Common Breast Conditions Flashcards
(44 cards)
1
Q
State some common causes for breast lumps (9)
A
- Fibroadenoma
- Fibrocystic breast disease (fibroadenosis)
- Breast cysts
- Breast abscess
- Fat necrosis
- Lipoma
- Phyllodes tumour
- Breast cancer
- Mammary duct ectasia
2
Q
Of the breast lumps we have previously stated, state which are inflammatory
A
- Breast abscess
- Breast cyst
- Fat necrosis
- Mammary duct ectasia
3
Q
Of the breast lumps we have previously stated, state which are benign tumours
A
- Fibroadenoma
- Fibrocystic breast disease
- Lipoma
- Phyllodes tumour
4
Q
Discuss for fibroadenoma:
- Alternative name
- What they are
- Who they are common in
- How they feel on examination
- Prognosis/development
- Indications for surgical removal
A
- Breast mouse (because they are small & mobile)
- Benign tumours of stromal and epithelial breast duct lobules
- Younger pts (<40yrs)
- Smooth, well-circumcised, firm, mobile lump, usually up to 3cm
- 10% dissappear ever yr, hormone dependent so regress after menopause. Very low malignant potential
- Size >3cm or pt preference
5
Q
Discuss for fibrocystic breast disease (fibroadenosis):
- Symptoms & signs
- Who they are common in
- Whether they change throughout menstrual cycle
- Prognosis/progression
- Management
A
- Symptoms & signs:
- Bilateral breast lumpiness
- Bilateral breast pain/tenderness (mastalgia)
- Fluctation of breast size
- Fibrous & cystic changes in breast epithelium; refers to wide variety of benign histological changes in breast epithelium
- Menstruating women (pre-menopausal)
- Related to hormonal changes in menstrual cycle; symptoms occur prior to menstruating (~10 days) and resolve afterwards
- Benign but can vary in severity and therefore have impact on quality of life. Usually resolve after menopause
- Treatment:
- Supportive clothing/bras
- NSAIDs
- Weight loss
- Hormone contraception may worsen so consider stopping this
6
Q
Discuss for breast cysts:
- What they are
- Who they are common in
- How they feel upon examination
- Any variation with menstrual cycle
- Management
- Complications
A
- Epithelial lined fluid-filled cavities, which form when lobules become distended due to blockage
- 30-60yrs
- Smooth, well-circumscribed, mobile, possibly fluctuant lump that may be tender on palpation. Can be singular, multiple. Can be unilateral or bilateral.
- Can fluctate in size during menstrual cycle
- Management:
- Usually resolve therefore no further management
- If large, symptomatic or persisting may be aspirated (so long as aspirate contains no blood don’t need to send for cytology)
- Complications:
- Re-occurence (common)
- Fibrocystic breast disease
- Increased risk of breast ca (2-3 times greater risk)
7
Q
Discuss for breast abscess:
- What it is
- Symptoms & signs
- How the lump feels on examination
- Management
A
- A breast abscess is a collection of pus within the breast lined with granulation tissue due to an infection in breast tissue (usually bacterial)
- Breat lump & associated features e.g. fever, pus discharge from nipple, local erythema, tenderness & heat
- Fluctuant lump
- Mangement:
- Antibiotics and therapeutic needle aspiration
- Larger abscesses may require surgical drainage
8
Q
Discuss for fat necrosis of breast:
- What it is
- Common causes
- Symptoms
- How the lump feels on examination
- Associated signs upon examination
- Management
A
- Acute inflammatory response in breat tissue leading to ischaemic necrosis of fat lobules/tissue in breast; can lead to fibrotic changes in breast (the lump)
- Trauma, breast surgery, radiological intervention
- Usually asymptomatic or presents with lump; lump may sometimes has associated signs
- Firm, irregular, fixed
- Skin dimpling, nipple inversion, nipple discharge
- Management: usually conservative (reassurance, analgesia if required).
9
Q
Discuss for lipoma:
- What it is
- Symptoms
- How lump feels on examination
- Management
A
- Benign collection of fat
- Asymptomatic other than lump
- Soft, mobile lump, non-tender
- Mangement: reassurance. Only excise if becoming large, have compressive symptoms or aesthetic issues
10
Q
Discuss for phyllodes tumour:
- What it is
- Who it is common in
- Whether they are benign or malignant
- Common?
