Breast disease Flashcards
What is the triple assessment?
Clinical assessment: symptoms, risk factors, family history particularly age, HRT and medications
Imaging assessment - if <40 USS, if >40 mammogram
Needle biopsy : core biopsy allows you to test for receptors etc as big chunk, fine needle aspiration of lymph nodes allows you to check for malignancy to see if axillary node clearance is indicated.
what are lobules and ducts of the breast?
The lobules are the glands that produce milk.
The ducts are tubes that carry milk to the nipple.
What is the most common overall breast cancer?
Invasive ductal carcinoma (no special type)
breast cancer screening program
The NHS Breast Screening Programme is offered to women between the ages of 50-70 years.
Women are offered a mammogram every 3 years.
After the age of 70 years women may still have mammograms but are ‘encouraged to make their own appointments’.
do people need referred if they have a first degree relative with breast cancer?
If the person concerned only has one first-degree or second-degree relative diagnosed with breast cancer they do NOT need to be referred unless any of the following are present in the family history:
age of diagnosis < 40 years
bilateral breast cancer
male breast cancer
ovarian cancer
Jewish ancestry
sarcoma in a relative younger than age 45 years
glioma or childhood adrenal cortical carcinomas
complicated patterns of multiple cancers at a young age
paternal history of breast cancer (two or more relatives on the father’s side of the family)
or three first-degree or second-degree relatives diagnosed with breast cancer at any age
inheritance of BRCA 1 and BRCA 2
autosomal dominant
2ww referral criteria for breast cancer
aged 30 and over and have an unexplained breast lump with or without pain or
aged 50 and over with any of the following symptoms in one nipple only: discharge, retraction or other changes of concern
consider if:
skin changes that suggest breast cancer or
aged 30 and over with an unexplained lump in the axilla
where does breast cancer metastasise to
L – Lungs
L – Liver
B – Bones
B – Brain
can go anywhere though
when is axillary node clearance indicated?
if lymphadenopathy
if no lymphadenopathy but a postive sentinal node biopsy on first surgery
when is wide local excision indicated?
Solitary lesion
Peripheral tumour
Small lesion in large breast
DCIS < 4cm
when is mastectomy indicated
Multifocal tumour
Central tumour
Large lesion in small breast
DCIS > 4cm
when is radiotherapy indicated for breast cancer? type?
Whole breast radiotherapy is recommended after a woman has had a wide-local excision as this may reduce the risk of recurrence by around two-thirds.
For women who’ve had a mastectomy radiotherapy is offered for T3-T4 tumours and for those with four or more positive axillary nodes
management of estrogen receptor positive breast cancer?
Tamoxifen for premenopausal women
Aromatase inhibitors for postmenopausal women (e.g., letrozole, anastrozole or exemestane)
Pharamcology tamoxifen
Tamoxifen is a selective oestrogen receptor modulator (SERM).
It either blocks or stimulates oestrogen receptors, depending on the site of action.
It blocks oestrogen receptors in breast tissue, and stimulates oestrogen receptors in the uterus and bones.
This means it helps prevent osteoporosis, but it does increase the risk of endometrial cancer.
adverse effects of tamoxifen
menstrual disturbance: vaginal bleeding, amenorrhoea
hot flushes - 3% of patients stop taking tamoxifen due to climacteric side-effects
venous thromboembolism
endometrial cancer
pharmacology aromatase inhibitors such as Anastrozole
Aromatase is an enzyme found in fat (adipose) tissue that converts androgens to oestrogen. After menopause, the action of aromatase in fat tissue is the primary source of oestrogen. Aromatase inhibitors work by blocking the creation of oestrogen in fat tissue
adverse effects of aromatase inhibitors
eg Letrozole. Anastrozole. Exemestane.
osteoporosis
NICE recommends a DEXA scan when initiating a patient on aromatase inhibitors for breast cancer
hot flushes
arthralgia, myalgia
insomnia
what drug is used for HER2 +ve breast cancer?
what i main complication you need to monitor?
Trastuzumab (Herceptin)
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)
Neratinib (Nerlynx)
when is ‘neoadjuvanant’ chemotherapy used?
to downstage a primary lesion or after surgery depending on the stage of the tumour, for example, if there is axillary node disease - FEC-D is used in this situation.
A key reason for considering neo-adjuvant chemotherapy in breast cancer is to try to downsize the tumour before surgery and allow breast conserving surgery rather than mastectomy
what is peau d’orange linked to
inflammatory breast cancer
Looks like eczema of the nipple/areolar, spreads from nipple to areola
Erythematous, scaly rash
pagets disease of the nipple
what are phyllodes tumours
Phyllodes tumours are rare tumours of the connective tissue (stroma) of the breast, occurring most often between ages 40 and 50. They are large and fast-growing. They can be benign (~50%), borderline (~25%) or malignant (~25%). Malignant phyllodes tumours can metastasise.
blood supply of lattismus muscle ?
the thoracodorsal artery, and branch of the subscapular artery
Young patient with firm mobile mass
fibroadenoma
Soft, fluctuant swelling perimenopause
cyst
recurrent infection/abscess in smoker
periductal mastitis
nipple retraction and occasionally creamy nipple discharge
might be brown-green discharge
duct ectasia
Bloody discharge with no lump
Intraductal papilloma
obese/large breasts, following trauma Initial inflammatory response, the lesion is typical firm and round but may develop into a hard, irregular breast lump
fat necrosis
management of fibroadenoma
If greater than 4cm - core biopsy to exclude a phyllodes tumour.
10% will increase in size, 30% regress and the remainder stay the same. This does not apply during pregnancy and lactation when they may increase in size substantially and subsequently sequester milk.
Management:
If want excision - circumareolar incision. Smaller lesions may be removed using a mammotom
‘halo appearance’ on mammography.
cyst
what type of scan helps confirm a cyst
USS - fluid filled
first line management of mastitis
- continue breastfeeding
- If unwell etc. - flucloxacillin for 10-14 days
treatment of periductal mastitis
co-amoxiclav
Pathophysiology duct ectasia
Duct ectasia is a dilatation and shortening of the terminal breast ducts within 3cm of the nipple. It is common and the incidence increases with age. Associated with smoking
management of duct ectasia
Patients with troublesome nipple discharge may be treated by microdochectomy (if young) or total duct excision (if older).
Lumpiness
Breast pain or tenderness (mastalgia)
Fluctuation of breast size
fibrocystic breast change
management fibrocystic breast change
Options to manage cyclical breast pain (mastalgia) include:
Wearing a supportive bra
Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen
Avoiding caffeine is commonly recommended
Applying heat to the area
Hormonal treatments (e.g., danazol and tamoxifen) under specialist guidance
breastfeeding lady firm, mobile, painless lump, usually beneath the areola
galactocele
management galactcele
They are benign and usually resolve without any treatment. It is possible to drain them with a needle. Rarely, they can become infected and require antibiotics.
gynaecomastia drug causes
spironolactone
anabolic steroids
