Breast Surgery Flashcards
Most of the breast is _______ tissue. The _____ surrounds the nipple. Behind the nipple are the ______, which lead into the _______ where breast milk is produced. Milk is secreted through the ducts and out of openings on the nipple
Most of the breast is adipose (fatty) tissue. The areola surrounds the nipple. Behind the nipple are the ducts, which lead into the lobules, where breast milk is produced. Milk is secreted through the ducts and out of openings on the nipple
Explain the triple assessment of a breast lump to exclude or diagnose cancer?
- Clinical assessment (history and examination)
- Imaging (ultrasound or mammography)
- Histology (fine needle aspiration or core biopsy)
Clinical features that may suggest breast cancer are:
- 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 (peau d’orange)
The NICE guidelines (updated January 2021) recommend a two week wait referral for suspected breast cancer for:
- An unexplained breast lump in patients aged 30 or above
- Unilateral nipple changes in patients aged 50 or above (discharge, retraction or other changes)
The NICE guidelines recommend also considering a two week wait referral for breast cancer for:
An unexplained lump in the axilla in patients aged 30 or above
Skin changes suggestive of breast cancer
The NICE guidelines suggest considering non-urgent referral for…..
unexplained breast lumps in patients under 30 years.
What is Fibroadenoma
Fibroadenomas are common benign tumours of stromal/epithelial breast duct tissue. They are typically small and mobile within the breast tissue. They are sometimes called a “breast mouse”, as they move around within the breast tissue.
Who is fibroadenoma seen in?
They are more common in younger women, aged between 20 and 40 years.
On examination, fibroadenomas are:
- Painless
- Smooth
- Round
- Well circumscribed (well-defined borders)
- Firm
- Mobile (moves freely under the skin and above the chest wall)
- Usually up to 3cm diameter
Are Fibroadenomas cancerous
No
However
Complex fibroadenomas and a positive family history of breast cancer may indicate a higher risk.
Fibrocystic breast changes were previously called ________ _______ _______. However, fibrocystic breast changes, and generalised lumpiness to the breast, is considered a _________ of normal and not a disease
Fibrocystic breast changes were previously called fibrocystic breast disease. However, fibrocystic breast changes, and generalised lumpiness to the breast, is considered a variation of normal and not a disease
Fibrocystic Breast Changes are common in
women of menstruating ages
Fibrocystic Breast Changes
Symptoms often occur…
prior to menstruating (within 10 days) and resolve once menstruation begins. Symptoms usually improve or resolve after menopause.
Fibrocystic Breast Changes
Symptoms can affect different areas of the breast, or both breasts, with
- Lumpiness
- Breast pain or tenderness (mastalgia)
- Fluctuation of breast size
Management of fibrocystic breast changes is to exclude cancer and manage symptoms. Options to manage cyclical breast pain (mastalgia) include:
- Wearing a supportive bra
- Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen
- Avoiding caffeine is commonly recommended
- Applying heat to the area
- Hormonal treatments (e.g., danazol and tamoxifen) under specialist guidance
What are Breast Cysts
Breast cysts are benign, individual, fluid-filled lumps. They are the most common cause of breast lumps and occur most often between ages 30 and 50, more so in the perimenopausal period. They can be painful and may fluctuate in size over the menstrual cycle.
On examination, breast cysts are:
Smooth
Well-circumscribed
Mobile
Possibly fluctuant
Do Breasts cysts require further assessment?
Yes
Breasts cysts require further assessment to exclude cancer, with imaging and potentially aspiration or excision. Aspiration can resolve symptoms in patients with pain. Having a breast cyst may slightly increase the risk of breast cancer.
What is Fat necrosis
Fat necrosis causes a benign lump formed by localised degeneration and scarring of fat tissue in the breast. It may be associated with an oil cyst, containing liquid fat. Fat necrosis is commonly triggered by localised trauma, radiotherapy or surgery, with an inflammatory reaction resulting in fibrosis and necrosis (death) of the fat tissue. It does not increase the risk of breast cancer.
