Breast Disease Flashcards
Nipple discharge
- usually clear, yellow, and watery
- Bloody - pathological
most common aetiology of spontaneous nipple discharge is an intraductal papilloma or papillomas. - nipple discharge not associated with malignancy unless associated palpable mass
Mastitis signs/symptoms
fever, erythema, induration (localised hardening of soft tissue), tenderness, and swelling.
breast abscess presents as a flocculent sometimes-bulging mass
Mastitis Ix
USS: pus fluid filled centre
Drainage and culture
Mastitis Mx
NICE Management
• Treat empirically with flucloxacillin 500 mg four times a day for 10–14 days.
• If the woman is allergic to penicillin, prescribe either erythromycin 250–500 mg four times a day or clarithromycin 500 mg twice a day for 10–14 days.
Recurrent Mastitis: If an alternative diagnosis is unlikely:
• Send a sample of breast milk for microscopy, culture, and antibiotic sensitivity (if this has not already been done) — see the section on investigations for more information.
• Prescribe a second-line antibiotic, co-amoxiclav 500/125 mg three times a day, for 10–14 days; review this choice when breast milk culture results become available. Seek specialist advice if the woman is allergic to penicillin.
• Patient should be examined every 3 days to be certain the infection is responding to therapy and that there is no evidence of abscess formation.
Keep breastfeeding - monitor every 3 days
Abscess - aspirate
Nonpuerperal mastitis
uncommon and even rare in postmenopausal women. S. aureus, Peptostreptococcus magnus, and/or Bacteroides fragilis are the usual bacterial pathogens.
Chronic mastitis
- uncommon and can be associated with a subareolar abscess
- Peri-areolar fistulae can occur and should be surgically excised when the inflammation is quiescent.
- if spreads and unresponsive - examine for inflammatory carcinoma
Gynaecomastia
Breast development in the male
Ductal growth without lobular development. Lacks terminal ducts that females have
Causes: cannabis, endogenous/exogenous hormones, drugs and liver disease
Cyst
Palpable breast cysts commonly occur during the late reproductive years of a woman’s life
A discrete collection of fluid in the breast tissue
Most common between ages 30-60.
Can fluctuate in size over the menstrual cycle
Cyst signs/symptoms
cyst is typically palpable, clearly defined, soft, mobile, and smooth. The borders are distinct.
Cysts are often somewhat tender, especially before menstruation.
Cyst Ix
FNA - treats as well
only if bloody - cytological evaluation
Fibrocystic Change
female: 20-50
very common in menstruating age (related to hormonal changes around menstrual cycle)
benign condition
Fibrocystic Change signs/symptoms
Symptoms often occur prior to menstruating (within 10 days) and resolve after wards. Usually resolve post menopause
- Smooth discrete lumps
- Sudden pain or cyclical pain
- Bilateral breast lumpiness
- Bilateral breast pain / tenderness (mastalgia)
- Fluctuation of breast size
Fibrocystic Change pathology
blue domed and lined by apocrine epithelium (apocrine metaplasia)
Fibrocystic change Mx
- Supportive Clothing
- NSAIDs
- Weight Loss
- Hormonal contraception may make it worse (consider stopping)
- Exclude malignancy and reassure
- Excise if necessary
Hamartoma
Circumscribed lesion composed of cell types normal to the breast but present in an abnormal proportion or distribution
Fibroadenoma
