Breast Pathology Overview Flashcards
E - refer to hospital immediately
- this is likely to be an abscess due to presence of trauma + systemic symptoms
- there is a hard lump with red skin that feels hot to touch
- it is common to have abscesses following trauma as there is an entry point for bacteria
- need to refer to hospital immediately as the abscess needs drainage
D - reassure her, encourage milk expression and arrange a follow-up the next day
- this is lactational mastitis
- a blocked duct has led to inflammation of the skin and pain
- encourage milk expression as this works to try and unblock the duct
- this is common in new mums who may have a bad breastfeeding technique due to lack of experience
- want to follow-up the next day to ensure it has not become worse, otherwise she would need to go to hospital
C - co-amoxiclav
- this is non-lactational mastitis
- an abscess is starting to form
- she doesn’t currently have one as she has no systemic symptoms
- the piercing is a new foreign body that the breast is reacting to to cause mastitis
- lack of hygiene increases risk
- this is treated with co-amoxiclav
What are the 4 most common differentials in a younger woman presenting with a breast lump?
- benign cystic change
- fibroadenoma
- cyst
- carcinoma
When taking a breast lump history, what 7 areas need to be covered in order to narrow the differentials?
- age of patient
- time
- trauma
- pain (if present and location)
- risk factors
- FLAWS
- changes to the breast in any way (nipple, skin, etc.)
Why is it important to estabilish age to narrow breast lump differentials?
- as age increases, the concern about carcinoma increases
- younger people are more likely to have benign changes as their breasts are still developing
What are the more common causes of breast lumps in <30 and 30-45 year olds?
Patients < 30:
- benign cystic change
- abscess
- normal lumpy breast
- mastitis
- galactocoele
Patients 30-45:
- benign cystic change
- abscess
- cyst
- carcinoma
What are the more likely causes of a breast lump in 45-60 year olds and those >60?
Patients 45-60:
- abscess
- cyst
- carcinoma
- duct ectasia
Patients > 60:
- carcinoma
How can time be used to narrow the differentials of a breast lump?
Which questions can be asked to help with this?
-
abscesses and cysts appear rapidly
- i.e. they can appear overnight
- fibroadenomas and carcinomas take time to form
- benign cystic changes will fluctuate with periods
Questions to ask:
- When did you notice the lump?
- How long has the lump been there for?
- Does the lump change with your periods?
What 2 conditions that cause breast lumps are associated with trauma?
-
fat necrosis tends to only happen with seatbelt trauma
- sore breast following minor car accident/trauma is likely to be fat necrosis
-
diagnostic trauma can lead to abscess formation
- e.g. after biopsy / needle aspiration
- needle punctures the breast, creating an entry point for bacteria
How can seatbelt trauma lead to fat necrosis?
- if you crash into something whilst driving, you will lean forwards into the seatbelt
- this puts a lot of pressure on the breast
- if fat cells become damaged then necrosis can occur
- a sore breast following a minor car accident is likely to be fat necrosis
How can pain be used to narrow the differentials for a breast lump?
- carcinomas do not typically present with pain
- painful lumps include:
- benign cystic change
- acute mastitis
- abscess
- +/- cysts
What type of breast changes are shown here?
- peu d’orange
- inverted nipple
- bloody discharge
- scaling of the nipple
- milky discharge
- breast erythema
- palpable breast lump
What skin signs are more likely to point towards cancer and which are more likely to be due to inflammation?
Cancer:
- peau d’orange
- dimpling of skin
- ulceration
Inflammation / Infection:
- erythematous skin
- warm to touch
What nipple changes are more likely to be cancer?
Cancer:
- inversion of the nipple
- scaling of the nipple
- bloody discharge
- itching / irregular appearance
Benign:
- serous discharge
- milky discharge
- green-brown discharge
What characteristics of the texture of a breast lump raise suspicion of malignancy?
What is considered to be more benign?
Cancer:
- a solitary, hard lump
- it is irregular and immobile
- it has indistinct borders
- can you feel all the way around the outside?
- or does it feel more irregular and like it is stuck to a muscle or the skin?
