Breast Flashcards
(184 cards)
1
Q
What is the breast comprised of?
A
- Majority is adipose tissue
- Mammary glands
- Connective tissue stroma (fatty and fibrous tissue)
- Pectoral fascia
2
Q
What is the action of the ducts of the breast?
A
Carry milk from the lobules to the nipples
3
Q
What is the action of the lobules of the breast?
A
They are the mammary glands that produce milk during pregnancy/ breastfeeding
4
Q
What does each lobule consist of?
A
Many alveoli drained by a single lactiferous duct
5
Q
What hormone stimulates the development of breasts?
A
Oestrogen
6
Q
What is the action of progesterone on the breasts?
A
Stimulates formation of milk glands
7
Q
Why is lactation inhibited in pregnancy?
A
Progesterone produced in the placenta inteferes with prolactin binding
8
Q
What is responsible for breast growth in pregnancy?
A
Increased prolactin secretion
9
Q
What are the steps in breast examination?
A
Get consent/ chaperone/ explain what doing etc
Inspection
Palpation
Assess lump
10
Q
What are the 3 positions used to inspect the breast?
A
Relaxed with arms by sides
Hands pressed into hip
Hands placed behind head
11
Q
What are you looking for on inspection of the breast?
A
Asymmetry Scars Cosmetic augmentation Tethering, fixation or puckering of skin Nipple eversion/ inversion Nipple discharge Skin colour Paeu d'orange Paget's disease of the nipple
12
Q
What is Paeu d’orange?
A
Thickened, oedematous, dimpled skin found with inflammatory breast cancer
13
Q
What is Paget’s disease of the nipple?
A
Erythematous. scaly rash of the nipple that looks like eczema
14
Q
How do you palpate the breast?
A
Have them lying at 45 degrees with hand behind head
Use flat of fingers to palpate each quadrant, over the nipple and the axilla
15
Q
What features should you assess if a lump is found?
A
Location Size Shape Consistency Margins Tethered? Tenderness Skin colour Nipple discharge
16
Q
What are the potential causes of breast lumps?
A
Breast cancer Fibroadenoma Fibrocystic changes Cysts Fat necrosis Lipoma Galactocele Phyllodes tumur
17
Q
What are fibroadenomas?
A
Benign tumours of stromal/ epithelial breast duct tissue
18
Q
How do fibroadenomas usually feel on palpation?
A
Small (<3cm) Smooth Mobile Round Well circumscribed Firm
19
Q
In what age are fibroadenomas the most common?
A
20-40
20
Q
Why are fibroadenomas more common in younger women?
A
They respond to oestrogen and progesterone, so go after menopause
21
Q
What are fibrocystic breast changes?
A
When the breasts become fibrous and cystic in response to changes in the menstrual cycle
22
Q
When do fibrocystic breast changes usually occur and resolve?
A
Usually begin around 10 days before menstruation and then resolve once menstruation begins
23
Q
How may fibrocystic breast changes present?
A
Lumpiness
Breast pain/ tenderness
Fluctuation of breast size
24
Q
How can fibrocystic breast changes be managed?
A
Exclude cancer Manage symptoms: -Supportive bra -NSAIDs -Avoid caffeine -Apply heat to area -Hormonal treatments
25
Why do fibrocystic breast changes occur?
The connective tissues, ducts and lobules respond to female sex hormones
26
What are breast cysts?
Benign individual fluid filled lumps
27
What is the most common cause of breast lumps?
Cysts
28
At what age to breast cysts most commonly occur?
Between 30 and 50 (in the perimenopausal period)
29
What are cysts like on examination?
Smooth
Well circumscribed
Mobile
May fluctuate with the menstrual cycle
30
How are breast cysts managed?
Need to exclude cancer
| Aspiration or excision may resolve symptoms
31
What is fat necrosis of the breast?
When a benign lump forms due to localised degeneration and scarring of fat tissue in the breast
32
What may cause fat necrosis?
Localised trauma
Radiotherapy
Surgery
33
Why does fat necrosis occur?
Trauma causes an inflammatory reaction resulting in fibrosis and necrosis of the fat tissue
34
What may fat necrosis present on examination?
