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Phase 3a Jemima > Breast disease - women's health > Flashcards

Breast disease - women's health Flashcards

1
Q

what is Peau d’orange

A

it is an irregular patch of skin which may be associated with inflammatory breast cancer

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2
Q

what causes Peau d’orange

A

blocked lymphatic drainage from the affected skin area causes superficial oedema which makes the skin thickened. The sweat ducts cause small dimples within the oedematous skin leading to a thickened and dimpled appearance

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3
Q

what is pagets disease of the nipple

A

it is an erythematous scaly rash of the nipple region which resembles eczema, it can be itchy inflamed or ulcerated
- may indicate an underlying breast cancer

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4
Q

what is the basic anatomy of the breast

A

the breast sits in front of the chest wall. Most of the breast is adipose tissue, the areola surrounds the nipple. Behind the nipple are the ducts which lead into lobules where breast milk is produced. Milk is secreted through the ducts and out of openings in the nipple

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5
Q

what does triple assessment involve when screening for cancer

A

clinical assessment - history and exam
imaging - ultrasound or mammogram
histology - fine needle aspiration or core biopsy

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6
Q

what clinical features may suggest breast cancer

A

lumps that are hard, irregular, painless or fixed
lumps tethered to either the skin or the chest wall
nipple retraction
skin dimpling or oedema

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7
Q

when do you refer someone on two week wait for suspected breast cancer

A
  1. unexplained breast lump in patients aged 30 or above
  2. unilateral nipple changes in patients 50 or above
  3. consider referral if there is an unexplained lump in the axilla or if there are skin changes suggestive of cancer
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8
Q

what is a fibroadenoma

A

it is a common benign tumour of the stromal or epithelial duct tissue

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9
Q

when are fibroadenomas most common

A

in younger women between the ages of 20 and 40

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10
Q

on examination what are fibroadenomas like

A

painless
smooth
round
well circumscribed
firm
mobile
usually up to 3cm in diameter

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11
Q

what is fibrocystic breast changes

A

it is considered a variation of normal
it is a benign condition causing lumpiness and pain of the breast

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12
Q

what causes fibrocystic breast changes

A

the connective tissue (stroma), ducts and lobules of the breast respond to oestrogen and progesterone, and become fibrous and cystic. this can fluctuate with the menstrual cycle

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13
Q

when do the symptoms of fibrocystic breast changes present

A

it normally presents around 10 days prior to menstruation and will resolve once menstruation begins

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14
Q

what are the symptoms of fibrocystic breast changes

A

lumpiness
pain or tenderness (mastalgia)
fluctuation in breast size

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15
Q

what is the management for fibrocystic breast changes

A

wearing a supportive bra
non steroidal anti-inflammatories
avoid caffeine
apply heat to the area
hormonal treatments (danazol and tamoxifen)

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16
Q

what are breast cysts

A

these are benign, individual, fluid filled lumps

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17
Q

on examination what can breast cysts feel like

A

smooth
well circumscribed
mobile
possibly fluctuant
can be painful

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18
Q

what is the management of breast cysts

A

require further assessment to rule out cancer
aspiration is the patient is in pain

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19
Q

what happens if you get fat necrosis of the breast

A

you have a benign lump

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20
Q

what happens when there is fat necrosis of the breast

A

there is localised degeneration and scarring of the fat tissue due to inflammation and fibrosis, which may be associated with an oil cyst, causing a lump

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21
Q

what are common causes of fat necrosis in the breast

A

trauma
radiotherapy
surgery

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22
Q

on examination what is fat necrosis of the breast like

A

painless
firm
irregular
fixed in local structures
there may be dimpling of the skin or nipple inversion

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23
Q

what is the management of fat necrosis of the breast

A

need to have imaging and histology to rule out cancer
it is treated conservatively normally as it will go away over time
can have surgical excision if the symptoms are bad

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24
Q

what is a lipoma

A

benign tumours of fat tissue

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25
Q

what is a lipoma like on examination

A

soft
painless
mobile
does not cause any skin changes

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26
Q

how is lipoma treated

A

they are typically treated conservatively with reassurance
they can be surgically removed

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27
Q

what is a galactocele

A

it can occur in women that are lactating
they are breast milk filled cysts that occur when the lactiferous duct is blocked

