BREAST - Conditions Flashcards
Inflammatory Breast Diseases
Mastitis
Breast Abscess
Breast Cysts
Mammary Duct Ectasia
Fat Necrosis
1.) Mastitis - inflammation of breast tissue
- tenderness, swelling, erythematous
- often due to infection (S.aureus) or granulomatous
- can be lactational (more common) or non-lactational
- treated w/ flucloxacillin (10-14d) and simple analgesics
- can continue breastfeeding from the affected breast
2.) Breast Abscess - often develops from acute mastitis
- fluctuant masses w/ punctum potentially present
- treat w/ antibiotics and US-guided aspiration
- refer to general surgery, may require I+D under a local
3.) Breast Cysts
- singular/multiple lumps which affect both breasts
- distinct smooth masses which may also be tender
- mammogram (halo shape), diagnosed using USS
- aspirated if persisting, symptomatic, sent for cytology
- cysts ↑risk of developing breast cancer (2-3x)
4.) Mammary Duct Ectasia - dilation and shortening of the major lactiferous ducts (terminal breast ducts within 3cm of the nipple), it is quite common and often presents w/:
- nipple discharge (often green/brown or creamy/cheesy/black)
- often associated with an abscess with pus discharging
- slit-like nipple retraction, palpable mass
- identified by mammogram (dilated calcified ducts)
- managed conservatively unless malignant
5.) Fat Necrosis - acute inflammatory response leading to ischaemic necrosis of fat lobules
- usually asymptomatic or presents as a lump or rarely w/ fluid discharge, skin dimpling, pain, nipple inversion
- causes: trauma, surgical or radiological interventions
- USS (hyperechoic mass), biopsy to exclude cancer
Benign Breast Tumours
Fibroadenoma (+adenoma)
Papilloma
Lipoma
Phyllodes Tumours
1.) Fibroadenoma - proliferations of stromal+epithelial tissue of duct lobules, can be multiple and bilateral
- most common, women of reproductive age
- highly mobile, rubbery, well defined, <5cm, (‘breast mouse’)
- histology: well-circumscribed solid mass with duct-like structures lined by regular, low columnar cells, and separated by loose fibrous tissue
- can be excised if >3cm
2.) Adenoma - benign glandular tumours
- typically occurs in older women
- nodular and can easily mimic malignancy
3.) Ductal Papilloma - benign breast lesion usually occurring in the sub-areolar region, common in 40-50yr olds
- often presents as unilateral blood stained nipple discharge
- may also have a mass or clear discharge
- requires a biopsy
- has malignant potential so is often excised, microdochectomy can be used to treat multi-ductal papilloma (↑risk of cancer)
4.) Lipoma - soft and mobile benign adipose tumour
- only removed if significantly enlarging or aesthetics
5.) Phyllodes Tumours - rare fibroepithelial tumours comprised of epithelial and stromal tissue, grow rapidly
- difficult to differentiate from fibroadenoma, 1/3 have malignant potential so should be widely excised
Breast Cancer
Risk Factors
Clinical Features
Investigations
Breast Cancer Screening
Prognosis
1.) Risk Factors
- ↑age, BRCA1/2 mutations (chromosome 17), FH
- ↑exposure to unopposed oestrogen: early menarche, late menopause, nulliparous, OCPs/HRT
- benign breast disease, obesity (very strong risk factor), alcohol, geographic (developed countries)
2.) Clinical Features
- lump: firm, fixed, single mass w/ craggy surfaces
- asymmetry, swelling, mastalgia, abnormal discharge (clear/bloody), nipple retraction, lymphadenopathy
- skin changes: peau d’orange, Paget’s-like changes
- differentials:
3.) Investigations - triple assessment (‘one stop’ clinic (2WW) for suspicious breast lesions, referral criteria:
- >30 w/ an unexplained breast lump
- >50 w/ discharge, retraction, or concerning nipple changes in only one nipple
- triple assessment: 1.) history and examination
- 2.) imaging: mammogram (X-Ray) or USS in <35s (due to denser breast tissue)
- 3.) histology: core biopsy >FNA (provides full histology)
4.) Breast Cancer Screening - offered to 50-70yr olds
- women are offered a mammogram every 3 years
- self-referrals are available after the age of 70
- breast cancer patients that undergo treatment will receive follow-up mammograms every year for 5 years and will then return to screening
- can offer screening at a younger age for women at increased risk of breast cancer due to their FH:
- one close relative with breast cancer at <40 OR bilateral breast cancer OR male
- two or more close relatives with breast cancer
- Ashkenazi Jewish ancestry
5.) Prognosis - Nottingham prognostic index (NPI)
- calculates using size, nodal status and grade
- grading is using Bloom-Richardson classification
- poor prognosis: large size, high grade, lymph node spread, <35 at diagnosis, ER-ve, Her2+ve, BRCA 1/2+ve,
Types of Breast Cancer
Ductal Carcinoma
Lobular Carcinoma
Paget’s Disease
1.) Ductal Carcinoma - malignancy of the ductal tissue
- most common type of breast carcinoma
- in-situ is contained within the basement membrane
- in-situ (DCIS) is treated w/ complete wide excision (mastectomy if widespread or multi-focal)
- invasive (IDC) is most common breast cancer and can be further classified into 4 different types all showing distinct growth patterns
2.) Lobular Carcinoma - malignancy of secretory lobules (in-situ contained within basement membrane)
- LCIS usually before menopause and ↑risk -> invasive
- low grade LCIS monitored rather than excised
- ILC harder to detect (presents asymptomatically)
3.) Paget’s Disease of Nipple - eczematoid change of the nipple associated with an underlying breast malignancy
- painful and sensitive, itching or redness in nipple +/- areola w/ flaking and thickening skin on/around nipple
- mistaken for dermatitis or eczema (spares nipple)
- surgical removal of nipple and areola often needed
Management of Breast Cancer
Surgery
Supportive Surgical Procedures
Hormonal Therapy
Chemo/Radio/Immunotherapy
1.) Surgery - offered to most patients except frail, elderly patients with metastatic disease
- mastectomy indications: multifocal or central tumours, large tumour in small breasts, DCIS >4cm, risk reduction in those with high risk of developing breast cancer
- wide local excision indications: solitary or peripheral tumours, small tumour in large breast, DCIS <4cm
- mastectomy complications: breast swelling, soreness, hardness, phantom breast pain, seroma, depression
2.) Supportive Surgical Procedures
- sentinel lymph node biopsy: assess nodal burden in those w/ positive pre-op axillary node ultrasound
- axillary node clearance: for positive sentinel lymph node biopsy or clinically palpable lymphadenopathy, can lead to lymphoedema and functional arm impairment
- cosmetic breast reconstruction: offered to all women
3.) Hormonal Therapy - used in ER+ve tumours
- used as an adjuvant or prevention in high risk women
- Tamoxifen is a SERM (blocks ER in breast) which is used in pre-menopausal women, however there’s ↑risk of VTE and endometrial cancer (stimulates ER in endo…)
- Anastrozole is an aromatase inhibitor (↓oestrogen) used in post-menopausal women because it inhibits adrenally produced androgens (↑risk of osteoporosis). Taken for 5 years
4.) Chemo/Radio/Immunotherapy
- neoadjuvant or adjuvant chemotherapy
- adjuvant radiotherapy to reduce risk recurrence
- immunotherapy: trastuzumab (Herceptin) can be used in HER2+ve tumours (contraindicated in heart disorders)
