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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
BREAST CANCER What are the 2 main genes involved in breast cancer and how do they act?
- 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
26
BREAST CANCER What is the classic clinical presentation of breast cancer?
- Normal appearing breast with palpable painless lump - Pain + tenderness uncommon - Visually = nipple inversion, bloody nipple discharge
27
BREAST CANCER What warrants an urgent 2ww cancer referral? What happens under the 2ww referal?
- ≥30 with unexplained breast lump ± pain - ≥50 with discharge, retraction or other change of concern - Triple assessment
28
BREAST CANCER What is the triple assessment? What happens at end?
- 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
29
BREAST CANCER What are the pros of breast cancer screening?
- Earlier detection, - Reduces morbidity + mortality, - Detects asymptomatic cancers before present, - Not overly invasive
30
BREAST CANCER What are the cons of breast cancer screening?
- ?Overdiagnosis (frail women Dx with small low-grade cancers), - Anxiety if recalled, - Low dose XR > small amount of malignancies
31
BREAST CANCER What are some reasons that a woman may be recalled for further views, USS or biopsy?
- Mass (well or poorly defined, rough edges, spiculated = carcinoma) - Microcalcification (associated with DCIS) - Parenchymal deformity - Asymmetrical density - Clinical or technical recall
32
BREAST CANCER What is the high risk screening for breast cancer?
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)
33
BREAST CANCER What is the management of BRCA1/2 women?
- Genetic pedigree to identify at risk - Additional screening, lifestyle advice - ?Prophylactic tamoxifen or aromatase inhibitors - ?Risk reducing salpingo-oopherectomy or mastectomy
34
BREAST CANCER What are some complications of breast cancer?
- 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
35
METASTATIC BREAST CANCER How may metastatic breast cancer present?
- Bony pain or #
36
METASTATIC BREAST CANCER What is the management?
- Bisphosphonates + denosumab, radio/chemo + Sx control
37
BREAST CANCER What is breast conservation treatment?
- Lumpectomy or wide local excision where remaining breast tissue gets localised radiotherapy
38
BREAST CANCER What are the indications for breast conservation treatment?
- Small tumour relative to breast (<25%), - DCIS, - no previous radiotherapy, - not underneath nipple, - pt choice
39
BREAST CANCER What factors affect the outcome of breast conservation treatment?
- Tumour size relative to breast, - position of tumour in breast (lateral more favourable), - radiotherapy fibrosis
40
BREAST CANCER What is mastectomy?
- Uni or bilateral removal of breast
41
BREAST CANCER What are the indications for a mastectomy?
- Large tumour relative to breast size, - >1 cancer in same breast, tumour under nipple, - immediate or delayed reconstruction, - pt choice
42
BREAST CANCER What is full axillary clearance?
- Removal of all glands
43
BREAST CANCER What are the indications + benefits of full axillary clearance?
- Glands clinically involved, - good control, - no need for further surgery or axillary radiotherapy
44
BREAST CANCER What are the risks of full axillary clearance?
- 10% lymphoedema, - high complication rate (seromas, arm stiffness, drains, axillary numbness), - extends surgical time
45
BREAST CANCER What is limited axillary surgery? What are the benefits?
- 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
BREAST CANCER What adjuvant endocrine therapy may be given to women?
- 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
BREAST CANCER What endocrine therapy is given if... i) pre-menopausal? ii) post-menopausal?
i) Tamoxifen – inhibits oestrogen receptor on breast cancer cells ii) Anastrozole (aromatase inhibitors) – inhibits aromatase which converts androgens > oestrogen
48
BREAST CANCER what is tamoxifen?
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
BREAST CANCER what are the complications of tamoxifen?
hot flushes nausea vaginal bleeding rarely thrombosis and endometrial cancer
50
BREAST CANCER what are aromatase inhibitors?
letrozole Inhibit aromatase enzyme responsible for the conversion of androgens to oestogen in post-menopausal woman slightly better anticancer efficacy than tamoxifen
51
BREAST CANCER what are the side effects of aromatase inhibitors?
hot flushes reduced bone density joint pains
52
BREAST CANCER what is Her-2?
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
BREAST CANCER how is HER-2 breast cancer managed?
Currently 1 year of 3 weekly adjuvant Trastuzumab given alongside chemotherapy (usually FEC-T).
54
BBREAST CANCER how can you find impalpable cancers?
wire localisation
55
BREAST CANCER What other adjuvant treatment may be offered?
- 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
BREAST CANCER Reconstruction surgery can either be primary (immediately) or delayed. What are the pros and cons of primary reconstruction?
- Increased skin preservation options, reduced psychological trauma - May delay chemo/radiotherapy if complications, radiotherapy may ruin results (fibrosis)
57
BREAST CANCER Reconstruction surgery can either be primary (immediately) or delayed. What are the pros and cons of delayed reconstruction?
- Minimal risks of delay in adjuvant therapies, healthy tissue used to recreate breast - Limited skin preservation options, psychological impact (no breast)
58
BREAST CANCER What are some options for breast mound recreation?
- 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
BREAST CANCER What are some risks with breast mound recreation?
- Capsule formation - Shape changes with age, gravity - Rupture - Infection
60
BREAST CANCER what are the problems with radiotherapy?
- high rates of capsule formation with implants - skin viability risk - wound healing - loss of elasticity - fat necrosis - implant extrusion
61
BENIGN BREAST DISEASE What are 3 main causes of benign breast lumps?
