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My Phase 3a Revision > WOMEN'S HEALTH - BREAST MEDICINE > Flashcards

WOMEN'S HEALTH - BREAST MEDICINE Flashcards

1
Q

NON-INVASIVE DUCTAL CARCINOMA IN SITU (DCIS)
What is the pre-malignant form of breast cancer?

A
  • Non-invasive ductal carcinoma in situ (DCIS)
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2
Q

NON-INVASIVE DUCTAL CARCINOMA IN SITU (DCIS)
How is it detected?

A
  • Asymptomatic on screening
  • Epithelial lining of breast ducts thickens as cells proliferate, often with central necrosis
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3
Q

NON-INVASIVE DUCTAL CARCINOMA IN SITU (DCIS)
What is the pathology?

A
  • Epithelial lining of breast ducts thickens as cells proliferate, often with central necrosis
  • Microcalcification on mammography, unifocal lesion in one area of breast
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4
Q

BREAST CANCER
What imaging choices are there for investigating breast cancer and what would influence your choice?

A
  • Mammography, high resolution USS (good at Dx + targeting biopsy)
  • MRI (good assessment of implants, dense breasts or high-risk screening)
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5
Q

BREAST CANCER
If someone has breast cancer, what would you like to check now?

A
  • Oestrogen receptor (ER)
  • Human epidermal growth factor 2 (HER2)
  • Progesterone
  • Ki67 status
  • Nottingham Prognostic index = grade, size + nodal status to predict survival
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6
Q

BREAST CANCER
What staging is used in breast cancer?

A
  • CT CAP for TNM staging
  • T1 = confined to breast, mobile
  • T2 = confined to breast + LN in ipsilateral axilla
  • T3 = fixed to muscle, locally advanced disease
  • T4 = fixed to chest wall, metastatic
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7
Q

BREAST CANCER
What tumour marker can be used to monitor response to breast cancer treatment and disease recurrence?

A
  • CA 15-3
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8
Q

BREAST CANCER SCREENING
What is the NHS breast screening programme?

A
  • Women 50–70 invited every 3 years for dual-view mammography
  • it improves stage at diagnosis so 5 year survival risen from 80% to 95%
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9
Q

BREAST CANCER SCREENING
What is the process of mammography?

A

Breast pressed between 2 plates to flatten + improve resolution
- Cranio-caudal (CC) + medio-lateral oblique (MLO) views
- Graded 1 (normal) to 5 (likely malignant)

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10
Q

BREAST CANCER
What are some clinical signs of breast cancer?

A
  • Hard, irregular, painless, fixed lesions tethered to skin or chest wall
  • Indrawn nipple, peau d’orange (skin tethering), oedema or erythema
  • Palpable axillary nodes (axillary > supraclavicular > infraclavicular > neck)
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11
Q

BREAST CANCER
What are the 2 most common histological types of invasive breast cancer?

A
  • Invasive ductal carcinoma (70%) = invaded basement membrane, grows as little hard nots in breast
  • Lobular carcinoma (10%) = harder to feel, less likely to be visible on mammography, more diffuse so difficult to excise
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12
Q

BREAST CANCER
What are some other types of breast cancer?

A
  • Inflammatory breast cancer (presents like mastitis, no Abx response)
  • Medullary cancers (younger)
  • Colloid/mucoid cancers (elderly)
  • Breast sarcomas, phyllodes tumour + lymphoma rare
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13
Q

PAGET’S DISEASE OF THE NIPPLE
What is Paget’s disease of the nipple?

A
  • Eczematous change of nipple (affects nipple primarily and then spreads to areola)
  • Suspect if nipple eczema unresolved with 2w of steroid or anti-fungal cream
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14
Q

PAGET’S DISEASE OF THE NIPPLE
What causes Paget’s disease of the nipple?

A
  • Infiltration of tumours cells through the ducts onto nipple surface where they infiltrate the epidermis
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15
Q

PAGET’S DISEASE OF THE NIPPLE
what are the signs and symptoms?

A
  • rash like eczema or psoriasis on nipple
  • ulcerations/scabs/bleeding
  • itching/burning
  • lump
  • signs and symptoms of breast cancer
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16
Q

PAGET’S DISEASE OF THE NIPPLE
what are the risk factors?

