Breast Flashcards
Define fibroadenoma
- A benign breast lump most common in young women
- Arise in breast lobules, composed of fibrous and epithelial tissue
Describe epidemiology of fibroadenoma
- Most common type of breast cancer below age 30
- Generally arise age 20-24
- 68% of breast masses
List risk factors for fibroadenoma
- Thought to occur because of increased sensitivity to oestrogen
- Young age
- Obesity
- Consumption of oral contraceptives before age 20
- Family history
- Increase in size during pregnancy, breastfeeding, and HRT but become smaller afterwards
List signs and symptoms of fibroadenoma
- Firm, non-tender, highly mobile lumps
- Simple are 1-3cm
- Complex have different types of cells
- Giant or juvenile are more than 5cm
- Normal overlying skin, not fixed to surrounding parenchuma
List investigations for fibroadenoma
- Triple assessment
- Examination
- Imaging (ultrasound below 40 - well circumscribed, round to ovoid or macrolobulated mass with uniform hypoechogenicity)
- Needle biopsy (not required over age of 25)
Describe management of fibroadenoma
- Most can be left
- If they get bigger (giant or juvenile, or complex fibroadenoma) then they are removed
- May be vacuum assisted, this can be done under local anaesthetic
Describe prognosis of fibroadenoma
- Does not increase risk of breast cancer for most women
- If complex, risk is slightly increased
Describe complications of fibroadenoma
- Rare
- Slightly increased risk of breast cancer in some cases
- Giant fibroadenomas continue growing and can become large
Define duct ectasia
A benign (non-cancerous) breast condition that occurs when a milk duct in the breast widens and its walls thicken. This can cause the duct to become blocked and lead to fluid build-up.
Describe epidemiology of duct ectasia
- Occurs in perimenopausal women (age 45-55)
- Duct ectasia 5-9% of non-lactating women
List signs and symptoms of duct ectasia
- Often causes no symptoms
- May cause a thick nipple discharge
- Red tender nipple and nearby breast tissue
- Nipple may be pulled inward
- Scar tissue around the abnormal duct causing a hard lump (firm, stable, painful, under nipple)
List risk factors for duct ectasia
Smoking, close to menopause, obesity
Describe investigation for duct ectasia
- Mammogram
- Ultrasound
- Biopsy
Define intraductal papilloma
Solitary or multiple benign lesions that arise from the epithelium of the lectiferous breast ducts
Describe epidemiology of intraductal papilloma
- Peak incidence 40-50 years
- Multiple lesions more common when younger
- Solitary lesions more common when older
List signs and symptoms of intraductal papilloma
Solitary lesion (central)
- Bloody or serous nipple discharge (most common cause)
- Palpable lump close to or behind the nipple or areola
- Large central lesion
Multiple lesions
- Usually asymptomatic, rarely discharge
- Peripheral lesions which are smaller than solitary lesions
Describe investigations of intraductal papilloma
- Core needle biopsy if lesion is palpable, rule out malignancy (fibroepithelial tumour, with papillary cells and fibrovascular core covered by epithelial and myoepithelial cells
- Ductogram (mammogram with contrast, non specific findings such as ectasia and filing defects)
List examples of benign ductal disease
- Duct ectasia
- Papilloma
Define mastitis and breast abscess
- Inflammation of the breast with or without infection.
- Mastitis with infection may be lactational (puerperal) or non-lactational (e.g., duct ectasia).
- Non-infectious mastitis includes idiopathic granulomatous inflammation and other inflammatory conditions (e.g., foreign body reaction).
- 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.
Describe epidemiology of mastitis and breast abscess
- Global prevalence of mastitis in lactating women up to 10%
- Breast abscess in 2-11% of women with mastitis, with incidence of 0.1-3.0% in breastfeeding women
- 50% of infants with neonatal mastitis will develop breast abscess
- Tubecular mastitis is rare 0.1-3% incidence
Describe aetiology of mastitis and breast abscess
- With or without infection
- Infectious mastitis and breast abscesses are usually caused by bacteria colonising the skin.
- Cases due to Staphylococcus aureus are by far the most common, followed by those due to coagulase-negative staphylococci.
- Breast infections may sometimes be polymicrobial (up to 40% of abscesses), with isolation of aerobes as well as anaerobes
- Non-infectious mastitis may result from underlying duct ectasia (peri-ductal mastitis or plasma cell mastitis) and infrequently foreign material (e.g., nipple piercing, breast implant, or silicone).