```
Painless
Firm
Irregular
Fixed
Skin dimpling/ nipple inversion
```
35
How is fat necrosis diagnosed?
USS and mammogram may look similar to breast cancer so need histology to rule it out
36
What are lipomas?
Benign tumours of adipose tissue
37
How do lipomas feel on examination?
Soft
Painless
Mobile
Don't cause skin changes
38
What are galactoceles?
Breast milk filled cysts
39
Who gets galactoceles?
Women who are lactating who stop breastfeeding
40
How do galactoceles occur?
When the lactiferous duct is blocked, preventing the gland from draining milk
41
How do galactoceles present?
Firm, mobile painless lump, usually beneath the areola
42
How are galactoceles managed?
Usually resolve without any treatment but may drain them with a needle
43
What are phyllodes tumours?
Rare tumours of the connective tissue of the breast
44
What is the most likely cause of a breast lump in a 20 year old?
Fibroadenoma
45
What is the most likely cause of a breast lump in a 30 year old?
Localised benign lump
46
What is the most likely cause of a breast lump in a 60 year old?
Breast cancer
47
What is mastalgia?
Breast pain
48
Is cyclical or non-cyclical breast pain more common?
Cyclical
49
How does cyclical breast pain usually present?
Bilateral, generalised pain
Heaviness
Aching
50
At what age is non-cyclical breast pain more common?
In women age 40-50
51
What may cause non-cyclical breast pain?
Medications
Infection
Pregnancy
52
How can breast pain be investigated?
Breast pain diary to look for cyclical breast pain
| Exclude cancer, infection and pregnancy
53
How is mastalgia managed?
```
Supportive bra
NSAIDs
Avoid caffeine
Apply heat
Hormonal treatment
```
54
What is gynaecomastia?
The enlargement of the glandular breast tissue in males
55
In what ages is gynaecomastia most common?
Adolescents and older men (>50)
56
What are the causes of gynaecomastia?
- Idiopathic
- Hormonal imbalance between oestrogen and androgens (testosterone)
- Hyperprolactinaemia
- Medications/ drugs
57
What is the usual hormonal imbalance that causes gynaecomastia?
High oestrogen: Low androgens
58
What stimulates the breast development in gynaecomastia?
Oestrogen
59
What hormone may also be responsible for gynaecomastia?
Prolactin
60
What may cause hyperprolactaemia in males?
Dopamine antagonists (e.g. antipsychotics)
61
What may cause high oestrogen levels in males?
```
Physiological during puberty
Obesity
Testicular cancer
Liver cirrhosis
Hyperthyroidism
hCG secreting tumour
```
62
What examination should always be performed on a patient presenting with gynaecomastia and why?
Testicular examination as 2% of cases are due to a Leydig cell testicular tumour
63
What conditions that reduce testosterone can cause gynaecomastia?
```
Older age
Hypothalamus/ pituitary conditions
Klinefelter syndrome
Orchitis
Testicular damage
```
64
What medications can cause gynaecomastia?
```
Anabolic steroids
Antipsychotics
Digoxin
Sprinolactone
GnRH agonists
Opiates
Marijuana
Alcohol
```
65
What other condition may present like gynaecomastia?
Psuedogynaecomastia: Breast enlargement due to obesity
66
What will be found on examination of gynaecomastia?
Firm tissue behind the areolas
67
How may gynaecomastia be investigated?
Thorough history and examination
Blood tests
Imaging
68
What is the management of simple gynaecomastia in a healthy adolescent?
Watchful waiting
69
What blood tests may be done in a more complex case of gynaecomastia (eg. > 30 with unexplained rapid onset)?
```
U&E's
LFTs
TFTs
Testosterone
Sex hormone-binding globulin
estrogen
Prolactin
LH/ FSH
Alpha-fetoprotein/ beta-hCG (testicular cancer markers)
```
70
What imagine may be done for more complex cases of gynaecomastia?
Breast USS
Mammogram
Biopsy
Testicular USS
71
How is gynaecomastia managed?
Stop cause (e.g. if cause)
Watch and wait
Tamoxifen/ surgery if problematic
72
What is galactorrhoea?