most common benign neoplasm of the breast and usually is diagnosed as a palpable mass (for example, 1–3 cm) in the early reproductive years of a woman’s life (peak incidence 3rd)
Benign tumours of stromal/epithelial breast duct tissue
fibroadenoma signs/symptoms
Smooth Painless, firm, discrete, mobile mass
“breast mouse”
fibroadenoma Ix
USS (rubbery to firm, mobile, smooth with distinct borders, and is usually nontender Grey-white colour) and Core biopsy
Fibroadenoma Mx
dont need to be removed (become nonpalpable after menopause)
some women prefer to have such breast lumps excised
electively in the form of open lumpectomy or percutaneous vacuum-assisted core biopsy
Sclerosing Lesions
- Sclerosing adenosis
- Radial scar / Complex sclerosing lesion
- Benign, disorderly proliferation of acini and stroma
can cause mass or calcification
Sclerosing Adenosis
- Age 20-70
- Benign
- Negligible risk of subsequent carcinoma
- Increase in number and disortion but myoepethial is still intact
Sclerosing Adenosis signs/symptoms
- Pain, tenderness or lumpiness/thickening
* Asymptomatic
Radial scar
- Incidental finding
- Mammographically detected
- Mimic carcinoma radiologically
- Probably not premalignant per se
- Often show epithelial proliferation
- In situ or invasive carcinoma may occur within these lesions
- Stellate architecture, central puckering and radiating fibrosis
Radial scar vs CSL Size
RS: 1-9mm
CLS: > 10mm
RS and CLS Mx
Excise or sample extensively by vacuum biopsy
Fat necrosis
Lump formed by local degeneration/scarring of fat tissue
This is an inflammatory reaction resulting in fibrosis and eventually necrosis
caused by local trauma or breast surgery
Fat necrosis pathology
- Damage and disruption of adipocytes
- Infiltration by acute inflammatory cells
- “foamy” macrophages
- Subsequent fibrosis and scarring
Fat necrosis signs/symptoms
firm, irregular, fixed lump. May cause skin dimpling or nipple inversion.
Fat necrosis Mx
- May resolve spontaneously
- Treat conservatively or with surgical excision
- Confirm diagnosis
- Exclude malignancy
Duct ectasia
benign (non-cancerous) breast condition that occurs when a milk duct in the breast widens and its walls thicken. This can cause the duct to become blocked and lead to fluid build-up. It’s more common in women who are getting close to menopause
Duct ectasia signs/symptoms
- Affects sub-areolar ducts
- Pain
- Acute episodic inflammatory changes
- Bloody and/or purulent D/C
- Fistulation
- Nipple retraction and distortion
Duct ectasia Mx
- Treat acute infections
- Exclude malignancy
- Stop smoking
- Excise ducts
Phyllodes Tumour
cells resembles leaves, and the name “phyllodes” comes from the Greek word meaning “leaf-like.” Phyllodes tumors can grow quickly, but they do not always spread beyond the breast.
resemble fibroadenomas in clinical presentation and cytology but are often larger (3–6 cm) and tend to occur in older women (35–45 years old) and tend to increase in size.
Phyllodes Tumour behaviour + plus signs/symptoms
Benign
borderline
malignant
unilateral breast tissue
Phyllodes Tumour Mx
should be excised with wide (1-cm), clear, surgical margins and carefully followed up. Metastasis is rare
Intraduct Papilloma
- Sub-areolar ducts
- Papillary fronds containing a fibrovascular core
- Covered by myoepithelium and epithelium
- Epithelium may show proliferative activity
ages: 35-60
Intraduct Papilloma signs/symptoms
• Nipple discharge +/- blood
• Asymptomatic at screening