A
  • old age
  • FHx of breast cancer
  • Previous breast cancer
  • overweight
  • excess alcohol
  • smoking
  • risk factors for breast cancer
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17
Q

PAGET’S DISEASE OF THE NIPPLE
what are the risk factors?

A
  • old age
  • FHx of breast cancer
  • Previous breast cancer
  • overweight
  • excess alcohol
  • smoking
  • risk factors for breast cancer
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18
Q

PAGET’S DISEASE OF THE NIPPLE
what are the investigations?

A

clinical examination
mammogram/USS
biopsy

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19
Q

PAGET’S DISEASE OF THE NIPPLE
What is the management?

A
  • Needs biopsy, excision via mastectomy or central (nipple excising) wide local excision
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20
Q

BREAST CANCER
What are some other genetic mutations associated with breast cancer?

A
  • TP53 (Li Fraumeni)
  • Peutz-Jeghers
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21
Q

BREAST CANCER
What is the epidemiology of breast cancer?

A
  • 1 in 8 women will develop breast cancer in their lifetime
  • Most common cancer in women + second most common cause of death
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22
Q

BREAST CANCER
What are some modifiable risk factors of breast cancer?

A
  • Weight
  • Exercise
  • Smoking
  • Alcohol consumption
  • HRT for >5 years
  • OCP
  • post-menopausal obesity
  • first child birth >35
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23
Q

BREAST CANCER
What are some non-modifiable risk factors of breast cancer?

A
  • Female (99%)
  • Breast density
  • Age of menarche + menopause
  • BRCA1/2 status + FHx
  • Increasing age
  • Nulliparous
  • Not breastfeeding
  • HRT use >5y
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24
Q

BREAST CANCER
What are some protective factors of breast cancer?

A
  • Breastfeeding
  • Multiparity
  • Late menarche + early menopause
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25
Q

BREAST CANCER
What are the 2 main genes involved in breast cancer and how do they act?

A
  • BRCA1 = mutation of C17, 60-80% lifetime risk, stronger incidence
  • BRCA2 = mutation of C13, 45% lifetime risk
  • Tumour suppression genes that act as inhibitors of cellular growth
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26
Q

BREAST CANCER
What is the classic clinical presentation of breast cancer?

A
  • Normal appearing breast with palpable painless lump
  • Pain + tenderness uncommon
  • Visually = nipple inversion, bloody nipple discharge
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27
Q

BREAST CANCER
What warrants an urgent 2ww cancer referral?
What happens under the 2ww referal?

A
  • ≥30 with unexplained breast lump ± pain
  • ≥50 with discharge, retraction or other change of concern
  • Triple assessment
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28
Q

BREAST CANCER
What is the triple assessment?
What happens at end?

A
  • Clinical assessment (Hx + Examination)
  • Imaging (<35 USS as dense tissue, >35 USS + mammography)
  • Biopsy (histology + cytology) with core needle biopsy (or fine needle aspiration)
  • Each scored /5 (1=ok, 5=malignant), aim for score concordance (repeat test if one really high)
  • Pt discussed + reviewed in breast MDT
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29
Q

BREAST CANCER
What are the pros of breast cancer screening?

A
  • Earlier detection,
  • Reduces morbidity + mortality,
  • Detects asymptomatic cancers before present,
  • Not overly invasive
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30
Q

BREAST CANCER
What are the cons of breast cancer screening?

A
  • ?Overdiagnosis (frail women Dx with small low-grade cancers),
  • Anxiety if recalled,
  • Low dose XR > small amount of malignancies
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31
Q

BREAST CANCER
What are some reasons that a woman may be recalled for further views, USS or biopsy?

A
  • Mass (well or poorly defined, rough edges, spiculated = carcinoma)
  • Microcalcification (associated with DCIS)
  • Parenchymal deformity
  • Asymmetrical density
  • Clinical or technical recall
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32
Q

BREAST CANCER
What is the high risk screening for breast cancer?

A

BRCA1/2 screening –
- 30–40 annual MRI
- 40–50 annual MRI + mammograms
- 50–60 annual mammogram (+ MRI if dense breasts)
- 60–70 triennial mammograms (+ MRI if dense breasts)

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33
Q

BREAST CANCER
What is the management of BRCA1/2 women?

A
  • Genetic pedigree to identify at risk
  • Additional screening, lifestyle advice
  • ?Prophylactic tamoxifen or aromatase inhibitors
  • ?Risk reducing salpingo-oopherectomy or mastectomy
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34
Q

BREAST CANCER
What are some complications of breast cancer?