Breast milk production not associated with pregnancy or breastfeeding
73
What stimulates the production of breast milk?
Prolactin
74
Where is prolactin produced?
Anterior pituitary gland
| and some in breast and prostate
75
What blocks the secretion of prolactin?
Dopamine
76
What stimulates breast milk excretion?
Oxytocin
77
What are the key causes of hyperprolactinaemia?
Idiopathic
Prolactinomas
Endocrine disorders
Medications (dopamine antagonists)
78
What does prolactin supress?
GnRH release from the hypothalamus
79
What can hyperprolactinamia also present with and why?
```
It suppresses GnRH and therefore LH/ FSH so may present with:
Menstrual irregularities
Reduced libido
Erectile dysfunction
Gynaecomastia
```
80
What are prolactinomas?
Tumours of the pituitary gland that secrete excessive prolactin
81
Other than galactorrhoea, how may prolactinomas present?
Headaches
| Bitemporal hemianopia
82
What conditions can cause non-milk nipple discharge?
Mammary duct ectasia
Duct papilloma
Pus from breast abscess
83
What investigations should be done for galactorrhoea?
```
Pregnancy test
Blood tests:
-Serum prolactin
-Renal profile
-LFTs
-TFTs
MRI for pituitary tumour
```
84
How is galactorrhoea managed?
Depends on underlying cause:
- Dopamine agonists for hyperprolactinaemia
- Trans-sphenoidal removal or pituitary tumour
85
What is mammary duct ectasia?
Benign condition where there is inflammation and dilation of the large ducts in the breasts
86
In which women is mammary duct ectasia most common?
Perimenopausal women
87
What is the most significant risk factor in mammary duct ectasia?
Smoking
88
How may mammary duct ectasia present?
Nipple discharge (intermittend, may be white, grey or green)
Tenderness/ pain
Nipple retraction/ inversion
Breast lump
89
How is mammary duct ectasia diagnosed?
Exclude breast cancer (triple assessment)
Ductography
Nipple discharge cytology
Ductoscopy
90
What is the key mammogram finding with mammary duct ectasia?
Microcalcifications
91
How is mammary duct ectasia managed?
May resolve with no treatment
Symptomatic management
If problematic, may require surgical excision
92
What is an intraductal papilloma?
Warty lesion that grows within a breast duct
93
What is an intraductal papilloma the result of?
Proliferation of epithelial cells
94
What is the typical presentation of intraductal papilloma?
Often asymptomatic
Clear/ blood-stained nipple discharge
Tenderness/ pain
Palpable lump
95
Between what ages are intraductal papillomas most common?
35-55
96
How are intraductal papilloma diagnosed?
Triple assessment
| Ductography
97
What is ductography?
Injecting contrast into the abnormal duct and performing mammograms to visualise it
98
How are intraductal papilloma managed?
Complete surgical excision
99
What is mastitis?
Inflammation of the breast tissue
100
What causes mastitis?
- Obstruction in the ducts with accumulation of milk
| - Infection cause by bacteria entering nipple
101
When is mastitis most common?
Common complication of breastfeeding
102
What is the most common bacterial cause of mastitis?
Staph. aureus
103
How does mastitis present?
```
Breast pain/ tenderness
Erythema
Local warmth/ inflammation
Nipple discharge
Fever
```
104
How is mastitis managed if it is caused by duct blockage?
Conservative:
- Continued breastfeeding
- Expressing milk
- Breast massage
- Heat packs
- Warm showers
- Simple analgesia
105
How is mastitis managed when it is caused by infection/ conservative management is not working?
Flucloxacillin
| Send milk sample for culture and sensitivities
106
Should women keep breastfeeding even if they have infection?
Yes- won't harm baby and will help clear mastitis
107
What may occur after a course of antibiotics?
Candida of the nipple
108
What can candida of the nipple cause and why?
Recurrent mastitis as it causes cracked skin on the nipple that allows entrance for infection
109
What is a breast abscess?
A collection of pus within an area of the breast
110
What usually causes breast abscesses?
Bacterial infection
111
What are the two types of breast abscess?
Lactational abscess
| Non-lactational abscess
112
What does pus contain?