- Management
A
- Fibroepithelial tumours compromised of both epithelial and stromal tissue
- Older (40-50’s)
- About 50% benign, 25% bordeline and 25% malignant
- Rare
- Rare (1% of breast neoplasms)
- Management: excision (because of malignant potential)
11
Q
Discuss for mammary duct ectasia:
- What it is
- Symptoms
- Mammography findings
- Biopsy findings
- Management
A
- Inflammation of blocked mammary ducts resulting in dilation and shortening of mammary ducts; fluid can then collect in the widened ducts
- Palpable mass, yellow/green nipple discharge, nipple retraction
- Dilated calcified ducts on mammography
- Multiple plasma cells
- Managed conservatively (as usually resolves). May do surgical excision if persistent nipple dischare
12
Q
Discuss for intra-ductal papilloma:
- What it is
- Is it common
- Age it affects
- Typical presentation
- Increased risk of breast cancer?
- Management
A
- Benign tumour in ducts of breast tissue
- Rare
- 40-50yrs
- Often present with clear or bloody discharge. Some will present with a subareolar lump
- Risk of breast cancer only increased with multi-ductal papilloma
- Microdochectomy (removal of duct/affected ducts)
13
Q
Discuss for breast cancer:
- Presentation
- How lump feels on examination
A
- Presentation varies as pt may be aysmptomatic and cancer picked up on screening or pt may have: breast lumps, swelling, asymmetry, nipple retraction, nipple discharge, peau d’orange, Paget’s-like changes, mastalgia, lump in axilla
- Hard, irregular, fixed, painless to palpate
- Mangaement: surgical excision, hormone therarpy, radiotherapy, chemotherapy (more on this in Yr4 Cancer care)
14
Q
Nipple retraction can be slit like or circumferential; which is more likely to be associated with underlying carcinoma?
A
- Circumferential= more likely underlying carcinoma
- Slit like= often associated with duct ectasia
15
Q
Discuss which pts you would refer by the two week wait referral for breast cancer (NICE 2021)
A
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer if:
- They are aged 30 years and over and have an unexplained breast lump with or without pain, or
- They are aged 50 years and over with any of the following symptoms in one nipple only:
- Discharge.
- Retraction.
- Other changes of concern.
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer in people:
- With skin changes that suggest breast cancer, or
- Aged 30 years and over with an unexplained lump in the axilla.
Consider non-urgent referral in people aged under 30 years with an unexplained breast lump with or without pain.
16
Q
What is the triple assessment clinic?
A
- Hosptial based assessment clinic that allows for the early and rapid detection of brest cancer.
- One stop clinic that pts are referred to if breast cancer is suspected
17
Q
Discuss what is involved in the triple assessment
A
18
Q
State some key questions to ask in breast cancer history; include breast specific questions, lump specific questions (if appropriate) and general questions
A
Breast specific
- Lump
- Pain
- Nipple retraction
- Nipple discharge
- Skin changes
- Breast distortion
- Swelling/inflammation
Lump specific
- Site
- Size
- Shape
- Margins
- Increase in size
- Fixed/moile
- Hard/firm/smooth
19
Q
How do we convert results of triple assessment into a universally understood format/grading system?
A
At each stage, the suspicion for malignancy is graded based on examination score (P), imaging score (M or U) and histology score (B). Graded 1-5.
20
Q
State some features on mammogram that may suggest breast cancer
A
- Irregular, spiculated, radioopaque mass with microcalcification
21
Q
Who are mammograms more suitable for and why?
Who are USS more suitable for and why?
A
- Mammograms: >40yrs
- USS: <40yrs
Younger pts have denser breasts
22
Q
State some common places for breast cancer to metastasise to
A
- Lung
- Liver
- Bone
- Brain
- Adrenal
- Ovary
23
Q
Discuss a potential treatment regime for someoen with breast cancer
A
DXT= radiotherapy
24
Q
What are the two options for breast surgery for cancer?
A
- Wide local excision
- Mastectomy
- +/- axillary dissection/clearance
25
Hormonal treatments for breast cancer can be oestrogen antagonists or aromatase inhibitors; for each discuss:
* Examples
* Mechanism of action
* Whether works in pre & post-menopausal women
* DVT risk
* Osteoporosis risk
* Risks of developing any other cancers
26
Oncoplastic surgery to reconstruct breast may be required after surgery for breast cancer; state some of the options for oncoplastic surgery
27
For Paget'd disease of the nipple discuss:
* How it appears
* What it is associated with
* How to differentiate from eczema
* Red, scaley rash of skin over nipple & areola. May be ithcy, painful or have burning sensation. May have discharge or bleeding from nipple. Nipple may become inverted.
* Associated with breast cancer
* Paget's always starts at nipple and moves outwards
28
What is mastitis?
What is the most common cause?
Discuss the two different types of mastitis
* Inflammation of breast tissue
* Infection with Staphylococcus auerus
* Types:
* Lactational mastitis: *associated cracked nipples, milk stasis, more common first child, more common in first few months and when weaning*
* Non-lactational mastitis: *more common in women with conditions such as duct ectasia or in women who smoke*
29
How does smoking increase risk of non-lactational mastitis?
