Breast Flashcards
Define fibroadenoma
Arise from terminal duct lobular unit
Aberrations of normal breast development
Mixture of connective tissue and epithelium
Very low malignant potential
Clinical features of fibroadenoma
Affected by hormones - change in size during cycle
Extremely mobile, discrete, rubbery mass
- breast mice
Common in younger women
- make up 60% of palpable masses in women aged 20
Mx of fibroadenoma
Core biopsy to confirm diagnosis If < 3cm - reassure and discharge - if symptomatic - excise If > 3 cm - excise
Features of breast cyst
Epithelial lined fluid-filled cavities Formed when lobules become distended due to blockage Simple - 1 chamber Complex - multiple cysts in 1 area of inoculated
Clinical features of breast cyst
Most common in perimenopausal women
Smooth discrete breast masses
- can be firm due to increased pressure
Ix for breast cyst
USS
- halo - due to solid capsule
Aspiration
Mx of breast cyst
If simple and asymptomatic - reassure and discharge If large, symptomatic or complex - aspirate to dryness - if blood stained fluid send for cytology
Features of Phyllodes tumour
Clinically similar to fibroadenoma
Rare fibroepithelial tumours
Malignant potential and 10% benign will recur after excision
Features of adenoma
Benign glandular tumour
Older female population
Nodular - easily mimic malignancy
Clinical features of Phyllodes tumours
Rapid growing
Occur in older age group
Mx of Phyllodes tumour
Widely excised
Features of papilloma
Intraductal papillomas are benign breast lesions
Occur in females 40-50 years
Clinical features of papilloma
Typically occur in subareolar region
Bloody or clear nipple discharge
Mx of papilloma
Appear similar to ductal carcinomas on imaging
Require biopsy
Some excised to ensure no atypical cells or neoplasia present
Breast cancer risk only increased with multi-ductal papilloma - treated with microdoecotmy
Clinical features of lipoma
Soft and mobile
Low malignant potential
Only removed if significantly enlarging or causing symptomatic compressive or aesthetic issues
Define mastitis
Inflammation of the breast tissue
Commonly caused by infection
- S.Aureus
Types of mastitis
Lactational mastitis
- up to 1/3 of breast feeding women
- presents during first 3 months or during weening
- associated with cracked nipples and milk stasis
Non-lactational mastitis
- occur with other conditions such as duct ectasia
- tobacco smoking risk factor - causes damage to sub-areolar duct walls predisposing to infection
Clinical features of mastitis
Tenderness
Swelling
Erythema
Mx of mastitis
Systematic abx therapy
Simple analgesics
For lactational mastitis continue milk drainage or feeding
Define breast abscess
Collection of pus within breast lined with granulation tissue
- commonly developing from acute mastitis
Clinical features of breast abscess
Tender fluctuant and erythematous masses
Fever and lethargy
Confirmed by USS
Mx of breast abscess
Empirical abx and US guided needle therapeutic aspiration
More advanced abscesses may require incision and drainage under local anaesthetic
Define duct ectasia
Dilation and shortening of major lactiferous ducts
Common presentation in peri-menopausal women
Clinical features of duct ectasia
Coloured yellow/green nipple discharge
Palpable mass
Nipple retraction
Ix for duct ectasia
Mammography
- dilated calcified ducts
If biopsied mass
- multiple plasma cells
Mx of duct ectasia
Conservatively
Duct excision for unremitting nipple discharge
Define fat necrosis
Common condition caused by acute inflammatory response in the breast
Ischaemic necrosis of fat lobules
Associated with trauma, previous surgical or radiological intervention
Clinical features of fat necrosis
Usually asymptomatic or presenting as a lump
Acute inflammatory response can persist causing chronic fibrotic change - solid irregular lump
Ix for fat necrosis
Hyperechoic mass on USS
Mx of fat necrosis
Self-limiting
Analgesia and reassurance
Clinical features of nipple eczema
Itching
Dryness
Erythema
Areola affected first
Mx of nipple eczema
May need punch biopsy if unsure of diagnosis Reduce exposure to allergens - simple soap - hypoallergenic laundry soap Short course high conc steriod cream
Define mastectomy
Complete removal of the breast
Aesthetic outcomes are important
Indications for mastectomy
Mx of large or multifocal cancers
Risk reduction - those with BRCA1/2
Advantages of immediate reconstruction
Minimal time without breast mound
Preservation of skin envelope
Natural shape
Reduced need for symmetrising surgery
Disadvantages of immediate reconstruction
Prolonged operating time
Complications may result in delay to adjuvant treatment
Radiotherapy can cause poor cosmesis
Advantages of delayed reconstruction
Longer time for decision making
Psychological adjustment after diagnosis
Radiotherapy before reconstruction
Improved patient satisfaction
Disadvantages of delayed reconstruction
Replacement of larger amount of skin
Second operation, hospital stay and recovery
Features of autologous tissue flap reconstruction
