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Phase 3a > Breast medicine > Flashcards

Breast medicine Flashcards

1
Q

What are the types of breast cancer?

A
  • Invasive ductal carcinoma
  • Invasive lobular carcinoma
  • Ductal carcinoma-in-situ (DCIS)
  • Lobular carcinoma-in-situ (LCIS)
  • Inflammatory breast cancer
  • Paget’s disease of the nipple

Rare types - Medullary, mucinous, tubular, others

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2
Q

What are the causes/risk factors for developing breast cancer?

A

Multifactorial:
- Genetic: BRCA1/2, TP53, PTEN
- First degree relative affected
- Hormonal: Prolonged oestrogen exposure (early menarche, late menopause)
- COCP and HRT
- Radiation exposure to the chest
- Lifestyle: Alcohol, smoking, obesity

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3
Q

What chromosome is affected in BRCA1/2?

A

BRCA1 - chromosome 17
Around 70% will develop breast cancer by aged 80
Around 50% will develop ovarian cancer
Also increased risk of bowel and prostate cancer

BRCA2 - chromosome 13
Around 60% will develop breast cancer by aged 80
Around 20% will develop ovarian cancer

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4
Q

What is Ductal carcinoma in situ and what are the features?

A

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 (around 30%)
Good prognosis if full excised and adjuvant treatment is used

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5
Q

What is Lobular Carcinoma In Situ and what are the features?

A

A pre-cancerous condition occurring typically in pre-menopausal women
Usually asymptomatic and undetectable on a mammogram
Usually diagnosed incidentally on a breast biopsy
Represents an increased risk of invasive breast cancer in the future (around 30%)
Often managed with close monitoring (e.g., 6 monthly examination and yearly mammograms)

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6
Q

What is invasive ductal carcinoma?

A

Also known as invasive breast carcinoma of no special/specific type (NST)
Originate in cells from the breast ducts
80% of invasive breast cancers fall into this category
Can be seen on mammograms

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7
Q

What is invasive lobular carcinoma?

A

Around 10% of invasive breast cancers
Originate in cells from the breast lobules
Not always visible on mammograms

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8
Q

What is inflammatory breast cancer?

A

1-3% of breast cancers
Presents similarly to a breast abscess or mastitis
Swollen, warm, tender breast with pitting skin (peau d’orange)
Does not respond to antibiotics
Worse prognosis than other breast cancers

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9
Q

What is Paget’s disease of the nipple?

A

Looks like eczema of the nipple/areolar
Erythematous, scaly rash
Indicates breast cancer involving the nipple
May represent DCIS or invasive breast cancer
Requires biopsy, staging and treatment, as with any other invasive breast cancer

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10
Q

How does breast cancer usually present?

A

Often involves a woman aged over 50 years presenting with a unilateral, hard, painless lump in the upper outer quadrant of her breast.

  • Painless lump (hard, irregular, non-mobile)
  • Skin changes (erythema, peau d’orange, dimpling)
  • Nipple changes (inversion, deviation, pagets, discharge)
  • Axillary lymphadenopathy (most commonly)
  • Systemic (anorexia, weight loss, fatigue)

Mets - (bone, lung, liver, brain) - usually picked up through screening before mets

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11
Q

What does the breast cancer screening programme involve?

A

Mammogram every 3 years to women aged 50 – 70 years (being expanded to 47-73).

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12
Q

Who may be offered breast cancer screening earlier?

A

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

Offered annual mammogram and earlier screening

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13
Q

What is the potential management strategies for women with a high risk of developing breast cancer?

A

Chemoprevention may be offered for women at high risk, with:

  • Tamoxifen if premenopausal
  • Anastrozole if postmenopausal (except with severe osteoporosis)

Risk-reducing bilateral mastectomy or bilateral oophorectomy (removing the ovaries) is an option for women at high risk. (rare)

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14
Q

What is the referral criteria for suspected breast cancer?

