Breast Week Flashcards
What types of tissue make up the breast
Secretory tissue - 15-20 glands which drain via a series of ducts
Dense fibrous tissue
Adipose tissue - lots of it
How is the breast divided
It has lobes which are divided by connective tissue into lobules
There are about 15-20 lobes which each have an acinar gland which drains via ducts
Each lobe is served by a lactiferous duct
What compartment does the breast lie in
Subcutaneous compartment of skin
Lies on top of the fascia of pec major with the retromammary space in between
How are the breasts supported
Aggregations of connective tissue from between lobules form the suspensory ligaments
They run from clavicle to deep fascia and dermis of the skin
Provides support to the breast tissue
What is the functional secretory unit of the breast
The Terminal Duct Lobular Unit (TDLU)
Describe the path from the terminal ductules to the nipples
The terminal ductules lead into an intralobular collecting duct which leads into the lactiferous duct for that lobe
This duct then leads to the nipple and passes through an expanded part of the duct called the lactiferous sinus
What changes occur in the breast during pregnancy
Duct tissue is epithelial and will proliferate
Myoepithelial cells also proliferate
There is elongation and branching of the smaller ducts
Plasma cells and lymphocytes infiltrate the connective tissue
Secretory alveoli differentiate and mature
rER develops
Reduction in amounts of connective tissue and adipose
How does the connective tissue differ inside and outside the lobule of the breast
Inside the lobule the CT is loose and cellular
Outside it is dense and fibrous
What is the function of the myoepithelial cells of the breast
They can contract to push material out of the duct system
What lines the larger ducts of the breast
Epithelium which varies from thin stratified squamous to stratified cuboidal
Describe the structure of the nipple
Covered by a thin, highly pigmented keratinised stratified squamous epithelium
It has a wrinkled surface with multiple sebaceous glands which open directly onto the skin surface
The core of the nipple is dense, irregular connective tissue with bundles of smooth muscle
What happens to the breast during the luteal phase of the menstrual cycle
The epithelial cells increase in height, the lumina of the ducts becomes enlarged and small amounts of secretions appear in the ducts.
What is the function of the plasma cells in the breast
The secrete IgA antibodies which can be passed to the baby via breastmilk
What drives the development of the breast during pregnancy
Oestrogen and progesterone
Describe the composition of breast milk
Mostly water - over 80%
Then carbohydrate - mainly lactose
Then lipid
Then protein - mainly lactalbumin and casein
Also has small quantities of ions, vitamins and IgA antibodies
How are lipids secreted from the breast
Globules of fat are free in the cytoplasm and are taken up to the membrane for release
When they are released they are surrounded by a bit of membrane and cytoplasm
This is known as apocrine secretion
How are proteins secreted from the breast
Protein component of milk is made in the rER
In the golgi apparatus it is packaged into a vacuole which is taken to the apical end of the cell
This merges with the cell membrane and is can be released
Known as merocrine secretion
What is unique about secretion in the breast
You get two types of secretion from the one cell
Get apocrine and merocrine secretions
What happens to the breast during menopause
The secretory cells of the TDLU’s degenerate leaving only ducts
There are fewer fibroblasts and you lose elastic fibres - sagging
What is the most common cell type to become cancerous in the breasts
The epithelial cells as they are constantly changing
Carcinoma is therefore the most common
How do you perform fine needle aspiration
Use a 5ml syringe and a fine needle – move around the lesion to get a wide sample
Place it on a slide and stain for analysis
It is a fast and easy test
How can you sample from the breast for cytopathology
Fine Needle Aspiration (FNA)
Fluid
Nipple discharge
Nipple scrape
What type of cells are you trying to sample in FNA
Epithelial cells
Most likely cancer
What are the result classifications for cytology
C1 - Unsatisfactory C2 - Benign C3 - Atypia, probably benign C4 - Suspicious of malignancy C5 - Malignant
If C3 you don’t operate immediately but try and confirm diagnosis
When is a skin biopsy used in breast pathology
It is only useful if the lesion has skin involvement
What biopsy techniques are used for diagnosis in breast pathology
(Needle) core biopsy
Vacuum assisted biopsy (large volume)
Skin biopsy
Incisional biopsy of mass - only if suspected benign