A
  • Locally advanced (rare), try shrink with radio, chemo, or hormone therapy to try operate, salvage surgery + stage for mets
  • Metastatic breast cancer (2Ls 2Bs) = Lungs, Liver, Bones, Brain
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35
Q

METASTATIC BREAST CANCER
How may metastatic breast cancer present?

A
  • Bony pain or #
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36
Q

METASTATIC BREAST CANCER
What is the management?

A
  • Bisphosphonates + denosumab, radio/chemo + Sx control
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37
Q

BREAST CANCER
What is breast conservation treatment?

A
  • Lumpectomy or wide local excision where remaining breast tissue gets localised radiotherapy
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38
Q

BREAST CANCER
What are the indications for breast conservation treatment?

A
  • Small tumour relative to breast (<25%),
  • DCIS,
  • no previous radiotherapy,
  • not underneath nipple,
  • pt choice
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39
Q

BREAST CANCER
What factors affect the outcome of breast conservation treatment?

A
  • Tumour size relative to breast,
  • position of tumour in breast (lateral more favourable),
  • radiotherapy fibrosis
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40
Q

BREAST CANCER
What is mastectomy?

A
  • Uni or bilateral removal of breast
41
Q

BREAST CANCER
What are the indications for a mastectomy?

A
  • Large tumour relative to breast size,
  • > 1 cancer in same breast, tumour under nipple,
  • immediate or delayed reconstruction,
  • pt choice
42
Q

BREAST CANCER
What is full axillary clearance?

A
  • Removal of all glands
43
Q

BREAST CANCER
What are the indications + benefits of full axillary clearance?

A
  • Glands clinically involved,
  • good control,
  • no need for further surgery or axillary radiotherapy
44
Q

BREAST CANCER
What are the risks of full axillary clearance?

A
  • 10% lymphoedema,
  • high complication rate (seromas, arm stiffness, drains, axillary numbness),
  • extends surgical time
45
Q

BREAST CANCER
What is limited axillary surgery?
What are the benefits?

A
  • Clinically normal glands but removal of targeted ‘hot’ node by sentinel LN biopsy or blindly removes 4–6 nodes
  • Day surgery, no significant complications, no drains, no effect on mortality but may need full clearance if +ve
46
Q

BREAST CANCER
What adjuvant endocrine therapy may be given to women?

A
  • All ER+ve women need endocrine therapy as increases survival
  • Bisphosphonates to reduce rate of bone mets in ER+ve
  • Trastuzumab (Herceptin) used in HER2+ve + chemo
47
Q

BREAST CANCER
What endocrine therapy is given if…

i) pre-menopausal?
ii) post-menopausal?

A

i) Tamoxifen –inhibits oestrogen receptor on breast cancer cells
ii) Anastrozole (aromatase inhibitors) – inhibits aromatase which converts androgens > oestrogen

48
Q

BREAST CANCER
what is tamoxifen?

A

tamoxifen inhibits the oestrogen receptor on breast cancer cells
It increases survival by 15-25% in woman with ER+ cancer
give for 10 years in higher risk women

49
Q

BREAST CANCER
what are the complications of tamoxifen?

A

hot flushes
nausea
vaginal bleeding
rarely thrombosis and endometrial cancer

50
Q

BREAST CANCER
what are aromatase inhibitors?

A

letrozole
Inhibit aromatase enzyme responsible for the conversion of androgens to oestogen in post-menopausal woman
slightly better anticancer efficacy than tamoxifen

51
Q

BREAST CANCER
what are the side effects of aromatase inhibitors?

A

hot flushes
reduced bone density
joint pains

52
Q

BREAST CANCER
what is Her-2?

A

HER2-positive breast cancer is a breast cancer that tests positive for a protein called human epidermal growth factor receptor 2 (HER2), which promotes the growth of cancer cells

long known as a marker for poor prognosis

53
Q

BREAST CANCER
how is HER-2 breast cancer managed?

A

Currently 1 year of 3 weekly adjuvant Trastuzumab given alongside chemotherapy (usually FEC-T).

54
Q

BBREAST CANCER
how can you find impalpable cancers?

A

wire localisation

55
Q

BREAST CANCER
What other adjuvant treatment may be offered?

