreting malignancy
How do we manage gynaecomastia?
Depnds on the causative factors
In many cases, just reassurance
Tamoxifen can alleviate symptoms (tenderness)
Paget’s disease of the nipple
Eczematous change of the nipple associated with invasive ductal carcinoma
Complications of axillary node clearance
Lymphoedema and functional arm impairment
