Breast Flashcards
What are the mammary glands?
Modified sweat glands which consist of lobules and ducts
What are the lobules of the breast drained by?
They are drained by lactiferous ducts which all drain to the nipple
Where is the lymphatic drainage of the breast to?
Infra clavicular
Parasternal
Deep cervical
Posterior intercostal nodes
What are the reasons breast feeding is beneficial for babies?
Immunoglobulins
bactericidal enzymes
High energy content
Increased intelligence for baby
What are the reasons that breastfeeding is beneficial to the mother?
Promotes the bond between the baby and the mother
Decreases the risk of the mother developing breast cancer, ovarian cancer, T2DM
Free
What is the physiology behind breast milk production?
Sensory inputs like seeing/hearing a baby cry, emotional stress, nipple stimulation cause a nerve impulse to travel via. The spinal cord to the hypothalamus, this causes a release in oxytocin from the posterior pituitary and prolactin from the anterior pituitary.
What is the role of oxytocin?
Causes contraction of the myoepithelial cells around the mammary glands causing milk to be ejected into the lactiferous ducts.
What is the role of prolactin?
Stimulates milk production within the mammary gland, the amount of prolactin produced depends on the frequency and intensity of the stimulus.
What is the most common cause of a benign breast lump?
Fibroadenoma (especially in women under the age of 30).
What are the features of a fibroadenoma?
Discrete Rubbery Non tender Mobile Usually <5cm diameter Self resolving
What are fibroadenomas?
Proliferation of duct lobules
What are the indications of removal of a fibroadenoma?
Large (>3cm in diameter)
Or patient preference
If the benign growth of the lobules are fibroadenomas, what are benign growth of the ducts called?
Duct papillomas!
What would patients with duct papilloma present with?
Clear/blood stained discharge
Small breast lump
Why might you biopsy/excise a duct papilloma?
Because they present very similarly to duct carcinoma.
What is fibroadenosis? (Fibrocystic disease)
This is benign collections of fibrous tissue and cysts in the breast.
How does fibrocystic changes/fibroadenosis present?
Lumpy, swollen, painful breasts and sometimes clear nipple discharge.
Common in middle aged women
May be worse before menstruation
How do you treat fibroadenosis?
No cure
Can excise if large and painful
Give advise to women- wear supportive bras and take analgesia when needed
What is mastitis?
Inflammation of the breast tissue, usually due to infection
Can be classified as lactational, non lactational
What does mastitis present with?
Patient present with tenderness, erythema, swelling of the breast
What is lactational mastitis associated with?
Nipple fissuring (irritated, cracked or sore nipples) and milk stasis
When would you treat lactational mastitis and what with?
Treat if there is nipple fissuring (irritated, cracked, sore nipples)
If systemically unwell
If culture shows infection
If there is no improvement of symptoms after 12 to 24 hours of effective milk removal
Treat with flucloxacillin (erythromycin if they are penicillin allergic)
What is the treatment of non lactational mastitis?
Co amoxiclav (erythromycin And metronidazole if the patient is penicillin allergic)
What is non lactational mastitis associated with?
Commonly seen in women with other breast conditions like duct ectasia and tobacco smoking.
What is the most likely organism in lactational mastitis?
Staph aureus
What is the complication of mastitis if left untreated?
Breast abscess
What is a breast abscess?
Collection of pus caused by infection with staph aureus and commonly secondary to lactational mastitis
What does breast abscess present with?
An erythematous, warm, tender and fluctuant mass
What can occur if breast abscesses go untreated?
The overlying area can necrose and a mammary duct fistula can develop.
Note that overlying skin necrosis is an indication for surgical debridement.
Can people with breast abscesses continue to breastfeed on the affected side?
Yes if possible and not too painful and if the antibiotic they are taking are not harmful to the baby.
They should continue to express breast milk to avoid engorgement
What is the treatment for breast abscesses?