What biopsy techniques can be used therapeutically in breast pathology
Vacuum assisted excision
Excisional biopsy of mass
Resection of cancer - Wide local excision or mastectomy
How do you perform a core biopsy
Spring loaded needle which takes a sample very quickly from the centre of the lesion
Less painful than FNA
What are the result classifications for a core biopsy
B1 - Unsatisfactory / normal B2 - Benign B3 - Atypia, probably benign B4 - Suspicious of malignancy B5 - Malignant B5a - carcinoma in situ B5b - invasive carcinoma
How is vacuum assisted biopsy performed
The needle can be placed under radio guidance and then left in situ to then take the sample
Suction pulls the tissue into the tube when then closes to cut off a sample
Takes a much bigger section of tissue
Where does a carcinoma tend to spread
Within the segment that is began in
List some common developmental abnormalities of the breasts
Hypoplasia - can be unilateral
Juvenile hypertrophy - grow massively over a very short period
Accessory breast tissue - most often in axilla
Accessory nipple
What is gynaecomastia
Breast development in men
Hormone driven - imbalance between oestrogen relative to androgens
Ductal growth without lobular development
List common non-neoplastic breast diseases
Gynaecomastia Fibrocystic change Hamartoma Fibroadenoma Sclerosing lesions - sclerosing adenosis or radial scar
List common inflammatory breast diseases
Fat necrosis
Duct ectasia
Acute mastitis/abscess
What causes fat necrosis
Occurs after trauma to the breast – seatbelt injury common
Some develop it after starting warfarin therapy
There is damage to the adipocytes and fat comes out of the cells
Inflammatory cells come along to destroy it which leads to fibrosis and scarring
What causes gynaecomastia
Exogenous/endogenous hormones - can be transferred via breastmilk
Cannabis
Prescription drugs
Liver disease - disrupts metabolism of cholesterol so there can be an excess of oestrogen
Thyrotoxicosis
Oestrogen secreting neoplasms
Testicular and adrenal gland tumours
How do fibrocystic breast changes present
Smooth discrete lumps Sudden pain - from rupture or bleed Cyclical pain Lumpiness Incidental finding Screening
When does fibrocystic change usually occur
Women aged 20-50 - childbearing age
Commoner in the upper ages
Often resolve or diminish after menopause
Describe the gross pathology of fibrocystic breast changes
Cysts - usually multiple
Intervening fibrosis
Describe the microscopic pathology of fibrocystic breast changes
Cysts have thin walls but may be fibrotic
They are lined by apocrine epithelium
Intervening fibrosis
What is metaplasia
The change from one fully differentiated cell type to another fully differentiated cell type
How do you manage fibrocystic change
Exclude malignancy
Reassure
Excise if necessary - only if causing issue for the patient
What is a hamartoma
Circumscribed lesion composed of cell types normal to the breast but present in an abnormal proportion or distribution
Right cells but not in the correct structure or proportion
It is benign
How do you manage a hamartoma
Exclude malignancy
Reassure
Excise if necessary - only if causing issue for the patient
Which group are fibroadenomas more common in
Common in African women
Peak incidence in 3rd decade
Fibroadenoma is the most common lump in young women
How does a fibroadenoma present
Painless or non tender Discrete solitary mass Firm but not hard – may feel rubbery Will be solid on US Mobile Breast mouse – move away from your fingers as you try and examine them
What is a fibroadenoma
Overgrowth of epithelium and stroma - connective tissue
Biphasic lesion
Contains receptors for progesterone and oestrogen - affected by pregnancy and menstruation
How do you manage a fibroadenoma
Diagnose - US and histology
Mammogram if >40
Reassure - most are reabsorbed
Excise - easily done, if small enough it can be done by vacuum
Done if symptomatic or rapidly growing
What are sclerosing lesions
Benign, disorderly proliferation of acini and stroma
Can cause a mass or calcification
Describe sclerosing adenosis
Disordered myoepithelial cells
Doesn’t infiltrate the surrounding tissue - benign
How are radial scars defined
If over 10mm its called a complex sclerosing lesion
If less just called a radial scar
Describe the structure of a radial scar
Stellate architecture Central puckering Radiating fibrosis - contains distorted ducts Fibrocystic change Fibroelastic core Epithelial proliferation
What does a radial scar mimic
Carcinoma
Has epithelial proliferation
Appears similar on radiology
How do you treat a radial scar
Excise or sample extensively by vacuum biopsy
How do you manage fat necrosis
Confirm diagnosis
Exclude malignancy
How does fat necrosis present
Firm round lump
May be tender
