Breast medicine Flashcards
What are fibroadenomas
common benign tumours of stromal/ epithelial breast duct tissue
What age range is most commonly affected by fibroadenomas
age 20-40 (typically <30)
Give 5 features of fibroadenomas
- small and discrete
- non-tender/ painless
- firm
- smooth
- highly mobile breast lump (breast mouse)
When are surgical excisions done for breast fibroadenomas
if they are >3cm
What causes fibroadenosis (fibrocystic disease)
- connective tissue, ducts and lobules of the breast respond to oestrogen and progesterone, becoming fibrous and cystic
- these changes fluctuate with the menstrual cycle
Give 4 features of fibroadenosis
- lumpy breasts
- breast pain or tenderness
- symptoms may worsen prior to menstruation
- fluctuation of breast size
Describe the features of a breast cyst
- smooth discrete lump
- mobile
- may be fluctuant (variable, unstable)
How are breast cysts managed
- cysts should be aspirated
- those which are blood stained or persistently refill should be biopsied or excised
What is ductal papilloma
warty lesion that grows within one of the ducts in the breast due to epithelial proliferation
Describe the presentation of ductal papillomas
- nipple discharge: clear or blood-stained from a single duct
- tenderness or pain
- If large, may present with a mass
How are ductal papillomas treated
microdochectomy - duct excision
What is breast fat necrosis
benign lump formed by localised degeneration and scarring of fat tissue in the breast
Give 3 triggers for breast fat necrosis
- localised trivial/ unnoticed trauma
- radiotherapy
- surgery
Which group of women are at a higher risk for developing breast fat necrosis
obese women with large breasts
How does breast fat necrosis typically present
- painless
- typically firm initially and may develop into a hard and irregular lump
- lump fixed in local structures
- nipple inversion
What imaging techniques can show breast fat necrosis
ultrasound or mammogram
How is breast fat necrosis managed
- histology via fine needle aspiration or core biopsy to exclude breast cancer as it may mimic it
- after excluding, manage conservatively
What is mammary duct ectasia
- benign conditions where there is dilation of the large breast ducts
- common in menopause
Which group of women are at a higher risk for developing mammary duct ectasia
- menopausal women
- smokers
How may mammary duct ectasia present
- tender lumps around areola
- thick nipple discharge from several ducts - green/ grey/ white
- slit like nipple retraction/ inversion
How is mammary duct ectasia managed
- Reassurance after excluding cancer
- supportive bra and warm compresses for mastalgia
What is a breast abscess
collection of pus within the breast usually caused by bacterial infection (mc s.aureus)
What are the two types of breast abscess
- lactational abscess (associated with breastfeeding)
- Non-lactational abscess (unrelated to breastfeeding)
Give 3 RFs for breast abscesses and infective mastitis
- smoking
- breastfeeding
- breast cancer
Give 3 common causative bacteria for bacterial abscesses
- staph aureus (mc)
- streptococcal species
- anaerobic bacteria
How does a breast abscess present
- swollen, fluctuant, tender breast lump
- red and hot swelling
- pain
How may infective mastitis present
- nipple changes
- purulent nipple discharge
- painful, tender, red hot breast
- fever, and general malaise
- may precede development of an abscess
How is mastitis managed
- first line: continue breastfeeding
- analgesia and warm compress
- antibiotics indicated if effective milk removal has not improved symptoms within 12-24hrs
- antibiotics - oral flucloxacillin 10-14d
- non-lactational: treat underlying cause
How is a breast abscess managed
- referral
- broad spec antibiotics
- ultrasound guided aspiration
RFs for breast cancer
- BRCA1 and BRCA2 genes
- FHx (1st degree relative)
- nulliparity
- early menarche and late menopause
- combined HRT
- COCP
- obesity
- p53 gene mutations
State the 4 common types of breast cancer
- Invasive ductal carcinoma - no special type (mc)
- Invasive lobular carcinoma
- Ductal carcinoma-in-situ (DCIS)
- Lobular carcinoma-in-situ (LCIS)
Give 4 rarer types of breast cancer
- Medullary breast cancer
- Mucinous (mucoid or colloid) breast cancer
- Paget’s disease of the nipple
- Inflammatory breast cancer
Describe ductal carcinoma in situ
- Pre-cancerous or cancerous epithelial cells of the breast ducts
- Localised to a single area
- Often picked up by mammogram screening
- Potential to spread locally over years
- Potential to become an invasive breast cancer
Describe lobular carcinoma in situ
