Breast Conditions Flashcards
1
Q
What is a breast abscess
A
A collection of pus within an area of the breast, usually caused by a bacterial infection
2
Q
What are the two types of breast abscess
A
Lactational abscess (associated with breast feeding) Non-lactational abscess (unrelated to breast feeding)
3
Q
What is pus
A
A thick fluid produced by inflammation
It contains dead white blood cells of the immune system and other waste from the fight against the infection
4
Q
What is mastitis
A
Refers to inflammation of breast tissue
Can be related to breastfeeding (lactational mastitis) or caused by infection
Bacteria can enter at the nipple and back track into the ducts causing infection and inflammation
Can precede the development of an abscess
5
Q
What are the causes of breast abscess
A
Staphylococcus aureus (the most common)
Streptococcal species
Enterococcal species
Anaerobic bacteria (such as Bacteroides species and anaerobic streptococci)
6
Q
Which are the best antibiotics for gram positive bacteria (such as staph aureus, streptococcal and enterococcal)
A
Penicillins
Flucloxacillin used against staph aureus skin infections especially
7
Q
Which antibiotics should be used against anaerobic bacteria
A
Simple penicillins do not cover anaerobic bacteria
Co-amoxiclav (amoxicillin plus clavulanic acid) covers anaerobes
Metronidazole gives excellent anaerobic covers so may be added too
8
Q
How does a breast abscess present
A
Usually acute (onset within a few days) Mastitis with infection in the breast tissue presents with breast changes of: -Nipple changes -Purulent nipple discharge (pus from the nipple) -Localised pain -Tenderness -Warmth -Erythema (redness) -Hardening of the skin or breast tissue -Swelling
Key feature of a breast abscess is a swollen, fluctuant, tender lump within the breast
Generalised symptoms of infection may also be present:
- Muscle aches
- Fatigue
- Fever
- Signs of sepsis (eg. tachycardia, raised respiratory rate, and confusion)
9
Q
What does fluctuant mean
A
Refers to being able to move fluid around within the lump using pressure during palpation
10
Q
How is a diagnosis of breast abscess made
A
Usually clinically with a history and examination
11
Q
How is lactational mastitis managed
A
Conservatively:
- Continued breastfeeding
- Expressing bilk
- Breast massage
- Heat packs
- Warm showers
Medicinally:
- Simple analgesia
- Antibiotics (Flucloxacillin or erythromycin/clarithromycin if penicillin allergic) if symptoms do not improve or suspected infection
12
Q
How is non-lactational mastitis managed
A
Analgesia
Antibiotics (broad spectrum eg. co-amoxiclav or erythromycin/clarithromycin plus metronidazole)
Treatment for the underlying causes ( eg. eczema or candidal infection)
13
Q
How is a breast abscess managed
A
Referral to the on-call surgical team in the hospital for management
Antibiotics
Ultrasound (confirm the diagnosis and exclude other pathology)
Drainage (needle aspiration or surgical incision and drainage)
Microscopy, culture and sensitivities of the drained fluid
14
Q
What are the risk factors for breast abscess
A
- Female
- > 30years
- Poor breastfeeding technique
- Lactation
- Milk stasis
- Nipple injury
- Previous mastitis
- Prolonged mastitis
- Prior 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
15
Q
What are the differentials in suspected breast abscess
A
Breast pain
- usually linked to periods
- can be due to injury or sprain to the neck, shoulder or back
- medicines ie contraceptive pill and some antidepressants
- pregnancy (early sign)
- menopause
Breast pain when breastfeeding
- breast engorgement due to breasts being too full of milk
- blocked milk ducts
- thrush
Breast lumps
- often harmless ie non cancerous tissue growth (fibroadenoma) or a build up of fluid (breast cyst)
- breast cancer
16
Q
What are fibrocystic breast changes
A
Previously called fibrocystic breast disease
Generalised lumpiness to the breast is considered a variation of normal breast and not a disease
The connective tissues (stroma), ducts and lobules of the breast respond to the female sex hormones, becoming fibrous and cystic, with the changes often fluctuating with the menstrual cycle
A benign condition but can vary in severity
17
Q
What does fibrous mean
A
Irregular and hard
18
Q
What does cystic mean
A
Fluid filled
19
Q
Who is affected by fibrocystic breast changes
A
Common in women of menstruating age, peak incidence in third and fourth decades of life
54% of clinically normal breasts