Surrounding skin can be dimpled or thickened
Nipple can become retracted
What are the clinical features of duct ectasia
Pain Acute episodic inflammatory changes Bloody and/or purulent D/C Fistulation Nipple retraction and distortion
What happens in duct ectasia
Sub-areolar duct dilatation Periductal inflammation Periductal fibrosis Scarring and distortion Ducts get blocked and inflamed – can form an abscess
How do you manage duct ectasia
Treat acute infections
Exclude malignancy
Stop smoking
Excise ducts
Which lifestyle choice is associated with duct ectasia
Smoking
What are the 2 main causes of acute mastitis
Duct ectasia - non infectious blockage of lactiferous duct
Seen in heavy smokers
Foreign body such as piercing
Lactation (cracked nipples) - staph aureus or strep pyogenes
Seen in breastfeedin mums
How do you manage acute mastitis and abscesses
Antibiotics
Percutaneous drainage or incisional drainage for an abscess
Treat underlying cause
Describe a phyllodes tumour
Slow growing unilateral breast mass
Biphasic tumour caused by stromal
Can be benign or malignant
Which papillary lesions can affect the breast
Intraduct papilloma
Nipple adenoma
Encapsulated papillary carcinoma
How does an intraduct papilloma present
Nipple discharge +/- blood
May have nodules or calcification at screening
Can be asymptomatic
What is the current trend in breast cancer incidence and mortality
Incidence is rising
Mortality is falling
How does breast cancer present
50% asymptomatic via screening route
50% symptomatic and half with a lump
When is breast screening started
Age 50
After the menopause - more effective then
Screening is difficult in a young, dense breast
List some risk factors for breast cancer
Age - risk increases from 40 if pre-meno and 50 for post-meno
Being female
Family history
Prior history of breast cancer
Genetics - BRCA1 and 2
Multiple exposures to therapeutic radiation
Nulliparity or first pregnancy over 30
Combination hormone replacement therapy
BMI over 25, exercise, smoking, diet and alcohol consumption
What is involved in the triple assessment carried out in breast clincis
See symptomatic ladies in clinic
They get a clincial diagnisis - breast exam,
Radiological diagnosis - mammogram and US
And pathological diagnosis - a biopsy
What type of imaging is used in breasts
Mammography - 4 views
US
How can breast cancer be treated
Locally - surgery (wide excision or mastectomy) or radiotherapy
Systemic - chemo, hormonal or targeted therapies
What is oncoplastic breast surgery
Where you remove the tumour but try and conserve the breast as much as possible
Makes reconstruction easier
How do hormone therapies work in the treatment of breast cancer
Block production of oestrogen as this drives the division and growth of breast cancer cells
Most common example is tamoxifen
What is Herceptin
A targeted therapy for breast cancer
The monoclonal antibody trastuzumad is used to target Human Epidermal Growth Factor Receptor 2
Where does breast cancer metastasise to
Primarily bone mets
Then soft tissue – liver, brain, lung
What causes a breast cyst to form
Caused by a milk duct not reabsorbing the fluid it has produced – common at end of cycle as body has been prepping for pregnancy
What age group is most commonly affected by cysts
More common in 40s-50s
What is a papilloma
It is like a skin tag within a duct that produces fluid
Creates a more complex cysts
Very rarely they can contain malignant cells
How can you manage benign breast pain
Making sure bra fits and reducing caffeine can help with pain
Can be affected by cycle
Some women can get low does tamoxifen which reduces effect of oestrogen
Which groups are prone to mastitis
Breastfeeding women
Smokers
What commonly causes angiosarcoma
previous radiotherapy
Which tumours often metastasise to the breast
Bronchial carcinoma Ovarian serous carcinoma Clear cell carcinoma of kidney Malignant melanoma Leiomyosarcoma - often from uterus
Define a breast carcinoma
A malignant tumour of breast epithelial cells
Technically an adenocarcinoma as it’s a glandular epithelium
Where does a breast carcinoma usually arise
Arises in the glandular epithelium of the terminal duct lobular unit
List ductal lesions that are often precursor lesions to carcinoma
Epithelial hyperplasia
Columnar cell change
Atypical Ductal Hyperplasia
Ductal Carcinoma in situ
List lobular lesions that are often precursor lesions to carcinoma
Lobular in situ neoplasia
May be atypical
What is meant by carcinoma in situ
Confined within basement membrane of acini and ducts
Cytologically malignant but non - invasive
A precursor to invasive cancer
Describe the cells commonly seen in lobular in situ neoplasia
Small-intermediate sized nuclei
Solid proliferation
ER positive
E-cadherin negative - dyscohesive cells as lacking this adhesion protein
