Breast Medicine Flashcards
What is mastitis?
who does it occur in?
what can it be caused by?
occurs in lactating women, can still occur in non-lactating.
inflammation of breast tissue.
caused by bacterial infection, blocked milk ducts or combination of both.
features of mastitis
breast pain and tenderness
swelling and redness of the breast
warmth and hardness of affectd area
flu-like symptoms : fever, chills and fatigue
skin changes: dimpling or puckering
nipple discharge, blood or pus-like
lymphadenopathy - in axilla
abscess formation - severe cases
How would you manage mastitis?
1st line: continue breastfeeding
analgesia, warm compress
tx if systemically unwell, if nipple fissure, if sx dont get better after 12-24 hrs of effective milk removal or if culture indicates infection
1st line abx: oral flucloxacillin - 10-14 days. - mc organism causing it staph aureus.
abx for nonlactational mastitis : broad spectrum - co-amox, erythromycin/clarithro (macrolides) + metronidazole (covers anaerobes)
breastfeeding/expressing continue during abx tx.
what’ll happen if mastitis is untreated?
breast abscess
incision and drainage
What is a breast abscess?
mc causative organisms
peak incidence
complication of infectious mastitis
collection of pus within an area of breast.
mc in breastfeeding women with mastitis.
mc: staph aureus
mrsa.
coagulase-negative Staphylococcus, diphtheroids and Pseudomonas aeruginosa.
peak : 30-40
common risk factor for brain abscess
smoking.
damage to nipple - provides bacteria entry.
underlying breast disease - cancer - affect drainage of breast, predisposing to infection
mc causative bacteria for mastitis/abscess
stap aureus - mc
streptococcal
enterococcal
anaerobic - bacteroides species and anaerobic streptococci
penicillins are effective in which bacterias
gram positive, staph, stepto enterococcal
anaerobic bacteria tx
coamoxiclav
metronidazole
non lactational abscess are common amongst who?
obese women
smokers
diabetes
nipple piercings: group b streptococcus and mycobacterium
pathophysiology of breast abscess
Milk stasis in lactating women due to either breastfeeding technique or blocked duct causes mastitis.
then mastitis gets infected by bacterial contamination from skin.
abscess forms- capsule of granulomatous tissue around developing infection to contain it.
what might a non lactional breast abscess be caused by?
duct ectasia
thickening and widening of mild duct - 45-55. cause mastitis and subsequent infection
features of abscess
tenderness and pain
swelling - poss fluctuant
erythema and warmth
nipple discharge: poss purulent/serous discharge
nipple retraction: rare
skin changes: in longstanding case: skin might look thinned, or if severe sinus or fistula develop
lymphadenopathy: enlarged/tender axillary lymph nodes
systemic:
fever chills
malaise fatigue
tachycardia if sepsis
ix for abscess
bloods - fbc u+e, crp, blood cultures if clinically unwell/septic
pregnancy tesT: if not breast-feeding women
imging:
breast ultrasound to characterise abscess.
mammogram - rule out underlying breast lesion.
microbiology:
- culture of needle aspirate of abscess to inform abx choice.
- milk culture might be helpful
Differentials of abscess
tb mastitis - rare presentation of tb - do mantoux test.
cellulitis
fat necrosis - firm round tender lump no erythema - biopsy
fibroadenoma - benign breast tumour. - do ultrasound. no systemic
invasive breast cancer - mammogram and ultrasound with biopsy
fibrocystic breast: multi-focal lumps with monthly pain around menses, improve with menstration. ultrasound.
galactocele - milk cyst on lactating women. no localised pain or systemic infection sign.
how would you manage breast abscess?
surgery
1st line - needle aspiration of abscess under 5cm - local anaesthetic - ultrasound guidance. - can be repeated daily over 5-7 days.
larger abscess: surgical incision and drainage with washout, or percutaneous drainage with indwelling catheter.
adjuvant medical mx:
- abx - if mrsa ruled out and systemically well then use fluclox or dicloxacilli
if penicillin allergic or if mrsa : doxycycline or clindamycin
systemically unwell pts: iv abx vancomycin
breast emptying in lactational abscess
- continue to express breast milk gives sx relief from breast engorgment.
- if suckling is painful especially during acute period, encourage mum to express manually or using pump to avoid breast engorgment
What is duct ectasia?
who it happens in
peak incidence
benign breast condition characterisd by dilation and thickening of subareolar ducts.
perimenopausal and postmenopausal women
can occur i younger women rarely men
50-60
aetiology of duct ectasia
involution: age releated change in breast tissue causing ductal dilation and thickening
inflammation: chronic inflammation of ducts might contribute to duct ectasia.
smoking: cigarettes.
features of duct ectasia
nipple discharge: can be serous, serosanguineous, or green-black in colour - thick and stikcky
nipple inversion or retraction: occurs due to fibrosis of periductal tissue.
subareolar mass: palpable, non tender mass might be present in subareolar region.
mastalgia: pain/discomfort in breast in some pts
ix for duct ectasia?
imaging:
mammography - initial imaging - identify dilated ducts.
ultrasound: nature of any lumps found. differentiate between solid and cystic lesiosn.
