Breast Flashcards
What is mastitis and what Is it caused by?
Mastitis is inflammation of the breast tissue and caused by infection - Staph Aureus
What 2 types of mastitis are there?
- Lactational mastitis
seen in women breastfeeding
present during first 3 months
Associated with cracked nipples and milk stasis - Non lactational mastitis
Risk factors –> smoking and Duct ectasia
What are the clinical features and management of mastitis?
Clinical features
- Tenderness, swelling and erythema, induration
Management
- Abx - cephlaxin (beta lactam - cell wall inhibitor)
- In lactational mastitis - continued milk drainage and feeding is recommended
What are breast cysts and clinical features?
Breast cysts are epilthelial lined, fluid filled sacs, which form lobules when distended due to blockage
occurs in perimenopausal age
clinical Features:
- one or more lesions
- one or both breasts
- smooth, fluid filled masses
- can be tender
How do breast cysts appear on investigations
and give management?
Mammogram - Halo shape
Ultrasound - to confirm diagnosis
Aspiration - if persisting or symptomatic, or undeterminable
- if the fluid is free from blood or the lump disappears - cancer may be excluded
Management
- self resolving
- aspiration for aesthetic reasons or patient reassurance
What are the complications of breast cysts?
2-3x greater risk of developing breast cancer in the future
- Fibroadenosis (benign - fibrocystic change) - tenderness and asymmetry
What is mammary duct ectasia and what are the clinical features?
Duct ectasia is the shortening and dilation of the major lactiferous ducts.
It occurs in perimenopausal women
Clinical features
- Green or yellow nipple discharge
- Palpable mass
- Nipple retraction
What are the investigations and management for duct ectasia?
Investigations
- mammogram - Dilated calcified ducts without any malignant features
- Biopsy - multiple plasma cells
Management
- Conservative
- Duct excision - unremitting nipple discharge
What is fat necrosis and the clinical features?
Acute inflammation of the breast leading to ischaemic necrosis of the fat lobules
- associated with trauma
- previous surgical or radiological intervention to the breast
- usually asymptomatic
- Lump
- Less commonly - fluid discharge, skin dimpling, pain and nipple inversion
What investigations are used in fat necrosis and management?
Positive traumatic history Ultrasound - hypererchoic
Core biopsy - to rule out malignancy
Management
- self limiting
- analgesics and reassurance
What benign breast tumours are there?
Fibroadenoma
Adenoma
Papilloma
Lipoma
What is the most common benign growth in the breast?
Fibroadenoma
What age women get fibroadenomas?
Women of reproductive age more likely get fibroadenomas
What is a fibroadenoma and how does it appear?
Fibroadenomas are prolferations of stromal and epithelial tissue of the duct lobules
- high mobile lesions
- well defined and rubbery, smooth
- <5cm
- can be multiple and bilateral
What is the management of fibroadenoma?
There is a low malignancy potential
Can be left in situ with routine follow up appointments
- core biopsy or fine needle aspiration
What is an adenoma?
Benign glandular tumour (older female population)
Nodular lesions
- Easily mimic malignancy
- Most cases with escalate for triple assessment
What is a breast triple assessment?
- History + exam
- Imaging
- Histology
What is a papilloma?
Intraductal papillomas are benign breast lesions
- 40-50 yrs
biopsy
risk of breast cancer with multiductal papillomas
What are the general features of benign lesions?
- more mobile
- smoother borders
- can get multiple lumps
What are general features of malignant lesions?
Craggy surfaves
Firm consistency
Fixed to tissue
Single mass
subareolar region
blood or clear nipple discharge
require biopsy die to similarity to ductal carcinomas
What is gynaecomastia?
Development of breast tissue in males.
Due to the imbalance of Oestrogen and Androgens - delayed testosterone at puberty
Usually benign disease but breast cancer can develop in 1% cases
What is the difference between physiological and pathological gynaecomastia?