Dead white blood cells and other waste leftover from immune response
113
How does an abscess form?
When pus becomes trapped in a specific area and cannot drain
114
What are the most common bacteria that cause breast abscesses?
Staph. aureus
Streptococcal species
Enterococcal species
Anaerobic bacteria
115
How do breast abscesses present?
Acute onset
Swollen, fluctuant tender lump
Generalised symptoms of infection
116
What does fluctuance mean?
Able to move fluid around within the lump on palpation
117
How are abscesses diagnosed?
History/ examination
118
What is the management for breast abscesses?
```
Treat mastitis (antibiotics)
Refer to surgical team
USS
Drainage
Microscopy, culture and sensitivities of drained fluid
```
119
What is the most common cancer in the UK?
Breast cancer
120
How many women will develop breast cancer in their lifetime?
1 in 8
121
What are the risk factors for developing breast cancer?
```
Female
Increased oestrogen exposure
More dense breast tissue
Obesity
Smoking
Family history
COCP
HRT
```
122
What genes increase the risk of breast cancer?
BRCA genes
123
What is BRCA?
Breast Cancer gene- tumour suppressor genes
124
On which chromosome is the BRCA1 gene?
Chromosome 17
125
On which chromosome is the BRCA2 gene?
Chromosome 13
126
What are the different types of breast cancer?
```
Ductal carcinoma in situ
Lobular carcinoma in situ
Invasive ductal carcinoma
Invasive lobular carcinomas
Inflammatory breast cancer
```
127
What is the most common type of breast cancer?
Invasive ductal carcinoma (NST)
128
What is a DCIS?
Ductual carcinoma in situ= cancerous/ pre-cancerous epithelial cells in the breast ducts, usually localised to a single area
129
What is LCIS?
Lobular carcinoma in situ= pre-cancerous condition found incidentally on breast biopsy
130
What does NST stand for?
No special/ specific type
131
What percentage of breast cancers are invasive ductal carcinomas of no specific type?
80%
132
How do inflammatory breast cancers present?
Similarly to breast abscess or mastitis
| paue d'orange
133
Between what ages does breast cancer screening occur and how often?
Every 3 years for women age 50-70
134
What are the potential downsides to screening/
Anxiety
Exposure to raditation
False negatives/ positives
Unecessary further tests/ treatments
135
What patients are classified as higher risk for breast cancer?
First degree relative with breast cancer (<40/ male/ bilateral)
Two first-degree relatives
136
What may be offered to women at increased risk?
Annual mammogram
Chemoprevention
Risk reducing bilateral mastectomy or oophorectomy
137
What clinical features may suggest breast cancer?
Hard, irregular, painless or fixed lumps
Nipple retraction
Peau d'orange
Lymphadenopathy
138
What would trigger a 2WW referral for breast cancer?
Unexplained breast lump >30
| Unilateral nipple changes >50
139
What diagnostic assessment is used for breast cancer?
Triple assessment:
1. Clinical assessment
2. Imaging
3. Biopsy
140
What does the clinical assessment component of the triple assessment involve?
Examination and history
141
What imaging is done during the triple assessment in younger women?
USS
142
What imaging is done during triple assessment for older women?
Mammograms
143
Why do older and younger women have different breast imaging?
Breast tissue is much more dense in younger women so it is hard to distinguish lumps with mammograms
144
When might MRI be used in breast cancer?
To screen women at higher risk
| To further assess the size/ features of a tumour
145
What else should be assessed when a woman is diagnosed with breast cancer?
Lymph nodes
146
How are the lymph nodes assessed?
USS of axilla and ultrasound-guided biopsy of any abnormal nodes
147
What may be done during breast cancer surgery to look for abnormal nodes?
Sentinel lymph node biopsy
148
What is a sentinel lymph node biopsy?
When an isotope contrast and blue dye are injected into the tumour area. These travel through the lymphatics to the sentinel lymph node which will show up blue and then a biopsy can be performed or they can be moved
149
What is a sentinel lymph node?
The first lymph node draining a cancer
150
What are the 3 types of breast cancer receptors?
Oestrogen receptors
Progesterone receptors
Human epidermal growth factor
151
Why are the receptors found on tumours important on breast cancer?
