Yr 3 - Core Conditions > Breast > Flashcards

Breast Flashcards

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1
Q

What is a breast abscess?

A

A collection of pus within an area of the breast. Infection can either present as simple mastitis or form a breast abscess.

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2
Q

What are the 4 most common pathogens causing breast abscesses

A
  1. Staph aureus (most common)
  2. Streptococcal species
  3. Enterococcal species
  4. Anaerobic species (e.g. Bacteriodes species & anaerobic streptococci)
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3
Q

What are the 2 types of breast abscess?

A
  1. Lactational abscess
  2. Non-lactational abscess
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4
Q

What is a lactational abscess related to?

A

Breastfeeding

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5
Q

What is pus?

A

Pus is a thick fluid produced by inflammation – contains dead WBCs and other waste

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6
Q

How odes an abscess form?

A

When pus becomes trapped in a specific area and cannot drain, an abscess forms and gradually increases in size

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7
Q

Define mastitis

A

Inflammation of breast tissue

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8
Q

What may precede the formation of an abscess?

A

Mastitis

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9
Q

What is a key risk factor for infective mastitis and breast abscesses?

A

Smoking

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10
Q

Why is smoking a risk factor for mastitis?

A

People who smoke have an increased risk of periductal mastitis because substances in cigarette smoke can damage the ducts behind the nipple.

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11
Q

Give some risk factors for breast abscesses

A
  • Smoking
  • Breastfeeding
  • Damage to nipple (e.g. nipple eczema, candida infection or piercings) provides bacteria entry
  • Underlying breast disease (e.g. cancer) can affect the drainage of the breast, predisposing to infection
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12
Q

Why can cancer predispose to breast abscesses?

A

cancer can affect the drainage of the breast, predisposing to infection

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13
Q

Should breastfeeding be stopped in women with mastitis or breast abscesses?

A

No

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14
Q

Why should women with mastitis or breast abscesses continue to breast feed or regularly express breast milk?

A

This is NOT harmful to the baby and is important in helping resolve the mastitis or abscess.

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15
Q

Onset of mastitis/breast abscess?

A

Acute (within a few days)

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16
Q

Describe some breast signs/symptoms seen in mastitis with infection in the breast tissue

A
  • Nipple changes
  • Purulent nipple discharge (pus from nipple)
  • Localised pain (acutely painful)
  • Tenderness
  • Warmth
  • Erythema
  • Hardening of skin or breast tissue
  • Swelling
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17
Q

What key features of a breast lump would suggest its an abscess?

A
  • Swollen
  • Tender
  • Fluctuant
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18
Q

Define fluctuance of a lump

A

being able to move fluid around within the lump using pressure during palpation

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19
Q

Lump in mastitis vs breast abscess?

A

when there is infection WITHOUT an abscess, there can still be hardness of the tissue forming a lump BUT will not be fluctuant (as not filled with fluid)

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20
Q

What makes a breast abscess fluctuant?

A

Fluid

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21
Q

Other signs seen in breast abscess?

A
  • Muscle aches
  • Fatigue
  • Fever
  • Signs of sepsis e.g. tachycardia, raised RR, confusion → sepsis 6
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22
Q

Describe the management plan for lactational mastitis

A

Caused by blockage of ducts → managed conservatively:

  • Continued breastfeeding
  • Expressing milk
  • Breast massage
  • Heat packs, warm showers & simple analgesia to manage symptoms
  • Antibiotics (flucloxacillin or erythromycin/clarithromycin where there is penicillin allergy) – required where infection is suspected or symptoms do not improve
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23
Q

Describe the management plan for non-lactational mastitis

A
  • Analgesia
  • Antibiotics – need to be broad spectrum (co-amoxiclav or erythromycin/clarithromycin + metronidazole)
  • Treatment for underlying cause (e.g. eczema or candida infection)
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24
Q

What Abx are indicated in non-lactational mastitis?