nipple discharge exam: if present send for cytological analysis.
ductography/galactography: inject contrast medium into nipple duct followed by mammography. detailed image. esp useful when discharge.
biopsy: rule out malignancy. - fine needle aspiration, core needle biopsyor vacuum-assisted biopsy
how would you manage duct ectasia?
observe: if minimal sx.
med: oral abx. nsaids for pain/inflammation
surgery: if recurrent infection, severe nipple discharge, or persistent pain, consider surgery. : duct excision, microdochectomy, subareolar resection
What is a fibroadenoma?
peak incidence
benign breast tumour.
mc breast mass - seen in woman of reproductive age
doesnt progress to breast cancer - may shrink over time
peak: 20-30
Aetiology of fibroadenoma
genetic gene
mc during:
mc in?
mc - young women of reproductive age - men incidence rare.
mc during:
menses
pregnancy
while using combined oral contraceptives.
unknown aetiology - potentially related to sensitivity of breast tissue to oestrogen.
genetic: MED12 gene
pathophysiology of fibroadenoma
benign - dont mutate into malignancy
they represent a proliferation of breast tissue but not exhibit any pleomorphism.
arise from terminal duct lobular unit.
compromised of both stromal tissue and epithelial connective tissue cells. - biphasic.
histology: sheets of epithelial cells in honeycomb or antler-like pattern.
stromal and epithelial cells arranged in 2 patterns:
- pericanalicular: stromal cells proliferate surrounding epithelial structures
- intracanaliccular: stromal cells proliferate invaginating glandular tissue
Features of fibroadenoma
where most are found
poss no sx
if sx:
- painless non tonder
-mobile/non tethered
-smooth
-well circumscribed
-solitary
-2-3cm in diameter (unless giant fibroadenoma (has 1% breast masses,can measure upto 5cm)
upper outer quadrant of breast. no overlying skin changes.
how would you investigate for fibroadenoma?
imaging:
- ultrasound - younger women under 35 and in men, as it has greater sensitivity in denser breast tissue.
- mammograms - women 35 and over
- MRI not routinely.
histology: core biopsy - or fine needle aspiration cytology.
- clinical exam, imaging, pathology.
risk assessment : examination score P1(normal) - P5 (malignant) and imaging scores M1 -M5 or U1-U5 - depends on modality and pathology scores from B1-B5
referral criteria for fibroadenoma
2 week wait suspected cancer referral
for pt 30 and over with unexplained breast lump with or without pain.
non urgent if under 30 with unexplained with or without pain
how would you manage fibroadenoma?
asx - no tx or follow up.
removal:
- surgical lumpectomy or excisional biopsy to remove mass.
- vacuum-assisted biopsy
- cryoablation - low temp to destroy breast tissue.
-high intensity focused ultrasound for ablation of fibroadenoma tissue.
indications for surgical removal of fibroadenoma
large size - greater than 500g or larger than 5cm
continued growth of mass
patient request.
differentials of fibroadenoma
mastitis - both unilateral but mastitis red warm pain systemic sx
breast cancer - both unilateral but cancer has skin changes nipple affected, discharge pain.
phyllodes tumour: both smooth firm well circumscribed. but phylloes older 40-50 and faster growing
cyst: both distinct mobile round/oval mass with menses related onset but cyst is older 35-50 and poss nipple discharge and pain.tenderness.
fibrocystic change both smooth lumpy changes, most prominent in reproductive yrs. difference is multiple bilateral lumps
What is Pagets Disease of the nipple?
where does it effect?
what might it be associated with?
mc
rare breast cancer
malignant cells in nipple-areolar complex.
affects epidermis of nipple and areola - lead to erythema, scaling and ulceration.
poss associated with underlying in situ or invasive ductal carcinoma.
mc - infants
Pathophysiology of pagets disease of nipple
unclear
2 theories
epidermotropic thory: malignant cells underlying ductal carcinoma migrate through lactiferous ducts and invade epidermis of nipple and areola.
intraepidermal origin: pagets cell arise independently within nipple epidermis and later infiltrate underlying breast tissue.
features of pagets disease of nipple
unilateral - texture of nipple and areola.
sx:
erythema scaling thickening of skin
itching buring pain in nipple and areola
nipple discharge poss bloody or serous
nipple ivnersion or retraction
ulceration or erosions in advanced case.
canbe misdiagnosed as other benign skin conditions: eczema dermatitis.
ix for pagets disease of nipple
imaging:
- mammography
-ultrasound
-mri
skin biopsy:
- punch/shave biopsy of nipple/areola - histopathology
- paget cells : large round pale staining cells with abundant cytoplasm and large nucli confirms
mx for pagets disease of nipple
depends if underlying invasive/in situ breast cancer present.
diagnosis: skin biopsy of nipple lesion. mammogram + uss of breast and axillary lymph nodes. MRI to see extent of disease.
surgery: 2 options
- breast conserving surgery: wide local excision. - excise nipple-areolar complex and margin of healthy tissue. preffered if no underlying breast carcinoma or if carcinoma is limited to area beneath the nipple-areolar complex. - bcs followed by radiation.
mastectomy : removal entire breast tissue underlying. in breast parenchyma.
if axillary lymph nodes spread. sentinel lymph node biopsy or axillary node dissection.
options breast reconstruction discussed before surgery.
radiation: after bcs to reduce local recurrence not after mastectomy until multiple positive lymph nodes.
systemic therapy: hormone or chemo, depends on her2 status an present of lymph node or distant mets. if er-positive tumour give adjuvanthormone therpay.
her2 positive - targeted therapy with trastuzumab
What cancers are caused by brca 1 and 2. what chromosmes are they found on?
