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Year 3 Knowledge - Conditions and Procedures > Breast > Flashcards

Breast Flashcards

1
Q

Define benign ductal disease (duct ectasia and papilloma).

A

Duct ectasia - a condition which occurs when a milk duct beneath the nipple widens, the duct walls thicken and the duct fills with fluid.

Papilloma - a group fo rare and benign papillary salivary gland tumours arising from the ductal system.

Inverted ductal papilloma - surface epithelial cells grow downward into the underlying supportive tissue

Sialadenoma papilliferum

Intraductal papilloma - 2-3% humans - the abnormal proliferation of epithelial cells lining the breast ducts (peripheral = higher risk of malignancy)

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2
Q

Explain the aetiology / risk factors of benign ductal disease (duct ectasia and papilloma).

A

As a result of secretory stasis, including stagnant colostrum, which also causes periductal inflammation and fibrosis.

Bilateral - maybe systemic causes?

Causes of Duct Ectasia:

  • Ageing - peri / post-menopausal age
  • Smoking
  • Inverted nipples
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3
Q

Summarise the epidemiology of benign ductal disease (duct ectasia and papilloma).

A

Ectasia - n/a

Papilloma - intraductal incidence 2-3%

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4
Q

Recognise the presenting symptoms of benign ductal disease (duct ectasia and papilloma).

A

Symptoms of Duct Ectasia:

  • Nipple retraction
  • Nipple inversion
  • Nipple pain
  • Green-brown discharge

Symptoms of Duct Papilloma:

  • Bloody nipple discharge - 20-40 years
  • Small size - do not show up on mamography or palpation
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5
Q

Recognise the signs of benign ductal disease (duct ectasia and papilloma) on physical examination.

A

Symptoms of Duct Ectasia:

  • Nipple retraction
  • Nipple inversion
  • Nipple pain
  • Green-brown discharge

Symptoms of Duct Papilloma:

  • Bloody nipple discharge - 20-40 years
  • Small size - do not show up on mamography or palpation
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6
Q

Identify appropriate investigations for benign ductal disease (duct ectasia and papilloma) and interpret the results.

A

(Duct Ectasia)

Biopsies

  • Dilation of the large duct
  • Widening associated with periductal fibrosis
  • Plasma cell rich lesions diagnosed on core biopsies

Duct Papilloma

  • MRI - shows convulted cerebriform pattern (CCP)
  • Histology
  • Galactogram
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7
Q

Define breast cancer.

A

Malignancy arising from breast tissue.

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8
Q

Explain the aetiology / risk factors of breast cancer.

A

Combination of genetic and environmental factors.

Polygenic risk - 5-10% inherited

  • BRCA-1 (17q), BRCA-2 (13q) in 2% - 87% risk for carriers
  • Li-Fraumeni Snydrome - TP53
  • Cowden’s Syndrome - PTEN
  • Peutz-Jeghers Syndrome - STK11 / LKB1
  • Ataxia-telangiectasia - ATM
  • Muir-Torre Syndrome - MSH2/ MLH1

Risk Factors:

  • Age
  • Prolonged exposure to female sex hormones - particularly oestrogen
  • Nulliparity
  • Early menarche
  • Late menopause
  • Menopausal horone replacement therapy
  • Obesity
  • Alcohol
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9
Q

Summarise the epidemiology of breast cancer.

A

Worldwide, leading cause of cancer death in women - 2nd to lung cancer.

Lifetime risk if 1:9 in the UK.

Peak incidence - 40-70 year olds

Rare in men - <1% of all breast cancers

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10
Q

Recognise the presenting symptoms of breast cancer.

A

Detected from screening

Symptoms of Primary:

  • Breast lump
  • Painless
  • Changes in breast shape
  • Nipple discharge

Symptoms of Secondary Spread

  • Axillary lump
  • Bone pain
  • Weight loss
  • Paraneoplastic syndromes - e.g. cerebellar syndrome
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11
Q

Recognise the signs of breast cancer on physical examination.

A

Inspection of the breasts with teh patient upright and supine, assessing for asymmetry, peau d’orange appearance of the skin (oedema), dimpling or tethering, nipple scaling or inversion or, in advanced cases, ulceration.

Palpation using clockwise radial technique (for hard, irregular, fixed lumps)

Examination for palpable axillary, supraclavicular lymph nodes, chest abnormalities, hepatomegaly, bony tenderness.

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12
Q

Identify appropriate investigations for breast cancer and interpret the results.

