Breast medicine Flashcards
What is the main constituent of breasts?
Adipose tissue
What is the area around the nipple known as?
Areola
What structures sit behind the areola and allow milk to drain?
Network of ducts
Where is milk produced in the breast?
Lobules
these then drain into ducts –> out of nipple
How are women in the UK screened for breast cancer (age, how often)?
- Between 50 and 71st birthday
- Every 3 years
What are some downsides to breast cancer screening (4)?
- Anxiety + stress
- Exposure to radiation
- Missing cancer –> false reassurance
- Unnecessary further tests
How much does breast screening reduce the risk of death from breast cancer by?
About 20%
What are 2 genetic variations that increase your risk of breast cancer?
- BRCA 1 (chromosome 17) and 2 (chromosome 13)
- Li-Fraumeni
What cancers does Li-Fraumeni increase the risk of (5)?
- Breast
- Brain
- Adrenal
- Leukaemia
- Osteosarcoma
auto dom inheritance pattern
When should BRCA and Li-Fraumeni be screened for breast cancer?
Annually in over 20 year olds
What is the most common BRCA gene?
BRCA 1
What cancers do the BRCA genes increase the risk of (4)?
- Breast
- Ovarian
- Prostate
- Pancreatic
What is the most common site of breast lumps?
Upper outer quadrant
including tail of spence
What is the sentinel node for breast cancers?
Axillary nodes
What is the “triple lock” for breast cancer investigations (3)?
- History + exam
- Imaging
- Biopsy
What imaging techniques are used to analyse breast lumps (3)?
- Mammography
- USS
- MRI
When are USS better at identifying breast lumps compared to mammography?
In younger, dense breasts
When is an MRI particularly useful for identifying breast lumps?
When there is a breast implant
What are two biopsy techniques used for breast cancer?
- Fine needle biopsy (now rarely used)
- Core biopsy (can identify if cancer is invasive or in situ)
What are some causes of breast lumps/ changes (11)?
- Fibroadenoma = very common
- Cysts = very common
- Breast cancer
- Fibrocystic breast changes (mammary dysplasia)
- Fat necrosis
- Lipoma
- Phyllodes tumours
- Mastitis/ abscess
- Duct ectasia
- Intraductal papilloma
- Pagets disease of the nipple
What is a fibroadenoma?
Benign tumours of epithelial breast tissue
What age is typically affected by fibroadenomas?
20 - 40 year olds
oestrogen + progesterone sensitive so often change throughout cycle and shrink after menopause
What are some key features of fibroadenomas (5)?
- Mobile
- Well defined
- Painless
- Firm
- Fluctuating size
How should a fibroadenoma be treated?
Surgical excision if > 3cm
What is a breast cyst?
Individual fluid filled lump, usually caused by blockage in duct/ shrinking of tissues
What age are breast cysts most common?
40-60 years
What are some features of a breast cyst (5)?
- Painful
- Smooth
- Well defined
- Mobile
- Fluctuate in size
How is a breast cyst treated?
Aspirated
What features of the aspiration of a breast cyst should indicate a biopsy may be needed (2)?
- Blood stained fluid
- Repeatedly refill
What are fibrocystic breast changes?
Fluctuating general lumpiness due to fibrous and cystic changes in the breast in response to oestrogen and progesterone
What is the pathophysiology of fat necrosis causing beast lumps?
Localised degeneration and scaring of fat tissue
often triggered by trauma, surgery or radiotherapy resulting in inflammation
What are some features of fat necrosis lumps in breasts (4)?
- Irregular
- Firm
- Painless
- Skin dimpling/ nipple inversion
How should fat necrosis in the breast be investigated?
Biopsy is often needed
due to the similarity to breast cancer lumps in examination and USS findings
What are lipomas?
Benign tumours of adipose tissue
What are some features of lipomas in the breast (4)?
- Soft
- Painless
- Mobile
- No skin changes
What is mastitis?
Inflammation of breast tissue
What are the two main causes of mastitis?
- Obstruction in the ducts whilst breastfeeding
- Infection
What bacteria most commonly causes mastitis?