20
Q
How do fibrocystic breast changes present
A
Symptoms often occur prior to menstruating (within 10 days) and resolve once menstruation begins
Symptoms often improve or resolve after menopause
Symptoms can affect different areas of the breast or both breasts, with:
-lumpiness
-breast pain or tenderness (mastalgia)
-fluctuation of breast size
21
Q
How are fibrocystic breast changes managed
A
Exclude cancer and manage symptoms wear supportive bra NSAIDs Avoid caffeine Apply heat to the area Hormonal treatment (eg. danazol and tamoxifen) under specialist guidance
22
Q
What are the risk factors for fibrocystic breast changes
A
Age 30-50 Late onset menopause Later age at first childbirth Nulliparity (never given birth) Obesity Oestrogen replacement therapy
23
Q
What are the differentials in suspected fibrocystic breast changes
A
Chest wall pain Costochondritis Fibroadenoma Breast cancer Intracystic papilloma
24
Q
How is fibrocystic breast change investigated
A
Mammography
Breast ultrasound
Cyst aspiration
Breast biopsy
25
What are the important discussions to have with patients with fibrocystic breast changes
Fibrocystic change of the breast is a non-specific term, commonly understood as a continuum of physiological changes that expand to the pathological spectrum.
Lumpy breasts associated with pain and tenderness that fluctuate with the menstrual cycle
These changes do not correlate with an increased risk of breast cancer.
26
What is intraductal papilloma
A warty lesion that grows within one of the ducts in the breast as the result of the proliferation of epithelial cells
Typically presents with clear or blood stained nipple discharge
Benign tumours but may be associated with atypical hyperplasia or breast cancer
27
How do intraductal papilloma's present
Can occur at any age but most often between 35-55 years
Often asymptomatic and may be picked up incidentally on mammograms or ultrasound
May present with:
-nipple discharge (clear or blood stained)
-tenderness or pain
-a palpable lump
-typically one larger lump near nipple or multiple smaller lumps further from nipple
28
How is a diagnosis of intraductal papilloma made
Patients require triple assessment with:
- clinical assessment (history and examination)
- imaging (ultrasound, mammography and MRI)
- histology (usually by core biopsy or vacuum assisted biopsy)
Ductography may also be use
29
What is ductography
Involves injecting contrast into the abnormal duct and performing mammograms to visualise that duct
The papilloma will be seen as an area that does not fill with contrast (a filling defect)
30
How are intraductal papillomas managed
Complete surgical excision
| After removal, tissue is examined for atypical hyperplasia or cancer that may not have been picked up on biopsy
31
What are the differentials in suspected intraductal papilloma
Ductal hyperplasia
Atypical papilloma
Papillary ductal carcinoma in situ
Papillary apocrine metaplasia
32
What is the prognosis for intraductal papilloma
Good prognosis once surgically removed
| If multiple papillomas and under age 35 then talk about increased risk of breast cancer
33
How common is breast cancer and who is affected
Most common form of cancer in the UK
Mostly affects women and is rare in men ( only 1% of cases)
Around 1 in 8 women will develop breast cancer in their lifetime
34
What are the risk factors for breast cancer
Female (99% of cases)
Increased oestrogen exposure (early onset of periods or late menopause)
More dense breast tissue (ie more glandular tissue)
Obesity
Smoking
Family history (first-degree relatives)
Hormone replacement therapy (particularly combined HRT of both oestrogen and progesterone)
Small increased risk from combined contraceptive pill but risk returns to population risk after 10 years after stopping the pill
35
What is BRCA
Refers to the BReast CAncer gene
BRCA genes are tumour suppressor genes
Mutations in these genes lead to an increased risk of breast cancer as well as ovarian and other cancers
BRCA1 on chromosome 17:
- ~70% will develop breast cancer by aged 80
- ~50% will develop ovarian cancer
- Increased risk of bowel and prostate cancer
BRCA2 on chromosome 13:
- ~60% will develop breast cancer by aged 80
- ~20% will develop ovarian cancer
36
What are the key types of breast cancer
```
Ductal carcinoma in situ (DCIS)
Lobular carcinoma in situ (LCIS)
Invasive ductal carcinoma (NST)
Invasive lobular carcinoma
Inflammatory breast cancer