What drives the growth of lobular in situ neoplasia
Oestrogen
So incidence drops after menopause (less oestrogen)
What are the features of lobular in situ neoplasia
Frequently multifocal and bilateral
Not usually palpable or visible grossly
May appear as calcification on mammography
Often an incidental finding
How do you manage a lobular in situ neoplasia
If found on core biopsy then proceed to excision or vacuum biopsy
Need to exclude higher grade lesions
If nothing else found then just follow up
Where does DCIS usually affect
Arises in the terminal duct lobule unit
Usually affects a single segment – one duct
What is Paget’s disease of the breast
An eczemoid change of teh nipple
When underlying malignancy involves the nipple skin - typically high grade DCIS
Still considered in situ as its stays within the basement membrane
Risk factors are the same as for breast cancer
Describe the cells found in DCIS
Cytologically malignant epithelial cells in the ducts
Can be subtyped based on cell architecture
Confined by basement membrane of duct - don’t invade BM
Can involve the lobules and nipples
Which grade of DCIS features necrosis
High grade only
How do you manage DCIS
Surgery with adjuvant chemotherapy
Can use endocrine therapy
What is a micro invasive carcinoma
It is a high grade DCIS which has invaded <1mm past the basement membrane
Low risk of metastasis
Treat as a high grade DCIS
What is the definition of an invasive breast carcinoma
Malignant epithelial cells which have breached the BM
Infiltration of normal tissues
Risk of metastasis and death
In what age group is breast cancer incidence the highest
Older women
Starts to peak at late 40’s and rises
What are the risk factors for breast carcinoma
Age Early menarche Age at first birth Later menopause Hormones - endo/exo including OCP and HRT Previous breast disease More common in the West Lifestyle - overweight, lack of exercise, high alcohol consumption, smoking Genetics
What factors can protect you from breast cancer
Having more children and breastfeeding them reduces your risk
Fewer cycles = less oestrogen
Exercise
NSAID use
What risks are associated with the BRCA genes
High risk of breast, ovarian, prostate cancer for both
BRCA 1 often have prophylactic surgery as the risk is so high
BRCA 2 not ass high risk so often just get regular MRI follow up
What is the commonest female cancer
Invasive breast carcinoma
It is also the 2nd commonest cause of cancer death in women
Where can invasive breast cancer spread to
Locally to stroma and skin of breast and the muscles of the chest wall
Via lymphatics to the nodes
Via blood to the Bone, liver, brain, lungs, abdominal viscera, female genital tract
What are the sentinel nodes
The first nodes that the cancer would drain to
This is the one you may need to biopsy
What is the difference between stage and grade of tumour
Stage is how far the tumour has spread
Grade is how differentiated the cells are (and their behaviour)
How do you grade breast carcinoma
Tubular differentiation (1-3) Nuclear pleomorphism (1-3) Mitotic activity (1-3)
Total out of 9
Low(3,4,5) , intermediate (6 or 7) or high classes (8 or 9)
What hormone receptors do you look for in breast cancer
Oestrogen receptors
Progesterone receptors
HER2
if a cancer is ER positive how can it be treated
May have a response to anti-oestrogen therapy
Tamoxifen
Aromatase inhibitors
Oophorectomy
How can you treat HER2 positive cancers
Should respond to trastuzamab (Herceptin) which is a monoclonal antibody
HER2 positive cancer has a better prognosis - true or false
False
Worse prognosis
What scores can you use to predict the prognosis of breast cancer
Nottingham Prognostic Index - uses grade, node status and size
NHS PREDICT
What is adjuvant treatment
Adjuvant is back-up treatment – wont cure on its own but will help survival
Neo-adjuvant is the same but is given before the main treatment – e.g. before surgery
Which treatments are used as neoadjuvant in breast cancer
Hormonal therapy given to ER positive tumours to try and shrink them before surgery - better outcomes
Chemo to shrink the tumour
How is radiotherapy used in breast cancer
Used routinely after wide local excision
It reduces recurrence risk by about half
Usually external beam therapy with a boost for younger patients or those with positive margins
What are the side effects of tamoxifen
More clotting so can get DVT or PE
Can cause hot flushes and vaginal dryness
Can affect endometrium – can lead to bleeding, polyps or even endometrial cancers
How can tamoxifen be used as adjuvant treatment
5 years of Tamoxifen helps reduce risk of relapse by 15%
Which chemo drugs are use in adjuvant therapy for breast cancer
Usually include anthracycline and often a taxane
