Breast Lump Flashcards
The genetic predisposition to breast cancer
continues to be delineated with the strong
predisposition from mutations in the genes ______ and _____
BRCA1
and BRCA2
The commonest lumps are those associated with
______
mammary dysplasia (32%)
_______ is also a common cause of
cysts, especially in the premenopause phase
Fibrocystic disease
Over________ of isolated breast lumps prove to be
benign but clinical identification of a malignant tumour
can only definitely be made following aspiration
biopsy or histological examination of the tumour
75%
What is the triple test for breast masses?
1 Clinical breast examination
2 Imaging—mammography and/or ultrasound ± MRI
3 Fine-needle aspiration cytology ± core biopsy
Breast cancer is the most common cancer in
females. The risk of developing breast cancer
before age 85 in Australian women is ______
1 in 8
The average age of diagnosis of breast CA is ____
60.7 years
About _____ of all new cancers in women are
breast neoplasms.
25%
Ddx for different types of dc
— intraduct papilloma (commonest)
— intraduct carcinoma
— fibrocystic disease
Bloodstained
What is the discharge?
— fibrocystic disease
— mammary duct ectasia
Green–grey
What is the dc?
— fibrocystic disease
— intraduct carcinoma (serous)
— breast abscess (pus)
Yellow:
What is the dc?
— lactation cysts
— lactation
— hyperprolactinaemia
— drugs (e.g. antipsychotic, cocaine)
Milky white (galactorrhoea):
Causes of periareolar inflammation
Causes may be
inverted nipple or mammary duct ectasia.
It starts as an eczematous-looking, dry
scabbing red rash of the nipple and then proceeds to
ulceration of the nipple and areola
Paget disease of the nippl
Time of examination for breast lumps: ideally,__________
4 days after the end
of the period
Red flag pointers for breast lumps
- Hard and irregular lump
- Skin dimpling and puckering
- Skin oedema (‘peau d’orange’)
- Nipple discharge
- Nipple distortion
- Nipple eczema
- Postmenopausal women
What are the draining lymphatic nodes of the breast
The draining lymphatic nodes are in the axillae,
supraclavicular fossae and internal mammary chain
Most cancers occur in the ________
upper outer quadrant
Lumps that are usually benign and require no
immediate action are
tiny (<4 mm) nodules in
subcutaneous tissue (usually in the areolar margin);
elongated ridges, usually bilateral and in the lower
aspects of the breasts; and rounded soft nodules
(usually <6 mm) around the areolar margi
A hard mass is suspicious of malignancy but
cancer can be soft because of______
fat entrapment
The _________ which is usually found in
the heavier breast, is often nodular and firm to hard.
inframammary ridge,
Positive signs of malignancy on Xray mammography include an _________
irregular infiltrating mass with focal spotty microcalcification.
Xray Mammo for screening
• established benefit for women _______
• possible benefit for women in their ______
• follow-up in those with breast cancer, as 6%
develop in the opposite breast
• localisation of the lesion for fine-needle aspiration
over 50 years
40s
This is mainly used to elucidate an area of breast
density and is the best method of defining benign
breast disease, especially with cystic changes.
