Breast Flashcards
Describe the areas of the breast
4 quadrants: upper inner, upper outer
Lower inner, lower outer
Tail of spence
What makes up the nipple?
Smooth muscle fibres
Areola: glands of Montgomery
How many lobules are there in the mammary glands?
15-20
What is the blood supply of the breast?
Medially: internal mammary
Laterally: superficial thoracic
What is the lymphatic drainage of the breast?
Axillary lymph nodes (75%)
Intermal mammary lymph nodes: 20%
What are the different types of benign breast lumps?
Fibroadenosis / fibrocystic change Fibroadenoma Cysts Fat necrosis Phylloides tumour
What is the most common cause of benign breast lump?
Fibroadenosis / Fibrocystic change
What is the presentation of fibroadenosis?
Cyclical breast pain, localised fibrosis
inflammation
cyst formation
Present between menarche and the menopause with ‘lumpy breasts’ and cyclical pain
What is the treatment of fibroadenosis?
Reassurance, anti-inflammatories, topical evening primrose oil or hormone manipulation
What is a fibroadenoma?
benign, non-tender, mobile breast limp
Who gets fibroadenoma?
Women 25-35
What is the presentation of fibroadenoma?
Painless (or very localised pain)
Highly mobile, firm and smooth lump. Sometimes referred to as ‘breast mice’
What is the rule of 1/3 in fibroadenoma?
1/3 regress
1/3 remain the same
1/3 get bigger
What is the management of fibroadenoma?
Reassurance - low malignant potential
if >3cm, surgical excision
What is a breast adenoma?
Benign glandular tumour in the older population
Benign, but can send for triple assessment in unsure cases
What is a breast cyst?
Cavity lined by flattened epithelium derived from the ductal unit, filled with watery fluid
What is the presentation of a breast cyst?
Perimenopausal women - round, symmetrical lumps, occasionally with pain
What is the management of breast cysts?
Drained with USS guidance, and if the fluid is suspicious e.g. blood stained, they should be sent away for cytology
What is the cause of fat necrosis?
trauma to breast
Clinically can mimic neoplastic disease
What is a phyllodes tumours?
Rapidly growing benign tumour of the stroma
smooth, hard lumps
What is the risk of carcinoma of the breast?
1 in 8
Incidence increases with age, with 5% related to an identifiable genetic abnormality (BRCA1/2)
40% = detected on screening
What is the morphology of most breast carcinoma?
invasive adenocarcinoma
90% are invasive ductal carcinoma and 5% are invasive lobular carcinoma
What are the two categories of breast carcinoma with regard to oestrogen?
Oestrogen receptor (ER) positive or negative
ER positive carcinomas offer a better prognosis
What other hormone receptors are there for breast carcinoma?
HER-2 and progesterone receptors are also therapeutic targets
What is Paget’s disease of the nipple?
Spread of intra-ductal carcinoma of the breast, leading to eczematous changes around the nipple.
Any eczematous rash on the breast should thus raise suspicion
How can breast carcinoma spread?
Local - onto the overlying skin / into the pectoral muscles to cause deep fixation of the tumour
Lymphatic - can prevent lymphatic drainage: peau d’orange
nodes in axilla / clavicle
Vascular: distal dissemination is most common to the bone (pathological fractures and hypercalcaemia)
lung
ovary (krunkenberg)
What is the presentation of a malignant breast tumour?
Lumps Abnormal discharge / retration asymmetry mastalgia skin changes
What are the risk factors for carcinoma of the breast?
Genetic: PH, FH, BRCA positive (25%) Environmental: 75% early menarche/late menopause Nulliparity (or late age of first child) Not breast feeding HRT Obesity
Smoking is also a risk factor
How are breast lumps investigated?
Triple assessment:
clinical examination
Breast imaging (USS + mammogram if >35)
Cytology: FNAC if cystic, core biopsy if solid
Why is mammography less sensitive in women under the age of 35?
Breast tissue is much more dense
What is the apprarance of a breast carcinoma on mammography?
Spiculated mass lesion with associated micro calcification
What are core biopsies better than FNAC?
FNAC cannot distinguish between in-situ and invasive cancers, whereas core biopsies preserve the tissue architecture so invasion can be determined along with grading
How are tumours staged?