Staph aureus
What are the features of mastitis (5)?
- Breast pain + tenderness
- Erythema
- Warmth + inflammation
- Nipple discharge
- Fever
What is the main risk factor for mastitis?
Breast feeding
How should mastitis be treated (3)?
- Lactating 1st = warm compress, expressing, analgesia
- Lactating 2nd = flucloxacillin or erythromycin
- Non-lactating = co-amox (erythromycin + metronidazole if penicillin allergy)
What organism commonly causes mastitis in breastfeeding women?
Candida
How does candida mastitis present?
Cracked flaky skin with baby also affected
How is candida mastitis treated (2)?
- Topical miconazole
- Oral fluconazole
What is a complication of mastitis?
Breast abscess
What is a major risk factor for breast abscesses?
SMOKING
What bacteria can cause breast abscesses (4)?
- Staph aureus = mc
- Streptococcal
- Enterococcal
- Anaerobes
What features suggest a breast abscess, not just mastitis (3)?
- Fluctuance (moving fluid around within lump)
- Swollen
- Very tender
How should breast abscess be managed (2)?
- Co-amox (or erythromycin + metronidazole)
- Surgical drainage
What is duct ectasia?
Benign condition where milk ducts become dilated and inflamed
Who is most commonly affected by duct ectasia?
Peri + postmenopausal women
What is the presentation of duct ectasia?
Sticky brown/ green nipple discharge
How is duct ectasia managed (2)?
- Conservatively
- Antibiotics if severe
What is an intraductal papilloma?
A lesion growing within one of the ducts in the breast
What age are intraductal papillomas most common?
35-55 years
How do intraductal papillomas present?
Clear/ blood stained nipple discharge
How are intraductal papillomas treated?
Surgical excision + histological examination
risk of malignancy
What are some risk factors for developing breast cancer (7)?
- Female
- Increased oestrogen exposure (early periods, late menopause)
- Denser breast tissue
- Obesity
- Smoking
- Family history
- Genetics
How does COCP affect risk of breast cancer?
Small increased risk
lasting only for 10 years
How does HRT affect risk of breast cancer?
Increases risk of breast cancer (particularly combined HRT)
What family history of breast cancer is considered high risk?
- 1st degree relative < 40 years
- 2 first degree relatives
- 1st degree bilateral breast cancer < 50 years
- 1st degree male breast cancer
What is the lifetime risk of developing breast cancer for women?
1 in 8
most common cancer affecting women
What is the average age of diagnosis for breast cancer?
62
What is the histological type of the vast majority of breast cancers?
Adenocarcinoma
What are the two most common types of breast cancer?
- Ductal carcinoma (70 %)
- Lobular carcinoma (10%)
Other than ductal and tubular what are some other types of breast cancer (4)?
- Tubular
- Medullary
- Mucinous
- Phyllodes
How can the spread of the tumour be categorised (2)?
- In-situ = not invaded BM (asymptomatic)
- Invasive = invaded BM
How can women at high risk of developing breast cancer be managed?
- Chemoprevention
- Bilateral mastectomy
What chemoprevention can be offered to women at higher risk of breast cancer?
- Tamoxifen (premenopausal)
- Anastrozole (postmenopausal)
What are suspicious signs of breast cancer in terms of examination (6)?
- Dimpling/ depression
- Deviation (asymmetry)
- Discolouration
- Discharge
- Tethering
- Nipple eczema
What examination findings should be referred under the 2 week wait for breast cancer?
- Unexplained breast or axilla lump in patients 30+
- Unilateral nipple changes in patients 50+
- Skin changes suggestive of breast cancer
What is an important investigation for all women diagnosed with breast cancer?
Sentinel node biopsy
What is a useful feature of some breast cancers that help target treatments?
Breast cancer receptors
What are the 3 breast cancer receptors?
- Oestrogen receptors (ER)
- Progesterone receptors (PR)
- Human epidermal growth factor (HER2)
What is it know as when breast cancer does not contain any of the receptors?
Triple negative breast cancer
worse prognosis as can’t target chemo
What is a method of predicting how aggressive a breast cancer may be?
