Breast Medicine Flashcards

Question

What is an intraductal papilloma?

Answer 1

* **Intraductal papilloma** = **warty lesion** that grows within a **breast duct** - as a result of **proliferation of epithelial cells** * **Intraductal papillomas = benign tumours** (but can be associated with atypical hyperplasia or breast cancer)

Answer 2

Typically **asymptomatic** Occur at any age - typically 35-55 years * **Nipple discharge (clear or blood-stained)** * **Tenderness** or **pain** * A **palpable lump**

Answer 3

Patients require triple assessment with: * **Clinical assessment** (history and examination) * **Imaging** (ultrasound, mammography and MRI) * **Histology** (usually by core biopsy or vacuum-assisted biopsy) **Ductography** = may also be used This involves injecting contrast into the abnormal duct and performing mammograms to visualise that duct. The papilloma will be seen as an area that does not fill with contrast (a “filling defect”).

Answer 4

**Complete surgical excision** After removal, the tissue is examined for atypical hyperplasia or cancer that may not have been picked up on the biopsy.

Answer 5

**Collection of pus** within the area of the breast - usually caused by a bacterial infection * **Lactational abscess** (associated with breastfeeding) * **Non-lactational abscess** (unrelated to breastfeeding)

Answer 6

Lactational abscess

Answer 7

**Dead white blood cells** Pus = a thick fluid produced by inflammation. It contains dead white blood cells of the immune system and other waste from the fight against the infection. When pus becomes trapped in a specific area and cannot drain, an abscess will form and gradually increase in size.

Answer 8

**Mastitis = inflammation of breast tissue** * Often related to breastfeeedimg (**lactational mastitis**) - although can be caused by **infection** * Bacteria can enter at the nipple and back-track into the ducts, causing infection and inflammation. * **Mastitis caused by infection** = may precede the development of an **abscess**

Answer 9

**Damage to the nipple:** * Nipple eczema * Candidal infectiom * Piercings Underlying **breast disease:** * Cancer (Can affect the drainage of the breast - prepdisposing it to infection)

Answer 10

* **Staphylococcus aureus** (the most common) * Streptococcal species * Enterococcal species * Anaerobic bacteria (such as Bacteroides species and anaerobic streptococci)

Answer 11

**Penicillins** **Flucloxacillin** = used against **staph aureus** skin infections

Answer 12

* Co-amoxiclav (plus clavulanic acid) * **Metronidazole** Simple penicillins (amoxicillin or flucloxacillin) = wont work

Answer 13

Usually acute (a few days)

Answer 14

* **Nipple changes** * **Purulent nipple discharge** (pus from the nipple) * **Localised pain** * Tenderness General inflammation: * Warmth * Erythema (redness) * Hardening of the skin or breast tissue * Swelling

Answer 15

Swollen, **fluctuant**, tender lump within the breast **Fluctuance** = being able to move fluid around within the lump using pressure during palpation. Where there is infection without an abscess, there can still be hardness of the tissue, forming a lump, but it will not be fluctuant as it is not filled with fluid.

Answer 16

**Abscess** → **fluctuance** around the hard lump Where there is infection without an abscess, there can still be hardness of the tissue, forming a lump, but it will not be fluctuant as it is not filled with fluid.

Answer 17

* Muscle aches * Fatigue * Fever * Signs of sepsis (e.g., tachycardia, raised respiratory rate and confusion)

Answer 18

**Lactational mastitis** = caused by blockage of the ducts **Conservative management**: * Continued breastfeeding, expressing milk, breast massage * Heat packs, warm showers, simple analgesia **Antibiotics** (**flucloxacillin** or erythromycin/clarithromycin (penicillin allergy)) = required where infection is suspected or symptoms do not improve

Answer 19

* **Analgesia** * **BROAD-SPECTRUM ANTIBIOTICS** (**co-amoxiclav**; or **erythromycin/clarithromycin + metronidazole**) * Treatment for **underlying cause** (e.g. eczema or candidal infection) ## Footnote Erythromycin/clarithromycin (macrolides) Metronidazole (to cover anaerobes)

