Breast Flashcards
What 7 factors must you take into account when coming up with differentials for breast lump?
- Pain
- Age
- Trauma
- Time
- Changes in size/shape/skin/discharge
- RF
- FLAWS
5 Differentials for breast lump in under 30s
Physiologically normal lumpy breast Benign cystic change Fibro- adenoma Abscess/mastitis (if breast-feeding) Galactocele (if breast-feeding)
LOW risk of cyst/cancer
4 Differentials for breast lump in 30-45yrs
benign cystic change
cyst
abscess (especially smokers)
carcinoma
4 Differentials for breast lump in 45-60yrs
cyst
abscess (smokers)
carcinoma
duct ectasia
Differential for breast lump in >60yrs
carcinoma
benign cystic change (less common)
Which breast lumps develop rapidly?
Abscesses
Cysts
Which breast lumps develop slowly?
Fibroadenomas
Carcinomas
Which breast lump fluctuates with hormonal cycle?
Benign cystic changes
Which breast lumps develop with a history of trauma?
Seat belt injury –> fat necrosis
Aspiration –> predispose to infection + abscess
Which breast lumps are painful?
Benign cystic change
Acute mastitis
Abscess
+/- Cysts
Large breast lumps are more likely to be what?
Abscess/cyst
What skin signs must you look for in breast lump?
Peau d’orange Dimpling Ulceration Warmth Erythema
What nipple signs must you look for in breast lump?
Inversion Scaly Bloody discharge Itching Irregularity
What are the 3 different breast discharges and what can they indicate?
Serous discharge
Green-brown discharge
Milky discharge
How can FLAWS help differentiate diagnoses?
F- Acute mastitis, abscess, carcinoma
L- Carcinoma, acute mastitis, abscess
AWS- Carcinoma
What factors can increase oestrogen exposure? (therefore breast ca risk)
− Early menarche (<13 years) − Late menopause (>51 years) − Nulliparity − Having a first child after the age of about 30 years − Not breast-feeding − Hormonereplacementtherapy(HRT)‡ − Use of combined oral contraceptive pill (COCP) − Obesity
What factors can decrease oestrogen exposure?
Breast feeding
Pregnancy
Late menses
Early menopause
There is a higher incidence of more serious cancer in which cohort of patients?
Black ethnicity
Their cancer tends to be triple negative (so can’t be treated with tamoxifen)
How does obesity increase oestrogen exposure?
Adipose cells convert androstenedione –> estrone
Especially for post-menopausal women this increases their E2 exposure
Hereditary conditions increasing risk of breast cancer
Klinefelter’s
Peutz-Jeghers
Cowden
Li-Fraumeni
Key breast cancer risk factors
Age
Being female
RF breast cancer
- FHx - close blood relatives (1x before 40, 2x before 60, 3x)
- Previous breast/endometrial/ovarian/bowel cancer
- Irradiation to the chest wall (such as mantle irradiation for Hodgkin’s lymphoma)
- Increased exposure to oestrogens, especially cyclical stimulation
What aspects of a breast lump should you inspect? (Straps Need Tightening)
STRAPS NEED TIGHTENING:
- Size
- Shape
- Skin
- Nipple
- MeNstruation
- Nodes
- Trauma
- Tethering
- Temperature
- Time
- Tender
- Texture
What 5 features do you use to describe a breast lump?
SURFACE- smooth/irregular BORDERS- distinct/indistinct CONSISTENCY- firm/rubbery/lax MOBILITY- move around breast FIXITY- tethered to skin/underlying muscle LYMPHADENOPATHY
Briefly describe breast anatomy
- Lobules containing alveoli feed into lactiferous ducts which converge at the nipple
- Fat lies between the lobules
- Suspensory ligaments of Cooper separate lobules and provide structural integrity
Define mastitis/abscess
Inflammation of the breast tissue that may be due to bacterial infection
Causes/aeitiology of mastitis/abscess
Clogged ducts with milk stasis Nipple injury (teething infants/breast pump)
Bacteria enter damaged breast (staph. Aureus) leading to infectious mastitis and then abscess
Pathogenesis of mastitis
- Blockage of the milk flow
- Backlog of milk up into the lactiferous ducts and alveoli (within the lobule)
- Alveoli distend
- Lobule distends and can be felt as a palpable lump in the breast
- Milk protein leaks into surrounding tissue (capillaries, connective tissue, fat etc)
- Body reacts to ‘foreign substances’ causing local inflammation = mastitis
What are the different types of mastitis?