Breast ultrasound
When is breast UTZ usually useful
It is
generally most useful in women less than 35 years old
Indications for breast UTZ
• pregnant and lactating breast • differentiating between \_\_\_\_ and \_\_\_ • palpable masses at \_\_\_\_\_\_\_ • for more accurate localisation of lump during fine-needle aspiration
fluid-filled cysts and solid mass
periphery of breast tissue (not screened by mammography)
- <35 years: _____
- 35–50 years: __________
• >50 years: bilateral mammography ± bilateral
ultrasound
bilateral ultrasound; bilateral mammography if ultrasound suspicious
bilateral mammography + bilateral ultrasound
Ddx: Very young women—12 to 25 years
Inflamed cysts or ducts, usually close to areola
Fibroadenomata, often giant
Hormonal thickening, not uncommon
Malignancy rare
Investigations for 12-25 years old presenting with mass
- mammography contraindicated
* ultrasound helpful
Young women—26 to 35 years DDx
Classic fibroadenomata
Fibrocystic disease with or without discharge
Cysts uncommon
Malignancy uncommon
Investigations for 26-35 years old presenting with mass
- mammography: breasts often very dense
* ultrasound often diagnostic
Women—36 to 50 years (premenopausal) ddx
Cysts Fibrocystic disease, discharges, duct papillomas Malignancy common Fibroadenomata occur but cannot assume Inflammatory processes not uncommon
Investigations for 36-50:
1
2
- mammography useful
* targeted ultrasound useful
Women—over 50 years (postmenopausal) ddx
Any new discrete mass—malignant until proven
otherwise
Any new thickening—regard with suspicion
Inflammatory lesions—probably duct ectasia (follow to
resolution)
Cysts unlikely
over 50, post menopausal dxtics
- mammography usually diagnostic (first line)
* ultrasound may be useful
Ddx Women—over 50 years, on hormones
Any new mass—regard with suspicion
Cysts may occur—usually asymptomatic
Hormonal change not uncommon
Dxtics Women—over 50 years, on hormones
• mammography usually diagnostic but breast may
become more dense
• ultrasound may be useful if above normal or unhelpful
and lump suspicious
Oestrogen receptors are uncommon in normal
breasts but are found in _____ of breast cancers,
although the incidence varies with age
two-thirds
If the lump is cystic—_____;
if solid—perform a _______ and then manage according to outcomes.
If it is suspicious, an_______ is
the preferred option
aspirate
fine-needle biopsy
excisional biopsy
Indications for biopsy or excision
of lump
• The cyst fluid is bloodstained.
• The lump does not disappear completely with
aspiration.
• The swelling recurs within 1 month
Ninety per cent of breast cancers are _________, the remainder being lobular carcinoma, papillary carcinomas,
medullary carcinomas and colloid or mucoid
carcinomas.
invasive ductal carcinomas
RF for breast CA
(>40 years), Caucasian race, pre-existing benign breast lumps,
alcohol >1–2 SDs/day, HRT >5 years, personal
history of breast cancer, family history in a first-degree
relative (raises risk about threefold), nulliparity, late
menopause (after 53), obesity, childless until after
30 years of age, early menarche, ionising radiation
exposure.
Up to ______ of cases are familial, with most being
autosomal dominant
5%
The majority of patients with breast cancer
present with a lump ______
(76%).
________ is a non-invasive abnormal proliferation of milk
duct epithelial cells within the ductal–lobular system
and is a precursor lesion for invasive breast cancer
DCIS
Tumour excision followed by whole breast
irradiation was the most preferred local therapy
for most women with _______
stage I or II cancer
T or F
Total mastectomy and breast-conservation
surgery had an equivalent effect on survival
T
________is preferred for a large tumour,
multifocal disease, previous irradiation and
extensive tumour on mammography
Total mastectomy
Recommendations for radiotherapy after
mastectomy are
— tumours >4 cm in diameter
— axillary node involvement of >3 nodes
— the presence of positive or close tumour
margins
________ following tumour
excision is one of several techniques for partial
breast irradiation
Intraoperative radiotherapy
Cytotoxic chemotherapy has an important place
in management, especially in young healthy
women who are ____ and ______
E receptor negative and have
visceral spread
Newer regimens containing _________ have largely replaced the traditional CMF (cyclophosphamide, methotrexate and fluorouracil) regimen
anthracyclines (e.g. epirubicin) and a taxane (e.g. docetaxel)
Adjuvant hormonal therapy by the anti-oestrogen
agent _______ (o) daily if E receptor + ve,
which is a specific modulating agent, is widely used
and is most suitable in postmenopausal women
tamoxifen 20 mg
________ (for hormone receptor + ve
cancer in postmenopausal women): anastrozole,
letrozole, exemestane
aromatase inhibitors
________: recommended for women
with bony metastases since evidence indicates
reversal of bone density loss and cancer
recurrence
bisphosphonates
fibroadenosis, chronic mastitis, mammary
dysplasia, cystic hyperplasia
Fibrocystic disease
FCC
•Most common in women between_____
• _______-related (between menarche and
menopause)
30 and 50 years
Hormone
FCC
Consider mammography if ______
diffuse lumpiness is
present in patient >40 years
Common in women aged 40–50 years
(perimenopausal)
• Rare under 30 years
• Associated with mammary dysplasia
Breast cyst
Dx of breast cyst
- Mammography
- Ultrasound (investigation of choice)
- Cytology of aspirate
Mx of breast cyst
• Drainage with a fine needle
Surgery is rarely required
Localised nodularity
Usually: • in upper\_\_\_\_\_ of breast • a physiological change to breast • managed with \_\_\_\_\_\_\_ • investigate with imaging in older women if asymmetric or perceived change
outer quadrant
clinical surveillance
These milk-containing cysts arise during
pregnancy and present postpartum with similar
signs to perimenopausal cysts.