- Nodularity - Fibroadenoma - Breast cyst
62
BENIGN BREAST DISEASE What is nodularity? What is the management?
- Normal variation, some ladies have lumpy breasts, often cyclical (more prominent pre-menstrual) - Re-examine after period as nodularity should lessen or disappear
63
FIBROADENOMA What is a fibroadenoma?
- Benign tumours of stromal/epithelial breast duct tissue
64
FIBROADENOMA What is the epidemiology?
most common 20-40yrs responds to oestrogen so become less common after menopause
65
FIBROADENOMA What is the rule with fibroadenomas?
- 1/3 shrink, 1/3 same, 1/3 enlarge
66
FIBROADENOMA How does it present?
- 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
FIBROADENOMA What is the management?
reassurance + only remove if large
68
BREAST CYSTS What are breast cysts?
- fluid filled lumps - Abnormal response of part of the breast to hormonal stimulation, commonly seen in 40–60 year olds
69
BREAST CYSTS What are features of a benign cyst?
- Smooth - Well-circumscribed - Mobile - Possibly fluctuant - Dx confirmed on aspiration
70
BREAST CYSTS How is it managed?
- aspiration
71
NIPPLE DISCHARGE What are some causes of nipple discharge?
- Duct ectasia - Duct papilloma - Galactorrhoea - Infection
72
NIPPLE DISCHARGE What are some features of surgically significant nipple discharge?
- Persistent - Unilateral + unifocal - Spontaneous - Bloody or clear
73
NIPPLE DISCHARGE What are some differentials of bloody nipple discharge?
- Duct papilloma - Duct ectasia - Occasionally invasive/in-situ Ca
74
DUCT ECTASIA What is duct ectasia?
- Ducts become dilated + fill with debris, prone to secondary infections
75
DUCT ECTASIA How does it present?
- Yellow, green, thick + occasionally bloody nipple discharge - lump behind the nipple - inverted nipple - pain (not common)
76
DUCT ECTASIA What is the management?
Expectant management If symptoms persist then operation to remove affected ducts may be offered
77
PAPILLOMA What is duct papilloma? How does it present?
- Benign warty growth behind nipple
78
PAPILLOMA what is the clinical presentation?
- bloody or clear discharge from a single duct
79
PAPILLOMA what are they associated with?
atypical hyperplasia - this increases the risk of developing breast cancer
80
PAPILLOMA what are the investigations?
- USS - mammogram - biopsy
81
PAPILLOMA what is the management?
- removal via vacuum assisted excision (VAE)
82
BENIGN BREAST DISEASE What is galactorrhoea? How does breast infection nipple discharge present?
- Milky (physiological or iatrogenic) - Purulent
83
BREAST INFECTION What are the 2 types of breast infection (mastitis)?
- Lactational (usually peripheral in breast) - Non-lactational (associated with duct ectasia + so central)
84
BREAST INFECTION what are the signs and symptoms of breast infections?
- fever - decreased milk outflow - breast warmth - breast tenderness - breast firmness - breast swelling - flu-like symptoms - nipple discharge - nipple inversion
85
BREAST INFECTION what is a breast abscess?
a localised area of infection with a walled off collection of pus
86
BREAST INFECTION What is the management of lactational mastitis?
- Continue breastfeeding - Rx if systemically unwell with flucloxacillin or erythromycin if allergic - May develop abscess (lump + erythema) so need drainage
87
BREAST INFECTION What is the management of non-lactational mastitis?
- Same as lactational mastitis (flucloxacillin or erythromycin) but + metronidazole
88
BREAST INFECTION what is the management of breast abscesses?
aspiration + antibiotics + supportive care surgical intervention only if aspiration and antibiotics repeatedly fail
89
BREAST INFECTION What is the most common cause of mastitis? What is there a caution with?
- S. Aureus then anaerobes (esp. non-lactational) - Repeated incision in non-lactational abscess as can develop mammary fistula which is difficult to treat
90
BREAST PAIN What is mastalgia? What are the two types?
- Breast pain - Cyclical = worse prior to and better after period - Non-cyclical (responds well to NSAIDs)
91
BREAST PAIN What is the management of cyclical mastalgia?
- Supportive bra, reassurance, PO/topical analgesia - Danazol (weak androgen) but SEs = breast shrinkage, acne, weight gain - Tamoxifen (risk of endometrial cancer) - Goserelin
92
GYNAECOMASTIA What is gynaecomastia? What is a differential?
- >2cm lump of breast tissue behind male nipple - Pseudo-gynaecomastia (deposition of fat in overweight men)
93
GYNAECOMASTIA What are the two broad causes of gynaecomastia?
- Physiological = oestrogen + testosterone imbalance (puberty) - Pathological
94
GYNAECOMASTIA What are some pathological causes of gynaecomastia?
- Drugs (spironolactone, oestrogen, anabolic steroids) - Marijuana - Liver failure - Testicular failure or tumour (Can produce beta-hCG)
95
GYNAECOMASTIA What is the management of gynaecomastia?
- Older men >50 exclude breast cancer by biopsy - Remove or reverse cause/drug - Reassure teenagers
96
BENIGN BREAST DISEASE When investigating breast disease, what are features of a benign disease?
- Breast exam = soft + mobile mass - Mammography = rounded mass, smooth edged, well-defined margins, low score
97
BREAST IMPLANTS what are the different types?
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
BREAST IMPLANTS what is the problem with using radiotherapy on breast implants?
there is a high rate of capsule formation
99
BREAST IMPLANTS what are the complications?
- 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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