What are some of the side effects of chemotherapy
Anorexia Malaise Alopecia Pain - myalgia and bone pain Infections
What are the side effects of Herceptin (trastuzumab)
Causes allergic reactions and cardiac failure
Need cardiac monitoring during treatment
How is Herceptin given as adjuvant treatment
Given by s/c injection (sometimes IV)#
One year of 3-weekly treatment
What palliative treatments are available from advanced breast cancer
Localised cancer – radio or surgery
If systemic cancer you need a systemic treatment – ER blockers or chemo
Bisphosphonates appear to reduce the risk of crush fractures from bone mets
What organs are at risk of exposure in breast radiotherapy
Lungs and heart
Risk of IHD
More techniques to help protect them
How can you determine if bone pain is caused by Mets
The worse the tumour (high grade) the more likely the bone pain is due to bone metastasis from the original breast cancer
Need to request a Ct or MRI of the affected bone
Only useful if you see a shower of mets in the axial skeleton
How do you deal with neutropenia during chemotherapy
Neutropenia is very common in chemo – don’t need to worry if they are well
Need to get them in for antibiotics urgently and get oncologist if they have signs of sepsis
What are tumour markers used for
Good for monitoring
Not good for diagnosis – common to get false positive
Only used to monitor confirmed metastatic disease
How are bisphosphonates used in breast cancer
Used if metastatic disease
If a patient is on aromatase inhibitors they are given to prevent the associated osteoporosis
What is the risk with giving bisphosphonates
Risk of jaw osteonecrosis
Need to get dental work done before starting
What are the side effects of radiotherapy straight to the breast
Erythema and swelling
Can be pretty painful
Larger the cup size the higher the risk
What is the main complication of axillary node clearance
Lymphoedema of the arm
If they show signs then refer to nurses immediately so they can start treatment early – sleeves etc
What is the most likely diagnosis if you find a new lump after surgery
Usually it is fat necrosis as a result of the trauma of surgery
If unsure then investigate via the one stop clinic
What are the signs of cord compression
radicular pain, severe back pain, loss of sensation, cant really walk properly
Common if spinal mets
Which type of medication can interfere with tamoxifen
Antidepressants
Need to weigh up pros/cons on an individual basis
If some with HER2 positive breast cancer gets recurrent headaches or blurred vision what must you consider
headaches = brain mets
Must do a head scan
Vision = retinal mets
Refer to optho
Where does lobular breast cancer often spread to
Preferential metastases to peritoneum and gut
May present with sub-acute bowel obstruction
What happens to breast density with age
It decreases with age from puberty onwards
HRT and weight can affect it
What is the gold standard diagnostic test in breast
MRI
What is a mammogram
Low energy x-ray of the breast
Gives contrast between tumour and fat
Taken in 2 views - oblique and cranial caudal
Describe a contrast enhanced spectral mammogram
Mammogram taken after IV injection of contrast
Take 2 images: 1 like a standard mammogram and 1 sensitive to contrast
Subtract the 2 images (so only shoes what is enhancing)
Useful if have a very dense breast
When is US used in breast medicine
Used in women under 50 Used in women with symptoms (better than mammography in women with a lump)
Used to further investigate lumps found on mammography
Image guided biopsy
What is stain elastography
US test
Provides a colourmap of stiffness of a lump - qualitative
Allows clues for diagnosis as cancer is harder
Not a great test
What is shear wave elastography
US test
Provides a measurement of the stiffness of the lump - quantitative
Better than the stain elastography
What is the structure of collagen like in breast cancer
It is more irregular than in normal breast tissue
Can be picked up on US
When is MRI used to image breasts
Used in patients where not sure how big the tumour is
E.g. lobular, didn’t show up on mammogram or in Paget’s (look for it in breast)
What is the most common type of biopsy
Core - almost all
FNA is hardly ever used
Which pathologies can be removed by vacuum biopsy
Papilloma’s and radial scars
They both have malignant potential
What is the most common lump in the under 30s
Fibroadenoma
What is the most common lump in those age 30-50
Cysts
Need oestrogen in system for a cyst so not likely after menopause
What is the most common lump in the over 50s
Cancer
In what age do you use mammograms
Over 40s will get mammograms
Not effective in under 40s are breast too dense but can use if cancer is suspected
