Breast fifth yr Flashcards
(27 cards)
Clinical features of breast cancer?
Lumps that are hard, irregular, painless or fixed in place
Lumps may be tethered to the skin or the chest wall
Nipple retraction
Skin dimpling or oedema (peau d’orange)
When to 2ww for suspected breast cancer?
The NICE guidelines (updated January 2021) recommend a two week wait referral for suspected breast cancer for:
An unexplained breast lump in patients aged 30 or above
Unilateral nipple changes in patients aged 50 or above (discharge, retraction or other changes)
The NICE guidelines recommend also considering a two week wait referral for:
An unexplained lump in the axilla in patients aged 30 or above
Skin changes suggestive of breast cancer
Summary of fibroadenoma?
common benign tumours of stromal/epithelial breast duct tissue
typically small and mobile - ‘breast mouse’
young women (20-40) - respond to female hormones, hence why more common in younger women and regress after menopause
painless, smooth, round, well circumscribed, firm, mobile, up to 3cm diameter
complex fibroadenoma with FHx - higher risk of BC
Summary of fibrocystic breast changes?
considered variation of normal - not disease
stroma, ducts and lobules response to hormones and become fibrous and cystic - changes fluctuate with menstrual cycle, with Sx prior to menstruating and resolve once menstruation begins
Sx resolve with menopause
Sx - lumpiness, mastalgia, fluctuation of breast size
Tx - exclude breast cancer, manage symptoms - wear supportive bra, NSAIDs, avoid caffeine, applying heat, hormonal Tx (danazol and tamoxifen)
Summary of breast cysts?
benign, individual, fluid-filled lumps
most common cause of breast lumps and occur most often between ages 30 and 50 - common in perimenopausal
painful and fluctuate in size over menstrual cycle
O/E - Smooth, Well-circumscribed, Mobile, Possibly fluctuant
Need to exclude cancer - imaging, aspiration, excision
Slightly increase risk of breast ca
Summary of fat necrosis?
benign lump formed by localised degeneration and scarring of fat tissue in the breast
may be associated with an oil cyst, containing liquid fat
triggered by localised trauma, radiotherapy or surgery - inflammatory reaction resulting in fibrosis and necrosis of fat tissue
O/E - Painless, Firm, Irregular, Fixed in local structures, There may be skin dimpling or nipple inversion
USS or mammogram can show similar appearance - histology (by fine needle aspiration or core biopsy) to confirm diagnosis
Treated conservatively. May resolve spontaneously with time. Surgical excision if required.
Summary of lipoma?
benign tumours of fat (adipose) tissue - can occur anywhere on the body
O/E - soft, painless, mobile, do not cause skin changes
Treated conservatively with reassurance. Also surgically removed.
Summary of galactocele?
Occur in women that are lactating (producing breast milk), often after stopping breastfeeding
Breast milk filled cysts that occur when the lactiferous duct is blocked, preventing the gland from draining milk
O/E - firm, mobile, painless lump, usually beneath the areola
Benign and resolve w/o Tx. Rarely can become infected and require antibiotics
Summary of phyllodes tumour?
rare tumours of the connective tissue (stroma) of the breast, occurring most often between ages 40 and 50
large and fast-growing
benign (~50%), borderline (~25%) or malignant (~25%) - malignant can metastasise
Tx - surgical removal of tumour and wide excision. They can reoccur after removal
Chemo in malignant or metastatic tumours
Summary of gynaecomastia?
refers to the enlargement of the glandular breast tissue in males
high oestrogen and low androgen - raised oestrogen stimulates breast development, whilst androgens have an inhibitory effect on breast development.