They can guide treatment
152
What is triple-negative breast cancer?
Where the breast cancer cells do not express any of the three breast cancer receptors
153
What is gene expression profiling?
Assessing which genes are present in breast cancer on a histological sample
154
What are the most common metastasis of breast cancer?
```
(2L 2B)
Lungs
Liver
Bones
Brain
(can spread anywhere)
```
155
How is breast cancer staged?
Triple assessment
Lymph node assessment/ biopsy
MRI
Liver USS/ CT thorax, abdomen or pelvis, bone isotope
156
What system is used to stage breast cancer?
TNM
| Tumour, nodes, metastasis
157
What are the treatment options for breast cancer?
```
Surgery
Radiotherapy
Chemotherapy
Hormone treatment
Targeted treatments
```
158
What are the two options for breast cancer surgery?
Breast-conserving surgery
Mastectomy
(axillary clearance)
159
What is breast-conserving surgery also called?
Lumpectomy/ wide local excision
160
What is lymphoedema?
Chronic condition caused by impaired lymphatic drainage
161
When is lymphoedema common?
After axillary clearance during breast cancer surgery
162
What causes Lymphoedema?
The lymphatic system is usually responsible for draining excess fluid from the tissues, so when the lymphatic system is impaired, the tissues become swollen with excess protein-rich fluid
163
What are the complications of axillary clearance?
Lymphoedema
| Increased infection in area
164
What treatments can be used to manage Lymphoedema?
Massage techniques
Compression bandages
Exercises to improve lymph drainage
Weight loss
165
When is radiotherapy usually used in breast cancer?
In patients with breast-conserving surgery to reduce risk of recurrence
166
How is radiotherapy given in breast cancer?
High dose radiation given from multiple angles on a targeted area.
Usually have a course after surgery (e.g. every day for 3 weeks)
167
What are the common radiotherapy side effects?
```
General fatigue
Local skin/ tissue irritation and swelling
FIbrosis
Shrinking
Skin colour changes
```
168
What are the three uses of chemotherapy in breast cancer?
Neoadjuvant
Adjuvant
As treatment
169
What is neoadjuvant therapy?
Treatment given as the first step to shrink the tumour before surgery
170
What is adjuvant therapy?
Treatment given after surgery to reduce recurrence
171
When can hormone treatment be used in breast cancer?
When patients have oestrogen-receptor positive breast cancer they can be given treatment that disrupts the oestrogen stimulating the breast cancer
172
What are the two options for hormone treatment in breast cancer?
```
Tamoxifen (premenopausal)
Aromatase inhibitors (postmenopausal
```
173
What is the action of tamoxifen?
Selective oestrogen receptor modulator that blocks oestrogen receptors in breast tissue
174
What is the action of aromatase inhibitors?
Aromatase is an enzyme found in adipose tissue that converts androgens to oestrogen. After menopause it is the primary source of oestrogen so inhibitors work bu blocking the creation of oestrogen.
175
For how long after oestrogen-receptor positive breast cancer is diagnosed should hormone treatment be given?
5-10 years
176
What targeted treatments can be used in breast cancer?
Trastuzumab/Pertuzumab= monoclonal antibodies that targets HER2 receptor
177
What follow up do women treated for breast cancer get?
Surveillance mammograms yearly for 5 years.
178
What reconstructive options is offered to women having a mastectomy?
Immediate reconstruction
Delayed reconstruction
Reconstruction
Reduction and reshaping
179
What is partial reconstruction?
Using a flap or fat tissue to fill the gap left after breast-conserving surgery
180
What is reduction and reshaping?
Removing tissue and reshaping both breasts to match after breast-conserving surgery
181
What are the options for reconstructing the breast after mastectomy?
Breast implants
| Flap reconstruction
182
What are the options of tissue that can be used in flap reconstruction surgery?
Portion of the latissimus dorsi and associated skin and fat
Transverse rectus abdominis
Deep inferior epigastric perforator
183
What does pedicled refer to?
Keeping the original blood supply and moving the tissue under the skin to a new location
184
What does 'free flap' refer to?
Cutting the tissue away completely and transplanting to a new location
