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3A Womens health > Breast Medicine > Flashcards

Breast Medicine Flashcards

1
Q

What can the breast be divided into? (2 regions)

A

○ Circular body
○ Axillary tail - runs into axillary fossa

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2
Q

How can the breast be divided structurally?

A

● Can also be divided structurally:
○ Mammary glands - consist of the functional apparatus of the breast in a highly
branched structure:
■ Lactiferous Ducts - one per lobe, exiting at the nipple.
■ Lobes - 15-20 per breast, each made up of 20-40 TDLUs.
■ TDLUs (terminal duct lobular units) - secretory functional units, made up
of approximately 100 acini that drain into a terminal duct.
○ Stroma - fibrous connective tissue, supports the structure of the breast and forms
the suspensory ligaments of Cooper.
■ Each lobule is demarcated by a Cooper ligament.

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3
Q

What is the ductal - lobular system lined by?

A

cuboidal and columnar epithelial cells.

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4
Q

What 3 key sites does the breast drain lymphatic fluid to?

A

○ Axillary lymph nodes (75%)
○ Parasternal lymph nodes (20%)
○ Posterior intercostal lymph nodes (5%).

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5
Q

What is the basic breast anatomy?

A

The breasts sit in front of the chest wall, which contains the ribs and pectoral muscles. Most of the breast is adipose (fatty) tissue. The areola surrounds the nipple. Behind the nipple are the ducts, which lead into the lobules, where breast milk is produced. Milk is secreted through the ducts and out of openings on the nipple

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6
Q

What is triple assessment of a breast lump to exclude diagnosis of cancer?

A

Clinical assessment (history and examination)
Imaging (ultrasound or mammography)
Histology (fine needle aspiration or core biopsy)

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7
Q

What are the clinical features that may suggest breast cancer?

A
  • Lumps that are hard, irregular, painless or fixed in place
  • Lumps may be tethered to the skin or the chest wall
  • Nipple retraction
  • Skin dimpling or oedema (peau d’orange)
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8
Q

What are the NICE guidelines which recommend a 2 week wait referral for suspected breast cancer?

A

An unexplained breast lump in patients aged 30 or above
Unilateral nipple changes in patients aged 50 or above (discharge, retraction or other changes)

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9
Q

What do the NICE guidelines also recommend considering a 2 week wait referral for?

A
  • An unexplained lump in the axilla in patients aged 30 or above
  • Skin changes suggestive of breast cancer
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10
Q

What do NICE guidelines suggest for breast lumps in under 30 years?

A

The NICE guidelines suggest considering non-urgent referral for unexplained breast lumps in patients under 30 years.

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11
Q

What is the definition of a fibroadenoma?

A

● Benign tumour of the breast.

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12
Q

What is the histology of a fibroadenoma?

A

● Composed of glandular epithelium and interlobular stroma of a TDLU.
● Well-circumscribed, non-encapsulated.
● Does not infiltrate into the parenchyma of the breast.

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13
Q

What is the epidemiology of fibroadenoma?

A

● Most common in women under 30.

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14
Q

What is the aetiology of fibroadenoma?

A

● Unclear - typically sex steroid-responsive (grow in pregnancy, shrink in menopause).

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15
Q

What is the presentation for a fibroadenoma?

A

● Solitary, mobile breast lump with a regular border.

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16
Q

What are the investigations for a fibroadenoma?

A

● First Line: breast imaging (USS or mammogram)
○ Typically stratified by age and clinical suspicion:
■ Women <30: breast ultrasound.
● Smooth, well-circumscribed mass with uniform hypoechogenic
appearance.
■ Women >30 or highly suspicious for cancer: mammogram.
● Distinct, well-circumscribed mass.

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17
Q

What is the management for fibroadenoma?

A

● None usually needed.

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18
Q

What is the definition of fibrocystic disease?

A

● Condition causing multiple small breast lumps.

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19
Q

What is the epidemiology of fibrocystic disease?

A

● Commonest benign breast disease.
● Most common in women aged 30-50.

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20
Q

What is the aetiology and pathophysiology of fibrocystic disease?

A
  1. Normal menstrual cycle oestrogen fluctuation leads to epithelial proliferation and
    stromal fibrosis in the TDLUs.
  2. This can lead to obstruction of ductules and terminal ducts.
  3. Obstruction causes cyst formation or degeneration of the ductules.
  4. Cyst rupture leads to inflammation and subsequent fibrosis.
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21
Q

What are the presentations for fibrocystic disease?

A

● Bilateral diffuse, symmetrical lumpiness.
● Breast pain (mastalgia) - often cyclical.
● (Sometimes) nipple discharge.