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28
Q

how does a galactocele present

A

firm
mobile
painless
usually beneath the areola

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29
Q

how do you treat galactocele

A

benign and usually resolve without treatment
can be drained
rarely become infected and require antibiotics

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30
Q

what is phyllodes tumour

A

rare tumour of the stroma (connective tissue) which are large and very fast growing
- can be benign, borderline and malignant

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31
Q

what age are phyllodes tumours most common in

A

ages 40-50

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32
Q

how do you treat phyllodes tumour

A

surgical removal and surrounding tissue
chemotherapy if malignant

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33
Q

what are they two types of breast pain

A

cyclical
non cyclical

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34
Q

what is cyclical pain

A

it is breast pain that is related to hormonal fluctuations in the menstrual cycle

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35
Q

when does cyclical breast pain typically present

A

normally presents two weeks before menstruation and settles during the menstrual period

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36
Q

what are the other symptoms of premenstrual syndrome other that breast pain

A

low mood
bloating
fatigues
headaches

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37
Q

what are symptoms of cyclical breast pain

A

bilateral and generalised breast pain
heaviness
aching

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38
Q

when is non cyclical breast pain common

A

more common in women aged 40-50

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39
Q

what can be causes of non cyclical breast pain

A

medications - hormonal contraceptives
infection
pregnancy
chest wall pain - costochondritis
skin issues - shingles, post herpetic neuralgia

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40
Q

how do you diagnose breast pain

A

breast pain diary - cyclical breast pain
history and exam to rule out cancer
perform pregnancy test to rule out pregnancy
need to rule out infection

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41
Q

how do you manage breast pain

A

wearing a supportive bra
NSAIDS - oral or topical
avoiding caffeine
applying heat to the area
hormonal treatments - danazol and tamoxifen

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42
Q

what is gynaecomastia

A

it is the enlargement of glandular breast tissue in males

43
Q

what causes gynaecomastia

A

it is caused by a hormonal imbalance between oestrogen and androgens (testosterone), with it being caused by higher oestrogen levels
high levels of prolactin can also stimulate glandular breast tissue development

44
Q

what are causes of gynaecomastia

A

idiopathic
dopamine antagonists - increased prolactin
physiological in adolescence due to increased oestrogen in puberty
obesity - increased oestrogen
testicular cancers
liver cirrhosis and liver failure
hyperthyroidism
hGC secreting tumour - small cell lung cancer
testosterone deficiency of old age
hypothalamus/pituitary changes
klinefelters syndrome
orchitis
testicular damage

45
Q

what are some medications that can cause gynaecomastia

A

anabolic steroids
antipsychotics
digoxin - stimulates oestrogen receptors
spironolactone - inhibits testosterone production
GnRH agonists
opiates
marijuana
alcohol

46
Q

how do you tell the difference between gunaecomastia and breast enlargement due to obesity

A

on palpation there will be firm tissue behind the areolas in gynaecomastia due to growth of the gland and duct tissue

47
Q

what points should be covered in a gynaecomastia examination

A

if its true gynaecomastia or weight gain
unilateral or bilateral
and palpable lumps, skin changes or lymphadenopathy
BMI
testicular examination
signs of testosterone deficiency
signs of liver disease
signs of hyperthyroidism

48
Q

what investigations would you want to do for gynaecomastia

A

Bloods: U+E, LFT, TFT, testosterone, sex hormone binding globulin, oestrogen, prolactin, LH and FSH, alpha fetoprotein and beta-hCG, genetic karyotyping

imaging: breast ultrasound, mammogram, biopsy, testicular ultrasound, chest X-ray

49
Q

how is gynaecomastia managed

A
  • stop causative drug
  • tamoxifen to reduce effect of oestrogen
  • surgery
  • refer to specialist if cancer suspected
50
Q

what is galactorrhoea

A

it is breast milk production not associated with pregnancy or breastfeeding

51
Q

where is prolactin produced

A

anterior pituitary gland

52
Q

what inhibits the secretion of prolactin in pregnancy

A

oestrogen and progesterone

53
Q

what stimulated milk excretion

A

oxytocin

54
Q

what are key causes of hyperprolactinaemia

A

idiopathic
prolactinomas - hormone secreting tumours
endocrine disorders - hypothyroidism and PCOS
medications - dopamine antagonists