o Nodules
o Calcification
Breast carcinoma
malignant tumour of breast epithelial cells
Arises in the glandular epithelium of the terminal duct lobular unit (TDLU)
It is an adenocarcinoma
In situ or invasive (direct infiltration of pre-existing tissues)
Precursor lesions - breast carcinoma
Ductal
- Epithelial hyperplasia of usual type
- Columnar cell change (+/- atypia)
- Atypical Ductal Hyperplasia (ADH)
- Ductal Carcinoma in situ (DCIS)
Lobular (Lobular in situ neoplasia)
- Atypical Lobular Hyperplasia (ALH) < 50% of lobule
- Lobular Carcinoma in situ (LCIS) >50%
In situ carcinoma
Confined within basement membrane of acini and ducts
Cytologically malignant but non - invasive
Lobular Carcinoma in situ (LCIS)
Asymptomatic and undetectable on mammogram
Usually diagnosed incidentally on breast biopsy
Lobular Carcinoma in situ (LCIS) Mx
L(is)N discovered on core biopsy
- Proceed to excision or vacuum biopsy to exclude higher grade lesion
L(is)N discovered on vacuum or excision biopsy
o Follow up
o Clinical trials: endocrine therapy
Ductal Carcinoma in situ Mx
Surgery: (Trials of mammographic follow-up in low risk DCIS)
Adjuvant radiotherapy: after surgery
Chemoprevention: Endocrine therapy
Microinvasive Carcinoma
Rare
DCIS (high grade) with invasion of <1mm
Treat as high-grade DCIS
Invasive Breast Carcinoma
Ductal carcinoma is the most common histologic type of breast cancer, accounting for as many as 80% of breast malignancies
Invasive lobular carcinoma spreads diffusely with a typical histologic Indian file pattern. Thus, invasive lobular carcinoma is often not apparent, either by palpation or by imaging, until the cancer is at an advanced stage
Risk factors for breast carcinoma
- Female
- Age: older
- Post menopause obesity
- Reproductive history
Early menarche
o Age at first birth: > 30
o Nulliparity
o Breastfeeding: lower
o Age at menopause
Hormones: oestrogen exposure
- Endogenous
- Exogenous: OCP & HRT
Previous breast disease
o atypical ductal or lobular hyperplasia
o lobular carcinoma in situ
o atypical epithelial hyperplasia
Geography
o Highest rates in Australia and new Zealand. UK is number 5
Life-style o Bodyweight o Physical activity (protective) o Alcohol consumption o Diet o NSAID (lower risk) o Smoking
Genetics
o Affected first degree relative doubles risk
Cancer syndromes: BRAC1, BRAC2
Breast cancer screening
Offered to women aged 50 to 70 (extended in some areas)
Individual offered screening every 3 years
Involves a simple mammogram
Breast cancer signs/symptoms
- dimpled or depressed skin
- visible lump
- nipple change ex inversion
bloody discharge - texture change
- colour change
Breast cancer assessment (triple assessment)
Clinical Assessment including history & breast examination
Breast imaging (US or mammography)
Biopsy (fine needle aspiration or core biopsy)
Mammography vs USS
Mammography: More effective in older women and Pick up calcifications missed by ultrasound
USS: helpful in defining malignant solid mass, particularly in a young woman or in any woman with mammographically dense breasts, but ultrasound is not effective in evaluating calcifications that are often not perceived on ultrasound. Useful in distinguishing solid lumps (e.g. fibroadenoma / cancer) from cystic lumps
lymph nodes?
axillary USS and Ultrasound biopsy of abnormal nodes
Sentinal lymph node biopsy: during surgery where no abnormal lymph nodes identified prior to surgery
grading breast cancer?
