Breast Flashcards
What is duct ectasia?
Duct ectasia is when the ducts become blocked and secretions stagnate, causing nipple discharge (+ or - nipple retraction and/ or lump) (BENIGN)
What is the aetiology / risk factors of benign ductal disease (duct ectasia & papilloma)?
In duct ectasia, the central ducts become dilated with ductal secretion due to a blockage of the lactiferous ducts.
Both occur near the menopause age.
What is the epidemiology of benign ductal disease (duct ectasia &papilloma)?
Occurs in women around the time of menopause
What are the presenting symptoms of benign ductal disease (duct ectasia and papilloma)?
Duct ectasia: green/brown/bloody nipple discharge
(intraductal)
Papilloma: small lump near nipple, discharge. Multiple papillomas are smaller and occur further away from the nipple.
Swelling or lump. History of breast discomfort/pain
What are the signs of benign ductal disease (duct ectasia and papilloma) on physical examination?
Focal or diffuse modularity of the breast
Discharge
Features of malignancy are ABSENT e/g/ dimpling, enlarged axillary lymph nodes, peau d’orange (orange peel like appearance- inflammatory breast cancer)
What are the appropriate investigations for benign ductal disease (duct ectasia & papilloma)?
Triple assessment:
- Clinical examination
- Imaging (mammography and ultrasonography)
- Needle biopsy (fine needle aspiration- cytology, excision biopsy- histology)
What are the two regions that the breast is composed of?
The circular body and the axillary tail
What is the pigmented area of skin surrounding the nipple?
Areolae
What is the function of mammary glands?
Mammary glands are modified sweat glands, consisting of a series of ducts and secretory lobules.
Each lobule consists of many alveoli drained by a single lactiferous duct which converge at the nipple.
What is the function of connective tissue stroma?
A supporting structure surrounding the glands
What are the three lymph nodes that receive lymph from the breast tissue?
Axillary nodes (75%) Parasternal nodes (20%) Posterior intercostal nodes (5%)
What does breast cancer assessment involve?
Triple assessment: 1. Clinical examination 2. Imaging- Mammogram if > 35 years Ultrasonography if < 35 years - tissue is too dense 3. Biopsy
What are the common associations with breast cancer?
Due to blockages the lymphatic drainage: excess lymph builds up in the subcutaneous tissue therefore clinical features include-
Nipple deviation and retraction
Prominent skin between small dimpled pores (peau d’orange)
What is a fibroadenoma?
BENIGN overgrowth of collagenous mesenchyme of one breast lobule
Benign tumour that consists of glandular and connective tissue
What is the aetiology / risk factors of fibroadenoma?
Formed of a combination of stromal and epithelial tissue
1/3 regress
1/3 stay the same
1/3 get bigger
What is the epidemiology of fibroadenoma?
Common in 15-35 years olds.
What are the presenting symptoms of fibroadenoma?
Firm, smooth, rubber, mobile lump
Painless
May be multiple
What are the signs of fibroadenoma on physical examination?
Firm, smooth mobile lump
What are the appropriate investigations for fibroadenoma? Interpret the results
Triple assessment:
Clinical examination- firm, smooth mobile lump
Imaging- oval or round, circumscribed (confined to a limited area) lump. May have coarse calcifications.
Biopsy- will show epithelial and stromal elements
What is the management plan for a patient with fibroadenoma?
Observation and reassurance- usually no treatment needed
If in doubt refer for USS + or - fine needle aspiration
If large, growing quick, causing discomfort or preferred by patient- surgical excision done by excisional biopsy
What are the possible complications of fibroadenoma?
Most fibroadenomas (only complex but again is uncommon) do not affect you risk of breast cancer. Complications of surgical excision are rare.
What is the prognosis for patients with fibroadenoma?
Benign tumour with usually no treatment needed
1/3 regress
1/3 stay the same
1/3 get bigger
What are the 6 types of benign breast disease?
- Fibroadenoma
- Duct ectasia
- (Intraductile) papilloma
- Breast cyst
- Fibrocystic damage
- Sclerosing adenosis
What is mastitis?
Inflammation of the breast with or without infection
What are breast abscesses?
A breast abscess is a localised area of infection with a walled-off collection of pus
It may or may not be associated with mastitis (as a complication)
What are the two types of mastitis with infection?
Lactational (puerperal)
Non-lactational (e.g. duct ectasia)
What is the aetiology for mastitis/ breast abscesses?
Infectious mastitis and breast abscesses are usually caused by bacteria colonising the skin. Cases due to Staphylococcus aureus are by far the most common.
Non-infectious mastitis may result from underlying duct ectasia and infrequently foreign material (e.g. nipple piercing, breast implant)
What is the epidemiology for mastitis/breast abscesses?
The global prevalence of mastitis in lactating women is approximately 1% to 10% but may be higher.
Breast abscess develops in 3% to 11% of women with mastitis
What are the presenting symptoms for mastitis/breast abscesses?
Fever
Decreased milk outflow (if lactational)
Breast warmth/ tenderness/ swelling/ redness (erythema)
Flu like symptoms- malaise and myalgia
What are the signs of mastitis/breast abscesses on physical examination?
Breast erythema
UNCOMMON: Breast mass, fistula, nipple inversion/retraction, nipple discharge, lymphadenopathy, extra-mammary lesions
What are the appropriate investigations for mastitis/breast abscesses?
1st line:
Breast ultrasound-hypoechoic lesion (abscess), may be well circumscribed, irregular, or ill defined
Diagnostic needle aspiration- purulent fluid indicates a breast abscess
Cytology of nipple discharge or needle aspirate- indicate infection/malignancy
(CMS- cytology, microscopy and sensitivity)
Others: pregnancy test, mammogram, blood culture
What is the management for mastitis/breast abscesses?