Paget's disease of the nipple
```
37
What is ductal carcinoma in situ
Pre-cancerous or cancerous epithelial cells of the breast ducts
Localised to a single area
Often picked up by mammogram screening
Potential to spread locally over years
Potential to become an invasive breast cancer (around 30%)
Good prognosis if fully excised and adjunct treatment is used
38
What is lobular carcinoma in situ
A pre-cancerous condition occurring typically in pre-menopausal women
Usually asymptomatic and undetectable on a mammogram
Usually diagnosed incidentally on a breast biopsy
Represents an increased risk of invasive breast cancer in the future (around 30%)
Often managed with close monitoring (e.g., 6 monthly examination and yearly mammograms)
39
What is invasive ductal carcinoma (NST)
NST means no special/specific type, where it is not more specifically classified (e.g., medullary or mucinous)
Also known as invasive breast carcinoma of no special/specific type (NST)
Originate in cells from the breast ducts
80% of invasive breast cancers fall into this category
Can be seen on mammograms
40
What is invasive lobular carcinoma
Around 10% of invasive breast cancers
Originate in cells from the breast lobules
Not always visible on mammograms
41
What is inflammatory breast cancer
1-3% of breast cancers
Presents similarly to a breast abscess or mastitis
Swollen, warm, tender breast with pitting skin (peau d’orange)
Does not respond to antibiotics
Worse prognosis than other breast cancers
42
What is Paget's disease of the nipple
Looks like eczema of the nipple/areolar
Erythematous, scaly rash
Indicates breast cancer involving the nipple
May represent DCIS or invasive breast cancer
Requires biopsy, staging and treatment, as with any other invasive breast cancer
43
What are the rarer types of breast cancer
Medullary breast cancer
Mucinous breast cancer
Tubular breast cancer
Multiple others
44
What is the NHS breast cancer screening program
Offers a mammogram every 3 years to women aged 50-70 years
Aims to detect breast cancer early, which improves outcomes
~1 in 100 women are diagnosed with breast cancer after going for a mammogram
45
What are the downsides of the NHS breast cancer screening program
Anxiety and stress
Exposure to radiation, with a very small risk of causing breast cancer
Missing cancer, leading to false reassurance
Unnecessary further tests or treatment where findings would not have otherwise caused harm
46
How does breast cancer present
Lumps that are hard, irregular, painless or fixed in place
Lumps may be tethered to the skin or the chest wall
Nipple retraction
Skin dimpling or oedema (peau d’orange)
Lymphadenopathy, particularly in the axilla
47
What is the referral criteria for two week wait in suspected breast cancer
An unexplained breast lump in patients aged 30 or above
Unilateral nipple changes in patients aged 50 or above (discharge, retraction or other changes)
Consider also:
An unexplained lump in the axilla in patients aged 30 or above
Skin changes suggestive of breast cancer
Non-urgent referral for unexplained lumps in patients under 30 y/o
48
What is the triple diagnostic assessment
Once a patient has been referred for specialist services under a two week wait referral for suspected cancer, they should initially receive a triple diagnostic assessment comprising of:
- Clinical assessment (history and examination)
- Imaging (ultrasound or mammography)
- Biopsy (fine needle aspiration or core biopsy)
49
What imaging can be done in suspected breast cancer
Ultrasound:
- typically used in younger women (under 30 y/o)
- help distinguish solid lumps (eg. fibroadenoma or cancer) from cystic (fluid-filled) lumps
Mammograms:
- generally more effective in older women
- can pick up calcifications missed by ultrasound
MRI:
- for screening in women at higher risk of developing breast cancer
- to further assess the size and features of a tumour
50
What is the lymph node assessment
To see if cancer has spread to lymph nodes
All women offered an ultrasound of axilla and ultrasound guided biopsy of any abnormal nodes
A sentinel lymph node biopsy may be used in breast cancer surgery where the initial ultrasound does not show any abnormal nodes
51
What is a sentinel lymph node biopsy
An isotope contrast and a blue dye are injected into the tumour area
Contrast and dye travel through the lymphatics to the first lymph node (sentinel node)
The first node in the drainage area shows up blue and on the isotope scanner.