NON-INFECTIOUS
- aka duct ectasia
INFECTIOUS
- non-lactational mastitis
- lactational
- complicated –> abscess
when does lactational mastitis occur?
6-8 weeks of breastfeeding or at weaning
Nipple injury due to infant teeth of baby or from over-suctioned breast pump
Mastitis symptoms (use SNT structure)
size/shape/skin:
- Palpable hard wedge
- Red
- Swollen
menstruation/nipples/nodes:
- cracked nipples
- lactation
Trauma/tethering/temp/time/tender/texture:
- 1-2 months of breastfeeding
- Painful
- Solid
- Hot
Classic mastitis presentation
Breast feeding for 1/12
Hot
Painful
Wedge-shaped lump
RF for mastitis/abscess
Lactation Milk stasis Nipple injury Poor technique Shaving Foreign body
Abscess symptoms (use SNT structure)
size/shape/skin:
Palpable single lump
Red
Swollen
menstruation/nipples/nodes:
- cracked nipples
- lactation
Trauma/tethering/temp/time/tender/texture:
- 1-2 months of breastfeeding
- VERY Painful
- Fluctuant
- Hot
Classic abscess presentation
Breast feeding for 1/12 Hot Painful Difficulty sleeping More SYSTEMIC symptoms
RF abscess
Previous mastitis
Smoking (non-lactational)
Mastitis Ix
Moderate- examination only
Severe- breast milk culture
Abscess suspected (unstable/septic) - refer to hospital for USS and aspiration
Mastitis Mx
- Reassure
- Analgesia
- ENCOURAGE MILK
- Abx only if no improvement
If no improvement after 48 hours seek advice
Abscess Mx
Referral US confirmation ± aspiration Surgical drainage Fluid culture Abx
When do you refer a patient with mastitis to hospital?
- haemodynamic compromise
- Sepsis signs (tachycardia, sustained fever, chills)
- rapid infection spread
When do you give antibiotics in lactating mastitis?
if Sx are worse/no improvement after 12-24 hours of effective milk removal
If breast culture is positive
Signs of infection on the nipple
Which Abx do you give for mastitis?
Lactational: flucloxacillin
Non-lactational: - co-amoxiclav
erythromycin if penicillin allergic
State the common causative organisms for mastitis/abscess
AEROBES
- Staphylococcus
- Streptococcus
- E.Coli
ANAEROBES
- Clostridium
OTHER
- TB
- Bartonella henselae
Mastitis to Abscess Progression steps
Mastitis >
Infectious Mastitis >
Abscess >
Complicated abscess
35 y/o comes into the GP for a follow up after her recent breast augmentation, 1 week previously. The surgery was successful with no complications in theatre or directly post-op. The patient complains that her left breast is feeling particularly tender just superior to the incision site with a palpable lump. There has been no nipple discharge and the wound sites look clean with mild swelling. O/E there is a palpable hard lump with the overlying skin looking red and feels hot to the touch. The patient reports feeling feverish and has a temperature of 38.0. What is the best next step in her management?
Send for 2-week wait referral to oncology Take bloods immediately Refer for next day US scan Give Antibiotics and send home Refer to hospital immediately
The fever, red hot skin with a palpable lump indicates this is likely an abscess. Especially considering the recent breast trauma of surgery. So the management of abscess is to refer urgently to hospital to the general surgeons for US diagnosis and drainage of the abscess. If she was haemodynamically unstable we would admit her immediately for IV AB. In the GP setting, urgent hospital referral is needed, same day due to the risk of further infection and sepsis.
new mum, Katie, has come to the GP for her baby clinic appointment. Baby Joe has been doing well and is here to have his first set of vaccinations. The GP questions how Katie has been coping and she states that Joe is a dream of a baby but her breasts have been feeling more tender, specifically her right breast that has become red, swollen and hot since last night. Joe has been feeding regularly but Katie finds it particularly painful from her right breast and has been using her left instead. She is concerned that she has contracted some form of infection and really does not want to make her beautiful baby boy sick! What advice would you give Katie?