On examination, fat necrosis can be
- Painless
- Firm
- Irregular
- Fixed in local structures
- There may be skin dimpling or nipple inversion
Diagnosis of fat necrosis
Ultrasound or mammogram can show a similar appearance to breast cancer. Histology (by fine needle aspiration or core biopsy) may be required to confirm the diagnosis and exclude breast cancer.
fat necrosis management
usually treated conservatively. It may resolve spontaneously with time. Surgical excision may be used if required for symptoms.
What is Lipoma
Lipomas are benign tumours of fat (adipose) tissue. They can occur almost anywhere on the body where there is adipose tissue, including the breasts.
On examination, lipomas are typically:
Soft
Painless
Mobile
Do not cause skin changes
Management of lipoma
They are typically treated conservatively with reassurance. Alternatively, they can be surgically removed.
What are Galactocele
are they malignant or benign
Galactoceles occur in women that are lactating (producing breast milk), often after stopping breastfeeding. They are breast milk filled cysts that occur when the lactiferous duct is blocked, preventing the gland from draining milk. They present with a firm, mobile, painless lump, usually beneath the areola.
hey are benign and usually resolve without any treatment. It is possible to drain them with a needle. Rarely, they can become infected and require
What are Phyllodes tumours
Phyllodes tumours are rare tumours of the connective tissue (stroma) of the breast, occurring most often between ages 40 and 50. They are large and fast-growing. They can be benign (~50%), borderline (~25%) or malignant (~25%). Malignant phyllodes tumours can metastasise
leaf like
.
Treatment for Phyllodes tumour
Treatment involves surgical removal of the tumour and the surrounding tissue (“wide excision”). They can reoccur after removal.
Chemotherapy may be used in malignant or metastatic tumours.
Breast pain (mastalgia) is common. It can be:
Cyclical – occurring at specific times of the menstrual cycle
Non-cyclical – unrelated to the menstrual cycle
What is Cyclical Breast Pain
When does it occur
Cyclical breast pain is more common and is related to hormonal fluctuations during the menstrual cycle. The pain typically occurs during the two weeks before menstruation (the luteal phase) and settles during the menstrual period. There may be other symptoms of premenstrual syndrome, such as low mood, bloating, fatigue or headaches.
Cyclical Breast Pain
Symptoms are typically
Bilateral and generalised
Heaviness
Aching
Non-Cyclical Breast Pain
Who is common in?
What is it caused by?
Non-cyclical breast pain is more common in women aged 40 – 50 years. It is more likely to be localised than cyclical breast pain. Often no cause is found. However, it may be caused by:
- Medications (e.g., hormonal contraceptive medications)
- Infection (e.g., mastitis)
- Pregnancy
The pain may not originate in the breast but instead come from:
- The chest wall (e.g., costochondritis)
- The skin (e.g., shingles or post-herpetic neuralgia)
The three main things to exclude when someone presents with breast pain are:
- Cancer (perform a thorough history and examination)
- Infection (mastitis)
- Pregnancy (perform a pregnancy test)
A ____ ___ _____ can help diagnose cyclical breast pain.
A breast pain diary can help diagnose cyclical breast pain.
Management
Options to manage cyclical breast pain include:
- Wearing a supportive bra
- Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (oral or topical)
- Avoiding caffeine is commonly recommended
- Applying heat to the area
- Hormonal treatments (e.g., danazol and tamoxifen) under specialist guidance
What is Gynaecomastia
Gynaecomastia refers to the enlargement of the glandular breast tissue in males. Male breast enlargement is relatively common, particularly in adolescents and older men (aged over 50 years). It may also be present in newborns due to circulating maternal hormones, resolving as the maternal hormones are cleared.
Gynaecomastia can be caused by conditions that increase oestrogen like:
- Obesity (aromatase is an enzyme found in adipose tissue that converts androgens to oestrogen)
- Testicular cancer (oestrogen secretion from a Leydig cell tumour)
- Liver cirrhosis and liver failure
- Hyperthyroidism
- Human chorionic gonadotrophin (hCG) secreting tumour, notably small cell lung cancer
Gynaecomastia is generally caused by which two hormonal imbalance
oestrogen and androgens (e.g., testosterone)
with higher oestrogen and lower androgen levels
______ oestrogen stimulates breast development, whilst androgens have an _______ effect on breast development.
Raised oestrogen stimulates breast development, whilst androgens have an inhibitory effect on breast development.
aised ___________ (_________) can also cause gynaecomastia.
aised prolactin (hyperprolactinaemia) can also cause gynaecomastia.
