WH: Breast Flashcards
breast anatomical location
paired structures located on the anterior thoracic wall in the pectoral region (spans 2nd - 6th ICS)
- present in M + F but more prominent in females following puberty
what glands do breasts contain ? what are these similar to ?
breasts contain mamary glands (assessors gland of F reproductive system)
- modified sweat glands
describe the anatomy of breasts. describe
mammory glands surrounded by connective tissue storm
- at the centre is the nipple: made mostly of smooth muscle fibres
- Surrounding this is the areola (pigmented skin with sebaceous glands)
What is lactation ? (where does the milk go?
maternal physiological response where milk is secreted for mammory gland
- lobules => ducts => nipple
Describe breast dev. what hormones ?
at puberty, oestrogen causes ducts to sprout and the ends form alveoli
- with each menstrual cyst there are cyclic changes due to change in oestrogen + progesterone
describe breast changes during pregnancy ?
significant hypertrophy of ductular-lobular-alveolar system
what is the quantity of milk secretion like during pregnancy ? why is this ?
little milk secretion due to high progesterone:oestrogen ratio
What are the main constituents of breast milk ? (5) main bit ?
- water (90%)
- lactose
- fat
- protein
- mins + vits
How does colosseum vary compared to normal breast milk ? how much per day
colosseum has more fat soluble vitamins + proteins (immunoglobulins)
- 40 ml/day
What hormones are involved in milk production ? briefly describe what they do ?
- prolactin: stimulate milk production
- oxytocin: let-down reflex
where is prolactin released ? controlled by what ? what stimulates its production ?
prolactin (AP) controlled by dopamine (prolactin inhibiting hormone (hypo))
- suckling (neuro-endocrine reflex)
What hormone levels would stimulate prolactin release ? (2)
- low dopamine secretion from hypo (from suckling)
- low pregoesteron: oestrogen ration
How is oxytocin involved in lactation ? explain. where does it act on ?
in response to suckling, oxytocin is release => myoepitheaial ells surrounding alveoli contract => squeeze milk out of breast (let-down reflex)
What tissue is most breast tissue ?
adipose tissue
Name some causes of Breast lumps ? (7)
- breast cancer
- Fibroadenoma
- Fibrocystic breast changes
- Breast cysts
- Fat necrosis
- Lipoma
- Galactocele
Describe the lumps associated with breast cancer ? concerning lump. and other breast features ?
- lumps that are hard, painless, fixed in place, tethered to skin/chest wall
- nipple retraction
- skin dumpling or oedema (peu d’orange)
What is fibroadenoma ? what tissue involved ?
common, benign tumour of stromal/epithelial breast duct tissue
fibroadenoma Epi. how common? what age?
common young women (20-40)
- respond to oestrogen + progesterone (regress after menopause)
describe the lumps associated with fibroadenoma ? size ?
painless, smooth, round, well circumscribed, firm
- usually less than 3cm
- mobile (freely move under skin - “breast mouse”)
What are fibrocystic breast changes ? what tissue involved ? explain pathophys
connective tissue (stroma), ducts + lobules répond to oestrogen + progesterone => fibrous + cystic (fluctuate with menstrual cycle)
fibrocystic breast changes symptoms ? (3) how might symptoms fluctuate ?
lumpiness, mastalgia, fluctuation of breast size
- Sx often occur in days prior to menstruation (10 days)
managment of fibrocystic breast changes ? (4)
- supportive bra
- NSAIDs
- avoid caffeine
- hormonal treatment (danazol)
What are breast cysts ?
benign individual fluid filled lumps (most common cause of lumps)
what would be found OE of a breast cyst ? (4)
smooth, well circumscribed, mobile, fluctuant
Breast cyst managment ?
require further investigations (scan + potentially aspiration) to exclude cancer
What is fat necrosis of the breast ? pathophys
benign lump formed by localised degernation + scarring of breast fat tissue
what could cause fat necrosis ?
trauma/radiotherapy/surgery => inflam reaction => fibrosis + necrosis of fat tissue
what would be found OE of fat necrosis ?
similar to cancer
- painless, firm, irregular, fixed, skin dimpling, nipple inversion
Fat necrosis Ix ?
USS, mammogram, histology (diagnostic + exclude cancer)
What is lipoma ?
benign tumour of fat/adipose tissue (occur anywhere in body where there is fat)
what would be seen OE of lipoma ?
soft, painless, mobile, no skin changes
What is galactocele ? who does it affect
women who lactate, after stopping breast feeding
What is mastalgia ?