First set of vaccinations lets us know that it has been about 8 weeks since he has been born. So she is in the perfect period for mastitis to occur (1-2 months of breast feeding). The signs on examination are indicative of mastitis and as she is lactating without a fever or other systemic symptoms then we are less likely to think there is an infection but likely milk stasis. So we will encourage milk expression and if it does not improve in at least 48 hours since onset then AB can be prescribed.
A 26 y/o comes to the GP complaining of a red, tender breast that started two days ago. Her periods are normal and regular, she is not pregnant or breastfeeding and has no significant PMH or FH but is a current smoker of 5 a day. She is otherwise fit but has been struggling recently with her coursework so has been lacking in sleep and not maintained her normal hygiene care. O/E the left breast looks red around the areola, is hot to the touch and tender. The nipple looks slightly inverted compared to the right and contains a piercing that looks red around the edges and swollen. There are no systemic symptoms. What medication would you prescribe?
Considering this is a non-lactating woman with mastitis then according to NICE we prescribe co-amoxiclav for 10-14 days. We would also encourage cleaning of the piercing if not removal of it as she might’ve had it very recently or due to her lack of hygiene it has gotten infected. It it unlikely to be an abscess due to lack of systemic symptoms and no palpable lump. Her being a smoker increases risk for non-lactational mastitis due to the increased risk of periductal mastitis already being present.
Define fibroadenoma
Benign neoplasm of a lobule formed from stroma (fibro) and glandular (adenoma) epithelium
aka ‘breast mouse’
Fibroadenoma epidemiology
Most common form of benign breast lump- specifically in younger patients (20-30 YEARS)
Can be found up to the age of 55
basically REPRODUCTIVE AGE
Fibroadenoma symptoms (use SNT structure)
size/shape/skin:
- Palpable lump
- Small
- Regular
- Round/lobular
menstruation/nipples/nodes:
- normal
trauma/tethering/temp/time/tender/texture:
- Smooth
- Rubbery
- Painless
- Mobile
- Takes time to form
RF fibroadenoma
Obesity
OCP
Recent puberty
The four most common diagnoses for a breast lump are…
Benign cystic change (also known as fibrocystic change, fibroadenosis, or benign breast change)
Fibroadenoma
Cyst
Carcinoma
Typical presentation fibroadenoma
Young woman of reproductive age
Single, mobile, painless small lump
“breast mouse”
Jules, a 29 y/o comes to the practice with a lump in her breast. She states that it is not painful unless she wears a specific bra. She has had no systemic symptoms, is a non-smoker, is not pregnant, takes the OCC and had her last period 10 days ago. Her PMH is non-significant and her FH includes her aunt being diagnosed with breast cancer at 42. Jules is very concerned that this is breast cancer. O/E the breasts look normal with no changes to the skin or nipples. There is a discrete, mobile, smooth lump about the size of a soya bean superior to the nipple in the right breast. There are no discrete palpable lumps elsewhere or in the left breast. What is the likely diagnosis?
Her age makes carcinoma less likely as the epidemiology suggests <2% are under 30 but this it not something to go by alone.
Due to the lack of other lumps in the same breast or lumps in the opposite breast it makes fibrocystic change unlikely as that is symmetrical ’lumpy breasts’.
Therefore we are thinking fibroadenoma and the mobile, smooth and small size of the lump makes us think it is a breast mouse.