Prolactin also stimulates glandular breast tissue development, dopamine inhibits prolactin so dopamine antagonists also cause gynaecomastia.
causes increased oestrogen - obesity, testicular cancer, liver cirrhosis/failure, hyperthyroidism, hCG (SCLC)
causes that reduced testosterone - deficiency in older age, hypothalamus/pituitary conditions that reduce LH/FSH, Klinefelter syndrome, orchitis, testicular damage
medications - anabolic steroids, antipsychotics, digoxin, spironolactone, GnRH agonists, opiates, marijuana, alcohol
O/E - firm tissue behind areola (not soft and evenly distributed like in pseudogynaecomastia)
Ix - U&E, LFT, TFT, testosterone, SHBG, oestrogen, prolactin, LH + FSH, AFP and b-hCG, genetic karyotyping
If problematic - tamoxifen, surgery
Summary of galactorrhea?
refers to breast milk production not associated with pregnancy or breastfeeding.
breast milk is produced in response to prolactin (from AP). oxytocin stimulates breast milk excretion. during pregnancy O+P inhibit secretion of prolactin.
due to hyperprolactinaemia:
idiopathic
prolactinomas
endocrine disorders - hypothyroidism, PCOS
medications - dopamine antagonists
other Sx of hyperprolactinaemia - menstrual irregularities, reduced libido, ED, gynaecomastia
Ix - pregnancy test, prolactin, U&Es, LFTs, TFTs, MRI
Tx - dopamine agonists (bromocriptine, Cabergoline), transphenoidal surgery
Summary of mammary duct ectasia?
benign condition where there is dilation of the large ducts in the breasts. There is inflammation in the ducts, leading to intermittent discharge from the nipple. The discharge may be white, grey or green
occurs most frequently in perimenopausal women.
RF - Smoking
Features - nipple discharge, tenderness or pain, nipple retraction or inversion, breast lump
Dx - exclude breast ca
Microcalcifications found on mammogram
Ductography - contrast and mammogram
Nipple discharge cytology
Ductoscopy
Tx - may resolve w/o Tx, not associated with increased risk of cancer
Reassurance, Sx relief of mastalgia, ABx, surgical excision in problematic cases
Summary of intraductal papilloma?
Warty lesion that grows within one of the ducts in the breast. Result of proliferation of epithelial cells. Benign tumours but can be associated with atypical hyperplasia or breast cancer
Commonly 35-55
Features - clear or blood-stained nipple discharge, tenderness/pain, palpable lump
Dx - triple assessment, duct-graphs (‘filling-defect’)
Tx - complete surgical excision - tissue examined for atypical hyperplasia or cancer
Summary of mastitis?
refers to inflammation of breast tissue and is a common complication of breastfeeding. W or w/o infection
Caused by obstruction in ducts and accumulation of milk, or by infection - most common bacterial cause is Staph aureus
Features - breast pain and tenderness (unilateral), erythema in focal area of breast tissue, local warmth and inflammation, nipple discharge, fever
Tx - continued breastfeeding, expressing milk, breast massage, heat packs, warm showers, simple analgesia, if conservative management not effective or suspect infection > flucloxacillin (or erythromycin)
milk sample for C&S.
breast abscess if mastitis not adequately treated - incision and drainage
Summary of candida of the nipple?
Candidal infection of the nipple can occur, often after a course of antibiotics.
Can lead to recurrent mastitis - causes cracked skin on the nipple that creates an entrance for infection
Associated with oral thrush and candidal nappy rash in the infant.
Features - bilateral sore nipples, nipple tenderness and itching, cracked, flaky or shiny areola, baby - white patchs in mouth/tongue, candid nappy rash
Tx - both mother and baby - Topical miconazole 2% to the nipple, after each breastfeed, Treatment for the baby (e.g., oral miconazole gel or nystatin)
Summary of breast abscess?
a collection of pus within an area of the breast, usually caused by a bacterial infection. This may be a:
Lactational abscess (associated with breastfeeding)
Non-lactational abscess (unrelated to breastfeeding)
RF - Smoking, Damage to the nipple (e.g., nipple eczema, candidal infection or piercings), Underlying breast disease (e.g., cancer) can affect the drainage of the breast, predisposing to infection.