Answer 20

* **Referral** to the on-call surgical team in the hospital for management * **Antibiotics** * **Ultrasound** (confirm the diagnosis and exclude other pathology) * **Drainage** (**needle aspiration** or **surgical incision** and **drainage**) * **Microscopy**, **culture** and **sensitivities** of the drained fluid ## Footnote Women who are breastfeeding are advised to continue breastfeeding when they have mastitis or breast abscesses. They should regularly express breast milk if feeding is too painful, then resume feeding when possible. This is not harmful to the baby and is important in helping resolve the mastitis or abscess

Answer 21

**Mammary duct ectasia** = benign condition - there is dilation of the large ducts in the breasts **Ectasia = dilation** There is **inflammation in the ducts** → leading to **intermittent discharge from the nipple** → **white, grey, or green discharge**

Answer 22

**Perimenopausal women**

Answer 23

Smoking ## Footnote Smoking is very bad for boobs!

Answer 24

* **Nipple discharge (white, grey, green)** * **Tenderness or pain** * **Nipple retraction or inversion** * A **breast lump** (pressure on the lump may produce nipple discharge)

Answer 25

Priority is to exclude breast cancer (as they can present in similar ways) * **Clinical assessment** (history and examination) * **Imaging** (ultrasound, mammography and MRI) * **Histology** (fine needle aspiration or core biopsy) **Microcalcifications** = are found on the **mammogram** (but no specific to mammary duct ectasia) Other investigations: * **Ductography** – contrast is injected into an abnormal duct, and mammograms are performed to visualise the duct * **Nipple discharge cytology** – examining the cells in a sample of the nipple discharge * **Ductoscopy** – inserting a tiny endoscope (camera) into the duct

Answer 26

May resolve without any treatment * **Reassurance** * **Symptomatic management of mastalgia** (supportice bra + warm compress) * **Antibiotics** (if infected) * **Surgical excision** (microdochectomy) - may be required in problematic cases

Answer 27

Normally clinical diagnosis Investigations to consider: * **Breast ultrasound**: used to confirm breast abscess

Answer 28

* Effective milk removal (encourage **breastfeeding**) * Antibiotics: **Flucloxacillin** = first-line

Answer 29

* First-line: **co-amoxiclav** * Analgesia * Hot compress

Answer 30

Refer urgently to surgeons: for confirmation of diagnosis by ultrasound and drainage of the abscess (by ultrasound-guided aspiration or incision and drainage)

Answer 31

* **Cessation of breastfeeding** → increased risk of **breast abscess ** * **Emotional distress** * **Sepsis** (immunocomprised patients are at higher risk)

Answer 32

Breast cancer

Answer 33

* 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) The **combined contraceptive pill** = gives a small increase in the risk of breast cancer, but the risk returns to normal ten years after stopping the pill **Hormone replacement therapy (HRT)** = increases the risk of breast cancer, particularly combined HRT (containing both oestrogen and progesterone). MORE OESTROGEN EXPOSURE THROUGHOUT LIFE

Answer 34

**BRCA** = refers to the **BR**east **CA**ncer gene. * **BRCA genes = tumour suppressor genes** * Mutations in these genes lead to an increased risk of breast cancer (as well as ovarian and other cancers). The **BRCA1 gene** is on **chromosome 17**. In patients with a faulty gene: * Around 70% will develop breast cancer by aged 80 * Around 50% will develop ovarian cancer * Also increased risk of bowel and prostate cancer The **BRCA2 gene** is on **chromosome 13**. In patients with a faulty gene: * Around 60% will develop breast cancer by aged 80 * Around 20% will develop ovarian cancer There are other rarer genetic abnormalities associated with **breast cancer** (e.g., **TP53** and **PTEN** **genes**).

Answer 35

Adenocarcinomas

Answer 36

Site: **ductal** or **lobular** **Invasion** of **basement membrane (BM)** : * **In-situ: no invasion** of the BM * **Invasive: invasion** of the BM

Answer 37

* ** Pre-cancerous** or **cancerous epithelial cells** of the **breast ducts** * Localised to a **single area** * Often picked up by mammogram screening * Potential to spread locally over years * Potential to become an invasive breast cancer (around 30%) * **Good prognosis** if full excised and adjuvant treatment is used

