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Reproduction Year 3 > Breast week > Flashcards

Breast week Flashcards

1
Q

Developmental breast Anomalies examples

A

a. Hypoplasia
b. Juvenile hypertrophy
c. Accessory breast tissue
d. Accessory nipple

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2
Q

Non-neoplastic breast conditions

A

a. Gynaecomastia
b. Fibrocystic change
c. Hamartoma
d. Fibroadenoma
e. Sclerosing lesions
f. Sclerosing adenosis
g. Radial scar/complex sclerosing lesions

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3
Q

Inflammatory breast conditions

A

a. Fat necrosis
b. Duct ectasia
c. Acute mastitis/abscess
4. Tumours

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4
Q

Gynaecomastia

A

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 newborn due to circulating maternal hormones, resolving as the maternal hormones are cleared.

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5
Q

Gynaecomastia can be caused by conditions that reduce testosterone:

A

 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)

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6
Q

Gynaecomastia can be caused by conditions that increase oestrogen:

A 
	Obesity 
	Testicular cancer 
	Liver cirrhosis and liver failure
	Hyperthyroidism
	Human chorionic gonadotrophin (hCG) secreting tumour, notably small cell lung cancer
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7
Q

There is a long list of medications and drugs that can cause gynaecomastia:

A
  1. Anabolic steroids (raise oestrogen levels)
  2. Antipsychotics (increase prolactin levels)
  3. Digoxin (stimulates oestrogen receptors)
  4. Spironolactone (inhibits testosterone production and blocks testosterone receptors)
  5. Gonadotrophin-releasing hormone (GnRH) agonists (e.g., goserelin used to treat prostate cancer)
  6. Opiates (e.g., illicit heroin use)
  7. Marijuana
  8. Alcohol
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8
Q

Hamartoma

A

Circumscribed lesion composed of cell types normal to the breast but present in an abnormal proportion or distribution

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9
Q

Fibroadenoma

A

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.

They are more common in younger women, aged between 20 and 40 years. They respond to the female hormones (oestrogen and progesterone), which is why they are more common in younger women and often regress after menopause.

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10
Q

Fibroadenoma presentation

A 
	Painless
	Smooth
	Round
	Well circumscribed 
	Firm
	Mobile 
	Usually up to 3cm diameter
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11
Q

Fibrocystic breast changes

A

It is a benign (non-cancerous) condition, although it can vary in severity and significantly affect the patient’s quality of life if severe. It is common in women of menstruating age. Symptoms often occur prior to menstruating (within 10 days) and resolve once menstruation begins. Symptoms usually improve or resolve after menopause.
 Lumpiness
 Breast pain or tenderness (mastalgia)
 Fluctuation of breast size

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12
Q

Options to manage cyclical breast pain (mastalgia) include:

A

Options to manage cyclical breast pain (mastalgia) include:

  1. Wearing a supportive bra
  2. Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen
  3. Avoiding caffeine is commonly recommended
  4. Applying heat to the area
  5. Hormonal treatments (e.g., danazol and tamoxifen) under specialist guidance
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13
Q

Mastalgia

A

Breast pain

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14
Q

Breast cysts

A 
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
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15
Q

Fat necrosis

A

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.

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16
Q

Fat necrosis features

A
  1. Painless
  2. Firm
  3. Irregular
  4. Fixed in local structures
  5. There may be skin dimpling or nipple inversion
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17
Q

Differentiating fat necrosis form breast cancer

A

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.
After excluding breast cancer, fat necrosis is usually treated conservatively. It may resolve spontaneously with time. Surgical excision may be used if required for symptoms.

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18
Q

Galactoceles

A

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. They are benign and usually resolve without any treatment. It is possible to drain them with a needle. Rarely, they can become infected and require antibiotics.

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19
Q

Phyllodes tumours

A

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.

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20
Q

A breast abscess

A

A breast abscess is a collection of pus within an area of the breast, usually caused by a bacterial infection. This may be a:

  1. Lactational abscess (associated with breastfeeding)
  2. Non-lactational abscess (unrelated to breastfeeding)
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21
Q

Causes of breast abscess

A
  1. Staphylococcus aureus (the most common)
  2. Streptococcal species
  3. Enterococcal species
  4. Anaerobic bacteria (such as Bacteroides species and anaerobic streptococci)
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22
Q

Presentation of breast abscess

A 
	Nipple changes
	Purulent nipple discharge (pus from the nipple)
	Localised pain
	Tenderness
	Warmth
	Erythema (redness) 
	Hardening of the skin or breast tissue
	Swelling
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23
Q

Lactational mastitis and its management

A

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.