The goal of treatment for mastitis is to provide prompt and appropriate management to prevent complications such as a breast abscess.
Lactational:
- Effective milk removal
- Antibiotic therapy
- Warm compresses
- Symptomatic relief
Non-lactational:
- Antimicrobial therapy (observational period)
- Supportive measures should include analgesia, if necessary.
- For granulomatous mastitis (idiopathic granulomatous inflammation)- glucocorticosteroids
What are the complications of mastitis/breast abscesses?
Breast abscesses (less than 10% of patients with mastitis)
Cessation of breastfeeding (most patients can continue to breastfeed)
Sepsis
Scarring (recurrent infections)
Functional mastectomy (breast that is unable to effectively lactate as a complication of prior tissue destruction from infection or treatment)
What is the prognosis for mastitis/breast abscesses?
When treated promptly and appropriately, most breast infections, including abscess, will resolve without serious complications.
Resolution of mastitis after 2-3 days of appropriate antibiotic therapy is expected among most patients.
Lactational abscesses tend to be easier to treat than non-lactational abscesses- these are multi-factorial and have a greater risk of becoming chronic
What is papilloma?
Papilloma is a wart-like lump that develops in one or more of the milk ducts (BENIGN)
What is fine needle aspiration?
A type of biopsy procedure where a thin needle is inserted into an area of abnormal-appearing tissue or body fluid
What are the indications for fine needle aspiration?
Removes some fluid or cells from a breast lesion (a cyst, lump, sore or swelling) with a fine needle used in cytology, microscopy and sensitivity to help make a diagnosis
What are the possible complications for fine needle aspiration?
Minimal bleeding and bruising, especially for those taking anticoagulation or anti-platelet medication- can result in a tender, swollen area called a hematoma.
Infection at the biopsy site is rare, because sterile techniques and equipment are used for all fine needle aspirations.
Rare complication is pneumothorax
What are breast cysts?
Fluid-filled sacs inside the breast, which are usually benign
What are breast cysts often described as?
Round or oval lumps with distinct edges- usually feels like a grape or a water-filled balloon, but can sometimes feel firm
What is the aetiology of breast cysts?
Breast cysts develop as a result of fluid accumulation inside the glands. Can be micro cysts where they are too small to feel but can picked up on imagining or macro cysts which are large enough to feel.
Large cysts can put pressure on nearby breast tissue, causing breast pain or discomfort
What is the epidemiology of breast cysts?
Breast cysts are common in women before menopause, between ages 35 and 50
But they can be found in women of any age
They can also occur in postmenopausal women taking hormone therapy
What are the presenting symptoms of breast cysts?
- Smooth, easily movable round or oval lump with distinct edges (which typically, though not always, indicates it’s benign)
- Nipple discharge that may be clear, yellow, straw coloured or dark brown
- Breast pain or tenderness in the area of the breast lump
- Increase in breast lump size and breast tenderness just before your period
- Decrease in breast lump size and resolution of other symptoms after your period
*can be found in one or both breasts. Can be multiple.
What are the signs of breast cysts on physical examination?
Smooth, easily movable round or oval lump with distinct edges
What are the appropriate investigations for breast cysts?
Three step approach:
- Clinical examination
- Imaging
- Needle biopsy (fine needle aspiration- cytology, excision biopsy- histology)
What is the management for breast cysts?
Don’t require treatment unless a cyst is large and painful or uncomfortable - draining the fluid from a breast cyst can ease symptoms
What is breast cancer?
A malignancy originating in the breast(s) and nodal basins
What is the aetiology of breast cancer?
Unknown.
Factors that have a role:
-Genetic: 5% to 10% of breast cancers are linked to inherited genetic mutations- BRCA1 and BRCA2 mutations are the most common inherited genetic mutation found in breast cancer
-Hormonal: increased levels of endogenous sex hormones (oestrogen) increase risk of breast cancer
What is the epidemiology of breast cancer?
Breast cancer is the most common female malignancy
It is most commonly diagnosed in middle-aged or older women (median age at diagnosis is 62 years)
Women are affected 100x more than men
What are the presenting symptoms of breast cancer?
Breast mass (does not have to be a new mass)
Nipple discharge
Skin thickening
Retraction of the nipple
What are the signs of breast cancer on physical examination?
Breast mass:
-Is it tender?
-Are there changes in the size or character of the mass?
-Have the characteristics of the mass have been affected by the menstrual cycle
Nipple discharge:
-May be watery, serous, milky, or bloody
-Bloody discharge is more classically associated with a neoplasm
Axillary lymphadenopathy:
the probability of axillary nodal involvement increases in proportion to the size of the tumour (clinical assessment can be inaccurate- imaging is needed)
Overlying skin changes:
-Peau d’orange (dimpling of the skin)
-Erythema
-Ulceration
*always associated with locally advanced or inflammatory breast cancer
Retraction of the nipple: may be related to Paget’s disease of the breast
What are the appropriate investigations for breast cancer?
Triple assessment:
(clinical examination)
-Mammogram: an irregular spiculated mass, clustered microcalcifications, and linear branching calcifications
-Core biopsy: histological findings confirming an invasive ductal carcinoma, invasive lobular carcinoma, medullary carcinoma, mucinous carcinoma, or metaplastic carcinoma
Other imaging:
- Breast ultrasound (adjunct to mammogram): a hypoechoic mass, an irregular mass with internal calcifications, and enlarged axillary lymph nodes
- Breast MRI: more sensitive but less specific, used in screening for patients with positive FH