A
  • Radiotherapy = always after WLE, sometimes after mastectomy if high risk (cons = skin viability risk, fibrosis, fat necrosis, loss of elasticity)
  • Chemotherapy = high/risk or aggressive disease (HER2+ve, ER-ve, node+ve)
56
Q

BREAST CANCER
Reconstruction surgery can either be primary (immediately) or delayed.
What are the pros and cons of primary reconstruction?

A
  • Increased skin preservation options, reduced psychological trauma
  • May delay chemo/radiotherapy if complications, radiotherapy may ruin results (fibrosis)
57
Q

BREAST CANCER
Reconstruction surgery can either be primary (immediately) or delayed.
What are the pros and cons of delayed reconstruction?

A
  • Minimal risks of delay in adjuvant therapies, healthy tissue used to recreate breast
  • Limited skin preservation options, psychological impact (no breast)
58
Q

BREAST CANCER
What are some options for breast mound recreation?

A
  • Implant based (implant alone or implant augmented latissimus dorsi)
  • Autologous (own tissues) such as TRAM flap, lat dorsi
  • Lat dorsi uses muscle ± skin ± fat but C/I if chronic back pain or physical hobby
59
Q

BREAST CANCER
What are some risks with breast mound recreation?

A
  • Capsule formation
  • Shape changes with age, gravity
  • Rupture
  • Infection
60
Q

BREAST CANCER
what are the problems with radiotherapy?

A
  • high rates of capsule formation with implants
  • skin viability risk
  • wound healing
  • loss of elasticity
  • fat necrosis
  • implant extrusion
61
Q

BENIGN BREAST DISEASE
What are 3 main causes of benign breast lumps?

A
  • Nodularity
  • Fibroadenoma
  • Breast cyst
62
Q

BENIGN BREAST DISEASE
What is nodularity?
What is the management?

A
  • Normal variation, some ladies have lumpy breasts, often cyclical (more prominent pre-menstrual)
  • Re-examine after period as nodularity should lessen or disappear
63
Q

FIBROADENOMA
What is a fibroadenoma?

A
  • Benign tumours of stromal/epithelial breast duct tissue
64
Q

FIBROADENOMA
What is the epidemiology?

A

most common 20-40yrs
responds to oestrogen so become less common after menopause

65
Q

FIBROADENOMA
What is the rule with fibroadenomas?

A
  • 1/3 shrink, 1/3 same, 1/3 enlarge
66
Q

FIBROADENOMA
How does it present?

A
  • Painless
  • Smooth
  • Round
  • Well circumscribed (well-defined borders)
  • Firm
  • Mobile (moves freely under the skin and above the chest wall)
  • Usually up to 3cm diameter
67
Q

FIBROADENOMA
What is the management?

A

reassurance + only remove if large

68
Q

BREAST CYSTS
What are breast cysts?

A
  • fluid filled lumps
  • Abnormal response of part of the breast to hormonal stimulation, commonly seen in 40–60 year olds
69
Q

BREAST CYSTS
What are features of a benign cyst?

A
  • Smooth
  • Well-circumscribed
  • Mobile
  • Possibly fluctuant
  • Dx confirmed on aspiration
70
Q

BREAST CYSTS
How is it managed?

A
  • aspiration
71
Q

NIPPLE DISCHARGE
What are some causes of nipple discharge?

A
  • Duct ectasia
  • Duct papilloma
  • Galactorrhoea
  • Infection
72
Q

NIPPLE DISCHARGE
What are some features of surgically significant nipple discharge?

A
  • Persistent
  • Unilateral + unifocal
  • Spontaneous
  • Bloody or clear
73
Q

NIPPLE DISCHARGE
What are some differentials of bloody nipple discharge?

A
  • Duct papilloma
  • Duct ectasia
  • Occasionally invasive/in-situ Ca
74
Q

DUCT ECTASIA
What is duct ectasia?

A
  • Ducts become dilated + fill with debris, prone to secondary infections
75
Q

DUCT ECTASIA
How does it present?

A
  • Yellow, green, thick + occasionally bloody nipple discharge
  • lump behind the nipple
  • inverted nipple
  • pain (not common)
76
Q

DUCT ECTASIA
What is the management?

A

Expectant management
If symptoms persist then operation to remove affected ducts may be offered

77
Q

PAPILLOMA
What is duct papilloma?
How does it present?