Answer 38

* A **pre-cancerous condition** occurring typically in **pre-menopausal women** * Usually **asymptomatic** and undetectable on a mammogram * Usually diagnosed incidentally on a **breast biopsy** * Represents an **increased risk of invasive breast cancer** in the future (around 30%) * Often managed with close monitoring (e.g., 6 monthly examination and yearly mammograms)

Answer 39

* NST means no special/specific type, where it is not more specifically classified (e.g., medullary or mucinous) * Also known as **invasive breast carcinoma of no special/specific type (NST)** * **Originate in cells from the breast ducts** * **80% of invasive breast cancers fall into this category** * Can be **seen on mammograms**

Answer 40

* Around 10% of invasive breast cancers * **Originate in cells from the breast lobules** * **Not always visible on mammograms**

Answer 41

* 1-3% of breast cancers * **Presents similarly to a breast abscess or mastitis** * **Swollen, warm, tender breast with pitting skin (peau d’orange)** * **Does not respond to antibiotics** * Worse prognosis than other breast cancers

Answer 42

* Looks like **eczema of the nipple/areolar** * **Erythematous, scaly rash** * **Indicates breast cancer involving the nipple** * May represent **DCIS** or **invasive breast cancer** * Requires biopsy, staging and treatment, as with any other invasive breast cancer

Answer 43

* Ductal Carcinoma In Situ (DCIS) * Lobular Carcinoma In Situ (LCIS) * Invasive Ductal Carcinoma - NST * Invasive Lobular Carcinoma (ILC) * Inflammatory Breast Cancer * Paget's Disease of the Nipple

Answer 44

Endogenous vs exogenous oestrogen Endogenous oestrogen: * Obesity * Early menarche * Late menopause * Late pregnancy/nulliparity (breast feeding + multiparity are protective) Exogenous oestrogen: * Hormone replacement therapy * Oral contraceptive use

Answer 45

**Signs**: * **Palpable mass** (firm + non-tender; poorly defined; located in the upper outer quadrant most commonly) * **Evidence of metastasis** (Axillary lymphadenopathy; bone, liver, lung, brain) **Symptoms**: * **Tethering**: mass fixes to surrouning structures e.g. fascia, pectoral muscle or Cooper ligaments * **Discolouration** * **Erythema, sweeling and Peau d'orange** = suggestive of inflammatory carcinoma **Nipple changes**: * **Inversion** * **Bloody discharge** * **Eczema**

Answer 46

Two week wait referral for suspected breast cancer: * An unexplained breast lump in patients aged 30 or above * Unilateral nipple changes in patients aged 50 or above (discharge, retraction or other changes) Also: * Unexplained lump in the axilla in patients aged 30 or above * Skin changes suggestive of breast cancer The NICE guidelines suggest considering non-urgent referral for unexplained breast lumps in patients under 30 years.

Answer 47

Once a patient has been referred for specialist services under a two week wait referral for suspected cancer, they should initially receive a triple diagnostic assessment comprising of: * **Clinical assessment** (history and examination) * **Imaging** (ultrasound or mammography) * **Biopsy** (fine needle aspiration or core biopsy)

Answer 48

* **Younger women (under 30)** → **more dense breasts** with **more glandular tissue** → **ultrasound scan** (helpful in distinguishing solid lumps (e.g., fibroadenoma or cancer) from cystic (fluid-filled) lumps) * **Older women → mammogram** (pick up calcifications missed by ultrasound) **MRI scans** may be used: * For screening in **women at higher risk** of developing breast cancer (e.g., strong family history) * To **further assess** the size and features of a tumour

Answer 49

* **Core biopsy** * Fine needle aspiration

Answer 50

* Triple assessment * Biopsy (core biopsy, fine needle aspiration)

Answer 51

**Lymph node assessment** * To see if cancer has spread to the lymph nodes * **Ultrasound of the axilla (armpit)** and ultrasound-guided biopsy of any abnormal nodes. **A sentinel lymph node biopsy** may be used during breast cancer surgery where the initial ultrasound does not show any abnormal nodes.

Answer 52

* 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.

Answer 53

* Oestrogen receptor (ER) * Progesterone (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.