What inhibits prolactin
dopamine
What can block dopamine
And what are the effects of prolaction as a result
Dopamine antagonists (e.g., antipsychotic medications) block dopamine production, which can allow prolactin levels to rise and cause gynaecomastia and galactorrhea (breast milk production).
It is worth remembering the link between gynaecomastia and _____ _____ ________ ________ About 2% of patients presenting with gynaecomastia have a ______ _____. An examination question might describe a patient presenting with gynaecomastia and ask what additional examination should be performed. The answer will be a testicular examination. Also, examine for signs of ________ _____ and _________
It is worth remembering the link between gynaecomastia and Leydig cell testicular tumours. About 2% of patients presenting with gynaecomastia have a testicular tumour. An examination question might describe a patient presenting with gynaecomastia and ask what additional examination should be performed. The answer will be a testicular examination. Also, examine for signs of liver failure and hyperthyroidism.
Gynaecomastia can be caused by conditions that reduce testosterone like:
- Testosterone deficiency in older age
- Hypothalamus or pituitary conditions that reduce LH and FSH levels (e.g., tumours, radiotherapy or surgery)
- Klinefelter syndrome (XXY sex chromosomes)
- Orchitis (inflammation of the testicles, e.g., infection with mumps)
- Testicular damage (e.g., secondary to trauma or torsion)
There is a long list of medications and drugs that can cause gynaecomastia
Name a few
- Anabolic steroids (raise oestrogen levels)
- Antipsychotics (increase prolactin levels)
- Digoxin (stimulates oestrogen receptors)
- Spironolactone (inhibits testosterone production and blocks testosterone receptors)
- Gonadotrophin-releasing hormone (GnRH) agonists (e.g., goserelin used to treat prostate cancer)
- Opiates (e.g., illicit heroin use)
- Marijuana
- Alcohol
Blood tests for gynaecomastia
- Renal profile (U&Es)
- Liver function tests (LFTs)
- Thyroid function tests (TFTs)
- Testosterone
- Sex hormone-binding globulin (SHBG)
- Oestrogen
- Prolactin (hyperprolactinaemia)
- Luteinising hormone (LH) and follicle-stimulating hormone (FSH)
- Alpha-fetoprotein and beta-hCG (testicular cancer)
- Genetic karyotyping (if Klinefelter’s syndrome is suspected)
Imaging for gynaecomastia?
- Breast ultrasound (may help assess the extent of gynaecomastia)
- Mammogram (if cancer is suspected)
- Biopsy (if cancer is suspected)
- Testicular ultrasound (if cancer is suspected)
- Chest x-ray (if lung cancer is suspected)
Management depends on the underlying cause. Gynaecomastia almost always resolves with time in adolescents. Stopping a causative drug (e.g., anabolic steroids or spironolactone) will usually resolve the symptoms. Patients may be referred to the specialist breast clinic where the cause is unclear or cancer is suspected.
Treatment options in problematic cases (e.g., pain or psychological distress) include:
- Tamoxifen (a selective oestrogen receptor modulator that reduces the effect of oestrogen on the breast tissue)
- Surgery
Galactorrhoea refers to_____ ______ production not associated with pregnancy or breastfeeding. Breast milk is produced in response to the hormone ______
Galactorrhoea refers to breast milk production not associated with pregnancy or breastfeeding. Breast milk is produced in response to the hormone prolactin.
Whati nhibits breast milk production
. Milk production may start in small amounts during the second or third trimester of pregnancy, and leaking can occur during that timeOestrogen and progesterone inhibit the secretion of prolactin. In pregnancy, higher levels of oestrogen and progesterone inhibit breast milk production.