A
  • Benign warty growth behind nipple
78
Q

PAPILLOMA
what is the clinical presentation?

A
  • bloody or clear discharge from a single duct
79
Q

PAPILLOMA
what are they associated with?

A

atypical hyperplasia - this increases the risk of developing breast cancer

80
Q

PAPILLOMA
what are the investigations?

A
  • USS
  • mammogram
  • biopsy
81
Q

PAPILLOMA
what is the management?

A
  • removal via vacuum assisted excision (VAE)
82
Q

BENIGN BREAST DISEASE
What is galactorrhoea?
How does breast infection nipple discharge present?

A
  • Milky (physiological or iatrogenic)
  • Purulent
83
Q

BREAST INFECTION
What are the 2 types of breast infection (mastitis)?

A
  • Lactational (usually peripheral in breast)
  • Non-lactational (associated with duct ectasia + so central)
84
Q

BREAST INFECTION
what are the signs and symptoms of breast infections?

A
  • fever
  • decreased milk outflow
  • breast warmth
  • breast tenderness
  • breast firmness
  • breast swelling
  • flu-like symptoms
  • nipple discharge
  • nipple inversion
85
Q

BREAST INFECTION
what is a breast abscess?

A

a localised area of infection with a walled off collection of pus

86
Q

BREAST INFECTION
What is the management of lactational mastitis?

A
  • Continue breastfeeding
  • Rx if systemically unwell with flucloxacillin or erythromycin if allergic
  • May develop abscess (lump + erythema) so need drainage
87
Q

BREAST INFECTION
What is the management of non-lactational mastitis?

A
  • Same as lactational mastitis (flucloxacillin or erythromycin) but + metronidazole
88
Q

BREAST INFECTION
what is the management of breast abscesses?

A

aspiration + antibiotics + supportive care
surgical intervention only if aspiration and antibiotics repeatedly fail

89
Q

BREAST INFECTION
What is the most common cause of mastitis?
What is there a caution with?

A
  • S. Aureus then anaerobes (esp. non-lactational)
  • Repeated incision in non-lactational abscess as can develop mammary fistula which is difficult to treat
90
Q

BREAST PAIN
What is mastalgia?
What are the two types?

A
  • Breast pain
  • Cyclical = worse prior to and better after period
  • Non-cyclical (responds well to NSAIDs)
91
Q

BREAST PAIN
What is the management of cyclical mastalgia?

A
  • Supportive bra, reassurance, PO/topical analgesia
  • Danazol (weak androgen) but SEs = breast shrinkage, acne, weight gain
  • Tamoxifen (risk of endometrial cancer)
  • Goserelin
92
Q

GYNAECOMASTIA
What is gynaecomastia?
What is a differential?

A
  • > 2cm lump of breast tissue behind male nipple
  • Pseudo-gynaecomastia (deposition of fat in overweight men)
93
Q

GYNAECOMASTIA
What are the two broad causes of gynaecomastia?

A
  • Physiological = oestrogen + testosterone imbalance (puberty)
  • Pathological
94
Q

GYNAECOMASTIA
What are some pathological causes of gynaecomastia?

A
  • Drugs (spironolactone, oestrogen, anabolic steroids)
  • Marijuana
  • Liver failure
  • Testicular failure or tumour (Can produce beta-hCG)
95
Q

GYNAECOMASTIA
What is the management of gynaecomastia?

A
  • Older men >50 exclude breast cancer by biopsy
  • Remove or reverse cause/drug
  • Reassure teenagers
96
Q

BENIGN BREAST DISEASE
When investigating breast disease, what are features of a benign disease?

A
  • Breast exam = soft + mobile mass
  • Mammography = rounded mass, smooth edged, well-defined margins, low score
97
Q

BREAST IMPLANTS
what are the different types?

A

saline - silicone shells filled with saline (some are pre-filled and others are filled during operation)

silicone gel - silicone shell filled with silicone gel. Feel more like real breasts but more risky if leak

98
Q

BREAST IMPLANTS
what is the problem with using radiotherapy on breast implants?

A

there is a high rate of capsule formation

99
Q

BREAST IMPLANTS
what are the complications?

A
  • capsule formation
  • infection
  • rupture and shape changes with age
  • can hamper sensitivity of mammograms
  • breast implant associated anaplastic large cell lymphoma (BIA-ALCL)

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