*A pre-cancerous condition occurring typically in pre-menopausal women
* Usually asymptomatic and undetectable on a mammogram
* Usually diagnosed incidentally on a breast biopsy
* Often managed with close monitoring
Describe invasive ductal carcinoma
- no special type, where it is not more specifically classified
- Originate in cells from the breast ducts
- 80% of invasive breast cancers fall into this category
- Can be seen on mammograms
Describe invasive lobular carcinomas
- Originate in cells from the breast lobules
- Not always visible on mammograms
Cause of inflammatory breast cancers
cancerous cells block the lymph drainage resulting in an inflamed appearance of the breast
Features of inflammatory breast cancer
- progressive, erythema and oedema of the breast
- Swollen, warm, tender breast with pitting skin
- absence of signs of infection
- Does not respond to antibiotics
- Worse prognosis than other breast cancers
Describe Paget’s disease of the nipple
- eczematoid change of the nipple
- Reddening and thickening of nipple and areola
- May represent DCIS or invasive breast cancer
- Requires biopsy, staging and treatment
Describe the NHS breast cancer screening programme
offers a mammogram every 3 years to women age 50-70 years
What are the criteria for referring high risk breast cancer patients based on family history
- A first-degree relative with breast cancer under 40 years
- A first-degree male relative with breast cancer
- A first-degree relative with bilateral breast cancer, first diagnosed under 50 years
- Two first-degree relatives with breast cancer
Clinical features of breast cancer
- 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
- Lymphadenopathy, particularly in the axilla
What is the criteria for a two-week wait referral for suspected breast cancer
Refer:
* An unexplained breast lump in patients aged 30 or above
* Unilateral nipple changes in patients aged 50 or above (discharge, retraction or other changes)
Consider:
* aged 30 and over with an unexplained lump in the axilla
* Skin changes suggestive of breast cancer
How is breast cancer diagnosed
- triple assessment: clinical assessment, imaging and biopsy
- imaging - ultrasound (<35y) or mammogram (>35y)
- fine needle aspiration or core biopsy
- lymph node assessment - USS
Give 4 notable locations that breast cancer metastasises to
- Lungs
- Liver
- Bones (mc)
- Brain
How is management determined before breast cancer surgery?
By presence/absence of axillary lymphadenopathy:
* no palpable lymphadenopathy - pre-operative axillary USS before primary surgery
* if negative - sentinel node biopsy to assess the nodal burden
* palpable lymphadenopathy - axillary node clearance (radiotherapy) is indicated at primary surgery
What complications can arise from axillary node clearance?
arm lymphoedema and functional arm impairment
Describe the surgical management of breast cancer
- mastectomy
- wide local excision
- breast reconstruction - delayed or immediate
When is wide-local excision indicated for breast cancer surgery?
- solitary lesion
- peripheral tumour
- small lesion in large breast
- DCIS <4cm
When is mastectomy indicated for breast cancer surgery?
- multifocal tumour
- central tumour
- large lesion in small breast
- DCIS >4cm
Describe how radiotherapy is used in the management of breast cancer
Whole breast radiotherapy is recommended after a woman has had a wide-local excision as this may reduce the risk of recurrence
Describe how hormonal treatments are used to manage breast cancer
- adjuvant hormonal therapy is offered to patients with oestrogen-receptor positive breast cancer
- pre- and peri-menopausal women: tamoxifen
- postmenopausal women: aromatase inhibitor - e.g. anastrozole or letrozole
each given for 5-10 years
Give 3 side effects of tamoxifen
- increased risk of endometrial cancer
- increased risk of VTE
- menopausal symptoms
Describe how biological therapy is used in the management of breast cancer
- trastuzumab (Herceptin) is used in patients with HER2 positive breast cancer
- Pertuzumab (Perjeta) and Neratinib (Nerlynx) are others
How is chemotherapy used in the management of breast cancer
- Neoadjuvant therapy – intended to shrink the tumour before surgery
- Neoadjuvant FEC-D chemotherapy if nodal involvement
- Adjuvant chemotherapy – given after surgery to reduce recurrence
What are the options for breast reconstruction following a mastectomy
- Breast implants
- Flap reconstruction (using tissue from another part of the body to reconstruct the breast)
What are some issues with a synthetic breast implant
- feels unnatural: cold, less mobile, static size and shape
- hardening
- leakage
- shape change over time