Causes - Staphylococcus aureus (the most common), Streptococcal species, Enterococcal species, Anaerobic bacteria (such as Bacteroides species and anaerobic streptococci)
Features - mastitis Sx, swollen, fluctuant, tender lump within the breast, Sx of infection
Tx - referral to on-call surgical team, antibiotics, US, drainage, MC&S of drained fluid
RFs for breast cancer?
Female (99% of breast cancers)
Increased oestrogen exposure (earlier onset of periods and later menopause)
More dense breast tissue (more glandular tissue)
Obesity
Smoking
Family history (first-degree relatives)
Small increase - COCP (returns to normal 10yrs after stopping pill)
Combined HRT
BRCA genes - tumor suppressor genes, also TP53 and PTEN
Types of breast cancer?
Ductal carcinoma in situ - pre-cancerous/cancerous epithelial cells of breast ducts, localised to single area, picked up by mammogram, potential to become invasive, good prognosis if fully excised and adjuvant Tx
Lobular carcinoma in situ - pre-cancerous typically occurring in pre-menopausal women, usually diagnosed incidentally on breast biopsy, ^ risk of invasive breast cancer in future, close monitoring (6 month exams and yrly mammograms)
Invasive ductal carcinoma NST - no specific type, originates in cells from breast ducts, 80% of breast cancers, seen on mammograms
Invasive lobular carcinomas - originate in cells from breast lobules, not always visible on mammograms
Inflammatory breast cancer - presents similarly to breast abscess or mastitis, swollen, warm, tender breast with pitting skin, doesn’t respond to ABx, worse prognosis than other breast cancers
Paget’s disease of nipple - looks like eczema of nipple, erythematous, scaly rash, may represent DCIS or invasive breast cancer
Rarer types - medullary, mutinous, tubular, multiple others
How to manage high-risk patients of breast cancer?
There are specific criteria for a referral from primary care for patients that may be at higher risk due to their family history. For example:
A first-degree relative with breast cancer under 40 years
A first-degree male relative with breast cancer
A first-degree relative with bilateral breast cancer, first diagnosed under 50 years
Two first-degree relatives with breast cancer
Seen in 2’ care breast clinic or specialist genetic clinic. Genetic counselling. Annual mammogram. Chemoprevention (tamoxifen/anastrozole), Risk-reducing bilateral mastectomy or bilateral oophorectomy
What is sentinel LN biopsy?
Sentinel node biopsy is performed during breast surgery for cancer. An isotope contrast and a blue dye are injected into the tumour area. The contrast and dye travel through the lymphatics to the first lymph node (the sentinel node). The first node in the drainage of the tumour area shows up blue and on the isotope scanner. A biopsy can be performed on this node, and if cancer cells are found, the lymph nodes can be removed.
Where does breast cancer metastasise to?
L – Lungs
L – Liver
B – Bones
B – Brain
Breast cancer receptors?
Oestrogen receptors (ER)
Progesterone receptors (PR)
Human epidermal growth factor (HER2)
Triple-negative breast cancer is where the breast cancer cells do not express any of these three receptors. This carries a worse prognosis, as it limits the treatment options for targeting the cancer.
Staging of breast cancer?
Triple assessment
LN assessment and biopsy
MRI of breast and axilla
Liver US for mets
CT TAP
Isotope bone scan
TNM staging
Tx for breast cancer?
Surgery:
The objective is to remove the cancer tissue along with a clear margin of normal breast tissue. The options are:
Breast-conserving surgery (e.g., wide local excision), usually coupled with radiotherapy
Mastectomy (removal of the whole breast), potentially with immediate or delayed breast reconstruction
Removal of the axillary lymph nodes is offered to patients where cancer cells are found in the nodes. Usually, the majority or all lymph nodes are removed from the axilla. This increases the risk of chronic lymphoedema in that arm.
Radiotherapy and chemotherapy
Hormone therapy - ER +ve (tamoxifen and anastrozole), HER2 (trastuzumab (Herceptin) and pertuzumab (perjeta) both MAB, and neratinib (Nerlynx) which is tyrosine kinase inhibitor)