• They vary from 1–5 cm in diameter
Lactation cysts (galactoceles
Lactation cysts (galactoceles) aspirate
• Treat by aspiration: fluid may be clear or milky.
• A discrete, asymptomatic lump
• Usually in 20s (range: second to sixth decade,
commonly 15–35 years)
• Firm, smooth and mobile (the ‘breast mouse’)
Fibroadenoma
Location of Fibroadenoma
• Usually in upper outer quadrant
True about Fibroadenoma
They double in size about every_______
12 months
Fibroadenoma
____ and ________ is recommended plus mammography in older women
Ultrasound and fine-needle aspiration or core biopsy
with cytology
When to do excision biopsy for suspicious fibroad
Excision biopsy if
large (>3–4 cm), continues to enlarge, suspicious
biopsy or woman >40 years
These are giant fibroadenoma-like tumours that
are usually benign but 25% are malignant and
metastasise. They are completely excised with a rim
of normal breast tissue
Phyllodes tumour
_______s usually the end result of a large bruise
or trauma that may be subtle, such as protracted
breastfeeding
Fat necrosis
T or F
The full triple test is required in fat necrosis
t
These are benign hyperplastic lesions within large
mammary ducts and are not premalignant (nor
usually palpable).
Duct papillomas
Duct papillomas should be______
excised
Synonyms: plasma cell mastitis, periductal mastitis
Mammary duct ectasia
In this benign condition a whole breast quadrant
may be indurated and tender. The larger breast ducts
are dilated.
Mammary duct ectasia
Mammary duct ectasia:
The lump is usually located near the _____
margin of the areola and is a firm or hard, tender, poorly
defined swellin
It should be noted that mammography
may be of limited value in the presence of
prostheses, especially if a________
fibrous capsule exists
around the prosthesis.
This is a long-term complication of surgery plus
irradiation for breast cancer treatment when there is
a failure of the lymphatic system to adequately drain
extracellular fluid
Lymphoedema of arm
What to exclude in lymphedema of arm
Exclude obstruction of the
deep venous system by Doppler ultrasound
Cause of Neonatal enlargement of breasts
This is due to transplacental passage of
lactogenic hormones. The swelling usually lasts 7–10
days if left alone
The usual presentation is the development of one
breast in girls commonly 7–9 years of age but sometimes younger
Premature hyperplasia
Screening mammography should be encouraged for
women between ______ and ____
50 and 70 years, and performed at
least every 2 years
Sp of mammography
90%
regular BSE is
recommended for all women_____
35 years and over
_______ commonly occur in women in
their late teens and 20s,
________ between 35 years and the menopause,
and ______is the most common cause of a lump in
women over 50 years
Fibroadenomas
benign breast cysts
cancer
Never assume a palpable mass is a _____
in any woman over 30 years of age
fibroadenoma
Gentle palpation is required. Squeezing breast
tissue between finger and thumb tends to produce
_____
‘pseudolumps
_____ and _____ can be
clinically indistinguishable from breast cancer
Mammary duct ectasia and fat necrosis
Nine out of 10 women who get breast cancer do
not have a _______
strong family history
T or F
The oral contraceptive pill has been generally
shown not to alter the risk of breast cancer.
T
Never assume a lesion is a ________—prove it with
ultrasound or successful aspiration
cyst
T or F
Mammography can not detect breast cancers which
are too small to feel.
F
it can detect
T or F
Mammography is not a diagnostic tool.
T
Recommended mammography screening for
women:
50–69 years and those aged 40–49 who
request it.
