Breast Conditions Flashcards
(36 cards)
Cyclical Mastalgia
Typically, cyclical pain affects both breasts, beginning a few days before the beginning of menstruation and subsiding at the end. It is caused by hormonal changes, therefore most cases come in those actively menstruating or using HRT
Pain is usually diffuse and bilateral (may be more severe in one breast). It varies in intensity according to the phase of the menstrual cycle
There may be generalised swelling and lumpiness but no specific lump found.
ex: benign fibrocystic breast disease
Cyclical Mastalgia treatment
- Women should be advised to wear a supportive bra.
- use paracetamol and/or ibuprofen, or a topical NSAID
- Conservative treatments include flax seed oil and evening primrose oil (not routinely given).
Non-cyclical Mastalgia
More likely to be unilateral or focal DDx - Mastitis - Breast trauma - Breast cysts - Benign breast tumours. - Breast cancer. - Medications: HRT, COCP, antidepressants (sertraline, venlafaxine, mirtazapine), haloperidol, digoxin, spiranolactone, metronidazole, ketoconazole
Mastalgia - extra-mammary causes
- MSK, eg costochondritis, Tietze’s syndrome, Cervical and thoracic spondylosis/radiculopathy, fibromyalgia
- Pregnancy
- Herpes zoster
- Coronary artery disease/angina, pericarditis, PE
- GORD, PUD
- Sickle cell anaemia
Nipple discharge - differentials and assessment
Clear: physiological, during breast feeding
Milky: Pregnancy/pituitary adenoma (hyperprolactinemia)
Brown/green: mammary duct ectasia
Bloody: Intraductal papilloma 90%, Cancer 10%
or infection
Assessment
- clinical examination (any mass lesion should undergo triple assessment)
- consider mammography
Mastitis - features
- Associated with lactation
- Skin becomes dry and cracked
- Usually staphylococcus
- Clinically: Erythema, tender, hot, patient unwell
- Need to rule out inflammatory breast cancer
If left untreated, mastitis may develop into a breast abscess. This generally requires incision and drainage.
Mastitis - management
The first-line management of mastitis is to continue breastfeeding.
The BNF advises treating ‘if systemically unwell, if nipple fissure present, if symptoms do not improve after 12-24 hours of effective milk removal of if culture indicates infection’.
The first-line antibiotic is flucloxacillin for 10-14 days, Breastfeeding should continue during treatment.
Breast Abscess
Lactational/non lactational
Periareolar/peripheral
Associated with smoking
Infection is usually with Staphylococcus aureus
Clinically: Erythematous, hot tender on palpation, swelling, fluctuant, patient may be systemically unwell
Management: Antibiotics, US guided aspiration. If any necrosis, may need excision of overlying skin
Duct Ectasia
Dilatation and shortening of the terminal breast ducts within 3cm of the nipple. It is common and the incidence increases with age. It typically presents with slit like retraction of the nipple and creamy nipple discharge.
- Most common in menopausal women
- Discharge typically thick and green in colour
- Most common in smokers
- May present with a tender lump around the areola
If ruptures may cause local inflammation, sometimes referred to as ‘plasma cell mastitis’
Patients with troublesome nipple discharge may be treated by microdochectomy (if young)(removal of lactiferous duct) or total duct excision (if older).