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22
Q

What are the investigations for fibrocystic disease?

A

● First Line: breast imaging (USS or mammogram)
○ Stratified by age and clinical suspicion:
■ Women <30: breast ultrasound.
● Cysts / solid mass
■ Women >30 or highly suspicious for cancer: mammogram.
● Circumscribed density

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23
Q

What is the management for fibrocystic disease?

A

● First Line: simple analgesia e.g. paracetamol, ibuprofen.

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24
Q

What is the definition of mastitis?

A

inflammation of the breast, typically due to infection.
○ Divided into lactational and non-lactational (duct ectasia)

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25
Q

What is the definition of a breast abscess?

A

discrete collection of pus due to infection.

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26
Q

What is the aetiology and pathophysiology of mastitis?

A

● Bacterial colonisation - commonest is Staph. aureus.
● Lactational mastitis:
○ Combination of breastfeeding-related nipple trauma and milk stasis predisposes
the breast to local infection.
● Duct ectasia mastitis:
○ Blockage of lactiferous ducts due to squamous metaplasia leads to dilatation
and inflammation.
○ Strongly associated with cigarette smoking.

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27
Q

What is the aetiology and pathophysiology of abscess?

A

○ Progression of untreated infective mastitis; walled-off collection of infection forms.

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28
Q

What is the presentation for mastitis and then abscess?

A

● Symptoms include: fever, breast pain / tenderness (often during breastfeeding)
● Signs include: erythema, swelling, firmness.
● Duct ectasia is also associated with nipple discharge.

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29
Q

What are the investigations for mastitis and abscesses?

A

● Mastitis is usually a clinical diagnosis based on history and examination findings.
● Abscesses can be diagnosed with breast ultrasound and diagnostic needle
aspiration.

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30
Q

What is the management for mastitis and abscesses?

A

● Lactational Mastitis:
○ First Line: continued breastfeeding / milk expression plus simple analgesia
○ Second Line: >24 hour duration / severe pain - add PO flucloxacillin.
● Non-lactational Mastitis:
○ First Line: PO flucloxacillin
● Breast Abscess:
○ First Line: needle aspiration and drainage plus flucloxacillin (dependent on local
policy).

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31
Q

What are breast cysts?

A

Breast cysts are benign, individual, fluid-filled lumps. They are the most common cause of breast lumps and occur most often between ages 30 and 50, more so in the perimenopausal period. They can be painful and may fluctuate in size over the menstrual cycle

32
Q

On examination what are breast cysts like?

A
  • Smooth
  • Well-circumscribed
  • Mobile
  • Possibly fluctuant
33
Q

Why do breast cysts require further assessment?

A

to exclude cancer, with imaging and potentially aspiration or excision. Aspiration can resolve symptoms in patients with pain. Having a breast cyst may slightly increase the risk of breast cancer.

34
Q

What is fat necrosis and what does it cause?

A

Fat necrosis causes a benign lump formed by localised degeneration and scarring of fat tissue in the breast. It may be associated with an oil cyst, containing liquid fat

35
Q

What is fat necrosis commonly triggered by?

A

localised trauma, radiotherapy or surgery, with an inflammatory reaction resulting in fibrosis and necrosis (death) of the fat tissue. It does not increase the risk of breast cancer.

36
Q

What is fat necrosis like on examination?

A
  • Painless
  • Firm
  • Irregular
  • Fixed in local structures
  • There may be skin dimpling or nipple inversion
37
Q

What does ultrasound or mammogram show for fat necrosis?

A

Ultrasound or mammogram can show a similar appearance to breast cancer. Histology (by fine needle aspiration or core biopsy) may be required to confirm the diagnosis and exclude breast cancer.

38
Q

How is fat necrosis usually treated?

A

After excluding breast cancer, fat necrosis is usually treated conservatively. It may resolve spontaneously with time. Surgical excision may be used if required for symptoms.

39
Q

What are lipomas?

A

Lipomas are benign tumours of fat (adipose) tissue. They can occur almost anywhere on the body where there is adipose tissue, including the breasts.

40
Q

On examination what are lipomas?

A

Soft
Painless
Mobile
Do not cause skin changes

41
Q

How are lipomas treated?

A

They are typically treated conservatively with reassurance. Alternatively, they can be surgically removed.

42
Q

What are galactoceles

A

occur in women that are lactating (producing breast milk), often after stopping breastfeeding. They are breast milk filled cysts that occur when the lactiferous duct is blocked, preventing the gland from draining milk

43
Q

How do galactoceles present?