- Clogged ducts with milk stasis
List risk factors of mastitis and breast abscess
- Female sex
- Women aged >30 years
- Poor breastfeeding technique
- Lactation
- Milk stasis
- Nipple injury
- Previous mastitis
- Prolonged mastitis (breast abscess)
- Prior breast abscess (breast abscess)
- Shaving or plucking areola hair
- Anatomical breast defect, mammoplasty, or scar
- Other underlying breast condition
- Nipple piercing
- Foreign body
- Skin infection
- Staphylococcus aureus carrier
- Immunosuppression
- Hospital admission
- Breast trauma
- Primiparity
- Overabundant milk supply
- Post-maturity (breast abscess)
- Complications of delivery
- Maternal fatigue
- Tight clothing
- Antifungal nipple cream
- Fibrocystic breast disease
- Cigarette smoking
- Vaginal manipulation (breast abscess)
- Poor nutrition
- Antiretroviral therapy
List signs and symptoms of mastitis and breast abscess
- Fever
- Decreased milk outflow
- Breast warmth
- Breast tenderness
- Breast firmness
- Breast swelling
- Breast erythema
- Flu-like symptoms, malaise, and myalgia
- Breast pain
- Breast mass
- Fistula
- Nipple discharge
- Nipple inversion/retraction
- Lymphadenopathy
- Extra-mammary skin lesions
Describe investigations for mastitis and breast abscess
- Breast ultrasound (hyperechoic lesion, well circumscribed, macrolobulated, irregular, ill defined)
- Diagnostic needle aspiration drainage (purulent fluid indicates breast abscess)
- Cytology of nipple discharge or sample from fine-needle aspiration
- Milk, aspirate, discharge, or biopsy tissue for culture and sensitivity
- Histopathological examination of biopsy tissue (infection, granulomatous inflammation or malignancy)
- Pregnancy test
- Blood culture and sensitivity
- Mammogram
- Milk for leukocyte counts and bacteria quantification
- Culture from swab/aspirate from infant’s and mother’s oral cavity and nasopharynx
- FBC
- Tuberculin skin test (purified protein derivative)
Describe treatment of mastitis and breast abscess
Lactational mastitis
- Effective milk removal and supportive care (paracetamol and ibuprogen)
- Antibiotic therapy (flucloxacillin 10-14 days) if pain and severe symptoms, or lasting more than 12-24 hours. Continue breastfeeding bilaterally, as this reduces chance of abscess formation
- Antifungal therapy for candidiasis
- If systemic signs or prolonged, non beta-lactam antibiotic
- For breast abscess, surgical intervention (needle aspiration with local anaesthesia with or without ultrasound guidance to drain an abscess) + IV or oral antibiotics (flucloxacillin) + paracetamol
Non lactating - co-amoxiclav for 10-14 days
List complications of breast abscess and mastitis
- Cessation of breastfeeding
- Abscess (complicating mastitis)
- Sepsis
- Scarring
- Functional mastectomy
- Breast hypoplasia
- Necrotising fasciitis
- Extra-mammary skin infection
- Fistula
Describe prognosis of breast abscess and mastitis
- When treated promptly most resolve within 2-3 days with appropriate antibiotic therapy
- Lactational abscess easier to treat than non-lactational
- Most patients can continue to breastfeed
- Recurrence in delayed or inappropriate therapy, candidiasis, poor breastfeeding technique
- Granulomatous mastitis 50% recurrence
Define breast cyst
Fluid filled lump in the breast
Describe epidemiology of breast cyst
- Common over 35 years, especially in perimenopausal women
- Affect 7% of western women (common)
List risk factors for breast cysts
- Postmenopausal women taking HRT
- Perimenopausal
List symptoms and signs of breast cysts
- Fluid filled
- Not fixed to the surrounding tissue
- Occasionally painful
- May be soft or hard
Describe investigation of breast cysts
- Mammogram or ultrasound
- Identifies a fluid filled lump
- Fine needle aspiration confirms diagnosis (brown, green, tan or clear fluid)
Define breast cancer
- Malignant neoplasm of the breast
- Commonly adenocarcinomas. These may be invasive ductal (70-80%) or invasive lobular
Describe epidemiology of breast cancer
- Affects 1 in 8 women, most common malignancy of women
- 60000 new cases per year UK with incidence rising
- Rare in men, men make up 1% of all breast cancers
- 2nd most common cancer worldwide
List risk factors for breast cancer
- Family history (BRCA gene, li fraumeni syndrome - 5-10% genetic)
- Age
- Uninterrupted oestrogen exposure (nulliparity or 1st pregnancy over 30, early menarche/late menopaise and taking HRT therefore all risk factors)
- Not breastfeeding
- Past breast cancer
- Lifestyle factors : low fibre, high fat diet, smoking, alcohol, obesity in postmenopausal women
Describe aetiology of breast cancer
- BRCA1 or BRCA2 gene mutations are autosomal dominant
- Associated with increased risk of breast (70%) and ovarian cancer
- BRCA positive women develop cancer 15-20 years earlier. Found in 5-10% of all women with breast cancer
List types of breast cancer
- Non-invasive ductal carcinoma in situ is premalignant, seen as a microcalcification on mammogram, 25% of all newly diagnosed breast cancers.