US guided aspiration I and D (incision and drainage) And Antibiotics If it is too painful they should continue expressing breast milk to avoid engorgement
What is breast enorgement?
Where your breasts are painfully full of milk
One of the main causes of breast pain in breastfeeding women if usually occurs in the first few days after the infant is born and almost always affects both breasts, the pain or discomfort is typically worse just before a feed, and the infant may find it difficult to attach and suckle.
Fever may be present but usually settles within 24 hours
The breasts may appear erythematous and swollen
How do you manage breast engorgement?
Breastfeeding advice- encourage attachment, how to appropriately position a baby, wear a well fitting breastfeeding bra, put warm flannels on the breast before hand expressing, take ibuprofen or paracetamol to help with the pain.
What are the complications of engorgement?
Blocked milk ducts
Mastitis
Difficulty with breastfeeding and milk supply
What is raynauds disease of the nipple?
Rare condition characterised by intermittent pain during and immediately after breastfeeding.
Blanching of the nipple may be followed by cyanosis and/or erythema.
How would you treat raynauds disease of the nipple?
Using heatpacks
Avoiding cold
Avoiding caffeine
Stopping smoking
What is a breast cyst?
Small benign discrete lump caused by a buildup of fluid in the lobules of the breast due to increased levels of oestrogen.
Very common in >35y/o
How do you manage breast cysts?
Most self resolve however if the cyst is large/causing discomfort then treatment is by aspiration
If there is blood stained aspirate or the cyst refills persistently then aspirate should be biopsied.
What is duct ectasia?
Dilation of the lactiferous ducts
It is part of the normal involution and aging process
Most commonly affects perimenopausal or postmenopausal women.
Smoking increases the risk of duct ectasia 3x!!
What is the presentation of duct ectasia?
Blood stained/green nipple discharge
Tender lump around the alveolar
Nipple involution
Common in ladies >50 y/o
What are the criteria for 2WW referall in terms of breast lumps?
30+ year old with unexplained breast lump or lump in the axilla
50+ year old with nipple changes (discharge/retraction) which are unilateral
Skin changes suggestive of breast cancer
Consider non urgent referall in patients age under 30 with an unexplained breast lump
What are the types of breast cancer
Both lobular and ductal and in in situ and invasive
Inflammatory breast cancer
Pagets disease of the nipple
What are the risk factors for breast cancer?
Anything to do with prolonged exposure to unopposed oestrogen therefore HRT Nulliparity Early menarche and late menopause 1st pregnancy after 30 years
BRCA1/2 or P53 mutations
Hx of breast conditions
Obesity
What are the symptoms/signs of breast cancer?
Asymptomatic Breast lump Lump in axilla Skin changes of the breast Changes in the size of the breast Nipple changes
What is the breast triple assesment/one stop clinic?
Hospital based clinic where patients with suspected breast cancer are referred to for…
. Hx
. Examination
. Imaging
. Potential Biopsy
What imaging is done in the breast triple assesment?
In patients under the age of 35 then ultrasound imaging is done
Because the density of the breast tissue makes mammography difficult to interpret
Mammography is done for those over 35
What views are used in mammography of the breasts?
Oblique and cranial caudal
What type of biopsy is done for a suspicious mass?
Core biopsy is normally done as this gives a full histology- allows for tumour grading, staging and differentiation between invasive and in situ carcinoma, unlike fine needle which only shows presence of abnormal cells, must be followed up by core biopsy if abnormal!
What do you do if there is no palpable lymph node on examination?
Ultrasound
On USS if there is a LN seen- then a US guided fine needle aspiration would take place to check whether malignant or benign (if benign then a sentinel node biopsy would take place, if malignant then axillary clearance would take place)
On USS if there is no lymph node seen then sentinel node biopsy will occur
What do you do if there is a palpable LN on examination?