What other area should be imaged if breast cancer is found
Always do an axillary USS if have cancer
Measure thickness of cortex, if >3mm then do a core biopsy
How do you manage breast abscesses
USS guided drainage + antibiotics
Which type of cancer often has nipple discharge
DCIS
If suspected do a mammogram
Describe the breast screening programme
Mammography alone
Women 50-70
Every 3 years
If they have a FH of breast cancer then mammography is offered annually
High risk patients (BRCA carriers) are offered annual MRIs
What is considered a good margin on a breast cancer excision
Aim to take out 1cm either side of the tumour
Need at least 1mm of a margin on microscopy to be considered excised
Which cancer may present as calcification on mammogram
DCIS
in a branching pattern
Which pathologies can present with a stellate abnormality on mammograms
Radial scar or a low grade carcinoma
How can you identify the sentinel nodes
Can identify by injecting blue dye or a radioisotope and then imaging
Used to find the correct nodes to biopsy
What is the prognosis of tubular carcinoma of the breast
It is always grade one and has a good prognosis
Where is HER2 expressed
cell membrane
Is breast cancer painful
Not typically
The rare exception is inflammatory breast cancer - ducts become blocked by tumour cells
Do breast cysts fluctuate
No
They become very tense and sore
What surgical options are available for breast conservation
Lumpectomy
Partial or segemental mastectomy
Wide local excision
Wire guided local excision
What are the options for mastectomy
Traditional transverse
Skin sparing with immediate reconstruction
How is chemotherapy used in neoadjuvant breast cancer treatment
Currently used to control local disease as well as systemic
Can allow for less surgery eg breast conservation
How is oncoplastic breast conservation carried out
Larger breasts you can do a mammoplasty
Small breast will need a volume replacement technique
What are the options for breast replacement post mastectomy
External prosthesis
Reconstruction: Immediate or delayed
Implant only (+/- autologous cellular matrix)
Latissimus dorsi (LD) pedicled flap +/- implant
Deep inferior epigastric artery perforator (DIEP) free flap
Inferior gluteal artery perforator (IGAP) free flap
What are the issues with breast implants
Infection - leads to loss of implants
Capsular contracture
Implant rippling
Implant migration
How are chest expanders used
First surgery is the mastectomy and you create a submuscular pocket with expander inserted
Clinic visits every 2 weeks for expansion
2nd surgery the expander is replaced with a permanent implant
What muscles is the breast tissue in contact with
Mainly lies on the pec major
Also in contact with serratus anterior and superior part of the external oblique
Which ribs does the breast tissue lie between
Ribs 2-6
How are the lymph nodes around the breasts classified (levels)
Level 1 = lateral and inferior affected
Level 2 = deep affected
Level 3 = superior and medial affected
What are the 6 groups of axillary lymph nodes
Anterior Posterior Infraclavicular Central Apical Lateral
Where does lymph from the breast drain to
Most drains to the axillary nodes
These then drain to the supraclavicular nodes
Some lymph will drain to the parasternal nodes and some can even go to the abdomen
What changes occur to the breasts during pregnancy
They get bigger - fastest growth in first 8 weeks
Ducts develop and enlarge
Fat content decreases as ducts take up more room
Nipples get larger and more erect
Areola enlarges and gets darker
What changes occur to the breasts during menopause
Loss of elastin = sagging
Increased fat content - make mammograms more effective
What is the blood supply to the uterus
The uterine artery - branches off the internal iliac
There is also an anastomosis from the ovarian artery
What are the histological features of fibroadenoma
Made of epithelial and stromal cells
nucleus:cytoplasm ratio is normal
Some have muscle/bone cells in them
Should you continue breastfeeding with mastitis
Yes - if they can tolerate the pain
Hand express if unable to feed
What is the most common organism causing mastitis
Staph aureus
How does nipple thrush present
Typically bilateral
Sharp burning pains in the nipple and retro areolar tissue
Red, swollen areas
Can be associated with severe itching leading to inflammation and fissures
How can a baby be affected by nipple thrush
Can the transmitted to them via breastfeeding
Will present with oral thrush - white patches in mouth
How is nipple thrush treated
Mother should apply topical miconazole after feeds for 2 weeks
Baby can be treated with oral miconazole gel (licensed in babies over 4 months old)
What can cause lactational mastitis
Commonly linked to improper breastfeeding technique.