Benign:
- multiple breast lumps
- rubbery/lax
- smooth
- mobile
- distinct borders
What are other concerning signs associated with a breast lump that point towards carcinoma?
-
new lymphadenopathy
- ask about new lumps appearing in the axilla or by the clavicles
- fixation / tethering to the skin or underlying muscle
What features of FLAWS are present in breast pathology other than carcinoma?
- acute mastitis and abscess may present with fever and lethargy
- there will not be any weight loss or appetite changes
In general, what are “good” and “bad” risk factors for breast carcinoma?
- “bad” risk factors are anything that increases oestrogen exposure
- “good” risk factors are anything that decreases oestrogen in the body
What are examples of risk factors for breast carcinoma?
- risk factors include anything that increases oestrogen exposure
- e.g. taking any form of oral contraceptive pill
- family history of first degree relative with cancer
- increasing age
-
obesity
- fat cells can convert some hormones into oestrogen
- obesity naturally increases the amount of oestrogen in the body
- being biologically female
- caucasian
- ionising radiation
- smoking
What are positive risk factors for breast carcinoma that indicate reduced risk?
-
decreased oestrogen exposure
- being pregnant
- having young children
- starting period at a later age
- having no family history of cancer
- young age
- decreased ionising exposure
- non-smoking
Why is it important to ask someone about when they started and stopped (if relevant) their periods?
- the longer period of time that someone has periods for, the more oestrogen cycles occur over their life time
- this increases oestrogen exposure
- starting periods at a later age is associated with decreased oestrogen exposure
When examining a breast lump, what mnemonic can be used to remember all the aspects that need to be commented on?
Straps Need Tightening
- Size
- Shape
- Skin
- Nodes
- Nipple
- meNstruation
- Tethering
- Tenderness
- Temperature
- Trauma
- Texture
- Time
What are the alveoli of the breast?
Where are they found?
- the alveoli are contained within lobules
- they are surrounded by fat
- they produce the milk, which travels through the lactiferous ducts
- the lactiferous ducts form lactiferous sinuses, which lead to the nipple
What is meant by mastitis?
What are the potential causes?
inflammation of the breast tissue that may be due to bacterial infection
- it can also occur due to clogged ducts in milk stasis
- or due to nipple injury
- if it is caused by bacteria entering the damaged breast, this is most commonly Staphylococcus aureus
Why does a lump develop in lactational mastitis?
How could this lump be described?
- when a duct is blocked, there is backlog of milk into the alveoli
- the pressure inside the alveoli increases and they increase in size
- this leads to an increase in size of the lobule containing the affected alveoli
- expansion of the lobule leads to a wedge-shaped lump which can be felt
- it is wedge-shaped due to inflammation of the entire lobule
Why can the skin appear red and inflamed in lactational mastitis?
- due to expansion of the lobule and increase in pressure, some of the milk proteins leak out into the surrounding fat
- the fat reacts to the milk proteins as they appear foreign
- this causes skin inflammation and erythema
What are the 3 different types of mastitis?
- mastitis can be infectious or non-infectious
- non-infectious mastitis is duct ectasia
- this is due to milk ducts becoming wider and their walls thickening
- infectious mastitis is referred to as non-lactational mastitis if the women is not breast-feeding
- if it becomes complicated, then it can lead to an abscess
- if lactational mastitis is not treated, over time infection can occur and this leads to an abscess
- this is a large collection of pus within the breast
How can the SNT method be applied to mastitis?
S - size, shape, skin:
- palpable hard wedge
- skin appears red and swollen
N - nodes, nipples, menstruation:
- nipples may be cracked
- cracked nipples are associated with lactation - particularly with a bad technique
- there may be lactation
T - time, texture, temperature etc:
- tends to occur within the first 1 - 2 months of breastfeeding
- painful
- hot to touch
What systemic symptoms are associated with mastitis?
- fever
- general malaise
What are the risk factors for mastitis?
- lactation
- milk stasis
- nipple injury
- poor breastfeeding technique
- shaving the hairs around the nipple
- foreign body - e.g. nipple piercing
How can the SNT method be applied to the symptoms of an abscess?