_______ stimulates breast milk excretion. Full milk production starts shortly after birth in response to _______ release and a rapid drop in oestrogen and progesterone
Oxytocin stimulates breast milk excretion. Full milk production starts shortly after birth in response to oxytocin release and a rapid drop in oestrogen and progesterone
There is a long list of causes of hyperprolactinaemia, but the key causes to remember are:
- Idiopathic (no cause can be found)
- Prolactinomas (hormone-secreting pituitary tumours)
- Endocrine disorders, particularly hypothyroidism and polycystic ovarian syndrome
- Medications, particularly dopamine antagonists (i.e., antipsychotic medications)
Prolactin suppresses _______ _____ _________ by the hypothalamus, leading to reduced LH and FSH release. Therefore, hyperprolactinaemia can also present with:
Prolactin suppresses gonadotropin-releasing hormone (GnRH) by the hypothalamus, leading to reduced LH and FSH release. Therefore, hyperprolactinaemia can also present with:
- Menstrual irregularities, particularly amenorrhoea (absent periods)
- Reduced libido (low sex drive)
- Erectile dysfunction (in men)
- Gynaecomastia (in men)
What are Prolactinomas
Prolactinomas are tumours of the pituitary gland that secrete excessive prolactin. This may be associated with multiple endocrine neoplasia (MEN) type 1, an autosomal dominant genetic condition.
Prolactinomas can be split into
Microprolactinomas – smaller than 10 mm
Macroprolactinomas – larger than 10 mm
Macroadenomas can have adverse effects relating to their size:
- Headaches
- Bitemporal hemianopia (loss of the outer visual fields in both eyes)
*
Other conditions can cause nipple discharge that is not breast milk:
- Mammary duct ectasia
- Duct papilloma
- Pus from a breast abscess
A pregnancy test is essential in women with childbearing potential presenting with breast milk production.
Blood tests include:
- Serum prolactin
- Renal profile (U&Es)
- Liver function tests (LFTs)
- Thyroid function tests (TFTs)
An MRI scan is the investigation of choice for diagnosing pituitary tumours.
Management for prolactinomas
Management is targeted at the underlying cause.
Dopamine agonists (e.g., bromocriptine or cabergoline) can be used to treat the symptoms of hyperprolactinaemia. They block prolactin secretion and improve symptoms.
Trans-sphenoidal surgical removal of the pituitary tumour is the definitive treatment of hyperprolactinaemia secondary to a prolactinoma. The pituitary gland and tumour are accessed and removed through the nose and sphenoid bone.
What is Mammary duct ectasia
Mammary duct ectasia is a benign condition where there is dilation of the large ducts in the breasts. Ectasia means dilation. There is inflammation in the ducts, leading to intermittent discharge from the nipple.
The discharge may be white, grey or green.
Mammary duct ectasia occurs most frequently in ________ women. _______ is a significant risk factor.
Mammary duct ectasia occurs most frequently in perimenopausal women. Smoking is a significant risk factor.
Mammary duct ectasia may present with
- Nipple discharge
- Tenderness or pain
- Nipple retraction or inversion
- A breast lump (pressure on the lump may produce nipple discharge)
- It may be picked up incidentally on a mammogram, leading to further assessment and investigations.
Diagnosis of Mammary duct ectasia
The initial priority is to exclude breast cancer, as they can present in similar ways. This involves triple assessment
Microcalcifications are a key finding to remember on a mammogram, although they are not specific to mammary duct ectasia.
Other investigations that may be performed:
- Ductography – contrast is injected into an abnormal duct, and mammograms are performed to visualise the duct
- Nipple discharge cytology – examining the cells in a sample of the nipple discharge
- Ductoscopy – inserting a tiny endoscope (camera) into the duct
Mammary duct ectasia may resolve without any treatment. It is not associated with an increased risk of cancer.
Management depends on the individual patient:
- Reassurance after excluding cancer may be all that is required
- Symptomatic management of mastalgia (supportive bra and warm compresses)
- Antibiotics if infection is suspected or present
- Surgical excision of the affected duct (microdochectomy) may be required in problematic cases
*
What is an intraductal papilloma
An intraductal papilloma is a warty lesion that grows within one of the ducts in the breast. It is the result of the proliferation of epithelial cells. The typical presentation is with clear or blood-stained nipple discharge.
Intraductal papillomas are benign tumours; however, they can be associated with atypical hyperplasia or breast cancer.