Benign breast conditions - ddx
- Fibroadenoma
- Breast cysts
- Fibrocystic disease
- Duct papilloma
- Epithelial hyperplasia
- Fat necrosis
Fibroadenoma
- Most common lesion of the breast
- Occurs in up to 25% of women between 15-35yrs
- Hormone dependent
- Composed of connective tissue and proliferating epithelium developing from a whole lobule
- Firm, non tender, highly mobile, single or multiple
- no increased risk of malignancy
Management
- Triple Assessment
- Conservative/surgical - if >4 cm excision is usual + core biopsy to rule out phyllodes tumour
Breast Cyst
Common over 35, often perimenopausal Fluctuates with menstrual cycle Smooth, well demarcated from surrounding tissue Firm, mobile, tender/non tender Small increase in risk of malignancy
Management
- Triple assessment - ‘halo appearance’ on mammography. US will confirm the fluid filled cyst
- Treat by Aspiration - if bloody fluid aspirated will need biopsy or if complete resolution not achieved may need surgical excision
- if purulent: send for culture and give abx
Fibrocystic disease (aka fibroadenosis or benign mammary dysplasia)
- Most common between ages 30- 50
- Loose association of cyst formation, breast nodularity, stromal proliferation, and epithelial hyperplasia
- A/w Imbalance of progesterone and estrogen
- Clinically -bilateral pain, usually cyclical, breast swelling /lumpy breast, palpable mass and heaviness
Management
- Triple Assessment
- Conservative management - supportive bra, pain relief
Duct Papilloma
- Local areas of epithelial proliferation in large mammary ducts: hyperplastic lesions rather than malignant or premalignant
- May present with blood stained nipple discharge
- Large papillomas may present with a mass
- No increase risk of malignancy
- Treatment –> Microdochectomy
Epithelial Hyperplasia
- Variable presentation ranging from generalised lumpiness through to discrete lump
- Disorder consists of increased cellularity of terminal lobular unit, atypical features may be present
- Atypical features and family history of breast cancer confers greatly increased risk of malignancy
Treatment
- no atypical features –> conservative, watchful wait
- atypical features –> close monitoring or surgical resection
Breast Cancer - risk factors
- Increasing age (>50)
- BRCA1, BRCA2 genes - 40% lifetime risk of breast/ovarian cancer
- 1st degree relative premenopausal with Ca breast
- nulliparity, 1st pregnancy > 30 yrs, early menarche, late menopause, not breastfeeding
- HRT or COCP use
- ionising radiation
- p53 gene mutations eg Li-Fraumeni
- obesity
- smoking, alcohol
Breast cancer - presentation
- Lump –hard, irregular, tethered
- Change in shape
- Ulceration
- Skin changes e.g. Peau d’orange
- Inflammatory breast cancer = cancerous cells block the lymph drainage resulting in an inflamed appearance
- Nipple changes e.g. Paget’s disease, discharge, inversion
- Metastatic cancer – axillary lumps, incidental on scans
Paget’s Disease of the nipple
Eczematoid change of the nipple associated with an underlying breast malignancy and it is present in 1-2% of patients with breast cancer.
Paget’s disease differs from eczema of the nipple in that it involves the nipple primarily and only latterly spreads to the areolar (the opposite occurs in eczema).
Diagnosis is made by punch biopsy, mammography and ultrasound of the breast.
Treatment will depend on the underlying lesion.
Breast Cancer - types
Most breast cancers arise from duct tissue followed by lobular tissue, described as ductal or lobular carcinoma
- Invasive ductal carcinoma - most common type of breast cancer. This has recently been renamed ‘No Special Type (NST)’. In contrast, lobular carcinoma and other rarer types* are classified as ‘Special Type’
- Invasive lobular carcinoma
- Ductal carcinoma-in-situ (DCIS)
- Lobular carcinoma-in-situ (LCIS)
*rarer types of breast cancer include medullary, mucinous, tubular cancer, lymphoma of the breast, phyllodes or cystosarcoma phyllodes etc.
Ductal carcinoma in situ (DCIS) - features
- Pre-invasive cancer picked up due to abnormal calcification in breast
- Can be palpable or impalpable (detected by screen)
- Malignant cells within ducts
- Proportion progress to invasive cancer
- Classification: low, intermediate and high nuclear grade
- Treatment: excision of tumour (mastectomy only if DCIS is large) +/- radiotherapy +/- endocrine therapy
2WW referral for breast cancer
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer if they are:
- aged 30 and over and have an unexplained breast lump with or without pain or
- aged 50 and over with any of the following symptoms in one nipple only: discharge, retraction or other changes of concern eg Paget’s/skin changes
Triple Assessment
Done if they have signs or symptoms that meet the breast cancer “2 week wait” referral criteria
- History and exam - breast exam
- Imaging
- Mammography (most cases, older women)
- US (more useful in young women or male pts) - Biopsy
- Core biopsy provides full histology
- FNA more useful for recurrent cystic disease
What does ER, PR and Her2 status mean?
- ER: estrogen receptor*
- PR: progesterone receptor*
- Her 2: In about 20% of breast cancers, the cells make too much of a protein known as HER2. These cancers tend to be aggressive and fast-growing. These are treated with the targeted drug trastuzumab (Herceptin)
*ER/PR-positive are much more likely to respond to hormone therapy than tumors that are ER/PR-negative
Triple negative Breast cancer
- ER, PR and Her 2 negative
- More aggressive type and has a poorer prognosis than other types of breast cancer, mainly because there are fewer targeted medicines that treat it
- Recurrence rates are much higher