55
Q

how can hyperprolactinaemia present

A

menstrual irregularities - amenorrhoea
reduced libido
erectile dysfunction in men
gynaecomastia in men

56
Q

what is a prolactinoma

A

it is a tumour of the pituitary which causes excessive secretion of prolactin
- may be associated with multiple endocrine neoplasia (MEN) type 1

57
Q

what are the two classes of prolactinomas

A

microprolactinomas - smaller than 10cm
macroprolactinomas - larger than 10cm

58
Q

what adverse effects can macroprolactinomas lead to

A

headaches
bitemporal hemianopia

59
Q

what breast diseases can cause nipple discharge that is not breast milk

A

mammary duct ectasia
duct papilloma
pus from a breast abscess

60
Q

what investigations should be done if someone who is having galactorrhoea

A

serum prolactin
renal profile (U+E)
liver function tests
thyroid function tests
pregnancy test should be done in women of childbearing age
MRI scan

61
Q

what is the investigation of choice for diagnosing a pituitary tumour

A

MRI scan

62
Q

what is the management for galactorrhoea

A

dopamine agonists (bromocriptine/cabergoline) used to treat the symptoms of hyperprolactinaemia
trans sphenoidal surgical removal or the pituitary tumour

63
Q

what is mammary duct ectasia

A

it is a benign condition where there is dilation of the large ducts in the breasts

64
Q

how can mammary duct ectasia present

A

nipple discharge - due to inflammation in ducts, may be white, green or grey
tenderness or pain
nipple retraction or inversion - slit like retraction
a breast lump (pressure on lump may produce discharge)

65
Q

how is mammary duct ectasia diagnosed

A

Need to exclude breast cancer !
clinical assessment - history and exam
imaging - ultrasound, mammography, MRI
histology - core biopsy or fine needle aspiration

66
Q

what key finding is seen in mammary duct ectasia mammogram

A

microcalcifications (although not specific)

67
Q

what other investigations may be performed in mammary duct ectasia

A

ductography - contrast injected into an abnormal duct and mammograms used to visualise the duct
nipple discharge cytology
ductoscopy - inserting tiny endoscope into the duct

68
Q

how is mammary duct ectasia managed

A

can resolve without any treatment
reassurance after excluding cancer
symptomatic management of mastalgia
antibiotics if infection is present/suspected
surgical excision of the affected duct in problematic cases

69
Q

what is an intraductal papilloma

A

it is a warty lesion that grows within a duct of a breast due to the proliferation of epithelial cells
- it is a benign tumour of the breast

70
Q

what is the typical presentation of intraductal papilloma

A

can present asymptomatically and picked up incidentally
clear or blood stained nipple discharge
tenderness or pain
palpable lump

71
Q

at what age are intraductal papillomas most common

A

35-55

72
Q

how are intraductal papillomas diagnosed

A

clinical assessment - history and exam
imaging - ultrasound, mammogram, MRI
histology- core biopsy, vacuum assisted biopsy
ductography may also be used to visualise the duct

73
Q

how are intraductal papillomas managed

A

complete surgical excision
after removal the tissue is examined for atypical hyperplasia or cancer

74
Q

what is mastitis

A

it is inflammation of the breast tissue
can occur with or without infection

75
Q

what are causes of mastitis

A

blockage - obstruction and accumulation of milk flow
infection - bacteria can enter at the nipple and back tract into ducts

76
Q

what is the most common cause of infective mastitis

A

staphylococcus aureus

77
Q

how does mastitis present

A

breast pain and tenderness (unilateral)
erythema in a focal area of the breast tissue
local warmth and inflammation
nipple discharge
fever

78
Q

how is mastitis managed

A

conservative - continue breastfeeding and breast massage, heat packs, warm showers, simple analgesia
medication - flucloxacillin (first line), erythromycin if allergic to penicillin, fluconazole for candidiasis

79
Q

what is a rare complication of mastitis

A

breast abscess

80
Q

how is a breast abscess managed

A

surgical incision and drainage

81
Q

how does candida infection of the nipple present

A

recurrent mastitis
sore nipples bilaterally particularly after feeding
nipple tenderness and itching
cracked flaky or shiny areola
symptoms in the baby such as white patched in the mouth, on the tongue or candidal nappy rash

82
Q

what is the treatment for candida of the nipple

A

topical miconazole 2%, put on nipple after each breastfeed
treatment for baby - oral miconazole gel or nystatin