S - size, shape, skin:
- palpable single lump
- opposed to a large-wedge shaped area, there is just one small collection of pus
- skin is red and swollen
N - nipples, nodes, menstruation:
- nipples may be cracked
T - temperature, time, texture etc.
- very painful
- hot to touch
- fluctuant
- tends to be fluctuant in the early stages and gradually becomes hard
- patient is often breastfeeding
What systemic symptoms are associated with abscess?
- fever
- this tends to be more intense than in mastitis
- coryzal symptoms
- e.g. sore throat, nasal discharge, cough, loss of taste/smell
- myalgia
What are the risk factors for breast abscess?
- the main risk factor is previous mastitis
- it may not have resolved completely and has now recurred and become complicated by bacteria
- it is rare to have abscesses in non-lactating women
-
smoking is a risk factor for a non-lactational abscess
- periductal mastitis is common in smokers
- this is a risk factor for abscess
What is the main distinguishing clinical feature between mastitis and a less severe abscess?
- they present with very similar symptoms
- abscesses will present with a single palpable lump
- mastitis will present with a larger wedge-shaped swelling
What is involved in the investigations for abscess and mastitis?
- moderate mastitis is diagnosed clinically with a breast examination
- if mastitis is severe and you suspect a further infection might be occurring, breast milk culture can be offered
- this is not a routine investigation
- if abscess is suspected, needs to be referred to hospital
- this can occur overnight within a few days
- the chance of it spreading quickly and leading to sepsis is relatively high
- if patient has signs of sepsis / haemodynamic instability, they should be referred to hospital
- e.g. sustained fever, hypotension, tachycardia, chills
What is the management for mastitis in someone who is lactating?
- reassure them that this is not an uncommon issue
- analgesia to help with the pain
-
encourage milk expression
- this attempts to unblock the clogged duct
- can be helped with warm compresses / massages
- only give antibiotics if there is no improvement after 2 days
What is the treatment for mastitis in non-lactating women?
- reassure them and give analgesia
- give co-amoxiclav for 2 weeks
- not breastfeeding so no risk of abx passing onto the baby
- mastitis occurring in non-lactating women is more likely to be associated with smoking
What is the treatment for a suspected abscess?
- after referral to hospital, surgeons perform USS to confirm diagnosis
- aspiration or surgical drainage
- fluid culture and IV antibiotics
- every case is different depending on size, age, etc. so the management needs to be tailored
What advice is given to patients after starting antibiotics for mastitis?
if symptoms worsen or do not improve after 48 hours then seek advice
need to rule out an abscess
What are the typical causative organisms of mastitis / abscess?
Aerobes:
- staphylococcus
- streptococcus
- E. coli
Anaerobes:
- clostridium
Others:
- TB
- Bartonella henselae - cat scratch disease
How can mastitis progress to abscess?
Mastitis:
- occurs due to lactation and blocked milk ducts
Infectious mastitis:
- occurs when bacteria are present
Abscess:
- abscess is present when there is pus formation
Complicated abscess:
- occurs when there are more systemic symptoms, sepsis, or infection spreads elsewhere
D - duct ectasia
- she is within the right age bracket
- takes time to form and lump has been present for a few months
- menopause is a risk factor
- lump is small, well demarcated, firm and just underneath the nipple
- thick, green discharge
D - fibroadenoma
What are the most common presentations of benign breast disease?
- duct ectasia
- fibroadenoma
- cyst
- intraductal papilloma
- fat necrosis
What is meant by fibrocystic changes in the breast?
- fibro means formation of hard tissue and presence of cysts
- this person will present with symmetrical lumpy breasts
- some parts will be hard and some parts will be softer
What is the definition of duct ectasia?
What causes it?
-
thickening of the wall of the milk duct under the nipple that can become clogged and have fluid build-up
- if the wall thickens, the lumen diameter decreases
- increased chance of duct becoming clogged
-
age-related cause
- as you get older your milk ducts naturally shorten and get wider
- more likely to occur in older women
How can the SNT approach be applied to duct ectasia?
S - size, shape, skin:
- palpable lump felt behind the nipple
N - nodes, menstruation, nipple:
- nipple may be inverted or red
- there is thick, sticky discharge (white / green / black)
- if discharge is red, more likely to be carcinoma than duct ectasia
T - time, temperature, tenderness etc.:
- lump is solid
- +/- tender
- tends to occur in older women and takes time to develop
What are the risk factors for duct ectasia?
