Breast topic session Flashcards
What are breast ducts?
Breast ducts are tube-like structures that carry milk from the lobules (milk-producing glands) to the nipple during breastfeeding.
What is the functional unit of the breast?
The terminal duct lobular unit (TDLU)
It is where the major components involved in milk production and transport are located.
What are the components of the terminal duct lobular unit?
Breast Lobules: These are small clusters of glandular tissue within the breast that contain milk-producing cells called alveoli. Each lobule is connected to a system of ducts.
Breast Ducts: Ducts are tube-like structures that carry milk from the lobules to the nipple during breastfeeding. They transport milk away from the lobules to the nipple, where it can be expelled.
Supportive Tissue: Surrounding the lobules and ducts are supportive tissues, including fibrous and adipose (fat) tissue, which provide structural support to the breast.
What are fibroadenomas?
Benign tumour of stromal/epithelial breast duct tissue
What is the underlying cause of fibroadenoma?
Response of breast tissue to oestrogen
What age group do fibroadenomas usually grow in?
Often grow in young women, during pregnancy, and shrink during menopause
When should a core needle biopsy and surgical excision be considered in fibroadenoma?
When the lump is >3cm and bothersome
Key features of fibroadenoma lump?
Firm, smooth, round, painless, and very mobile
Usually occurs in young premenopausal women.
Lump can be described as “breast mouse”, meaning that is very mobile (moveable).
Fibrocystic breast changes are benign. True/false?
True
Who do fibrocystic breast changes occur in and why?
Premenopausal women, fluctuates with menstruation
Type of non-proliferative change: cystic (fluid-filled) + fibrous (scarred)
Features of fibrocystic breast changes?
Lumpiness, breast tenderness, fluctuating breast size
Varies with menstruation
What is a breast cyst?
Benign, fluid-filled lump.
What is the typical age range for breast cysts?
Perimenopause, age 30-50 – this is the most common cause of lump!
Features of breast cysts?
Fluid-filled lump in middle-aged lady, require assessment to exclude cancer.
FNA (fine needle aspiration) for symptoms i.e. painful breast cyst.
Characteristic features of breath cyst include smooth, mobile, fluctuant lumps.
Breast cysts are associated with a small increase in cancer risk. True/false?
True
What is fat necrosis of the breast?
Death of adipose tissue, causing fibrosis (lumpy scar) in the breast
What is the main cause of fat necrosis of the breast and who is commonly affected?
Trauma: injury, radiotherapy/surgery – weeks/months/years earlier
Typically associated with obese women or women with larger breasts. Mainly middle aged.
Features of fat necrosis of the breast?
Painless, firm, irregular, fixed
Can cause skin dimpling and nipple inversion
Fat necrosis of the breast is malignant. True/false?
False
Benign however does mimic cancer and is identified by mammogram.
Biopsy may also be required.
What is a lipoma?
Benign fatty tumour.
Lipoma characteristics?
Soft, painless and mobile.
What age group is typically affected by lipomas?
Older women (age 40-60)
Out of all the benign breast masses, which one has a small risk of developing into cancer?
Breast cysts
What benign breast masses do NOT require further assessment?
Fibroadenoma
Fibrocystic breast changes
Lipoma
What benign breast masses do require further assessment?
Breast cysts
Fat necrosis of breast - can mimic breast cancer
What is lactational mastitis?
Breast pain associated with reduced milk output in breastfeeding women.
Characteristic features of lactational mastitis?
Tender area which can be firm, warm and swollen
No masses
Management of lactational mastitis?
- Continue breastfeeding normally – analgesia, warm compresses
- If this is too painful – specialist appointment with nurse
- If systemically unwell, nipple fissures present, or if symptoms persist after 24 hours of expressing – 10 to 14 days of Flucloxacillin
How does the blockage of milk induce infection in mastitis?
Lactational mastitis often occurs when milk ducts become blocked, leading to milk stasis.
This can happen due to factors such as inadequate milk removal, improper breastfeeding techniques, or pressure on the breast tissue.
When milk stasis occurs, it creates an environment where bacteria can multiply, leading to inflammation and infection of the breast tissue.
How does an abscess occur due to lactational mastitis?
Without effective expressing, the milk can sit in the breast, increasing likelihood of an abscess
What is the typical features of the mass on examination of lactational abscess?