Gene expression profiling
What investigations are done to stage breast cancer (5)?
- Lymph node assessment + biopsy
- MRI breast + axilla
- Liver USS (for metastasis)
- CT thorax, abdomen, pelvis
- Isotope bone scan (for bony mets)
What staging system is used to grade breast cancer?
TNM (1-4)
What are some common sites of metastasis for breast cancer (4)?
- Liver
- Lung
- Bone
-
Brain
2 Ls, 2 Bs
How are breast cancers managed (5)?
- Surgery
- Radiotherapy
- Chemotherapy
- Hormone treatment
- Targeted treatments
What are the two surgical options to treat breast cancer?
- Mastectomy
- Lumpectomy (wide local excision)
What would indicate the need for a mastectomy?
> 4cm/ more than 20% of breast affected
What treatment is a lumpectomy usually coupled with?
Radiotherapy
What treatment is often given before surgery for breast cancer?
Chemotherapy to shrink the tumour
What procedure is often done alongside the removal of the tumour for those with breast cancer?
Axillary lymph node clearance
What is a side effect of axillary lymph node clearance?
Chronic lymphoedema in the arm
can treat with compression bandages
What are some side effects of radiotherapy (4)?
- General fatigue
- Local skin irritation + swelling
- Fibrosis of breast
- Shrinking of breast
What are the scenarios chemotherapy is given for breast cancer (3)?
- Neoadjuvant = before surgery to shrink tumour
- Adjuvant = after surgery to reduce recurrence
- Treatment = for metastatic or recurrent breast cancer
What are two hormone treatments for ER +ve breast cancer?
- Tamoxifen (used for premenopausal women)
- Aromatase inhibitor - anastrozole or letrozole (used for postmenopausal women)
How does tamoxifen work?
Selective oestrogen receptor modulator - antagonist to oestrogen in breast tissue
What are 3 side effects of tamoxifen?
- Increased VTE risk
- Hot flushes
- Increased endometrial cancer risk
How does anastrozole/ aromatase inhibitors work?
Block the creation of oestrogen in adipose tissue (the main source of oestrogen in postmenopausal women)
What is a side effect of anastrozole?
Osteoporosis
What is a targeted treatment for HER2 +ve breast cancer?
Trastuzumab (Herceptin) - monoclonal antibody targeting HER2 receptor
What is a key side effect of trastuzumab (Herceptin)?
Cardiotoxicity (needs monitoring)
What are 2 options for reconstruction of breast after surgery?
- Silicone implants
- Flap reconstruction
can be delayed or immediate
What is an option for women who do not want surgical reconstruction after breast cancer surgery?
External implant in bra
What are some complications of breast implants (3)?
- Rupture
- Capsular contractures (fibrous scar tissue formation)
- BIA-ALCL (lymphoma associated with breast implant)
What is pages disease of the nipple?
A specific presentation of some breast cancers
What are the signs/ symptoms of pagets disease?
Persistent eczema of the nipple
What does pagets disease of the nipple often indicate (2)?
- Lump behind the nipple - usually invasive carcinoma
- In situ cancer
What is breast pain known as medically?
Mastalgia
What are the two presentations of breast pain?
- Cyclical
- Non-cyclical
What is the main cause of cyclical breast pain?
Pre menstrual syndrome
What age are typically affected by non-cyclical breast pain
40-50 years olds
What are some causes of non-cyclical breast pain (3)?
- Medications (hormonal medications)
- Infection
- Pregnancy
What is important to exclude in those with breast pain?
Cancer
although it rarely presents with pain
What is Galactorrhoea?
Discharge of milk from the nipple not related to breastfeeding or pregnancy
What are some causes of Galactorrhoea (4)?
- Idiopathic
- Prolactinoma
- Endocrine (e.g. hypothyroid, PCOS)
- Medications (dopamine antagonists - antipsychotics)
What are some causes of gynaecomastia (7)?
- Obesity (high oestrogen)
- Testicular cancer (secretes oestrogen- leydig cell)
- Liver failure
- Hyperthyroid
- Reduced testosterone
- Kleinfelters
- Medications