-
menopause
- tends to affect women around 50-60 y/o
- smoking
- obesity
What is involved in the investigations and management of duct ectasia?
Investigations:
- USS +/- biopsy to rule out carcinoma
Management:
- management is conservative with hot compresses + analgesia
- antibiotics and excision if necessary
What is the definition of fibroadenoma?
Who tends to be affected?
-
benign neoplasm of a lobule formed from stroma (fibro) and glandular (adenoma) epithelium
- sometimes called the “breast mouse”
- tends to affect younger women aged 20-30 or those of reproductive age
How can the SNT approach be applied to fibroadenoma?
S - size, shape, skin:
- it is a small, palpable lump
- it has a regular, round shape like a soy bean
N - nodes, nipples, menstruation:
- all normal
T - time, texture, tethering, etc:
- smooth, rubbery
- painless
- mobile
- takes time to form
What are the risk factors for fibroadenoma?
- anything that increases oestrogen exposure increases the chance of developing this
- it is a cancer (neoplasm) but it is benign
- obesity
- oral contraceptive pill < 20
-
recent puberty
- puberty causes a massive increase in all the hormones
- this is the time when the breasts change in texture
What are the investigations performed in fibroadenoma?
- USS is performed if patient is < 35
- mammogram is performed if patient is > 35
- fine needle aspiration / core biopsy may be performed if suspicious
What is involved in the management of fibroadenoma?
- management is conservative as they tend to disappear on their own after going through the menopause
-
excision in certain cases
- e.g. if causing a lot of pain, not 100% certain that it is fibroadenoma
What is the definition of fibrocystic changes?
Who tends to be affected?
- benign breast condition encompassing fibrous changes, cysts and adenosis that occurs bilaterally
- adenosis occurs when the milk-producing lobules are generally enlarged and may have more glands than normal
- tends to affect premenopausal women aged 30-50
How can the SNT approach be applied to fibrocystic changes?
S - size, shape, skin:
- multiple lumps that are smooth + regular
- bilateral
- tends to be symmetrical
N - nodes, nipples, menstruation:
- nipples are normal
- fluctuates with periods
T - time, tenderness, temp etc:
- rubbery (fibrous lumps)
- fluctuant (cysts)
- mobile
- slow-growing with fluctuations
- may or may not be tender
What is the difference between fibrous lumps and cysts when palpating them?
Fibrous lumps:
- these tend to be hard and rubbery
Cysts:
- these tend to be oval or round
- they are fluctuant / lax
- they become harder as time goes on and pressure builds up
What are the risk factors for fibrocystic changes?
- risk factors are anything to do with changing levels of oestrogen
- obesity
- nulliparity (never given birth)
- late menopause
- increased oestrogen exposure
What investigations are performed in fibrocystic changes?
- USS if patient is <35 and mammogram if patient is >35
- a fine needle aspiration may be performed which should show STRAW-COLOURED fluid
- this represents a normal cyst
- if there is blood present, needs to be sent to pathologist to look for cancer
What is involved in the management of benign cystic changes?
- management is conservative
- FNA if drainage is needed
What are the “buzz-words” associated with benign cystic changes?
- tends to occur in premenopausal women aged 30-50
- they will have multiple lumps in both breasts
- lumps / texture of breast fluctuates with periods and there is premenstrual breast pain
- lumps tend to be found in the UOQ
- straw-coloured fluid on FNA
What is meant by fat necrosis and who tends to be affected?
- occurs when fat tissue within the breast is damaged often secondary to trauma
- it is rare but can affect any age
How can the SNT approach be applied to fat necrosis?
S - skin, size, shape:
- skin is bruised / red
- lump is irregular
- +/- skin retraction / thickening
N -nipples, nodes, menstruation:
- +/- nipple retraction
T - time, temperature, tenderness etc:
- hard, fixed lump
- may be tender
- related to trauma
What are the risk factors for fat necrosis?