Answer 54

2Ls + 2Bs * L - Lungs * L - Liver * B - Bones * B - Brain

Answer 55

TOM TIP: Breast cancer can spread to any region of the body. In patients with a metastatic tumour, regardless of where it is, the primary could be breast cancer. This is worth remembering, as you may be asked “where might this metastasis have originated” in an exam or OSCE scenario. If the patient is female, answering “breast cancer” will be a good answer. The other cancer that can spread practically anywhere, and may be less obvious, is melanoma (a type of skin cancer).

Answer 56

TNM system * T - Tumour * N - Node * M - Metastasis

Answer 57

First step → triple assessment Additional investigations: * Lymph node assessment and biopsy * MRI of the breast and axilla * Liver ultrasound for liver metastasis * CT of the thorax, abdomen and pelvis for lung, abdominal or pelvic metastasis * Isotope bone scan for bony metastasis

Answer 58

* **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 * **Axillary clearance** - 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 → increases risk of **chronic lymphoedema** in that arm ## Footnote Areas of lympoedema = prone to infection → avoid taking blood/cannulating from that arm

Answer 59

* **Neoadjuvant therapy** – intended to shrink the tumour before surgery * **Adjuvant chemotherapy** – given after surgery to reduce recurrence * **Treatment** of metastatic or recurrent breast cancer

Answer 60

* **Tamoxifen** (for **premenopausal women**) * **Aromatase inhibitors** e.g. letrozole, anastrozole (for **postmenopausal women**)

Answer 61

Tamoxifen = a **selective oestrogen receptor modulator (SERM)** → either **blocks** or **stimulates** oestrogen receptors (depending on the site of action) * **Blocks** oestrogen receptors in **breast tissue** * **Stimulates** oestrogen receptors in the **uterus + bones** So - it helps prevent osteoporosis - but increases risk of endometrial cancer ## Footnote **B**locks **b**reast

Answer 62

Aromatase = an enzyme found in fat (adipose) tissue - that converts androgens to oestrogen After menopause - the action of aromatase in fat tissue is the primary source of oestrogen **Aromatase inhibitors = block the creation of oestrogen in fat tissue**

Answer 63

5-10 years

Answer 64

* **Fulvestrant** (selective oestrogen receptor downregulator) * **GnRH agonists** (e.g., goserelin or leuprorelin) * **Ovarian surgery**

Answer 65

* **Trastuzumab (Herceptin)** = a **monoclonal antibody** → targets HER2 receptor * **Pertuzumab (Perjeta)** = a **monoclonal antibody** → targets the HER2 receptor * **Neratinib (Nerlynx)** = **tyrosine kinase inhibitor** → reducing growth of breast cancers

Answer 66

Mammograms **yearly** for **5 years** (longer if they are not yet old enough for the regular breast screening programme)

Answer 67

* **Immediate reconstruction**, done at the time of the mastectomy * **Delayed reconstruction**, which can be delayed for months or years after the initial mastectomy

Answer 68

* **Partial reconstruction** (using a flap or fat tissue to fill the gap) * **Reduction + reshaping** (removing tissue + reshaping both breasts to match)

Answer 69

* **Breast implants** (inserting a synthetic implant) * **Flap reconstruction** (using tissue from another part of the body to reconstruct the breast)

Answer 70

The breast can be reconstructed using a portion of the **latissimus dorsi + associated skin and fat tissue**. The tissue is tunnelled under the skin to the breast area. * “**Pedicled**” = refers to keeping the original blood supply and moving the tissue under the skin to a new location. * “**Free flap**” = refers to cutting the tissue away completely and transplanting it to a new location.

Answer 71

The **breast** can be **reconstructed** using a portion of the **rectus abdominis, blood supply and skin**. This can be either as a: * **Pedicled flap** (tunnelled under the skin) * **Free flap** (transplanted). It poses a risk of developing an abdominal hernia due to the weakened abdominal wall.

Answer 72

* The **breast** can be **reconstructed** using **skin + subcutaneous fat from the abdomen (no muscle)** - as a **free flap**. * The **deep inferior epigastric artery**, with the associated fat, skin and veins, is transplanted from the abdomen to the breast. * The vessels are attached to branches of the internal mammary artery and vein. This is a complex procedure involving microsurgery. There is less risk of an abdominal wall hernia than with a TRAM flap, as the abdominal wall muscles are left intact.

Breast Medicine Flashcards

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