A biopsy can be performed on this node and if cancer cells are found, the lymph nodes can be removed
52
What are the breast cancer receptors
Breast cancer cells may have receptors that can be targeted with breast cancer treatments. These receptors are tested for on samples of the tumour and help guide treatment. There are three types of receptors:
- Oestrogen receptors (ER)
- Progesterone receptors (PR)
- Human epidermal growth factor (HER2)
53
What is triple-negative breast cancer
Where the breast cancer cells do not express any of the three breast cancer receptors.
This carries a worse prognosis, as it limits the treatment options for targeting the cancer.
54
What are the notable locations that breast cancer metastasis occur
```
LLBB
L-lungs
L-liver
B-bones
B-brain
```
However may spread anywhere in the body
55
What is the TNM system
```
Used to stage breast cancer
Grades the:
T-tumour
N-nodes
M-metastasis
```
56
What is the surgical management of breast cancer
Tumour removal:
- Remove cancer tissue with a clear margin of normal breast tissue
- Options are:
- - Breast conserving surgery (eg. wide local excision) usually coupled with radiotherapy
- - Mastectomy (removal of whole breast), potentially with immediate or delayed breast reconstruction
Axillary clearance:
- Removal of axillary lymph nodes
- Offered to patients where cancer cells are found in the nodes
- Usually the majority or all lymph nodes are removed from the axilla
- Increases risk of chronic lymphoedema in that arm
57
What is chronic lymphoedema
Caused by impaired lymphatic drainage of an area
Can occur in an entire arm after breast cancer surgery on that side with removal of the axillary lymph nodes in the armpit
The lymphatic system is responsible for draining excess fluid from the tissues. The tissues in areas affected by an impaired lymphatic system become swollen with excess, protein-rich fluid (lymphoedema).
The lymphatic system also plays an important role in the immune system. Areas of lymphoedema are prone to infection.
58
How is chronic Lymphoedema managed
There are specialist lymphoedema services that can help manage patients. Non-surgical treatment options include:
- Massage techniques to manually drain the lymphatic system (manual lymphatic drainage)
- Compression bandages
- Specific lymphoedema exercises to improve lymph drainage
- Weight loss if overweight
- Good skin care
59
Why should blood not be taken from, or cannula inserted in, the arm on the side of previous breast cancer removal surgery
Higher risk of complications and infection due to the impaired lymphatic drainage on that side
60
What are the common radiotherapy side effects
General fatigue from the radiation
Local skin and tissue irritation and swelling
Fibrosis of breast tissue
Shrinking of breast tissue
Long term skin colour changes (usually darker)
61
Which situations will require chemotherapy in breast cancer
Neoadjuvant therapy – intended to shrink the tumour before surgery
Adjuvant chemotherapy – given after surgery to reduce recurrence
Treatment of metastatic or recurrent breast cancer
62
What is the hormone treatment for breast cancer
Patients with oestrogen-receptor positive breast cancer are given treatment that disrupts the oestrogen stimulating the breast cancer.
There are two main first-line options for this:
Tamoxifen for premenopausal women
Aromatase inhibitors for postmenopausal women (e.g., letrozole, anastrozole or exemestane)
Tamoxifen or an aromatase inhibitor are given for 5 – 10 years to women with oestrogen-receptor positive breast cancer.
63
What are some targeted therapies for breast cancer
Trastuzumab (Herceptin) is a monoclonal antibody that targets the HER2 receptor. It may be used in patients with HER2 positive breast cancer. Notably, it can affect heart function; therefore, initial and close monitoring of heart function is required.
Pertuzumab (Perjeta) is another monoclonal antibody that targets the HER2 receptor. It may be used in patients with HER2 positive breast cancer. This is used in combination with trastuzumab (Herceptin).
Neratinib (Nerlynx) is a tyrosine kinase inhibitor, reducing the growth of breast cancers. It may be used in patients with HER2 positive breast cancer.
64
What are the follow up recommendations for those with breast cancer
Surveillance mammograms yearly for 5 years
Individual written care plan including details on:
-Designated contacts and details
-Adjuvant treatment review dates
-Surveillance dates
-Advice on identifying recurrence
-Support service details