Tender fluctuant mass
What is the typical pathogen that causes lactational breast abscess?
Staphylococcus aureus
Management of lactational abscess?
Flucloxacillin + USS-guided aspiration
Mastitis cannot present outside of breastfeeding. True/false?
False
Can present outside of breastfeeding: damage to the nipple, nipple piercing
Management of non-lactational mastitis?
Oral antibiotic for all non-lactational mastitis! (Co-amoxiclav)
Features of inflammatory breast cancer?
Erythematous skin changes but no fever
No discharge
Normal WCC and CRP
Elevated CA 15-3
What is a galactocele?
Blocked milk duct after stopping breastfeeding
Features of galactocele?
Milk filled cyst (blocked duct)
Firm, mobile, painless lump – beneath areola
Usually resolve, can be drained with FNA
Sometimes become infected
What are the main characteristics for a breast cancer lump?
Painless, hard, irregular, fixed
Tethered to skin/chest wall
What is the blood marker associated with breast cancer?
CA15-3
“Think the number ‘3’ as breasts”
Skin features of inflammatory breast cancer?
Skin thickening, purple/red bruising, swelling, hot to touch
Skin oedema and dimpling are features of what?
peau d’orange skin (orange peel skin)
This most commonly appears in inflammatory breast cancer.
What are nipple features of breast cancer?
Nipple retraction
Discharge: bloody or brown, spontaneous, unilateral
What are the main features of Paget’s disease of the breast?
Nipple/areola thickening/redness
(intraductal carcinoma – looks like eczema)
What is a duct papilloma?
Benign epithelial proliferation inside the ducts
What are the main features of duct papilloma?
Blood-stained discharge +/- lump
What is duct ectasia and what age group of women are mostly affected?
Peri/postmenopausal women
Age-related duct dilation and shortening
What are the main features of duct ectasia?
Thick brown-green discharge
May also notice a small lump behind the nipple, or slit-like nipple retraction
When is a non-urgent referral to breast clinic usually considered?
Women under 30 with a breast lump
When is the 2 week wait cancer referral pathway usually considered?
OVER 30 with an unexplained breast/axillary lump
Unilateral nipple changes
Skin changes suggestive of cancer
OVER 35 with new nodularity persisting for 2-3 weeks
Recurrent breast inflammation
What are the components of the triple assessment for breast cancer?
History and examination by a breast specialist
X-Ray Mammogram (USS if <30 years old)
USS with Core Biopsy
What is the scoring for the triple assessment?
Each section is scored from 1-5, for chance of malignancy.
1 = benign, 3 = maybe cancer, 5 = most likely cancer
Features of ductal carcinoma in situ (DCIS)?
It involves abnormal growth of cells within the milk ducts of the breast.
The abnormal cells are confined within the ducts and have not invaded surrounding breast tissue.
DCIS is considered a pre-invasive or non-invasive form of breast cancer. If left untreated can lead to invasive ductal adenocarcinoma.
Features of lobular carcinoma in situ (LCIS)?
LCIS involves abnormal growth of cells within the lobules of the breast.
Similar to DCIS, the abnormal cells are confined within the lobules and have not invaded surrounding breast tissue.
LCIS is considered a marker of increased risk for developing invasive breast cancer rather than a precursor to invasive cancer itself.
What is a feature of DCIS on mammogram?
May present as micro calcifications on mammography.
Micro calcifications will NOT present on mammogram of LCIS.
Invasive lobular adenocarcinoma is more common that invasive ductal adenocarcinoma. True/false?
False
Invasive ductal adenocarcinoma (80%) and invasive lobular adenocarcinoma (20%).
What are the main principles for breast cancer treatment?
Surgery, radiotherapy + systemic therapy
MRI not needed before surgery if biopsy is positive.
When is a wide-local excision carried out?
Wide-local excision (lumpectomy): small (<4cm) solitary peripheral lesion
When is a mastectomy used?
Mastectomy: large/multifocal central lesions
What is axillary node clearance?
Commonly performed in breast cancer patients to assess whether cancer has spread to the lymph nodes and to remove cancerous lymph nodes for staging and treatment purposes.
What are the axillary node levels?
Axillary lymph nodes are classified into levels based on their anatomical location within the axilla
Level I axillary node location and function?