TNM:
T1 <2cm, T2 2-5cm T3 >5cm T4: fixed to chest wall or peau d’orange
N0 = no nodes, N1 = mobile ipsilateral nodes, N2 = fixed nodes
M0= no distant mets M1 = distant mets
What investigations are done if mets are suspected?
Liver USS
CXR
Bone scan
What are the surgical options for breast tumours
WLE
Simple mastectomy
When is WLE performed
solitary lesion, peripheral tumour, small lesion in large breast, DCIS <4cm
Margins checked to ensure they are clear of disease
What is simple mastectomy perfomed?
Large tumours (or small breasts), central location of the tumour, or late presentation with complications
DCIS >4cm
How are the regional lymph nodes managed following carcinoma?
Sentinel node biopsy
Dye injected into / around the tumour bulk to identify the first 1/2 nodes that drain the tumour, which are removed and analysed histologically
If negative, it can be assumed there is no nodal involvement
If positive, full axillary clearance is required (20% risk of lymphedema
What further treatments are given fro breast carcinoma?
Adjuvant radiotherapy
If there is nodal disease / high grade therapy - chemotherapy is considered
hormone therapy
Breast reconstruction
What chemotherapy is given?
Anthracyclines
cyclophosphamide
methotrexate
What hormonal treatments are given for breast carcinoma?
If ER / HER +ve:
Tamoxifen if pre/perimenopausal
Aromatase inhibitors (e.g. letrazole, atomising, exemestone) if post menopausal, to stop peripheral oestrogen production
Herceptin (traztuzumab) if HER2 positive (25%)
always combined with chemotherapy
What are the factors affecting prognosis in breast cancer?
Tumour size, nodal status, grade, ER/PR status and vascular invasion
What is the ‘Nottingham Prognostic Index’?
Widely used tool to assess survival and risk of relapse, helping to select appropriate adjuvant therapy
What does NPI entail?
(tumour size x 0.2) + histological grade + nodal status
Tumour size: measured in cm
Grade of differentiation is scored form 1-3 by the histologists
Nodal status is also scored from 1-3
No nodes = 1
1-3 nodes = 2
>3 nodes = 3
What are the 10 year survival rates according to NPI?
<2.4 = 95% 2.4-3.4 = 85% 3.4-4.4 = 70% 4.4-5.4 = 50% >5.4= 20%
When might nipple discharge occur?
Clear = physiological
Milky discharge = pregnancy or hyperprolactinaemia
Green = physiological (duct ectasia) or due to fibroadenotic cyst
What is the initial management of blood stained discharge?
referral to breast
microductectomy will be performed for analysis
What is Mastitis?
Infection of the ducts beneath the nipple
more common in smoking / nipple piercings
Can also get when breastfeeding (lactational)
What is mastalgia?
Breast pain
either cyclical or non-cyclical
What is the treatment of mastalgia?
Evening primrose oil
Tamoxifen / danazol used for cyclical pain
What is duct ectasia?
Duct ectasia is a dilatation and shortening of the terminal breast ducts within 3cm of the nipple
What is the presentation of duct ectasia?
typically presents with nipple retraction and occasionally creamy nipple discharge
What is the mangement of duct ectasia?
troublesome nipple discharge may be treated by microdochectomy (if young) or total duct excision (if older).
What is intraductal papilloma?
Growth of papilloma in a single duct
Usually presents with clear or blood stained discharge originating from a single duct
No increase in risk of malignancy
SUMMARY: what are the different types of breast carcinomas?
Invasive ductal carcinoma. (most common type of breast cancer)
To complicate matters further this has recently been renamed ‘No Special Type (NST)’. In contrast, lobular carcinoma and other rarer types of breast cancer are classified as ‘Special Type’
Invasive lobular carcinoma
Ductal carcinoma-in-situ (DCIS)
Lobular carcinoma-in-situ (LCIS)
What are the criteria for referral for breast cancer?
aged 30 and over and have an unexplained breast lump with or without pain or
aged 50 and over with any of the following symptoms in one nipple only: discharge, retraction or other changes of concern
with skin changes that suggest breast cancer or
aged 30 and over with an unexplained lump in the axilla
What are the complications of breast surgery?
Long thoracic nerve injury (presents with winging of the scapula)
Intercostobrachial nerve injury
Cellulitis
Seroma
Lymphedema