BRCA 1 - breast/ovarian - chr 17
BRCA 2 - breast, prostate, ovarian (c13)
autosomal dominant
What is the most common type of breast cancer
invasive ductal carcinomas usually arising from ductal carcinomas in situ (DCIS)
risk factors for breast cancer
BRCA1&2 (40% lifetime risk of breast/ovarian)
FH
Nulliparity, 1st pregnancy > 30yrs
Early menarche, late menopause
Not breastfeeding
Ionising radiation
COCP Use (1.023x/year risk increase)
What oncogene is overexpressed in breast cancer?
HER2 receptor - enables cell growth, survival and proliferation
classification of breast cancer
In situ - Non invasive (into basement membrane)
Invasive - Penetrate basement membrane
Ductal - From walls of ducts into the lumen. In situ can become invasive
Lobular - Grow from ducts of walls into lumen
breast changes in breast cancer
Breast lump
- Painless, fixed, hard
Skin
- Tethering
- Oedematous
- Thickened and dimpled (peau d’orange)
Nipple
- Inverted
- Dilated veins
- Discharge
- Pagets (itchy, red, crusty)
How is breast cancer screened for?
mammogram every 3 years between 50-70
other ix for breast cancer
USS if under 40
Fine needle aspiration and core biopsy
Receptor status (check for progesterone and oestrogen receptors (PR+ and ER+), these enable treatment options.
Triple negative (HER2-, PR-, ER-) is bad for prognosis
when should breast cancer be referred via 2 week wait pathway?
Aged 30+ with unexplained lump
50+ with nipple changes: discharge, retraction, etc.
GP Should refer for triple assessment
- History/Examination
- Imaging (biopsy or USS)
- Histology
presurgical mx of breast cancer
If axillary lymphadenopathy, axillary node clearance.
If not palpable, pre-operative USS. If nothing found, sentinal node biopsy.
surgical mx of breast cancer
Mastectomy
- Multifocal tumour
- Central tumour
- Large lesion in small breast
- DCIS >4cm
Wide local excision
- Solitary lesion
- Peripheral tumour
- Small lesion in large breast
- DCIS<4cm
common metastasis sites for breast cancer
bone
lung
liver
brain
Pharmacological mx of breast cancer
HER2 positive - herceptin
ER/PR positive
- Tamoxifen (Oestrogen receptor blocker)
- Post menopausal, Anastrazole (aromatase inhibitor - prevents androgens being converted to oestrogen)
pages disease vs eczema of the nipple
Pagets affects nipple first then areolar (opposite in eczema)
What are breast cysts?
Benign, individual fluid filled lumps. Most common breast lump. Can be painful and fluctuate in size over cycle. 30-50y
Smooth, well circumscribed, mobile and possibly fluctuant.
What are fibrocystic breast changes?
Normal - not disease related. Stroma, ducts and lobules respond to female sex hormones and become fibrous and cystic (irregular, hard, fluid-filled). Changes fluctuate with cycle. Common in women of menstruating age
How do fibrocystic breast changes present?
One or both breasts:
- Lumpiness
- Pain/tenderness
- Fluctuation of breast size
Symptoms fluctuate in line with cycle, start 10 days before and end as menstruation begins
how to manage fibrocystic breast changes?
Exclude cancer.
- Wear supportive bra
- NSAIDs
- Avoiding caffeine
- Apply heat to area
- Hormonal treatments
What are breast cysts and how should they be managed?
Fluid filled benign lumps most common in women 30-50. Smooth, well circumscribed, mobile, can be fluctuant.
Need investigation and aspiration can resolve. Slightly increases risk of Breast cancer.
how does fat necrosis cause a breast lump
Degeneration and scarring of fat tissue. Usually triggered by local trauma, radiotherapy or surgery, with an inflammatory response causing fibrosis and necrosis of fat tissue.
how does fat necrosis present?
Painless
Firm
Irregular
Fixed in local structures
May cause nipple inversion or skin dimpling.
Investigated as expected. Resolves with time, surgical if symptoms
What is intraductal papilloma
A warty lesion that grows in a duct in the breast. Proliferation of epithelial cells. Usually presents with tenderness/pain and nipple discharge (clear or blood stained).
Normal investigations but ductography may also be used. Shows an area that does not fill with contrast (filling defect)
Require surgical excision (microdochectomy) and examination to ensure non cancerous
causes of non milk nipple discharge
duct papilloma
mammary duct ectasia
pus from abscess
types of benign breast lumps
fibroadenoma
breast cyst
fat necrosis