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24
Q

Management of non-lactational mastitis

A

Antibiotics for non-lactational mastitis need to be broad-spectrum.
 Co-amoxiclav
 Erythromycin/clarithromycin (macrolides) plus metronidazole (to cover anaerobes)

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25
Q

Should women with mastitis and breast abscess continue breastfeeding?

A

Women who are breastfeeding are advised to continue breastfeeding when they have mastitis or breast abscesses. They should regularly express breast milk if feeding is too painful, then resume feeding when possible. This is not harmful to the baby and is important in helping resolve the mastitis or abscess.

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26
Q

Sclerosing adenosis

A

Sclerosing adenosis is a benign breast condition that may occur as the result of the normal ageing process. Breasts are made up of lobules (milk-producing glands) and ducts (tubes that carry milk to the nipple), which are surrounded by glandular, fibrous and fatty tissue. Sclerosing adenosis is extra growth of tissue within the breast lobules.

27
Q

Sclerosing adenosis diagnosis

A

Sclerosing adenosis can be difficult to diagnose, as it can occasionally look like a breast cancer on a mammogram. Because of this, a biopsy may be needed to make a definite diagnosis. You may have one of the following types of biopsy:
 core biopsy
 stereotactic core biopsy
 vacuum assisted biopsy

28
Q

Radial scars and complex sclerosing lesions

A

Also benign areas of hardened breast tissue. They are similar to sclerosing adenosis, but they are usually larger and have features similar to a breast cancer when seen on a mammogram.
They are generally identified by size, with radial scars usually being smaller than 1cm and complex sclerosing lesions being more than 1cm.

29
Q

Mammary duct ectasia

A

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.

30
Q

Whats a significant risk factor for mammary duct ectasia?

A

Mammary duct ectasia occurs most frequently in perimenopausal women. Smoking is a significant risk factor.

31
Q

Mammary duct ectasia presentation

A

 Nipple discharge
 Tenderness or pain
 Nipple retraction or inversion
 A breast lump (pressure on the lump may produce nipple discharge)

32
Q

Mammary duct ectasia diagnosis

A
  1. Clinical assessment (history and examination)
  2. Imaging (ultrasound, mammography and MRI)
  3. Histology (fine needle aspiration or core biopsy)
33
Q

Microcalcifications

A

Are a key finding on a mammogram for mammary duct ectasia, although they are not specific to mammary duct ectasia.

34
Q

Mammary duct ectasia management

A

Conservative management, reassurance, analgesia, May not require any treatment

35
Q

Intraductal papilloma

A

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 papilloma are benign tumours; however, they can be associated with atypical hyperplasia or breast cancer.

36
Q

Presentation of indraductal papilloma

A

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

37
Q

Intraductal papillomas management

A

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.

38
Q

Mastitis presentation

A
  1. Breast pain and tenderness (unilateral)
  2. Erythema in a focal area of breast tissue
  3. Local warmth and inflammation
  4. Nipple discharge
  5. Fever
39
Q

Mastitis

A

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 obstruction in the ducts and accumulation of milk.
Mastitis can also be caused by infection. The most common bacterial cause is Staphylococcus aureus.

40
Q

Management of mastitis

A

Where mastitis is caused by blockage of the ducts, management is conservative, with continued breastfeeding, expressing milk and breast massage. Heat packs, warm showers and simple analgesia can help symptoms.

When conservative management is not effective, or infection is suspected (e.g., they have a fever), antibiotics should be started. Flucloxacillin is the first line, or erythromycin when allergic to penicillin. A sample of milk can be sent to the lab for culture and sensitivities. Fluconazole may be used for suspected candidal infections.

A breast abscess is a rare complication if mastitis is not adequately treated. This may need surgical incision and drainage.