Intraductal papillomas can occur at any age, but most often occur between __ __ years.
Intraductal papillomas can occur at any age, but most often occur between 35-55 years.
Intraductal papillomas are often asymptomatic. They may be picked up incidentally on mammograms or ultrasound.
They may present with:
- Nipple discharge (clear or blood-stained)
- Tenderness or pain
- A palpable lump
*
Diagnosis of Intraductal papillomas
Triple assessment
Ductography may also be used. This involves injecting contrast into the abnormal duct and performing mammograms to visualise that duct. The papilloma will be seen as an area that does not fill with contrast (a “filling defect”).
Management Intraductal papillomas
Intraductal papillomas require complete surgical excision. After removal, the tissue is examined for atypical hyperplasia or cancer that may not have been picked up on the biopsy.
What is Mastitis
Mastitis refers to inflammation of breast tissue and is a common complication of breastfeeding. It can occur with or without associated infection.
Mastitis can be caused by an _________ in the ducts and accumulation of milk. Regularly expressing breast milk can help prevent this from occurring.
Mastitis can be caused by an obstruction in the ducts and accumulation of milk. Regularly expressing breast milk can help prevent this from occurring.
Mastitis can also be caused by_______. Bacteria can enter at the nipple and back-track into the ducts, causing infection and inflammation. The most common bacterial cause is ___________ ____
Mastitis can also be caused by infection. Bacteria can enter at the nipple and back-track into the ducts, causing infection and inflammation. The most common bacterial cause is Staphylococcus aureus
Mastitis presents with:
Breast pain and tenderness (unilateral)
Erythema in a focal area of breast tissue
Local warmth and inflammation
Nipple discharge
Fever
Management for mastitis
Heat packs, warm showers and simple analgesia can help symptoms.
If infection is suspected (e.g., they have a fever), antibiotics should be started. Flucloxacillin is the first line, or erythromycin when allergic to penicillin
Fluconazole may be used for suspected candidal infections.
Women should be encouraged to continue breastfeeding, even when an infection is suspected
A ______ ______ is a rare complication if mastitis is not adequately treated. This may need ________ ______ and ______
A breast abscess is a rare complication if mastitis is not adequately treated. This may need surgical incision and drainage.
What can ead to recurrent mastitis,
Candidal infection of the nipple can occur
often after a course of antibiotics
What is Candida of the Nipple associated with
oral thrush and candidal nappy rash in the infant.
Candida infection of the nipple may present with:
- Sore nipples bilaterally, particularly after feeding
- Nipple tenderness and itching
- Cracked, flaky or shiny areola
- Symptoms in the baby, such as white patches in the mouth and on the tongue, or candidal nappy rash
Candida of the Nipple
Both the mother and baby need treatment, or it will reoccur. Treatment is with:
- Topical miconazole 2% to the nipple, after each breastfeed
- Treatment for the baby (e.g., oral miconazole gel or nystatin)
A breast abscess is a collection of pus within an area of the breast, usually caused by a bacterial infection. This may be a:
- Lactational abscess (associated with breastfeeding)
- Non-lactational abscess (unrelated to breastfeeding)
Breast Abscess
The most common causative bacteria are:
- Staphylococcus aureus (the most common)
- Streptococcal species
- Enterococcal species
- Anaerobic bacteria (such as Bacteroides species and anaerobic streptococci)
The presentation of mastitis or breast abscesses is usually acute, meaning the onset is within a few days.
Mastitis with infection in the breast tissue presents with breast changes of:
- Nipple changes
- Purulent nipple discharge (pus from the nipple)
- Localised pain
- Tenderness
- Warmth
- Erythema (redness)
- Hardening of the skin or breast tissue
- Swelling
The key feature that suggests a breast abscess is a ______ _____ ______ ______ within the breast.
The key feature that suggests a breast abscess is a swollen, fluctuant, tender lump within the breast.
What is Fluctuance
Fluctuance refers to being able to move fluid around within the lump using pressure during palpation.
There may be generalised symptoms of infection for breast abscess, such as:
Muscle aches
Fatigue
Fever
Signs of sepsis (e.g., tachycardia, raised respiratory rate and confusion)
The diagnosis of mastitis or a breast abscess can usually be made clinically, with a history and examination.
