breast_disease_20231205142237 Flashcards
What is Paget’s disease of the nipple?
An eczema like rash on the nipple that is associated with malignancy
What is paget’s disease of the nipple suggestive of?
An underlying ductal carcinoma in situ
What is the presentation of paget’s disease of the nipple?
Eczema like rash on the nipple that is itchy, red and inflamed
Bloody nipple discharge
Burning sensation or pain in the nipple
Retraction or inversion
Palpable breast lump
Non-healing ulcers
What are the differentials of paget’s disease of the nipple?
Atopic dermatitis Contact dermatitis Intraductal papilloma Mastitis Breast abscessPsoriasis
What investigations are used to diagnose paget’s disease of the nipple?
Physical breast examination Mammogram Breast ultrasound Biopsy of the skin Nipple discharge cytologyMRI
What is the management of paget’s disease of the nipple?
Surgery- Mastectomy - Modified radical mastectomy - LumpectomyChemotherapy Radiotherapy
What is a modified radical mastectomy?
Where the entire breast, as well as axilliary lymph node is removed
What are fibrocystic breast changes?
Fibrocystic breast changes are normal changes that cause lumpiness in the breast
What is the aetiology of fibrocystic breast changes?
The cyclical effects of hormones such as progesterone and oestrogen lead to chronic proliferative changes, and the formation of small cysts
Which women are fibrocystic breast changes common in?
Common in women aged 20 to 50
When are symptoms of fibrocystic breast disease typically worst?
Symptoms are worst in the week before menstruation
What are the differentials of fibrocystic breast changes?
Fibroadenoma Breast cancerBreast cysts Mastitis/breast abscess
What are the symptoms of fibrocystic breast changes?
Bilateral lumpy breastsBreast pain Symptoms that worsen in the week before menstruation
What are the investigations for fibrocystic breast changes?
Mammogram Ultrasound Biopsy
What is the management of fibrocystic breast changes?
Soft and well fitting braAnalgesiaReassurance about symptoms resolving post-menopause
What is cyclical mastalgia?
Breast pain that occurs in the weeks leading up to menstruation and improves once menstruation begins
What is the difference between cyclical mastalgia and fibrocystic breast changes?
In both conditions, symptoms are worst in the weeks leading up to menstruation In cyclical mastalgia there are no nodules throughout the breast - examination is normal
What are breast cysts?
Benign, individual fluid filled lumps
When do breast cysts typicall occur?
30-50 years of age
What is the most common cause of breast lumps?
Breast cysts
What are the features of breast cysts on examination?
Smooth Well-circumscribedMobile Possibly fluctuant
What is fat necrosis of the breast?
A benign breast lump caused by localised degeneration and scarring of fat tissue in the breast
What is fat necrosis commonly triggered by?
Trauma to the breast
Surgery
Radiotherapy
What are the features of fat necrosis on examination?
Painless Firm Irregular Fixed in local structures Skin dimpling or nipple inversion
What investigations are used to diagnose fat necrosis?
Ultrasound Mammogram Fine needle aspiration or core biopsy
What is a lipoma?
A benign tumour of adipose tissue
What are the features of lipoma on examination?
Soft PainlessMobile Do not cause skin changes
What is mastitis?
Inflammation of the breast tissue that is typically associated with breastfeeding
What is the epidemiology of mastitis?
10-20% of breastfeeding women will experience mastitis - Incidence peaks at the second and third weeks of breastfeeding, and is most common in the first 3 months
What is the aetiology of mastitis?
It can be caused by blocked ducts, or by bacteria entering the breast tissue, often through a cracked or sore nipple
What is the most common causative organism in infective causes of mastitis?
Staphylococcus aureus
What is the presentation of mastitis?
Painful, tender, red, hot breast Systemic symptoms - Fever- Malaise - Fatigue - Nausea - Headache Unilateral symptoms
What are the differential diagnoses of mastitis?
Plugged duct Breast abscessInflammatory breast cancer Engorgement
What investigations are used to diagnose mastitis?
Mainly clinical diagnosis Ultrasonography used to rule out an abscessCulture of any fluid drained
What is the first line management of mastitis?
Conservative management and analgesia
Warm compresses
Continuation of breastfeeding
What is the second line management of mastitis?