Tubular differentiation (1-3)
Nuclear pleomorphism (1-3)
Mitotic activity (1-3)
Intrinsic breast cancer subtypes
- Basal-like: ER-, HER2-, Basal CK+
- HER2: ER-, HER2+
- Normal breast-like: ER-, non-epithelial (?real)
- Luminal A: ER+, low proliferation
- Luminal B: ER+, high proliferation
- Luminal C: ER+, high proliferation
Anti oestrogen therapy
Oophorectomy
Tamoxifen
Aromatase inhibitors (Letrozole)
GnRH antagonists - (Goserilin [Zoladex])
HER 2
Human Epidermal growth factor Receptor 2
HER 2 overexpression or amplification predict response to Trastuzamab (Herceptin)
Triple negative early breast cancer
Chemo (neo/adjuvant)
clinical trials
Treatment overview of breast cancer
Local (Surgery, Radiotherapy)
Systemic (Chemotherapy, Hormonal and Targeted Therapies)
Adjuvant bisphonates
Breast cancer surgery
remove 2mm margin (clear margin) of normal breast tissue
Breast Conserving Surgery + radiotherapy
- Lumpectomy
- Wide Local Excision
- Quadrantectomy (removal of a quarter of the whole breast)
Mastectomy (removal of the whole breast)
Radiotherapy side effects
o General fatigue from the radiation
o Local skin and tissue irritation and swelling
o Fibrosis of breast tissue
o Shrinking of breast tissue
o Long term skin colour changes (usually darker)
Breast reconstruction types
External prosthesis
Implant only (+/- autologous cellular matrix)
Latissimus dorsi (LD) pedicled flap +/- implant
Deep inferior epigastric artery perforator (DIEP) free flap
Inferior gluteal artery perforator (IGAP) free flap
Superior gluteal artery perforator (SGAP) free flap
Transverse upper gracilis (TUG) free flap
Profunda artery perforator (PAP) free flap
Latissimus dorsi flap
Portion of the latissimus dorsi plus skin and fat tissue
Tunnelled under skin to the breast area
“Pedicled” refers to keeping the original blood supply and moving the tissue under the skin to a new location
“Free flap” refers to cutting the tissue away completely and transplanting it to a new location
Transverse rectus abdominis flap (TRAM flap)
Portion of rectus abdominis along with blood supply and skin
Either as pedicled flap (tunneled under skin) or free flap (transplanted)
Deep Inferior Epigastric Perforator Flap (DIEP flap)
- Skin and subcutaneous fat from abdomen (no muscle)
- Transplanted from abdomen to breast
- Transplant the Deep Inferior Epigastric Artery with fat and skin
- Tissue transplanted to reconstruct breast
- Vessels attached to branches of the internal mammary artery and vein
Acute side effects of chemotherapy
- Fatigue (most)
- Myelosuppression and risk of infection, anaemia, thrombocytopenia (most)
- N&V (FEC)
- Alopecia (anthracyclines and taxanes): most devastating side effect
- Mucositis
- Diarrhoea
- Constipation
- Renal
- Neurotoxicity
- Infertility – most drugs temp or permanent – need to discuss if appropriate
Late side effects of chemo
- Cardiac – anthracyliunes and anit-HER2 agents
- Infertility – premature menopause
- Neuropathy
- Renal impairment
- Osteoporosis
- Carcinogenesis – tiny but real risk is increased
Hormonal Therapy: Neoadjuvant
Premenopausal women should be offered Tamoxifen 20mg (12 months)
Post-menopausal women should be offered an aromatase inhibitors (anastrozole, exemestane or letrozole) 2.5mg (12 months)
Trastuzumab (herceptin)
Neoadjuvant
o Impacts heart function, therefore initial and close monitoring of heart function essential
o Contraindicated in women with congestive heart failure and certain heart conditions
o Common side effects: Diarrhoea, tumour pain, headaches.
Bevacizumab
recombinant humanized monoclonal antibody against vascular endothelial growth factor and has been approved as first-line therapy for metastatic breast cancer (mBC).
Inflammatory Breast Cancer signs/symptoms
- Presents similarly to a breast abscess or mastitis
- Swollen, warm, tender breast with pitting skin (peau d’orange)
- Does not respond to antibiotics
Paget’s Disease of the Nipple
- High grade DCIS extending along ducts to reach the epidermis of the nipple
- Still in situ carcinoma (i.e. non-invasive)
- Paget’s disease of the nipple (a variant of ductal carcinoma, intraductal, and/or invasive)
Paget’s Disease of the Nipple signs/symptoms
Erythematous weeping lesion on the surface of the nipple and the areola, although it usually presents as a dry, scaly, eczematous lesion (rash comes first before itch)
The patient may perceive this as nipple discharge.
Paget’s Disease of the Nipple Mx
Central excision and radiotherapy with DCIS