What is manageemnt
Lactational mastitis caused by blockage of the ducts is managed conservatively, with continued breastfeeding, expressing milk and breast massage. Heat packs, warm showers and simple analgesia can help symptoms. Antibiotics (flucloxacillin or erythromycin/clarithromycin where there is penicillin allergy) are required where infection is suspected or symptoms do not improve.
Management of non-lactational mastitis involves:
- Analgesia
- Antibiotics- Co-amoxiclav, Erythromycin/clarithromycin (macrolides) plus metronidazole (to cover anaerobes
- Treatment for the underlying cause (e.g., eczema or candidal infection)
Antibiotics for non-lactational mastitis need to be broad-spectrum. The NICE clinical knowledge summaries (last updated January 2021) recommend either:
Risk Factors of breast cancer
Female (99% of breast cancers)
Increased oestrogen exposure (earlier onset of periods and later menopause)
More dense breast tissue (more glandular tissue)
Obesity
Smoking
Family history (first-degree relatives)
The __________ _______ ______gives a small increase in the risk of breast cancer, but the risk returns to normal ten years after stopping ___ _____
The combined contraceptive pill gives a small increase in the risk of breast cancer, but the risk returns to normal ten years after stopping the pill.
_________ ________ _______ increases the risk of breast cancer, particularly ______ _____ (containing both oestrogen and progesterone).
Hormone replacement therapy (HRT) increases the risk of breast cancer, particularly combined HRT (containing both oestrogen and progesterone).
The BRCA1 gene is on chromosome….
The BRCA2 gene is on chromosome….
17
13
There are other rarer genetic abnormalities associated with breast cancer (e.g.,
TP53 and PTEN genes
Different types of breast cancer
Ductal Carcinoma In Situ (DCIS)
Lobular Carcinoma In Situ (LCIS)
Invasive Ductal Carcinoma – NST
Invasive Lobular Carcinomas (ILC)
Inflammatory Breast Cancer
Paget’s Disease of the Nipple
Examples of rare type of beast cancer
- Medullary breast cancer
- Mucinous breast cancer
- Tubular breast cancer
- Multiple others
The NHS breast cancer screening program offers a mammogram every _ years to women aged __ ___ years.
The NHS breast cancer screening program offers a mammogram every 3 years to women aged 50 – 70 years.
There are some potential downsides to breast screening:
What are they?
- Anxiety and stress
- Exposure to radiation, with a very small risk of causing breast cancer
- Missing cancer, leading to false reassurance
- Unnecessary further tests or treatment where findings would not have otherwise caused harm
Features of Ductal Carcinoma In Situ (DCIS)
- 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
Features of Lobular Carcinoma In Situ (LCIS)
- 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)
Features of Invasive Ductal Carcinoma – NST
- NST means no special/specific type, where it is not more specifically classified (e.g., medullary or mucinous)
- 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
Features of Invasive Lobular Carcinomas (ILC)
- Around 10% of invasive breast cancers
- Originate in cells from the breast lobules
- Not always visible on mammograms
Features of Inflammatory Breast Cancer
- 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
Features of Paget’s Disease of the Nipple
- 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
Breast Screening
There are specific criteria for a referral from primary care for patients that may be at higher risk due to their family history. For example:
- 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
Patients require _______ ____________ and ______ _________ before performing genetic tests. This is to discuss the benefits and drawbacks of genetic testing, such as the implications for family members and offspring.
Patients require genetic counselling and pre-test counselling before performing genetic tests. This is to discuss the benefits and drawbacks of genetic testing, such as the implications for family members and offspring.
_________ ________ screening is offered to women with increased risk, between specific age ranges, depending on their level of risk (potentially starting from aged 30, if high risk).
Annual mammogram screening is offered to women with increased risk, between specific age ranges, depending on their level of risk (potentially starting from aged 30, if high risk).
Anti-Endocrine
Chemoprevention may be offered for women at high risk, with
Tamoxifen if premenopausal
Anastrozole if postmenopausal (except with severe osteoporosis)
______ ______ ________ ______or ________ ________ (removing the ovaries) is an option for women at high risk. This is suitable for only a small number of women and requires significant counselling and weighing up risks and benefits.