Trauma to the breast and subsequent milk stasis and ineffective milk release make the breast
more likely to harbour bacteria and therefore be more prone to infection
How does mastitis present
inflammation - warmth, pain, swelling, firmness, erythema Nipple discharge Systemic infection symptoms - fever, malaise etc Decreased milk output - stasis Abscess - tender lump
What is the antibiotic of choice for lactational mastitis
Fluclox
Most commonly caused by staph aureus
What is colostrum
Thick, yellow-ish substance
First milk a breastfed baby receives and is more protein and vitamin rich than later milk
Essential for early immunological protection
What is the let-down reflex
The mechanism of milk release from the breast during feeding
Triggered by oxytocin release following baby suckling
How long should a baby be breastfed
Rceommended exclusively for first 6 months of life
Then up to 2 years alongside the introduction of solid food
What are the indications of ultrasound in breast disease
First-line diagnostic imaging
method in symptomatic women < 40 years
Useful adjunct in patient with dense parenchymal pattern on mammogram
Useful to differentiate cysts from solid masses
How often should a woman examine her own breasts
At least once a month
Menstruating women - 5 to 7 days after the beginning of their period
Menopausal women - same date each month
How does Paget’s disease of the breast present
Gradual onset
Unilateral
It appears as a red, scaly rash on the skin of the nipple and gradually extends to areola
Can be sore and inflamed and may discharge
Nipple may be retracted or deformed
Associated breast lump
How do you diagnose Paget’s disease of the breast
Punch biopsy of the nipple - histologic hallmark is Paget cells in the nipple epidermis
Bilateral mammogram to look for micro-calcifications and underlying masses
How do you treat Paget’s disease of the breast
Largely depends on the TNM staging
May do breast conservation therapy or mastectomy
Test for ER, PR and HER-2 as specific therapies can be used
Pus discharging from the nipple is suggestive of what
Breast abscess
Green/serous discharge from the nipple is suggestive of what
Duct ectasia
Bloody discharge from the nipple is suggestive of what
Duct papilloma
Carcinoma
Milky discharge from the nipple is suggestive of what
Galactocele
How do you investigate gynaecomastia
Medication review - look for cause First line - US scan Hormone testing liver, thyroid and kidney function tests to look for cause Genital exam if tumour suspected
How do you manage gynaecomastia
Treat underlying cause
Discontinue causative medication
If severe, acute and no underlying cause you can give medical treatment - first line Tamoxifen
Which cancers can cause gynaecomastia
Testicular - leydig cell, sertoli cell, gonadal germ cell
Ovarian - granulosa cell tumour
Adrenal tumours
Extragonadal germ cell - lung, gastric, renal, hepatocellular
How does medullary breast cancer appear histologically
large, high grade cells growing in sheets with associated lymphocytes and plasma cells
How does invasive ductal breast carinoma appear histologically
Duct like structures in a desmoplastic stroma
How does tubular breast cancer appear histologically
Well-defined tubules that lack myoepithelial cells
Good prognosis
How does mucinous breast cancer appear histologically
Abundant extracellular mucin
How does inflammatory breast cancer appear histologically
Carcinoma in dermal lymphatics
Poor prognosis
Mucinous breast carcinoma is more common in which women
Older - 70 and over
Relatively good prognosis
Medullary breast carcinoma is more common in which women
Increased incidence in BRCA1 carriers
What is the first line treatement for early breast cancer
Remove the tumour
Breast conserving surgery or mastectomy
Must also check the axilliary nodes - may need clearance
When is a sentinel node biopsy indicated
Indicated in the majority of invasive breast cancers
Describe axilliary lymph node dissection
1,2 or 3 levels of axilliary nodes are removed
Typically 10-15 nodes removed and stained for examination
How does a breast cysts present
May be multiple and/or bilateral
Will have a discrete, smooth surface
How does a cancerous breast lump feel
Usually a single lump
Will be hard and ill-defined
May be associated with lymph nodes and/or skin changes
May be fixed to surrounding tissues
How does a breast abscess feel/present
Tender, red, hot
Can be lactational or occur in smokers
How does gynaecomastia present
Can be unilateral or bilateral
‘Lump’ will be well defined, often tender and only be within the breast