Breast pain
is breast pain a common sign of breast cancer
not common of breast cancer so if no lump of skin changes then patient can be reassured
is cyclical or non cyclical breast pain more common. what causes it to be cyclical ?
related to menstrual cycle
- cyclical breast pain is more common
When in the menstrual cycle does cyclical breast pain usually occur ? describe the pain associated
usually occurs 2 weeks before mensturaiton (luteal)
- bilateral + generalised apin, heaviness, aching
what could cause non-cyclical mastalgia ? (3) who more common in ?
more common 40-50 yrs
- medications (hormonal contraception)
- Infeciton
- pregnancy
mastalgia mamangement ? (5)
- supportive bra
- NSAIDs
- Avoid caffien
- Apply heat
- Daniel (hormonal)
what is Gynaecomastia ?
enlargement of glandular breast tissues in males (quite common)
what pathophys causes Gynaecomastia ?
hormonal imbalance (high oestrogen + low androgens)
- high oestrogen => breast dev
- low androgens => lack of breast dev suppression
what could cause Gynaecomastia ?
- idiopathic
- Leydig cell testicular tumours
- drugs
what drugs could cause Gynaecomastia ? (3)
- anabolic steroids
- spironolactone
- antipsychotics (that decrease dopamine)
Px present with Gynaecomastia, what other examination will you do ?
genital examination
- to check fo Leydig cell testicular tumour
what is pseudogynaecomastisa ?
appearing large breast due to extra adipose tissue no glandular tissue (due to being obese)
when would you do imagine in Gynaecomastia ?
only if cancer suspected
what is the most common cause of cancer in the UK ? chance of developing in life ?
breast cancer (99% women)
- 1/8 women will develop
Breast cancer RF ?
- Female
- high oestrogen exposure (early menarche, later menopause)
- more dense breast tissue
- obesity
- smoking
- FHx
- COCP
- HRT
What genetic mutations are associated with breast cancer ? what other cancer does this increase risk of ?
BRCA (tumour suppressor genes): BRCA mutation => increase breast cancer risk (and ovarian cancer)
What different types of Brest cancer are there ?
- Ductal carcinoma in Situ (DCIS)
- Lobular carcinoma in Situ (LCIS)
- Incasive ductal carcinoma - NST (no specific type)
what is ductal carcinoma in Situ (DCIS) ? what cells ?
pre canc/canc epithelial cells of breast duct localised to a single area
DCIS prognosis ?
becomes invasive in around 30%
- good prognosis if fully excised
What is lobular carcinoma in Situ (LCIS) ?
pre-canc condition in pre- menopausal women
LCIS Mx ?
usually asymptomatic + managed with close monitoring
what is pages dies of the nipple ? appearance ?
looks like eczema of areolar/nipple
- erythematous caly rash of nipple region
- can be itch, inflamed or ulcerated
what could pages disease of nipple indicate ?
may indicate breast cancer involving the nipple (usually DCIS or invasive cancer)
what is the most common invasive breast cancer ?
invasive ductal carcinoma - NST (no specific type)
describe breast screening. to who ? how often ?
mammogram every 3 yrs (women aged 50-70)
if you are a high risk breast cancer patient, what other screening/ prevention are you offered ? (3)§
- offered genetic testing
- chemoprevention (tamoxifen)
- risk reducing bilateral mastectomy
Breast cancer presentation ?
- Lumps (hard, irregular, painless, fixed in place)
- nipple retraction
- skin dimpling or oedema (peu d’orange)
- Lympadenpathy (axillary)
what criteria would make a Px eligible for a two week wait referral for breast cancer ? (2)
- unexplained breast lump >30 yrs
- unilateral nipple changes > 50 yrs
breast cancer initial investigations ?
triple diagnostic assessment
- Clinical assessment (H+E)
- imaging (US, Mammogram)
- Biopsy (fine needle)
what determines what imaging is offered for triple assessment ? (3)
- US < 30 yrs
- Mammogram > 30 yrs
- MRI: high risk
what is a sentinel lymph node biopsy ?
during surgery
- isotope contract goes to first (sentinel) node
what are the 3 important breast cancer receptors ? is it good to have these or bad ?