Define fibrocystic changes
Benign breast condition encompassing fibrous changes, cysts and adenosis that occurs bilaterally
NOTE- You can have benign cysts on their own but most often they will occur with fibrous tissue
Epidemiology fibrocystic changes
Premenopausal 30-50 y/o
Define adenosis
When the milk-producing lobules are enlarged and there are more glands than normal
Fibrocystic changes symptoms (use SNT structure)
size/shape/skin:
- Multiple lumps
- Smooth
- Regular
- Bilateral
- Often symmetrical
menstruation/nipples/nodes:
- Normal nipples
- Fluctuates with periods
trauma/tethering/temp/time/tender/texture:
- ±Tender
- Rubbery
- Fluctuant
- Mobile
- Slow-growing with fluctuations
Compare the texture/feel of fibrous lumps vs cysts
FIBROUS LUMP
- Rubbery
- Hard
CYST
- Oval or round
- Fluctuant/lax
- Become harder as pressure builds
RF fibrocystic changes
Obesity
Nulliparity
Late menopause
Increased E2
Ix for fibrocystic changes
US or mammogram if >35
FNA – STRAW COLOURED
Management of fibrocystic changes
Conservative
FNA if drainage needed - send to cytology to rule out cancer
If solid masses on US/mammography- BIOPSY to rule out carcinoma
Classic fibrocystic changes presentation
30-50 y/o Lumpy breasts Premenstrual breast pain Multiple Fluctuates with period Straw-coloured on FNA
Define fat necrosis
When fat tissue within the breast is damaged often secondary to trauma
RF fat necrosis
Larger breasts
Previous FNA/biopsy/surgery
Any age
Fat necrosis symptoms (use SNT structure)
size/shape/skin:
- ±Skin retraction/thickening
- Irregular
- Red/bruised
menstruation/nipples/nodes:
- ±retraction
trauma/tethering/temp/time/tender/texture:
- Hard
- ±Tender
- Trauma
- Fixed
Classic fat necrosis presentation
Trauma
Hard lump
Bruising/red overlying skin
Ix for fat necrosis
Important to rule out carcinoma as it can present very similarly
Excision biopsy if it has grown in size, uncertain if malignant, painful for the PT continuously.
Define intraductal papilloma
Rare benign fibroepithelial tumour formed from the lactiferous duct epithelium
Epidemiology intraductal papilloma
30-55 years
Symptoms/features of intraductal papilloma
Bloody/serous discharge Solitary lump near nipple Peri/post menopause Full feeling- no mass Slow growing Tender
RF intraductal papilloma
peri-post menopause
Ix intraductal papilloma
US or mammogram if >35
FNA/core biopsy
Mx intraductal papilloma
Conservative
Excision of affected duct
A 65 year old woman attends her GP for her check up and is doing well. She mentions that she has been having some issues with her breasts recently. She states that she has to wash her bras more often as they keep getting some brown/red stain on them and this has been happening for the last 3 months. She is a non-smoker, has 3 grown children, went through the menopause at 56 and started menses at 11. She has been on HRT since turning 60. O/E the nipple has some bloody discharge with some skin dimpling as well as a non-discrete, immobile lump in the upper outer quadrant. What is the first line investigation?
As she is over 35 she will need to have a mammogram and this sounds a lot like carcinoma so likely she will need to have an MRI as well to stage the cancer and a biopsy.
Epidemiology breast cancer
50% of cases in >65
20% <50
2% <30
SNT symptoms of breast cancer
size/shape/skin:
- Palpable hard lump
- Irregular surface
- Indistinct borders
- Dimpling
- Ulceration
- Thickening
menstruation/nipples/nodes:
- Bloody discharge
- Nodes may be involved
trauma/tethering/temp/time/tender/texture:
- Slow growing
- Hard
- Painless
- Immobile- fixed - UNIQUE TO CANCER (others mobile)
- ±Warmth if inflammatory
commonest site for breast cancer
upper outer quadrant
Most common breast cancer- how does it present?
DUCTAL
Firm, immobile, fixed lump
Skin changes
30-50
How can malignant breast cancer be classified?
INVASIVE
- ductal- most common
- lobular- may be incidental finding
- phyllodes
- inflammatory- worse prognosis
CARCINOMA IN SITU
- ductal (50%>invasive) - no lump
- lobular (20%>invasive)- lump
- pagets (80% = carcinoma)
Why is DCIS defined as being premalignant?
It is confined to the milk duct by basement membrane
classic features of inflammatory invasive breast cancer
Early mets
Red
Pain
Peau d-orange
What is the classical Ix pathway for breast cancer?
TRIPLE ASSESSMENT:
- examination
- imaging - <35 USS or >35 mammogram
- tissue Analysis
Explain the triple assessment scoring system
EXAMINATION SCORE
P1-5 (opinion normal –> malignant)
IMAGING SCORE
M1-5 or U1-5 (opinion normal –> malignant)
HISTOLOGY
B1-5 for biopsy
Combine all scores to risk stratify patients and look for concordance between the scores