US guided FNA to detect whether malignant or benign
If benign- sentinel node biopsy
If malignant- axillary clearance
Note that each is performed in the breast surgery :)
Where does breast cancer commonly metastasise to?
Bone Brain Adrenal glands Liver Ovaries Lung
What other investigations, other than the triple assesment should be used in breast cancer?
Unfortunately breast cancer has often metastasised
Therefore bone scans (very rarely done now) , CXR, staging CT can be performed
What determines the treatment of a patients breast cancer?
The staging
Patient preference
Co morbidities
Tumour type
What are the complications of axillary node clearance surgery?
Paraesthesia due to damage of the nerves of the upper limb and lymphaedema (swelling of the arm on the side of the clearance due to reduced lymphatic drainage of the limb).
When is wide local excision performed?
When the tumour is solitary, peripheral and small
DCIS <4cm diameter
What does wide local excision involve?
Removal of the tumour and 1cm margin of the normal breast tissue
It has a shorter recovery time and a smaller scar
When is mastectomy performed?
Multifocal, central, large lesion
DCIS >4cm
What does mastectomy involve?
Removal of all tissue of the affected breast and the overlying skin
It has a longer recovery time and psychological impact
When is radiotherapy used?
This is often used to prevent relapse in breast cancers
Always used in patients who have had breast conserving surgery
Used if the patient has had a mastectomy with a high risk of local recurrence
If there is scarring/stiffness of the tissue
When is hormonal therapy used?
Used either neoadjuvantly to reduce tumour size before surgery or adjuvantly to prevent relapse
For receptor +ve cancers
What hormonal therapy is used for ER+ breast cancers?
Tamoxifen used in pre and post menopausal women
What is anastrozole and when is it used?
It is an aromatase inhibitor it is used in post menopausal women, these stop the production of oestrogen and prevent tumour growth.
What are the side effects of tamoxifen?
Increased risk of endometrial cancer
venous thromboembolism
Menopausal symptoms- hot flushes, mood changes,
(It is protective against osteoporosis).
When is herceptin used?
This is used in breast cancers that are HER2 positive.
What breast cancer can be treated by monitoring?
Lobular carcinoma in situ.
What does the breast cancer screening involve?
It is available for all biological women aged 47-73 years
It is a mammogram every 3 years
Women at higher risk of breast cancer due to FH qualify for earlier screening (at age 40)
How many quadrants are there in the breast?
4 Upper outer Upper inner Lower outer Lower inner
When would you do an MRI of the breast?
In select high risk patients
When there is dense breast tissue or equivocal or discordant findings on a mammogram or US
Determining the efficacy of neoadjuvant chemo
Differentiation of scar tissue from a tumour
Who does a breast cancer MDT involve?
Pathologist Surgeon Radiation oncologist Medical oncologist Nurse Social worker Physiotherapist
What features determine whether the surgery is breast conserving or mastectomy?
Tumour size: breast ratio Location of tumour Multifocality Risk of local recurrence Patient preference
When do you do chemo for breast cancer?
Young age Big size tumour Triple -ve disease Node +ve breast cahcer High grade Neoadjuvant for breast conserving surgery
How do selective oestrogen receptor modulators work, give examples, when you would use them and their side effects…
Tamoxifen
They prevent oestrogen from binding at breast cell receptors
They inhibit oestrogen synthesis
Used in both premenopausal and postmenopausal women
Side effects= hot flushes, vaginal dryness, endometrial cancer, VTE, weight gain, menstrual disturbance
When do you use aromatase inhibitors?
How do they work
Give examples
Give side effects
Use in postmenopausal women
They inhibit oestrogen synthesis
Anastrole, letrozole, exemestane
SEs= hot flushes, osteoporosis, fatigue, vaginal dryness, joint and muscle pain
What is duct ectasia of the breast?
Condition which occurs when a milk duct beneath the nipple widens, the duct walls thicken and the duct fills with fluid. Most common cause of greenish discharge and can mimic breast cancer.