A

Triple Assessment - standardized approach to investigating a breast lump, consisting of clinical examination, imaging (mammography, ultrasound, MRI) and tissue diagnosis (cytology or biopsy)

Mammogram

  • Useful screening investigation in women > 35 years
  • UK Screening - >50 years
  • Craniocaudal and mediolateral oblique views
  • Features of malignancy - branching or linear microcalcifications and spiculated lesions

US

  • Identify cystic lesions from sinister solid lesions
  • More useful in women <35 years

Fine-Needle Aspiration

  • Minimally invasive
  • Allows cytology of discrete breast lumps and draining of cysts

Core Biopsy
- Can be image-guided, enables histological diagnosis

Sentinal Lymph Node Biopsy

  • Radioactive tracer and / or blue dye is injected near the breast lesion
  • A nuclear scan identifies the sentinel node
  • Node is biopsied to detect spread

Staging

  • CT - chest, abdomen, pelvis
  • PET or bone scanning for metastases

Bloods

  • FBC
  • U&E
  • Ca2+
  • Bone profile
  • LFT
  • Tumour marker - CA-15-3

Histology

  • In situ carcinoma - non-invasive with basement membrane intact - ductal or lobular carcinoma in situ (DCIS, LCIS)
  • Invasive - ductal carcinoma (75% of breast cancers)
  • Others - lobular (10-15% with Indian filing arrangement of cells), tubular, mucinous, medullary, cribiform, papillary, Paget’s disease of the nipple (ductal carcinoma in situ infiltrating the nipple)

Grading:

  • Nottingham modification of the Bloom and Richardson grading system
  • Tubule formation, nuclear size / pleomorphism and number of mitoses
  • Scores used to generate Grades 1 to 3

Staging

  • The UICC TNM-staging system
  • Tumour size - T1 <2cm, T2 2-5cm, T3 >5cm, T4 - any size with chest wall or skin extension
  • Nodes - N1 mobile ipsilateral axillary, N2 fixed ipsilateral axillary, N3 ipsilateral internal mammary nodes
  • Metastases - M0 no distant metastases, M1 distant metastases
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13
Q

Define fine needle aspiration.

A

A thin needle is inserted into an area of abnormal-appearing tissue or body fluid. The sample collected can help to make a diagnosis or rule out conditions such as cancer.

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14
Q

Summarise the indications for fine needle aspiration.

A
  • Lymph nodes - reactive changes, lymphoma, metastatic cancer
  • Thyroid gland - solitary or dominant nodule, suspected malignancy, lymphoma, non-toxic goitre versus autoimmune thyroiditis
  • Salivary galnds - benign and malignant neoplasms, lymphoma, inflammatory lesions, cysts
  • Cystic lesions of the neck - brachial cleft and thyroglossal duct cysts
  • Miscellaneous - parathyroid neoplasms, dermoid cysts, teratomas
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15
Q

Identify the possible complications of fine needle aspiration.

A
  • Infection
  • Bleeding
  • Bruising (haematoma)
  • Recurrent larygneal nerve paralysis
  • Puncture of the trachea
  • Infarction and necrosis of mass
  • Seeding of the malignant cells
  • Monocular blindness
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16
Q

Define breast cysts.

A

Fibrocystic change - a non-specific term, commonly understood as a continuum of physiological changes that expand to teh pathological spectrum. Is characterised by lumpy breasts, associated with pain and tenderness that fluctuate with the menstrual cycle.

17
Q

Explain the aetiology / risk factors of breast cysts.

A

Unknown. A result of hormonal changes from monthly menstruation?

Risk Factors

  • Late-onset menopause
  • Later age at first childbirth
  • Nulliparity
  • Obesity
  • Oestrogen replacement therapy
18
Q

Summarise the epidemiology of breast cysts.

A

7% develop palpable breast cysts.

Males - rare, may be an indication of malignancy

19
Q

Recognise the presenting symptoms of breast cysts on physical examination.

A
  • Mastalgia - breast pain (cyclical or non-cyclical)
  • Disffuse symmetrical lumpiness through both breasts
  • Nipple dischare
  • Palpable breast mass
20
Q

Recognize the signs of breast cysts on physical examination.

A
  • Mastalgia - breast pain (cyclical or non-cyclical)
  • Disffuse symmetrical lumpiness through both breasts
  • Nipple dischare
  • Palpable breast mass
21
Q

Identify appropriate investigations for breast cysts and interpret the results.

A
  • Mammography - shows dense breasts, circumscribed density
  • Breast ultrasound - breast cysts, solid mass
  • Cyst aspiration - straw-coloured, bloody fluid
  • Breast biopsy - apocrine metaplasia, fibrosis, cyst formation, proliferative changes, atypical ductal hyperplasia
22
Q

Define fibroadenoma.

A

Common benign breast tumours made up of both glandular tissue and stromal (connective) tissue.

23
Q

Explain the aetiology / risk factors of fibroadenoma.

A

Benign overgrowth of collagenous mesenchyme of one breast lobule.

Hormone aetiology related to the increased sensitivity of breast tissue to the female reproductive hormone oestrogen.

Usually grows during pregnancy, shrinks during menopause.