A

They present with a firm, mobile, painless lump, usually beneath the areola. 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.

44
Q

What are phyllodes tumours?

A

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

45
Q

What are the types of phyllodes tumour?

A

They can be benign (~50%), borderline (~25%) or malignant (~25%). Malignant phyllodes tumours can metastasise.

46
Q

What is the treatment for phyllodes tumour?

A

Treatment involves surgical removal of the tumour and the surrounding tissue (“wide excision”). They can reoccur after removal.

Chemotherapy may be used in malignant or metastatic tumours.

47
Q

What is the background for breast cancer?

A

● Breast cancer is the commonest cancer in the UK (15% of new cancer cases annually).
● There are approximately 56,000 new cases of breast cancer every year.

48
Q

What are the pre-invasive types of
breast cancer?

A
  1. Ductal carcinoma in situ (DCIS).
    ● Neoplastic proliferation of epithelial cells - confined to duct without
    invasion through basement membrane.
    ● Precursor to invasive breast cancer.
    ● Comedo and non-comedo subtypes.
  2. Lobular carcinoma in situ (LCIS).
    ● Neoplastic proliferation of epithelial cells, confined to TDLU.
49
Q

What are the invasive (penetration through basement membrane) types of breast cancer?

A
  1. Invasive ductal carcinoma (commonest - 75%).
    ● Neoplastic proliferation of epithelial cells that invades through the ductal
    basement membrane.
  2. Invasive lobular carcinoma
  3. Medullary carcinoma
    ● More prevalent in the younger population.
    ● Higher grade than IDC.
  4. Many others - including mucinous, tubular, papillary, inflammatory etc.
50
Q

What is the Nottingham criteria which we use to grade how bad a breast cancer is?
What is it scored on?

A

○ Gland formation
○ Nuclear atypia / pleomorphism
○ Mitosis counts (indicates rate of cellular reproduction)
● A higher grade carcinoma is one that is markedly different from normal breast tissue
and is considered poorly differentiated.

51
Q

What is the aetiology and pathophysiology of breast cancer?

A

● Complex series of genetic mutations and deranged cellular signalling leads to generation
of malignant cells.
● Breast cancer can be linked to inherited genetic mutations such as BRCA1.

52
Q

What is the 5 step process for malignant cells to metastasise?

A
  1. Invasion through basement membrane
  2. Intravasation (entry into circulation)
  3. Circulation
  4. Extravasation
  5. Colonisation
53
Q

What are the commonest sites of breast cancer metastasis?

A

bones, liver, lungs and brain.

54
Q

What are the RFs for breast cancer?

A
  1. Increasing age
  2. Female sex (100:1 F:M incidence)
  3. Family history
  4. Inherited genetic mutations e.g. BRCA1
  5. Endogenous oestrogen exposure:
    a. Early menarche
    b. Nulliparity / absence of breastfeeding
    c. Late menopause
  6. Exogenous oestrogen and progestin exposure:
    a. Systemic hormonal HRT
    b. Systemic hormonal contraception
    Female (99% of breast cancers)
    Increased oestrogen exposure (earlier onset of periods and later menopause)
    More dense breast tissue (more glandular tissue)
    Obesity
    Smoking
    Family history (first-degree relatives)
55
Q

What are the signs and symptoms of breast cancer?

A

● Symptoms include: breast lump
● Signs include: nipple discharge, nipple retraction, skin changes e.g. peau d’orange,
axillary lymphadenopathy.

56
Q

What are the metastatic features of breast cancer?

A

weight loss, bony pain, shortness of breath.

57
Q

What are the different types of staging we use for breast cancer?

A

● TNM staging (tumour, node, metastasis) - see Cancer Research UK for full details.
● Alternative staging:
○ Stage 1A: <2cm, isolated to breast
○ Stage 1B: <2cm, minor axillary LN spread
○ Stage 2A: <2cm, spread to 1-3 ipsilateral LNs.
○ Stage 2B: 2 - 5cm, minor axillary nodal spread or 2 - 5cm with 1-3 ipsilateral
nodes or >5cm, no nodal spread
○ Stage 3A: 4-9 ipsilateral nodes or >5cm with 1-3 ipsilateral nodes
○ Stage 3B: spread to skin / chest wall
○ Stage 3C: >10 axillary nodes or supraclavicular spread or parasternal + axillary
spread
○ Stage 4: distant metastatic spread to organs.

58
Q

What is the screening programme for breast cancer?

A

● NHS screening programme: 3-yearly mammogram for women aged 50-71.