Causes damage to subareolar ducts which prediposes them to bacterial infection
30
State signs & symptoms of mastitis
The affected breast may be:
* Painful (mastalgia)
* Tender
* Swollen
* Erythematous
31
Discuss the mangaement of mastitis, include any additional management for lactational mastalgia
Mastitis management:
* Abx
* Simple analgesics e.g. paracetamol, NSAIDs
Additional management for lactational mastitis:
* Continue to feed from affected breast or express milk if cannot feed from it
* Dopamine agonists e.g. cabergoline may be used in women with persistent or multiple areas of infection
32
What is galactorrhoea?
**Copious, bilateral, multi-ductal, milky discharge, not associated with pregnancy or lactation.**
* In post-partum women this includes milk production occuring 6-12 months after pregnancy and the cessation of breast feeding.*
* IMPORTANT to distinguish between true galactorrhoea and other causes of nipple discharge*
33
Galactorrhoea is usually caused by hyperprolactinaemia; normoprolactinaemic galactorrhoea is rarer and typically idiopathic. State some causes of hyperprolactinaemia
* Idiopathic (40%)
* Pituitary Adenoma/prolactinoma
* **Drugs** e.g. SSRIs, anti-psychotics, or H2-antagonists
* **Neurological** (neurogenic pathways are activated to inhibit dopamine levels) such as varicella zoster infection or spinal cord injury
* **Hypothyroidism** (elevated TRH can also stimulate prolactin release)
* **Cushing’s disease, Acromegaly, and Addison’s disease** have also been associated with the condition.
* **Renal failure**
* **Liver failure**
* **Damage to the pituitary stalk from surgical resection, multiple sclerosis, sarcoidosis, or tuberculosis** (results in reduced dopamine reaching pituitary to inhibit prolactin release)
34
What might you find on clinical examination of someone with galactorrhoea?
* Breast examination often normal
* Check for other findings that may suggest cause of hyperprolactinaemia e.g. bitemporal hemianopia, signs of hypothyroidism
35
What investigations, and why, would you do for galactorrhoea include:
* Bedside
* Bloods
* Imaging
_Bedside_
* Pregnancy test
_Bloods_
* Prolactin: *is it hyperprolactinaemic galactorrhoea*
* TFTs: *rule out hypothryoidsm as cause*
* LFTs: *rule out liver failure*
* U&Es: *check kideny func, ?renal failure*
_Imaging_
* MRI head with contrast: *pituitary adenoma*
36
Discuss the management of galactorrhoea, inlcude management of:
* Hyperprolactinaemic galactorrhoea
* Normoprolactinaemic galactorrhoea
_Hyperprolactinaemia galactorrhoea_
* Treat underlying cause
* Dopamine agonists e.g. cabergoline if awaiting definitive treatment
_Normoprolactinaemic galactorrhoea_
* Often resolves spontaenously but if doesn't can trial low dose dopamine antagonist
* \*NOTE: if troublesome galactorrhoea intolerant of treatment can have bilateral total duct excision*
37
Gynaecomastia can be physiological or pathological; explain the difference
* Physiological occurs during adolescence resulting from delayed testosterone surge relative to oestrogen in puberty
* Pathological results from increase in oestrogen:androgen ratio and usually has an underlying cause
38
State some potential causes of pathological gynaecomastia
* Lack of testosterone
* Androgen insensitivtiy
* Testicular atrophy
* Renal disease
* Increased oestrogen
* Liver disease
* Hyperthyroid
* Obesity
* Adrenal tumours
* Testicular tumours e.g. Leydig tumours
* Medication:
* Anabolic steroids
* Spironolactone
* Metronidazole
* Digoxin
* Idiopathic
39
How does gynaecomastia feel on examination?
Rubbery, firm mass that starts underneath nipple and spreads outwards
40
Tests are only necessary if cause of gynaecomastia is uncertain; true or false?
True
41
What do following results suggest about gynaecmastia:
* LH high and testosterone low
* LH low and testosterone low
* LH high and testosterone high
* LH high and testosterone low = testicular failure
* LH low and testosterone low = increased oestrogen
* LH high and testosterone high = androgen resistance or gonadotrophin-secreting malignancy
42
Discuss the management of gynaecomastia
* Treat underlying reversible cause
* Tamoxifen can be used to alleviate symptoms e.g. tenderness
* Surgery if other treatment fails
43
If someone young presents with gynaecomastia, particularly a young person, what do you want to examine?
Testes
44
Compare the age distribution of the 4 main types of breast lumps according to age:
* Fibroadenoma
* Fibrocystic chagnes
* Cysts
* Cancer