Physiological
- Occurs in adolescence
- Delayed testosterone surge relative to oestrogen at puberty
Pathological
- results from changes in the oestrogen:androgen ratio due to:
- Lack of testosterone - Klinedelte’s syndrome, renal disease
- Inc oestrogen levels - hyperthyroidism, obesity
- Medication - anabolic steroids, metronidazole, spironolactone
What are the clinical features of gynaecomastia?
Insidious onset (gradual and subtle )
- Rubbery or firm mass > 2cm
- Starts from underneath the nipple and spreads outwards over the breast region
What are the investigations and management of Gynaecomastia?
Investigations
- ask about associated symptoms and co morbidities
- if cause is unknown
do LFT’s, U&E’s, Hormone profile
Management
- If reversible cause - treatment of cause should allow for resolution of gynaecomastia
- Tamoxifen - helps alleviate tenderness
What is a Carcinoma and give examples?
Malignant breast tumour = cancer
- 1 in 8
Ductal carcinoma in situ
Lobular carcinoma in Situ
Invasive Ductal carcinoma
Invasive Lobular carcinoma
Describe a ductal carcinoma in Situ
- investigations and management
Most common non invasive malignant breast tumour.
It is a malignancy of the ductal tissue of the breast contained within the basement membrane
Inv
- Asymtomatic
- Detected on Mammogram - microcalcifications
- Local or wide spread
- Confirmed on biopsy
Management
- Localised - complete wide excision (all margins to ensure no residual disease)
- Widespread - complete mastectomy
Describe a Lobular Carcinoma in situ
- Investigations
- Management
Malignancy of secretory lobules of the breast tissue contained within the basement membrane
- greater risk of invasive breast cancer
Investigations
- asymptomatic
- Diagnosed on incidental finding during biopsy of breast
Management
- low grade - monitoring
- Invasive - Bilateral prophylactic mastectomy (BRCA1/2+)
What is the most common Invasive breast cancer?
Invasice ductal carcinoma is the most common (75-85%)
- tubular, cribiform, papillary, mucinous
Invasive lobular carcinoma makes up 10% of cases
- older women
- Diffuse
Others
- medullary carcinoma
- colloid carcinoma
What are the risk factors of Invasive carcinomas?
- female
- Age (double every 10 yrs until menopause)
- FH
- BRCA1/2
- Previous benign disease
- Obesity + high alcohol intake
- Unopposed oestrogen
- Early menarche
- late menopause
- Nulliparous women (no pregnancies)
- HRT use
- first pregnancy after 30 yrs old
What are the features of malignant breast tumours?
- Breast lump (hard and craggy)
- Asymmetry
- Swelling
- abnormal nipple discharge
- Nipple retraction
- Skin changes
- Mastalgia
- Palpable lump in axilla
Differentials for breast lump
Malignant tumour
Benign tumour
Breast cyst
Infective causes
When is mammogram vs USS used?
Mammogram
- women > 40 yrs
- more fatty tissue = easier to see densities
characteristics
- ill defined, spiculated mass
- parenchymal distortion
- Overlying skin thickening
- malignant calcifications
- enlarged axillary lymph nodes
USS
- women < 40 yrs
- firm and dense glandular tissue
- ill defined and hyperechoic mass
- distal acoustic shadowing
- Surrounding halo caused by oedema and tumour infiltration
- abnormal axillary nodes
What age are the breast screening programmes?
50 - 70 yrs +/- 3 yrs
What are the different hormone treatments?
Tamoxifen
- premenopausal
Aromatase inhibitor
- post menopausal
Immunotherapy
- Express specific growth factor receptors
Describe Tamoxifen
Used for pre menopausal women
- Blocks oestrogen ER receptors
- Prophylaxis against breast cancer
Dis
- Risk of VTE - during and after surgery or periods of immobility
- Inc risk of uterine carcinoma (pre
Describe Aromatase inhibitors
Post menopausal women
- Blocks ER receptors and inhibits further malignant growth
- Prevents further oestrogen production
- Blocks conversation of androgens to oestrogen in peripheral tissues
- anastrozole
- Letrozole
Dis
- joint and muscle aches