59
Q

What is the 2 week wait criteria for breast cancer?

A

○ Unexplained breast lump in a woman aged >30.
○ Unexplained axillary lump in a woman aged >30.
○ Unilateral nipple changes in a woman aged >50.
○ Skin changes suggestive of breast cancer, any age.

60
Q

What is first line for breast cancer investigations for breast cancer?

A

breast imaging
○ >30 or highly suspicious for cancer: mammogram
○ <30: breast ultrasound
○ Plus: ultrasound of the axilla +/- needle biopsy

61
Q

What is second line investigations for breast cancer?

A

biopsy
○ Fine needle aspiration and cytology
○ Plus: oestrogen / progesterone receptor testing, HER2 receptor testing.

62
Q

If the patient has symptoms/ signs suggestive of metastasis what should we do?

A

○ CT scan (CT thorax-abdomen-pelvis, CT head).

63
Q

What are the features of a mammogram?

A

● Pre-invasive: unifocal / widespread microcalcifications
● Invasive carcinoma:
1. Irregular spiculated mass
2. Clustered microcalcifications
3. Linear branching calcifications.

64
Q

What is first line management for breast cancer?

A

● Dependent on histology, staging, receptor positivity, physiological reserve; but broadly:
● First Line: surgery
○ Tumour excision or mastectomy +/- breast reconstruction
○ Plus sentinel lymph node biopsy (no evidence of nodal spread) or axillary node
clearance.
● Plus: radiotherapy
○ Whole breast / partial-breast
○ If tumour is invasive (i.e. not DCIS, LCIS), systemic third line therapy is indicated:

65
Q

What is adjuvant therapy for breast cancer?

A

systemic therapy (guided by the PREDICT tool)
○ Oestrogen-receptor positive:
■ Pre-menopausal / male - tamoxifen (anti-oestrogen)
■ Post-menopausal - anastrozole / letrozole (aromatase inhibitor, prevents
peripheral oestrogen synthesis).
The Peer Teaching Society is not liable for any false or misleading information. 76
■ Note - tamoxifen therapy can be continued long-term (5 years) before
switching to an aromatase inhibitor.
○ HER2 (human epidermal growth factor receptor 2) positive:
■ Trastuzumab (Herceptin)
○ Chemotherapy:
■ Including a taxane and an anthracycline
■ E.g. ACT: doxorubicin, cyclophosphamide and paclitaxel

66
Q

What is systemic therapy for breast cancer

A

systemic therapies can be neoadjuvant i.e. used to reduce tumour size before
attempting surgery.

67
Q

What is Paget’s disease of the nipple/ breast

A

Rare cutaneous breast cancer manifestation

68
Q

What does pagets disease of the bone cause?

A

Eczema like skin changes in nipple, areola

69
Q

What is the pathogenesis for Paget’s?

A
  • Epidermotropic theory: underlying mammary carcinoma present > malignant cells migrate through ductal system > nipple epidermis
  • In situ transformation theory: nipple keratinocyte transformation > malignant cells
70
Q

What are the S + S of pagets?

A
  • Unilateral
  • Nipple + adjacent areolar skin
  • scaly
  • itching
  • burning
  • erythematous
  • Bloody nipple discharge
  • nipple inversion
  • pain
  • palpable masses - worst prognosis
71
Q

What investigations are done for paget’s?

A

Mammogram- identify assosciated mass, microcalcifications, tissue distortion
US guided mass core bopsy, histopathological analysis
Nipple scrape cytology/full-thickness wedge/ punch biopsy
Malignant, intraepithelial adenocarcinoma cells (paget cells) present

72
Q

What is the treatment for Paget’s?

A

Mastectomy, breast-conserving surgery
Whole breast radiotherapy

73
Q

What is an intraductal papilloma?

A

warty lesion that grows within one of the ducts in the breast. It is the result of the proliferation of epithelial cells

74
Q

What is the typical presentation of an intraductal papilloma?

A

The typical presentation is with clear or blood-stained nipple discharge.

75
Q

What type of tumours are intraductal papilloma’s?

A

Intraductal papillomas are benign tumours; however, they can be associated with atypical hyperplasia or breast cancer.

76
Q

What are the S + S of intraductal papilloma?

A

Intraductal papillomas can occur at any age, but most often occur between 35-55 years.

Intraductal papillomas are often asymptomatic. They may be picked up incidentally on mammograms or ultrasound.

They may present with:

Nipple discharge (clear or blood-stained)
Tenderness or pain
A palpable lump

77
Q

How is one diagnosed with papilloma?

A

3A Womens health (33 decks)

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