- oestrogen receptors (ER)
- progesterone receptors (PR)
- HER2
triple -ve is where cancer does not express any of these receptors (worse prognosis)
What are the common metastasis sites from breast cancer ? (4)
2Ls, 2 Bs
- Lungs
- Liver
- Bones
- Brain
(but can spread to anywhere tho)
What is done to stage breast cancer ?
- triple assessment
- Lymph node assessment
- CT (thorax, abdo, pelvis)
TNM (tumour, nodes, metastesis) staging
what surgical options are there for breast cancer ?
rumor removal
- breast conserving (+radiotherapy)
- mastectomy
plus axillary clearance (if cancer cells found in nodes)
What is chronic lymphedema ? Mx?
caused by impaired lymphatic drainage of an area
- manual lyphattic drainga
- compression bandages
- weight loss
(-do no take blood form this arm)
when might chemo be used in breast cancer Mx ? (3)
- neoadjuvant
- adjuvant
- treatment (of metastatic breast cancer)
What hormone treatment could be used for breast cancer ? describe who given to and course ?
tamoxifen (premenopausal), aromatase inhibitors (PM women)
- given for 5 - 10 yrs for oestrogen receptor +ve breast cancer
breast cancer follow up ?
surveillance mammograms yearly for 5 yrs
What is galactorrhea ?
breast milk production not associated with pregnancy or breast feeding
where is prolactin made ? (3) function ?
made maily in AP (but also prostate, breast)
- breast milk production, immune function + metabolism
causes of hyperprolactinaemia ? (4)
- idiopathic
- prolactinoma
- endocrine (hypothyroidism, PCOS)
- medications (dopamine antagonists (anti psychotics))
elevated prolactin effects on other hormones ?
prolactin surpasses GnRH => low LH + FSH => menstural abnormalities and low sex drive
what are prolactinomas ? associated with what ?
tumours of AP that secrete excessive prolactin (associated with multiple endocrine neoplasia (MEN) type 1)
- and bilateral hemianopia
what are causes of non-milk discharge ? (3)
- mammary duct ectasia
- duct papillomas
- pus (form an abscess)
Galactorhoea Ix ?
- pregnancy test
- serum prolactine
- U+E
= LFT - TFT
- MRI (for AP tumours)
Mx of galactohrea ?
depends on cuase
- dopamine agonists (cabergoline)
- transphenoidal surgical removal of pituitary tumour
What is mammary duct ectasia ?
bening condition where there is dilation of the large ducts in the breasts
- inflam => intermittent discharge (white, grey, green)
mammary duct ectasia presentaiton ? common among who ?
perimenopasual women, smoking (big RF)
- nipple discharge
- tenderness/pain
- nipple retraction/inversion
- breast lump
mammary duct ectasia Ix ?
exclude cancer: tipple assessment (H&E, imaging, histology)
mammary duct ectasia Mx ?
reassure, not cacnerous
- treat Sx (mastalgia => supportive bra)
What is intraductal papilloma ? what causes it ?
warty lesion that grows within 1 of the ducts of the breast due to proliferation of epithelial cells that line the duct
(benign but associated with hyperplasia/cancer)
intraductal papilloma presentation ? age ?
35-55
- often asympotmattic
- nipple discharge (clear of blood stained)
- pain
- palpable lump
intraductal papilloma Ix ?
tripple assessment to exclude cancer
intraductal papilloma Mx ?
require complete surgical excision
(then examine for atypical hyperplasia)
What is a breast abscess ? 2 types ?
collection of pus within area of breast, usually caused by bacterial infection
- lactations (associated with breast feeding)
- non-lactational
breast abscess RF ? (1)
smoking
causative organisms of breast abscess ? most common ?
s. aureus (most common)
streptococcal
enterococcal
Mastitis with infection Px ? (8)
acute (few days)
- nipple changes
- pus from nipple
- pain/tenderness
- warmth
- redness
- hardening
- swelling
- generalised Sx (muscle ache, fatigue, fever)
lactational mastitis Mx ?
conservative
continue breast feeding
breast massage
non-lactational mastitis Mx ? (2)
- analgesia
- Abx (broad spec: co-amoxiclav)
breast abscess Mx ? (5)
- hospital admission
- Abx
- US (rule out other pathology)
- drainage (and microscopy, culture + sensitivity testing)
- can continue to breast feed (if not to painful)