A

2 week wait referral for suspected breast cancer for:

  • Unexplained breast lump in patients aged 30+
  • Unilateral nipple changes in patients aged 50+ (discharge, retraction or other changes)

Consider 2 week referral:
- An unexplained lump in the axilla in patients aged 30 or above
- Skin changes suggestive of breast cancer

Non-urgent referral for under 30 with an unexplained breast lump with or without pain

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15
Q

What investigations are done in suspected breast cancer?

A

Clinical (Hx and exam)
Imaging (mammography/USS/MRI)
Biopsy (FNA or core biopsy)

Lymph Node assessment - if diagnosed with breast cancer:
- USS axilla
- Sentinel node biopsy during breast surgery

Staged using the TNM system

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16
Q

What are the common areas of metastasis for breast cancer?

A

LLBB:
Liver
Lungs
Bone
Brain

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16
Q

What is the general treatment options for breast cancer?

A

Surgery
Radiotherapy
Hormone therapy
Biological therapy
Chemotherapy

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16
Q

What breast cancer receptors can be targeted with treatment?

A

Oestrogen receptors (ER)
Progesterone receptors (PR)
Human epidermal growth factor (HER2)

Triple negative breast cancer is when none of these are present (worse prognosis)

17
Q

What are the surgical options for treating breast cancer?

A
  • Breast conserving (wide local excision)
  • Mastectomy

Indications -
Mastectomy (multifocal tumour, central, large, DCIS > 4cm)
Wide local excision (solitary lesion, peripheral, small, DCIS <4cm)

Breast reconstruction surgery for both

Axillary clearance (increases risk of chronic lymphoedema)

18
Q

What are some complications of surgical management of breast cancer?

A
  • Lymphoedema (swelling of arm due to impaired lymphatic drainage)
  • Seroma (fluid accumulation at surgical site)
  • Mastectomy flap necrosis (inadequate blood supply to the skin)
19
Q

When is radiotherapy used in breast cancer and what are the side effects?

A

Important in patients who have breast conserving surgery. Also used in post mastectomy.

SEs:
- General fatigue from the radiation
- Local skin and tissue irritation and swelling
- Fibrosis of breast tissue
- Shrinking of breast tissue
- Long term skin colour changes (usually darker)
- Radiation pneumonitis

20
Q

How is chemotherapy delivered in breast cancer?

A

Neoadjuvant to shrink tumour size pre-op and adjuvant in high risk cases

21
Q

What are the main biological therapies in breast cancer?

A

Trastuzumab (Herceptin) targets the HER2 receptor. It may be used in patients with HER2 positive breast cancer.
Notably, it can affect heart function; therefore, initial and close monitoring of heart function is required.

Pertuzumab - monoclonal antibody that targets the HER2 receptor used in combination with herceptin.

Neratinib (Nerlynx) - tyrosine kinase inhibitor, reducing the growth of breast cancers. Used in HER2 +ve.

22
Q

What hormonal therapies are used in hormone positive breast cancers?

A

Tamoxifen - selective oestrogen receptor modulator (SERM). Blocks oestrogen receptors in breast tissue, and stimulates oestrogen receptors in the uterus and bones. This means it helps prevent osteoporosis, but it does increase the risk of endometrial cancer.

Aromatase - found in fat (adipose) tissue that converts androgens to oestrogen. Primary source of oestrogen in postmenopausal. Blocking the creation of oestrogen in fat tissue.

Both are taken for 5-10 years in oestrogen positive breast cancer

23
Q

What are the types of benign breast lumps?

A
  • Fibroadenoma
  • Breast cyst
  • Fat necrosis
  • Sclerosing adenosis (radial scar)
  • Duct papilloma
24
Q

What are the features of a fibroadenoma?

A

Benign tumours of stromal/epithelial breast duct tissue:
- Painless, smooth, round, well-defined borders, firm, mobile
- Usually up to 3 cm diameter
- More common in younger women (20-40)

Remove if >3cm

25
Q

What are the features of breast cysts?

A

Benign, individual, fluid-filled lumps. More common in 30-50 years and perimenopause.

Smooth, well-circumscribed, mobile, possibly fluctuant, may be painful

Tx - Aspirate or excise, slight increase risk of breast cancer (histology)

26
Q

What are the features of fat necrosis in the breast?