- having larger breasts
- trauma
- previous FNA / biopsy / surgery
What are the investigations for fat necrosis?
- USS if patient is <35 and mammogram if patient is > 35
- FNA / core biopsy
What is the treatment for fat necrosis?
- management is conservative as the body will naturally break it down
- excision may occur if it is particularly large or painful
What is meant by an intraductal papilloma?
Who does this tend to affect?
- it is a rare benign fibroepithelial tumour formed from the lactiferous duct epithelium
- this is a small wart-like lump within the ducts
- tends to affect women aged 30-55
How can the SNT approach be applied to intraductal papilloma?
S - size, shape, skin:
- there is no mass present
- feeling of the breast being full
N - nodes, nipples, menstruation:
- bloody / serous discharge from one nipple only
T - tender, time, trauma etc:
- may be tender
- takes time to form but there is often no mass to be felt
What are the risk factors for intraductal papilloma?
- peri or post-menopause
What is involved in the investigations and management for intraductal papilloma?
- USS if <35 and mammogram if > 35
- FNA / core biopsy to rule out malignant carcinoma
- management is conservative and there may be excision of the affected duct
What is the defintion of breast cancer?
Who are you more concerned about?
-
malignant lesions within the breast that present with different features and behaviours
- there are many different types that all present differently
- 50% of cases occur in >65s so more concerned when older women present with a lump in the breast
How can the SNT approach be applied to breast cancer?
S - skin, size, shape:
- palpable, irregular lump
- skin may be red
- there may be dimpling, ulceration + thickening of the skin
N - nodes, nipples, menstruation:
- bloody discharge
- lymph nodes may be involved / palpable
T - time, temperature, texture etc:
- slow to develop
- firm
- painless
- immobile
What are the risk factors for breast cancer?
- increasing age
- anything that increases oestrogen exposure
- e.g. OCP
- obesity
- first degree relative with cancer
- radiation
- endometrial cancer
- inherited genes - BRCA1 and BRCA2
What is the only type of benign breast cancer and how does it present?
intraductal papilloma
- presents as a solitary lump near the nipple
- unilateral bloody / serous discharge
How can malignant breast cancers be divided into 2 categories?
malignant breast cancers can be invasive or carcinoma in situ
Invasive:
- ductal carcinoma
- lobular carcinoma
- phyllodes
- inflammatory carcinoma
Carcinoma in situ:
- Paget’s disease of the nipple
- lobular carcinoma
- ductal carcinoma
Where is a ductal carcinoma in situ found?
How does this change if it becomes invasive?
In situ:
- confined to the milk duct by the basement membrane
- this is a premalignant state and 50% will become invasive
- there is no palpable lump
- patient may also have Paget’s disease of the nipple
Invasive:
- most common form of breast cancer
- firm, immobile, fixed lump with skin changes
- tends to affect women aged 30-50
Where is a lobular carcinoma in situ found?
How does this change if it becomes invasive?
In situ:
- confined to the lobule
- presents as a palpable lump
- 20 % will become invasive
Invasive:
- 2nd most common breast cancer but worst prognosis
- often found incidentally
What is meant by Paget’s disease of the nipple?
- presents as itching, redness and crusting of the nipple
- it is often a sign associated with underlying breast cancer (80%)
- particularly invasive ductal carcinoma
What are the associated features of invasive inflammatory breast cancer?
- early mets
- red, painful breast
- peau d’orange
- symptoms are caused by cancer cells blocking lymph vessels in the skin
What is the series of investigations performed in suspected breast cancer?
triple assessment
- examination
- imaging
- USS in <35
- mammogram in > 35
- tissue analysis / biopsy
How is the likelihood of breast cancer calculated from the triple assessment?
- at each stage, a score /5 is given based on the likelihood of malignancy
- compare scores from examination, imaging and histology to determine diagnosis
What staging system is used to stage breast cancer?
TNM staging
- T - the size of the tumour
-
N - node involvement
- N0 - no node involvement
- N1 - some axillary node involvement
- N2 - extensive axillary node involvement
- N3 - node involvement beyond the axilla
-
M - if metastases are present
- M0 - no mets
- M1 - metastatic disease - commonly to bone, brain, lung & liver