Oral flucloxacillin
What is a fibroadenoma?
Benign tumours of fibrous and epithelial tissue
What is the presentation of a fibroadenoma?
A firm, non-tender breast massMass is rounded and has smooth edges Mass is highly mobile upon palpation Mass is not bigger than 3cm in diameter
What is the epidemiology of fibroadenoma?
Fibroadenoma is more common in younger women- Highest incidence is in early 20s
What are the differntial diagnoses of fibroadenoma?
Breast cystsInvasive breast cancerFibrocystic changes Intraductal papilloma Lipoma
What investigations are used to diagnose fibroadenoma?
Ultrasound Mammogram Needle biopsy
What is the management of fibroadenoma?
Many fibroadenomas do not require treatment Surgical excision may be considered if the fibroadenoma is large, is growing, or is causing significant problems
What is the indication for surgical resection of a fibroadenoma?
Fibroadenoma > 3cm
What are the risk factors for developing breast cancer?
Increased oestrogen exposure More dense breast tissue Obesity Age > 50Family history of breast or ovarian cancerBRCA 1 or BRCA 2 genesJewish ancestry
What is the lifetime risk of breast cancer in someone with BRCA1 or 2 genes ?
40%
What factors would increase oestrogen exposure?
Early menarche Late menopause Combined HRT COCPNulliparity
Where are the BRCA1 and BRCA2 genes?
BRCA1 - chromosome 17 BRCA2 - chromsome 13
What are the types of breast cancer?
Invasive ductal carcinoma Invasive lobular carcinoma Ductal carcinoma in situ Lobular carcinoma in situ
What is the most common type of breast cancer?
Invasive ductal carcinoma
What is an invasive ductal carcinoma?
A breast cancer that originates from cells in the breast ducts
What is an invasive lobular carcinoma?
A breast cancer that orginates from cells in the breast lobules
What is ductal carcinoma in situ?
Pre-cancerous or cancerous cells of the epithelial tissue They are localised to a single area and have the potential to spread
What is lobular carcinoma in situ?
A pre-cancerous condition that is typically asymptomatic and seen in pre-menopausal womenRepresents an increased risk of invasive breast cancer in the future
What is inflammatory breast cancer?
Where cancerous cells block the lymphatic drainage of the breast causing an inflammatory picture
What age women are offered breast screening?
50-70
How often are women aged 50-70 offered a breast screening appointment?
Every 3 years
Which high risk patients should be referred for assessment?
A first degree relative with breast cancer under 40 A first degree male relative with breast cancer A first degree relative with bilateral breast cancer under 50 Two first degree relatives with breast cancer
Which patients should be referred urgently for suspected breast cancer?
Age 30 and over with an unexplained breast lump with or without pain Age 50 and over with any of the following symptoms in one nipple only:- Nipple discharge, retraction or other changes of concernAge 30 and over with an unexpected pain in the axilla People with skin changes that are indicative of breast cancer
What is the triple diagnostic assessment?
Triple diagnostic assessment is the initial assessment for women referred under a two week wait:Clinical assesment Mammogram or ultrasoundBiopsy
What type of imaging is used for women under 30 and why?
Ultrasound is typically performed in women under 30 due to more dense breast tissue
When would MRI be used in the diagnosis of breast cancer?
To screen women at high risk of breast cancer
To determine size and features of a tumour
What type of receptors may a breast cancer have?
Oestrogen receptors Progesterone receptors HER2 (human epidermal growth factors)
What is triple negative breast cancer?
Breast cancer with a worse prognosis due to having no receptors that can be targeted by medication
Where does breast cancer typically metastasise to?
Lungs Liver Bone Brain
What investigations are carried out to stage breast cancer?
Lymph node biopsyMRI of breast and axillaLiver ultrasound CT thorax, abdo, pelvis Isotope bone scan
What are the differential diagnoses of breast cancer?
Fibroadenoma Cyst Mastitis Lipoma
What are the presenting features of breast cancer?
Nipple discharge Breast lump with or without pain Skin thickening or discolourationNipple inversion Axillary mass
Where can breast cancer spread to?
Breast cancer can spread anywhere in the body
What types of breast cancer surgery exist?
Wide local excision Mastectomy
When would a wide local excision be considered?