- Non-invasive lobar carcinoma in situ is rarer, tends to be multifocal
- Invasive ductal carcinoma 70% invasive breast carcinomas
- Invasive lobar carcinoma 10-15% invasive breast carcinomas
- Medullary cancers (5%) tend to affect younger women, and colloid/mucoid (2%) the elderly
- Others include papillary, tubular, adenoid cystic and pagets (ductal which infiltrates the nipple)
- 60-70% oestrogen receptor positive, better prognosis
- 30% express HER2 (more aggressive)
List symptoms and signs of breast cancer
- Developed late at advanced tumour stages
- Changes in breast size or shape (asymmetric breasts)
- Palpable mass (single, non-tender, firm mass with poorly defined margins, most commonly in the upper outer quadrant)
- Skin changes (retractions or dimpling, peu d’orange due to obstruction of lymphatic system - reddness, oedema and pitting of hair follicles)
- Nipple changes (inversion/blood-tinged discharge)
- Axillary lymphadenopathy (firm, enlarged lymph nodes fixed to the skin or surrounding tissues
- Ulcerations if advanced
- Pagets disease of breast
- Thrombophelbitis
Describe investigations of suspected breast cancer
- Triple assessment - clinical examination, histology/cytology and mammogram if over 35/ultrasound if under 35
- Core biopsy of solid lump
- Aspiration of cystic lump, if bloody cytology (if suspicious core needle biopsy needed to confirm diagnosis)
- Malignant: focal mass with poorly defined margins, clustered microcalcifications
- Determine whether oestrogen/ progestrone/ HER2 positive (via immunohistochemistry - best prognosis oestrogen+progresterone positive, HER2 negative)
Define fine needle aspiration
- A procedure where a thin needle is used to draw out cells or fluid from a lump or mass under the skin.
- This is then analysed to look for any cancer cells
- Often guided by ultrasound
List indications for fine needle aspiration
- Investigate and diagnose breast lumps where the nature is uncertain
- Monitor breast cancer response to treatment
- Also has use in thyroid, lymph nodes, lung, bone, liver, GI samples
List complications of fine needle aspiration
- Bleeding
- Infection
- Lung biopsy: pneumothorax
Define fibrocystic change
Benign breast condition encompassing fibrous changes, cysts and adenosis that occurs bilaterally
Describe epidemiology and risks of fibrocystic change
- Premenopausal 30-50
- Obesity
- Nulliparity
- Late menopause
- Increased E2
List symptoms and signs of fibrocystic change
- Multiple lumps
- Smooth, regular, bilateral, symmetrical
- Normal nipples, fluctuates with periods
- Tender, rubbery, fluctuant, mobile, slow growing
- Fibrous lumps hard and rubbery while cysts are oval or round and fluctuant
List investigations for fibrocystic changes
- US or mammogram
- FNA (straw coloured)
Define fat necrosis
Fat tissue is damaged secondary to trauma. Occurs at any age, though it is rare
List symptoms and signs of fat necrosis
- Skin retraction/thickening. May be bruised or irregular
- Hard, tender, fixed
List risk factors for fat necrosis
- larger breasts
- Previous FNA, biopsy or surgery
List investigations for fat necrosis
- US or mammogram
- FNA
Describe breast cancer screening
- All women age 50-71 who register for a GP are eligible for screening every 3 years using a mammogram
- If at high risk, age 40-50 annual mammography is used