A

Benign lump formed by localised degeneration and scarring of fat tissue. Can be caused by trauma, radiotherapy.

Painless, firm, irregular, fixed in local structures, may be skin dimpling or nipple inversion

No increase breast cancer risk. Mimics carcinoma so may need to FNA/core biopsy, USS/mammogram to rule out.

Tx - conservative or surgical removal

27
Q

How do intraductal papillomas present?

A

Usually present with nipple discharge (clear or blood stained)
Large papillomas may present with a mass
The discharge usually originates from a single duct
No increase risk of malignancy

Ix - Imaging, histology

Tx - microdochectomy (removal of milk duct)

28
Q

What is mastitis?

A

Refers to inflammation of the breast, usually associated with breastfeeding.

29
Q

What causes mastitis?

A
  • Obstruction in the ducts and accumulation of milk
  • Infection, bacteria entering at the nipple and back-track into the ducts, causing infection and inflammation (usually staphylococcus aureus)
30
Q

How does mastitis present?

A

Breast pain and tenderness (unilateral)
Erythema in a focal area of breast tissue
Local warmth and inflammation
Nipple discharge
Fever
Malaise

31
Q

What is the management of mastitis?

A

Blocked ducts - continue to breastfeed, analgesia, warm compress

If due to infection or systemic illness -
1st line: Oral flucloxacillin for 10-14 days (erythromycin if allergy)
Fluconazole if candida

Continue to breastfeed (not harmful)

32
Q

What is candida of the breast?

A

Candidal infection of the nipple, usually after a course of antibiotics. Can lead to recurrent mastitis, associated with oral thrush and candidal nappy rash.

Features:
- Sore nipples bilaterally, particularly after feeding
- Nipple tenderness and itching
- Cracked, flaky or shiny areola
- Symptoms in baby (white patches in the mouth/tongue, or candidal nappy rash)

Tx:
Topical miconazole 2% to the nipple, after each breastfeed
Treatment for the baby (e.g., oral miconazole gel or nystatin)

33
Q

What is mammary duct ectasia?

A

Dilation of large ducts in the breast (benign). The inflammation in the ducts leads to intermittent nipple discharge. Most common in perimenopause, smoking is a risk factor.

34
Q

How does mammary duct ectasia present?

A

Nipple discharge (thick may be white, grey or green)
Tenderness or pain
Nipple retraction or inversion
A breast lump (pressure on the lump may produce nipple discharge)

35
Q

What are the investigations for mammary duct ectasia?

A

Clinical
Imaging - mammogram may show microcalcifications
Biopsy

others: Ductography, nipple discharge cytology

36
Q

What is the management for mammary duct ectasia?

A
  • Reassurance
  • Manage mastalgia (analgesia, warm compress)
  • Abx if infection
  • Microdochectomy
37
Q

What are the types of breast abscess?

A
  • Lactational - more common, complication of mastitis
  • Non-lactational
38
Q

What are the risk factors for breast abscess?

A
  • Mastitis
  • Smoking
  • Damage to nipple (nipple eczema, candidal infection or piercings)
  • Underlying breast disease (cancer etvc)
39
Q

What are the most common organisms causing breast abscess?

A

Staphylococcus aureus (the most common)
Streptococcal species
Enterococcal species
Anaerobic bacteria (such as Bacteroides species and anaerobic streptococci)

40
Q

What is the presentation of a breast abscess?

A

Nipple changes
Purulent nipple discharge (pus from the nipple)
Localised pain
Warmth
Erythema (redness)
Hardening of the skin or breast tissue
Swollen, fluctuant, tender lump

Also:
Fatigue
Fever
Signs of sepsis

41
Q

What is the management of breast abscess?

A

Lactational - if signs of infection treat with oral flucloxacillin if conservative Mx is ineffective. (Erythromycin if allergy)

Non-lactational mastitis -
Analgesia
Treat underlying cause
Antibiotics:
- Co-amoxiclav or erythromycin + metronidazole

Abscess:
- Surgical referral
- Drainage/aspiration + MCS
- Antibiotics

Phase 3a (9 decks)

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