Risk-reducing bilateral mastectomy or bilateral oophorectomy (removing the ovaries) is an option for women at high risk. This is suitable for only a small number of women and requires significant counselling and weighing up risks and benefits.
Clinical features that may suggest breast cancer are:
- 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 (peau d’orange)
- Lymphadenopathy, particularly in the axilla
Explain the Referral Criteria for Breasrt cancer
The NICE guidelines (updated January 2021) recommend a two week wait referral for suspected breast cancer for:
- An unexplained breast lump in patients aged 30 or above
- Unilateral nipple changes in patients aged 50 or above (discharge, retraction or other changes)
The NICE guidelines recommend also considering a two week wait referral for:
- An unexplained lump in the axilla in patients aged 30 or above
- Skin changes suggestive of breast cancer
The NICE guidelines suggest considering non-urgent referral for unexplained breast lumps in patients under 30 years.
What is the Triple Diagnostic Assessment and what does it consist of
Once a patient has been referred for specialist services under a two week wait referral for suspected cancer, they should initially receive a triple diagnostic assessment comprising of:
- Clinical assessment (history and examination)
- Imaging (ultrasound or mammography)
- Biopsy (fine needle aspiration or core biopsy)
Ultrasound scans are typically used to assess lumps in younger women (e.g., under 30 years).
What are they useful for
They are helpful in distinguishing solid lumps (e.g., fibroadenoma or cancer) from cystic (fluid-filled) lumps.
Mammograms are generally more effective in older women.
What are they useful for
They can pick up calcifications missed by ultrasound.
MRI scans may be used in breast disease:
- For screening in women at higher risk of developing breast cancer (e.g., strong family history)
- To further assess the size and features of a tumour
Sentinel node biopsy is performed during breast surgery for cancer.
What is this
An isotope contrast and a blue dye are injected into the tumour area. The contrast and dye travel through the lymphatics to the first lymph node (the sentinel node). The first node in the drainage of the tumour area shows up blue and on the isotope scanner. A biopsy can be performed on this node, and if cancer cells are found, the lymph nodes can be removed.
Breast Cancer Receptors
Three types
What are they?
- Oestrogen receptors (ER)
- Progesterone receptors (PR)
- Human epidermal growth factor (HER2)
WHat is Triple-negative breast cancer
is where the breast cancer cells do not express any of these three receptors. This carries a worse prognosis, as it limits the treatment options for targeting the cancer.
What is Gene Expression Profiling
ene expression profiling involves assessing which genes are present within the breast cancer on a histology sample. This helps predict the probability that the breast cancer will reoccur as a distal metastasis (away from the original cancer site) within 10 years.
The NICE guidelines (2018) [DG34] recommend this for women with early breast cancers that are ER positive but HER2 and lymph node negative. It helps guide whether to give additional chemotherapy.
You can remember the notable locations that breast cancer metastasis occur using 2 Ls and 2 Bs:
Which are
L – Lungs
L – Liver
B – Bones
B – Brain
. This is worth remembering, as you may be asked “where might this metastasis have originated” in an exam or OSCE scenario
What would you
If the patient is female, answering “breast cancer” will be a good answer. The other cancer that can spread practically anywhere, and may be less obvious, is melanoma (a type of skin cancer).
The first step in staging is with triple assessment (clinical assessment, imaging and biopsy). Additional investigations may be required to stage the breast cancer:
- Lymph node assessment and biopsy
- MRI of the breast and axilla
- Liver ultrasound for liver metastasis
- CT of the thorax, abdomen and pelvis for lung, abdominal or pelvic metastasis
- Isotope bone scan for bony metastasis
Tumour Removal
The objective is to remove the cancer tissue along with a clear margin of normal breast tissue. The options are:
Breast-conserving surgery (e.g., wide local excision), usually coupled with radiotherapy
Mastectomy (removal of the whole breast), potentially with immediate or delayed breast reconstruction
What is Axillary Clearance
Removal of the axillary lymph nodes is offered to patients where cancer cells are found in the nodes. Usually, the majority or all lymph nodes are removed from the axilla. This increases the risk of chronic lymphoedema in that arm.