83
Q

what is a breast abscess

A

it is a collection of pus within an area of the breast, usually caused by bacterial infection

84
Q

what are the types of breast abscess

A

lactational - associated with breastfeeding
non lactational

85
Q

what is a key risk factor in the development of infective mastitis and breast abscess

A

smoking

86
Q

what are the most common causative bacteria of breast abscesses

A

staphylococcus aureus (most common)
streptococcus
enterococcus
anaerobic bacteria - Bacteroides and anaerobic streptococci

87
Q

how does breast abscess present

A

acute
nipple changes
purulent nipple discharge
localised pain
tenderness
tenderness
warmth
erythema
hardening of the skin or breast tissue
swelling

88
Q

what are key features of a breast abscess

A

swollen, fluctuant, tender lump within the breast

89
Q

how is non lactational mastitis managed

A

analgesia
antibiotics
treatment of the underlying cause - eczema, candida infection (broad spectrum abx)

90
Q

how are breast abscesses managed

A

referral to on call surgical team
antibiotics
ultrasound (confirm dx)
drainage - needle aspiration or surgical incision and drainage
microscopy, culture and sensitivities of drained fluid

91
Q

how many women will develop breast cancer in their life

A

1 in 8

92
Q

what are risk factors for breast cancer

A

female
increased oestrogen exposure - early period onset and later menopause
more dense breast tissue - more glandular tissue
obesity
smoking
family history - first degree relative
COCP - small increase
HRT - particularly combined HRT

93
Q

what genetic factor predisposes you to developing breast cancer

A

BRCA gene mutations in either BRCA1 or BRCA2
- BRCA1 is on chromosome 17 (increased risk of breast cancer in faults with this one over BRCA2)
- BRCA2 is on chromosome 13
rare genetic abnormalities - TP53, PTEN

94
Q

what are different types of breast cancer

A

ductal cancer in situ
lobular carcinoma in situ
invasive ductal carcinoma
invasive lobular carcinoma
inflammatory breast cancer
pagets disease of the nipple
medullary breast cancer
mucinous breast cancer
tubular breast cancer

95
Q

what are the characteristics of ductal carcinoma in situ

A

it is precancerous or cancerous epithelial cells of the breast ducts
localised to a single area
often picked up on mammogram screening
potential to spread over years
potential to become invasive breast cancer
good prognosis if excised and adjuvant treatment

96
Q

what are the characteristics of lobular carcinoma in situ

A

a pre-cancerous condition occurring in pre menopausal women (typically)
usually asymptomatic and undetectable on mammogram
usually diagnosed incidentally on breast biopsy
increased risk of future invasive breast cancer
managed with close monitoring

97
Q

what are characteristics of invasive ductal carcinoma - NST (non special/specific type)

A

originates from the cells in the breast ducts
80% of invasive breast cancers is this
can be seen on mammograms

98
Q

what are the characteristics of invasive lobular carcinomas

A

originate in cells from the breast lobules
10% of invasive cancers
not always visible on mammograms

99
Q

what are the characteristics of inflammatory breast cancer

A

presents similarly to a breast abscess or mastitis
swollen, warm, tender breast with pitting skin
doesnt respond to Abx
1-3% of breast cancers
worse prognosis than other breast cancers

100
Q

what are the characteristics of pagets disease of the nipple

A

looks like eczema of the nipple/areolar
erythematous, scaly rash
indicated breast cancer involving the nipple
may represent DCIS or invasive cancer

101
Q

what is the breast cancer screening program in the UK

A

it is a screening program that offers a mammogram every three years to women aged 50-70

102
Q

what is the recommendations for screening patients who are high risk of developing breast cancer

A

patients may be seen in a secondary care breast clinic or in a specialist genetic clinic
patients get genetic counselling and pre test counselling
annual mammograms are offered to women who are increased risk
chemoprevention may be offered to women who are high risk
risk reducing bilateral mastectomy or bilateral oophorectomy may be done in high risk women

103
Q

what criteria indicate a woman is high risk for developing breast cancer

A

first degree relative with breast cancer under 40
first degree male relative with breast cancer
first degree relative with bilateral breast cancer first diagnosed under 50
two first degree relatives with breast cancer

104
Q
A

Phase 3a Jemima (16 decks)

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