Females who take oral contraceptives before 20 years of age tend to suffer from fibroadenoma at higher rates than the general population.

Genetics - MED12 gene

Types:

  • Complex fibroadenoma - rapidly growing hyperplastic cells
  • Juvenile fibroadenoma - 10-18 years, faster growth rate and shrink/disappear eventually
  • Giant fibroadenoma - non-cancerous lesion compressing and replacing normal breast tissue
  • Phyllodes tumour - benign or malignant, not a fibroadenoma so needs to be watched closely
24
Q

Summarise the epidemiology of fibroadenoma.

A

Most common in women in their 20s and 30s.
Tend to shrink after a woman goes through menopause.
10% of women will develop a fibroadenoma during their lifetime.

25
Q

Recognise the presenting symptoms of fibroadenoma.

A
  • Firm, smooth, mobile lump, the breast mouse
  • Painless
  • May be multiple
26
Q

Recognise the signs of fibroadenoma on physical examination.

A
  • Firm, smooth, mobile lump, the breast mouse
  • Painless
  • May be multiple
27
Q

Identify appropriate investigations for fibroadenoma and interpret the results.

A

Observation and reassurance, but if in doubt refer for USS + FNA. Surgical excision if large.

28
Q

Generate a management plan for fibroadenoma.

A

Observation and reassurance, but if in doubt refer for USS + FNA. Surgical excision if large.

29
Q

Identify the possible complications of fibroadenoma and its management.

A
  • Bleeding
  • Infection
  • Haematoma
30
Q

Summarise the prognosis for patients with fibroadenoma.

A

1/3 regress
1/3 stay the same
1/3 get bigger

31
Q

Define mastitis / breast abscesses.

A

Localised infection with pus collection in breast tissue.

2 main forms - puerperal (lactational) and non-puerperal.

Mastitis -

32
Q

Explain the aetiology / risk factors of mastitis / breast abscesses.

A

Lactational:

  • Milk stasis associated with infection
  • Most commonly with Staphylococcus aureus, coagulase-negative staphylococci

Non-Puerperal:

  • Staphylococcus aureus and anaerobes
  • Enterococci or Bacteroides spp.
  • TB and actinomycosis - more rare
  • Smoking, mammary duct ectasia / periductal mastitis, associated inflammatory breast cancer excluded
  • Associated with wound infections after breast surgery, diabetes and steroid therapy
33
Q

Summarise the epidemiology of mastitis / breast abscesses.

A

Lactational breast abscesses are common and tend to occur soon after starting breast-feeding and on weaning, when incomplete emptying of the breast results in stasis and engorgement. Non-lactational abscesses are more common in those aged 30-60 years and in smokers.

34
Q

Recognise the presenting symptoms of mastitis / breast abscesses.

A

The patient complains of discomfort and development of a painful swelling in an area of the breast. She may complain of feeling unwell and feverish.

Women with a non-puerperal abscess often have a history of previous infections, systemic upset is often less pronounced.

35
Q

Recognise the signs of mastitis / breast abscesses on physical examination.

A

Local

  • Area of breast is swollen, warm and tender
  • Overlying skin inflammation
  • Cracks or fissures in nipple
  • Non-puerperal cases - evidence of scars or tissue distortion, or signs of duct ectasia (e.g. nipple retraction)

Systemic

  • Pyrexia
  • Tachycardia
36
Q

Identify appropriate investigations for mastitis / breast abscesses and interpret the results.

A
  • USS

- Aspiration for microscopy, culture and sensitivity of pus samples

37
Q

Generate a management plan for mastitis / breast abscesses.

A

Medical

  • Early, cellulitic phase treated with antibiotics - flucloxacillin for lactational, +metronidazole in non-puerperal
  • Breast drainage regularly to prevent milk stasis

Surgical

Lactational

  • Daily needle aspiration with antibiotic cover
  • Formal incision and drainage for >5cm
  • Cosmetically acceptable and ensures full drainage
  • Loculi explored and broken down
  • Wound may be packed lightly and left open, with daily packing, or primary closure performed
  • Breastfeeding should continue from the non-affected breast and the affected side emptied either manually or with a breast pump
  • Advice on avoided cracked nipples

Non-puerperal

  • Open drainage should be avoided
  • Carried out through small incision
  • Definitive treatment carried out once infection has settles by the excision of the involved duct system
38
Q

Identify the possible complications of mastitis / breast abscesses and its management.

A
  • Slow wound healing
  • Difficulties in breastfeeding
  • Poor cosmetic outcome
  • Mammary fistula formation
  • Overlying skin undergoes necrosis
39
Q

Summarise the prognosis for patients with mastitis / breast abscesses.

A
  • Untreated, it will eventually point and spontaneously discharge onto the skin surface
  • Non-puerperal abscesses tend to recur

Year 3 Knowledge - Conditions and Procedures (19 decks)

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