Solitary lesion Peripheral tumourSmall lesion Ductal carcinoma in situ < 4cm
When would a mastectomy be considered?
Multiple lesions Central tumours Larger lesions Ductal carcinoma in situ > 4cm
What treatements other than surgery are offered to women with breast cancer?
Radiotherapy Chemotherapy Biological therapy Hormonal therapy
What is the main complication of axillary lymph node clearance?
Chronic lymphodema
What is chronic lymphodema?
Impaired lymphatic drainage that leads to a build up of lymph (typically in one arm after breast surgery with lymph node removal)
What are the side effects of radiotherapy?
General fatigue Local skin irritation and swellingFibrosis of breast tissue Shrinking of breast tissue Long term skin discolouration
What medications can be given to patients with oestrogen receptor positive breast cancer?
Tamoxifen for premenopausal women Aromatase inhibitors for post-menopausal women
What class of drug is tamoxifen?
Selective oestrogen receptor modulator
What is the action of tamoxifen?
Blocks oestrogen receptors in breast tissue Stimulates oestrogen receptors in bones and the uterus
What is the action of aromatase inhibitors?
Aromatase blocks the creation of oestrogen in fat tissue
What treatments are used in patients with HER2 positive breast cancer?
Trastuzamab Pertuzamab
What are the side effects of tamoxifen?
Menopausal symptoms Increased risk of endometrial cancer Increased VTE risk
What are the options for reconstructive surgery?
Immediate reconstruction
Delayed reconstruction
What type of radiotherapy is recommended after a wide local excision?
Whole breast radiotherapy
What is the action of anastrazole?
Aromatase inhibitor - reduces the peripheral synthesis of oestrogen
What is the action of tamoxifen?
SERM (selective oestrogen receptor modulator) - partial oestrogen receptor antagonist
What is a breast abscess?
A collection of pus within an area of the breast, usually caused by a bacterial infection
What are the two types of breast abscess?
Lactational abscessNon-lactational abscess
What are the most common bacterial causes of breast abscesses?
Staphylococcus aureus Streptococcal speciesEnterococcal speciesAnaerobic bacteria
What is the presentation of a breast abscess?
Nipple changes Purulent nipple discharge Localised pain TendernessWarmth Erythema RednessHardening of the skin Swelling
What is the key feature of a breast abscess that helps differentiate from other lumps?
Fluctulance - being able to move around the fluid within the lump
What are the differentials of a breast abscess?
Breast engorgement Galactocele Fibrocystic breastsBreast trauma Breast cancerFibroadenoma
What are the risk factors for breast abscess?
Lactation Poor breastfeeding technique Nipple injury Previous mastitis Nipple piercings Skin infection Underlying breast diseaseSmoking
What investigations are used to diagnose a breast abscess?
Breast ultrasoundDiagnostic needle aspiration
What is the management of a breast abscess?
Antibiotics Incision and drainage or needle aspiration
What is duct ectasia?
A benign condition characterised by dilation of the large ducts in the breast
What is the presentation of duct ectasia?
Green nipple discharge
Tenderness or pain
Nipple retraction or inversion
A breast lump
What is the epidemiology of duct ectasia?
Occurs mostly in perimenopausal women
What imaging can be used to help diagnose duct ectasia?
Mammogram Ultrasound MRI
What other investigations can be helpful in the diagnosis of duct ectasia?
Ductography Nipple discharge cytology Ductoscopy
What is the management of duct ectasia?
Exclusion of cancerSymptomatic management of mastalgiaAntibiotics if infection is suspected Surgical excision of affected duct
What is an intraductal papilloma?
A warty lesion that grows within one of the ducts in the breast
When do intraductal papillomas most commonly occur?
35-55 years
What is the typical presentation of an intraductal papilloma?
Nipple discharge - clear or blood stained Tenderness or pain Palpable lump
What investigations are used to diagnose intraductal papilloma?
Triple assessment:- Clinical assessment - Imaging - ultrasound, mammogram, MRI- Histology - core biopsy or vacuum assisted biopsy
What is ductography?
Involved injecting contrast into the affected duct and performing a mammogram - the papilloma will be seen as an area that does not fill with contrast
What is the management of an intraductal papilloma?
Complete surgical excision
