Breast Flashcards
Fibrocystic change
- benign
- generalised lumpiness ‘cobblestone texture’ - especially in 2nd half of menstrual cycle
- examination shows: Fibrosis = ill-defined margins of irregular texture, ± Cysts = hard smooth mobile lump
- 30-50 year olds, rare in adolescence and after menopause
- management - aspiration of fluid and cytological analysis to check for malignancy
Fibroadenoma
- benign
- normally a single painless lump, increase in size
in 2nd half of menstrual cycle. Hard, well-defined margins, mobile on palpation, smooth but lobulated texture. - in young women <25
- no treatment but advise will shrink (may biopsy if >25 but not needed)
Breast cancer symptoms and classifications
- often asymptomatic, found on screening
- nipple discarge
- breast lump
- eczema like rash (Paget’s)
- if invasive - tethered lump, lymph node involvement, peau d’orange
DCIS (ductal carcinoma in situ) = proliferation of malignant epithelial cells in the ductal system, usually the duct in the terminal duct lobular unit, with no penetration through the basement membrane
LCIS (lobular carcinoma in situ) = same as above but in lobules and rarely -> cancer!
Invasive ductal carcinoma = malignant cells have spread beyond basement membrane
Invasive lobular carcinoma = same as above but in lobules
Epidemiology and risk factors for breast cancer
- common (10% of all cancers), 100x more in females
- DCIS comprises 85% and LCIS 15% of in situ carcinomas
- peak age for diagnosis is 70-74
- screening every 3 years if aged 50-70
Genetics - BRCA mutation carriers carries 87% risk - family history Factors associated with oestrogen exposure: - increasing age - female sex - early menarche, late menopause - nulliparity - combined oral contraceptive pill - HRT Other factors: - alcohol - radiation - increased breast density
Investigations and treatment of breast cancers
Triple assessment of the breast:
- Clinical examination
- Radiological imaging - mammography and ultrasound
- Pathology - fine needle aspiration or core biopsy
± hormone receptor testing on tumour (ER, PR, HER2R)
± genetic testing for BRCA
- surgery - wide local excision (lumpectomy) / mastectomy / lymph node removal
- radiotherapy (almost always) 3 weeks daily after surgery
- chemotherapy (before or after surgery)
- hormone therapy?
- targeted therapy?
Breast inflammation (abscess and mastitis)
- flu like symptoms (fever, malaise, myalgia)
- breast pain, tenderness, swelling, erythema, warmth
- decreased milk outflow
- typically age 15-45, esp if lactating (S. aureus)
Management
- continue expressing milk
- abx if severe
- surgical excision if abscess
Mastalgia
= breast pain
- common, but rarely worrying for cancer (may be referred pain, may be cyclical)
- advise re diet, exercise, caffeine, chocolate, fitted bra, NSAIDs
- anti-oestrogens if necessary – tamoxifen, danazol – but not in younger women, as causes menopause and androgenisation
Gynaecomastia
= benign enlargement of male breast with firm tissue extending concentrically beyond the nipple
- with obesity, acne, erectile dysfunction commonly
- normal in most newborns and for boys at the beginning of puberty
- check LFTs and creatinine levels
- then monitor, reassure, tamoxifen/surgery if severe
Paget’s disease of the breast
= type of cancer that looks like eczema of the nipple
- red itchy inflamed flakey nipple, discharge, burning pain, inverted nipple, maybe with lump
- rare (1-4% breast cancers)
- if with palpable lump, poor prognosis, if not then very good
Tamoxifen
Selective Estrogen Receptor Modulator (SERM)
- to treat breast cancer and increases bone protection, however increases risk of uterine cancer (+ PE, stroke)
- give orally for 5 years
Anastrozole
Aromatase inhibitor drug for ER+ and PR+ breast cancers
- reduces conversion of testosterone -> oestradiol
- but risk of osteoporosis and heart disease
- give orally for 5 years
Trastuzumab (Herceptin)
To treat HER2 receptor positive breast cancer
- monoclonal antibody, arrests cell in G1 phase of growth
- SEs flu-like symptoms, D+V
- never in pregnancy or with underlying heart condition
Investigations of breast conditions
2WW clinic
- Hx and examination
- USS
- Mammogram (all women over 40 with symptoms)
- Core biopsy if suspicious of lump
+ genetic testing
+ CT scan
+ isotope bone scan
+ liver USS