Natural texture and appearance
Aesthetic result improves over time
Multiple options for donor sites
Can be used after failed implant reconstruction
Features of non-autologous implant reconstruction
Good for small-moderate sized breasts
Shorter stay and recovery period
No donor site so no extra scar
Need healthy mastectomy skin flaps
Radiotherapy can lead to poor cosmesis and increased complications
Risk of breast-implant associated large cell lymphoma
Features of latissimus dorsi flap (LD)
Thoracodorsal artery
LD muscle + some overlying skin rotated 180 degrees on pedicle
Skin de-epithelialised with skin island in centre
Features of deep inferior epigastric perforator flap (DIEP)
Deep inferior epigastric perforating artery and vein
Anastomosed to perforating internal mammary artery and vein
Skin de-epithelialised with skin island in centre
Features of breast conserving surgery
Partial removal of breast tissue Complete removal of local disease Ideal for - high breast:tumour ratio - likely poor outcome with mastectomy
Symmetrising in breast conserving surgery
Volume displacement - parenchymal advancement - round block - therapeutic mastopexy - therapeutic reduction mammoplasty Volume replacement - lateral intercoastal artery perforator flap (LICAP) - mini latissimus dorsi flap (LD) - free flap
Features of sentinel lymph node biopsy
Evaluate microscopic lymph node involvement Radioactive colloid agent Blue dye Dissection and removal of up to 4 nodes Can lead to lymphoedema in up to 5%
Features of axillary node clearance
Confirmed axillary node involvement
Levels defined by location relative to pec major
- level I: below the lower edge of the pectoralis minor muscle
- level II: underneath/posterior the pectoralis minor muscle
- level III: above/medial the pectoralis minor muscle
Aim to remove all lymph nodes
Complications of axillary node clearance
Lymphoedema - 15%
Damage to long thoracic nerve
Poor mobility of shoulder and arm
Chronic pain
Views on mammogram
CC - craniocaudal
MLO - medial bilateral oblique
Features of normal mammogram
Shadow pec major
Blood vessels
Fluffy post-menopausal
Milk ducts leading to nipple
Wires on mammogram
Wire inserted if impalpable cancer found on screening to mark location
Development of breasts
Breast buds develop in both sexes 6-9th week of foetal life
At puberty female breast develops under influence of oestrogen and progesterone
Anatomy of breasts
2-6th rib
Sternal edge to anterior axillary line
15-20 lobes
Supported by Cooper’s suspensory ligaments
Arterial supply to the breast
External mammary artery
Internal mammary arteries
Intercostal arteries
Suspicious features on mammography
Irregular, spiculated, radiopaque mass
Microcalcification
Features of calcification on mammography
May be benign or malignant
Needs histological assessment
- stereotactic core biopsy
When is an MRI used for breast cancer
Dense breasts
Lobular carcinomas
Exclude multifocal disease
To screen <40s at high risk patients
Features of FNA
Fine Needle Aspiration Quick Less uncomfortable Lower morbidity Cytological assessment only
Features of core biopsy
Removes small amount of tissue
Higher morbidity and pain
Takes longer
Can determine receptor status and grade of tumour
Mx of axilla in breast cancer
If normal axillary USS - dye directed SLNB
If suspicious node perform USS guided FNA
- If malignant perform axillary clearance
- If benign perform dye directed SLNB
Features of oestrogen antagonists
Tamoxifen
Blocks ER
Can be used in both pre and post menopausal women
Disadvantages of oestrogen antagonists
Increased risk of DVT
Increased risk of endometrial Ca
Advantages of oestrogen antagonists
Protects bones from osteoporosis
Features of aromatase inhibitors
Armidex, Letrozole
Blocks enzyme aromatase
Prevents oestrogen production in post menopausal women
- cannot be used pre-menopausal as ovaries still releasing oestrogen
Disadvantages of aromatase inhibtors
Increased risk of osteoporosis
Whos invited to UK breast screening
Women 47-73
3 yearly intervals
2 view mammography
Breast cancer receptor status
Oestrogen receptor (ER) - 75% Progesterone receptor (PR) - most ER positive are PR positive - cannot be targeted Human epidermal growth factor 2 (HER2) - can be treated with monoclonal antibody trastuzumab (Herceptin)
Breast cancer grading
Based on differentiation - well, moderately or poorly
Graded on nuclear pleomorphism, mitotic rate and tubule formation
Two scores combined to give grade 1, 2 or 3
Define Paget’s disease of the nipple
Roughening, reddening and slight ulceration of the nipple
Vast majority have underlying malignancy
Presentation of Paget’s disease of the nipple
Itching or redness in nipple or areola
Flaking and thickened skin
Painful and sensitive
Involves the nipple then areola - eczema will spare the nipple
Ix for Paget’s disease of the nipple
Biopsy
Mammogram
Features of carcinoma in situ
Malignancies contained in basement membranes
Typically found on imaging as rarely symptomatic