Level I nodes are located along the lateral (outer) border of the pectoralis minor muscle.
These nodes receive lymphatic drainage from the lateral quadrants of the breast and the upper arm.
Level II axillary node location and function?
Level II nodes are situated beneath the pectoralis minor muscle.
These nodes receive lymphatic drainage from the central area of the breast.
Level III axillary node location and function?
Level III nodes are located above the pectoralis minor muscle, near the axillary vein and artery.
These nodes receive lymphatic drainage from the medial (inner) quadrants of the breast.
What is the surgical importance of level I nodes of the breast?
Level I nodes are typically the first nodes to be examined during axillary lymph node dissection or sentinel lymph node biopsy in breast cancer surgery.
What are complications of axillary node clearance?
Possible complications of axillary lymph node clearance include infection, bleeding, lymphedema (swelling of the arm), and nerve damage.
What is lymphoedema?
A common long-term complication that can occur when lymph nodes are removed, leading to fluid buildup and swelling in the arm.
Features include rings fitting tighter, arm heaviness, functional impairment.
What is the use of chemotherapy in breast cancer treatment?
Can be neo-adjuvant (shrinking before surgery) or adjuvant (after surgery to reduce recurrence)
What is the use of radiotherapy in breast cancer treatment?
Is offered after surgery (adjuvant). Especially consider this in wide local excisions – can reduce recurrence by 2/3rds.
Also considered where margins are not clean or node involvement.
This can be used once therapeutically, then palliative only.
What are the 3 main drug groups that can be used for endocrine (hormone) therapy in oestrogen receptor positive breast cancer?
Tamoxifen
Aromatase inhibitors (Anastrazole, letrozole).
GnRH analgogues
What is the mechanism of action for tamoxifen?
Binds to oestrogen receptors, blocking the effect of oestrogen at the breast tissue
What are side-effects and risks of tamoxifen?
Side effects similar to menopause
Also risk of DVT/PE (2x)
What does tamoxifen increase the risk of in postmenopausal women?
Increased risk of endometrial cancer in postmenopausal women (2-3x)
What is the mechanism of action for aromatase inhibitors?
Stops the conversion of testosterone to oestrogen in body tissues (adrenal glands, skin, muscle and fat) but not in the ovaries
Effects of aromatase inhibitors on postmenopausal and premenopausal women?
Reduce oestrogen levels in postmenopausal women but increase oestrogen in premenopausal women.
Examples of aromatase inhibitors?
Anastrozole, exemestane, letrozole
Risk associated with aromatase inhibitors?
Risk of osteoporosis
What are GnRH analogues (i.e. goserelin or leuprolide) particularly useful in?
Reversible ovarian suppression – useful in premenopausal women, with Tamoxifen.
When are GnRH analogues typically offered?
Usually offered in high risk of disease recurrence (those getting chemo).
Summary features for tamoxifen?
Premenopausal women
Blocks oestrogen
DVT/PE (2x), Endometrial cancer (2-3x)
Summary features for aromatase inhibitors?
Postmenopausal women
Stops oestrogen production from testosterone
Risk of osteoporosis
Summary features for GnRH analogues?
Add-on for premenopausal women
reversible ovarian suppression
What are HER2+ breast cancers?
The HER2 protein is a receptor found on the surface of some breast cells.
In normal breast cells, HER2 helps regulate cell growth and division.
However, in some breast cancer cells, there is an overexpression of HER2, meaning there are too many HER2 receptors on the cell surface.
Management of HER2+ breast cancers?
Monoclonal antibody (herceptin/trastuzamab)
Often alongside chemotherapy/endocrine therapy
What is the breast screening provided in the uk?
Mammogram every 3 years to those aged between 50-70.
Is typical breast screening different in women who have been treated for breast cancer?
Women treated for breast cancer get annual mammogram for 5 years after treatment.
What is the only benign breast lesion in males?
Gynaecomastia (enlargement of the male breast)
What is the underlying pathology of gynaecomastia in males?
Imbalance between oestrogen and androgen (too much oestrogen).
What are the main causes of gynaecomastia in males?
Elderly
Testicular cancer
Klinefelter syndrome
Liver cirrhosis
Spironolactone
Alcohol/marijuana/anabolic steroids