41
Q

Candida of the nipple presentation

A
  1. Sore nipples bilaterally, particularly after feeding
  2. Nipple tenderness and itching
  3. Cracked, flaky or shiny areola
  4. Symptoms in the baby, such as white patches in the mouth and on the tongue, or candidal nappy rash
42
Q

Candida of the nipple management

A
  1. Topical miconazole 2% to the nipple, after each breastfeed
  2. Treatment for the baby (e.g., oral miconazole gel or nystatin)
43
Q

Invasive ductal carcinoma

A

 Invasive ductal carcinoma. This is the most common type of breast cancer. To complicate matters further this has recently been renamed ‘No Special Type (NST)’. In contrast, lobular carcinoma and other rarer types of breast cancer are classified as ‘Special Type’

44
Q

Common breast cancer types include:

A
  1. Invasive ductal carcinoma.
  2. Invasive lobular carcinoma
  3. Ductal carcinoma-in-situ (DCIS)
  4. Lobular carcinoma-in-situ (LCIS)
45
Q

Paget’s disease of the nipple

A

Paget’s disease of the nipple is an eczematoid change of the nipple associated with an underlying breast malignancy and it is present in 1-2% of patients with breast cancer. In half of these patients, it is associated with an underlying mass lesion and 90% of such patients will have an invasive carcinoma. 30% of patients without a mass lesion will still be found to have an underlying carcinoma. The remainder will have carcinoma in situ.

46
Q

Risk factors for breast cancer

A

 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)
 COCP
 HRT
 BRCA gene types

47
Q

BRCA genes

A

The BRCA genes are tumour suppressor genes. Mutations in these genes lead to an increased risk of breast cancer.
The BRCA1 gene is on chromosome 17. In patients with a faulty gene:
1. Around 70% will develop breast cancer by aged 80
2. Around 50% will develop ovarian cancer
3. Also increased risk of bowel and prostate cancer

The BRCA2 gene is on chromosome 13. In patients with a faulty gene:

  1. Around 60% will develop breast cancer by aged 80
  2. Around 20% will develop ovarian cancer
48
Q

Ductal Carcinoma In Situ (DCIS)

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

49
Q

Lobular Carcinoma In Situ (LCIS)

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)

50
Q

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

51
Q

Breast screening

A

The NHS breast cancer screening program offers a mammogram every 3 years to women aged 50 – 70 years.

52
Q

Referral criteria in breast cancer

A

The NICE guidelines recommend a two week wait referral for suspected breast cancer for:
1. An unexplained breast lump in patients aged 30 or above
2. 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:
1. An unexplained lump in the axilla in patients aged 30 or above
2. Skin changes suggestive of breast cancer

53
Q

Breast cancer cells may have receptors that can be targeted with breast cancer treatments. These receptors are tested for on samples of the tumour and help guide treatment. There are three types of receptors:

A

> 

Oestrogen receptors (ER)
Progesterone receptors (PR)
Human epidermal growth factor (HER2)
54
Q

Triple-negative breast cancer

A

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.

55
Q

Management of breast cancers

A
  1. Breast-conserving surgery (e.g., wide local excision), usually coupled with radiotherapy
  2. Mastectomy (removal of the whole breast), potentially with immediate or delayed breast reconstruction
56
Q

Lymphoedema

A

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.

The lymphatic system is responsible for draining excess fluid from the tissues. The tissues in areas affected by an impaired lymphatic system become swollen with excess, protein-rich fluid (lymphoedema).

The lymphatic system also plays an important role in the immune system. Areas of lymphoedema are prone to infection.

57
Q

Chemotherapy uses in breast cancer

A
  1. Neoadjuvant therapy – intended to shrink the tumour before surgery
  2. Adjuvant chemotherapy – given after surgery to reduce recurrence
  3. Treatment of metastatic or recurrent breast cancer
58
Q

Treatment of estrogen-receptor positive breast cancer

A

There are two main first-line options for this:

  1. Tamoxifen for premenopausal women
  2. Aromatase inhibitors for postmenopausal women (e.g., letrozole, anastrozole or exemestane)
59
Q

Tamoxifen

A

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.

60
Q

Aromatase

A

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.
Tamoxifen or an aromatase inhibitor are given for 5 – 10 years to women with oestrogen-receptor positive breast cancer.

61
Q

Trastuzumab

A

Trastuzumab (Herceptin) is a monoclonal antibody that 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.

62
Q

Pertuzumab (Perjeta)

A

Pertuzumab (Perjeta) is another monoclonal antibody that targets the HER2 receptor. It may be used in patients with HER2 positive breast cancer. This is used in combination with trastuzumab (Herceptin).

63
Q

Neratinib (Nerlynx)

A

Neratinib (Nerlynx) is a tyrosine kinase inhibitor, reducing the growth of breast cancers. It may be used in patients with HER2 positive breast cancer.

Reproduction Year 3 (17 decks)

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