WHat is Chronic Lymphoedema
Lymphoedema is a chronic condition caused by impaired lymphatic drainage of an area. Lymphoedema can occur in an entire arm after breast cancer surgery on that side, with removal of the axillary lymph nodes in the armpit.
There are specialist lymphoedema services that can help manage patients. Non-surgical treatment options include
- Massage techniques to manually drain the lymphatic system (manual lymphatic drainage)
- Compression bandages
- Specific lymphoedema exercises to improve lymph drainage
- Weight loss if overweight
- Good skin care
Common radiotherapy side effects include:
- 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)
Oncologists will guide chemotherapy. Chemotherapy is used in one of three scenarios:
- Neoadjuvant therapy – intended to shrink the tumour before surgery
- Adjuvant chemotherapy – given after surgery to reduce recurrence
- Treatment of metastatic or recurrent breast cancer
What is the MoA of tamoxifen
Tamoxifen is a selective oestrogen receptor modulator (SERM). It either blocks or stimulates oestrogen receptors, depending on the site of action. It 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.
WHat is the MoA of Aromatase
Aromatase is an enzyme found in fat (adipose) tissue that converts androgens to oestrogen. After menopause, the action of aromatase in fat tissue is the primary source of oestrogen. Aromatase inhibitors work by blocking the creation of oestrogen in fat tissue.
Other options for women with oestrogen-receptor positive breast cancer, used in different circumstances, are
- Fulvestrant (selective oestrogen receptor downregulator)
- GnRH agonists (e.g., goserelin or leuprorelin)
- Ovarian surgery
Name two monoclonal antibodies that target HER2 receptors
Trastuzumab (Herceptin)
Pertuzumab (Perjeta)
__________ is a tyrosine kinase inhibitor, reducing the growth of breast cancers. It may be used in patients with HER2 positive breast cancer.
Neratinib (Nerlynx) is a tyrosine kinase inhibitor, reducing the growth of breast cancers. It may be used in patients with HER2 positive breast cancer.
Patients treated for breast cancer are given an individual written care plan, including details on:
- Designated contacts and details
- Adjuvant treatment review dates
- Surveillance dates
- Advice on identifying recurrence
- Support service details
Reconstructive surgery is offered to all patients having a mastectomy. There are two options:
- Immediate reconstruction, done at the time of the mastectomy
- Delayed reconstruction, which can be delayed for months or years after the initial mastectomy
After breast-conserving surgery, reconstruction may not be required. The standard options, if needed, are:
- Partial reconstruction (using a flap or fat tissue to fill the gap)
- Reduction and reshaping (removing tissue and reshaping both breasts to match)
After mastectomy, the options for reconstructing the breast(s) include:
- Breast implants (inserting a synthetic implant)
- Flap reconstruction (using tissue from another part of the body to reconstruct the breast)
What is Latissimus Dorsi Flap
WHat does Pedicled and Free Flap refer to?
The breast can be reconstructed using a portion of the latissimus dorsi and the associated skin and fat tissue. The tissue is tunnelled under the skin to the breast area.
“Pedicled” refers to keeping the original blood supply and moving the tissue under the skin to a new location.
“Free flap” refers to cutting the tissue away completely and transplanting it to a new location.
What is Transverse Rectus Abdominis Flap (TRAM Flap)
The breast can be reconstructed using a portion of the rectus abdominis, blood supply and skin. This can be either as a pedicled flap (tunnelled under the skin) or a free flap (transplanted). It poses a risk of developing an abdominal hernia due to the weakened abdominal wall.
What is Deep Inferior Epigastric Perforator Flap (DIEP Flap)
The breast can be reconstructed using skin and subcutaneous fat from the abdomen (no muscle) as a free flap. The deep inferior epigastric artery, with the associated fat, skin and veins, is transplanted from the abdomen to the breast. The vessels are attached to branches of the internal mammary artery and vein. This is a complex procedure involving microsurgery. There is less risk of an abdominal wall hernia than with a TRAM flap, as the abdominal wall muscles are left intact.