A

Broad spectrum e.g. co-amoxiclav or erythromycin/clarithromycin + metronidazole

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25
Describe the management of a breast **abscess**
* Referral to on-call surgical team * Antibiotics * US * Drainage (needle aspiration or surgical incision and drainage) * MC&S of drained fluid
26
Define fibrocystic breast changes
The **connective tissues** (stroma), **ducts** and **lobules** of the breast respond to the **female sex hormones** (oestrogen and progesterone), becoming **fibrous** (irregular and hard) and **cystic** (fluid-filled). These changes fluctuate with the **menstrual cycle**.
27
What drives fibrocystic breast changes?
Female sex hormones: oestrogen & progesterone
28
Who are fibrocystic breast changes common in?
Common in women of menstruating age
29
Prognosis of fibrocystic breast changes?
Is a benign (non-cancerous) condition but can vary in severity an affect patient’s quality of life if severe.
30
When do Fibrocystic Breast Changes tend to appear? When do they tend to resolve?
Symptoms usually occur **prior to menstruating** (within 10 days) and resolve once menstruation begins
31
How does menopause typically affect fibrocystic breast changes?
Symptoms usually improve or resolve after menopause
32
Breast symptoms seen in fibrocystic breast changes?
* **Lumpiness** * **Breast pain** or **tenderness** (mastalgia) * Fluctuation of breast size
33
Management of fibrocystic breast changes?
After exclusion of cancer, management involves managing symptoms: * Wearing a supportive bra * NSAIDs * Avoiding caffeine * Applying heat to area * Hormonal treatments (e.g. danazol and tamoxifen) under specialist guidance
34
Define a ductal papilloma
A **warty** lesion that grows within one of the milk **ducts** in the breast.
35
Is a ductal papilloma associated with cancer?
It is a **benign** tumour but can be associated with **atypical** **hyperplasia** or **breast** **cancer**.
36
A ductal papilloma is a proliferation of what cells?
Proliferation of **epithelial** cells that line the ducts.
37
Presentation of a ductal papilloma?
Often asymptomatic – often picked up incidentally on mammograms or ultrasound. * **Nipple** **discharge** – clear or blood-stained * Tenderness or pain * Palpable lump * Usually found \<1cm from nipple
38
Where is the lump of a ductal papilla located?
\<1cm from nipple
39
Describe triple breast assessment
* 1) Clinical assessment (history & examination) * 2) Imaging (US, mammography & MRI) * 3) Histology (usually by core biopsy or vacuum-assisted biopsy)
40
Management of ductal papilloma?
* **_Complete surgical_ _excision_** is required * After removal, tissue is examined for atypical hyperplasia or cancer that may not have been picked up on biopsy
41
What is the most common benign breast lump?
Fibroadenoma
42
Where does a fibroadenoma arise from?
**stromal/epithelial** breast **duct** tissue
43
Who are fibroadenomas typically seen in?
Younger women (20-40) i.e. of reproductive age.
44
Why are fibroadenomas typically seen in younger women?
These tumours respond to the **female** **hormones** (oestrogen & progesterone) which is why they are more common in younger women and often **regress after menopause**.
45
Are fibroadenomas associated with breast cancer?
Not cancerous and not usually associated with an increasing risk of developing breast cancer.
46
Features of a fibroadenoma breast lump
* **_Small_** (usually up to 3cm diameter) * **_Mobile_** within breast tissue (moves freely) – sometimes called a ‘breast mouse’ as they move around within the breast tissue * **Painless** * **Smooth** * **Round** * **Well** **circumscribed** (well-defined borders) * **Firm**
47
Give some **red flags** for a breast lump
* Tethered to skin * Nipple discharge (especially bloody) * Irregular shape * Lymphadenopathy * Dimpling of skin * Puckering of nipple
48
Describe the breast lump in fibrocystic change
Tender & rubbery
49
What is a lipoma? Where can they occur?
Benign tumours of fat (adipose) tissue. Can occur almost anywhere on the body where there is adipose tissue, including the breasts.
50
Presentation of a lipoma?
* Soft * Painless * **Mobile** * Does NOT cause skin changes
51
Management of lipomas?
* Often conservative (reassurance) * Can be surgically removed (only if a) rapidly enlarging or b) symptomatic or aesthetic problems)
52
What is a Phyllodes tumour?
Rare tumour of the **connective** **tissue** (stroma) i.e. fibroepithelial tumours
53
What age group do Phyllodes tumours typically affect?
Occurring most often between ages 40-50.
54
Are Phyllodes tumours malignant or benign?
Can be **benign** (50%), **borderline** (25%) or **malignant** (25%). Phyllodes tumours can _metastasise_.
55
Which 2 features characterise a Phyllodes tumour?
**Large** and **fast** growing
56
Management of Phyllodes tumour?
* Surgical removal of tumour and surrounding tissue (wide excision) * Can reoccur after removal * Chemotherapy in malignant/metastatic tumours
57
What is the most common form of cancer in the UK?
**Breast carcinoma** (around 1 in 8 women will develop breast cancer in their lifetime)
58
Give some risk factors for breast carcinoma
* 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** (1st degree relatives) * **COCP** gives small increase in risk of breast cancer, but risk returns to normal 10 years after stopping the pill * **HRT** (particularly combined HRT containing oestrogen & progesterone)
59
Why is obesity a risk factor for breast cancer?
Obesity increases oestrogen levels as **adipose tissue is the main source of oestrogen biosynthesis**
60
Presentation of breast lump in breast carcinoma
* Lumps that are **hard**, **irregular**, **painless** or **fixed** in palce * Lumps may be **tethered** to the skin or chest wall * **Nipple retraction** * **Skin** **dimpling** or **oedema** (peau d’orange) * **Lymphadenopathy**, particularly in the **axilla**
61
What are BRCA genes?
Tumour suppressor genes
62
Mutations in BRCA genes can increase your risk of what cancers?
Breast, ovarian, prostate, bowel etc
63
What chromosome is BRCA1 and BRCA2 on?
BRCA1 → 17 BRCA2 → 13
64
What is the risk of develop breast & ovarian cancer in those with the BRCA1 mutation?
Breast → around 70% will develop breast cancer by age 80 Ovarian → around 50% will develop ovarian cancer
65
What is the risk of develop breast & ovarian cancer in those with the BRCA2 mutation?
Breast → Around 60% will develop breast cancer by aged 80 Ovarian → Around 20% will develop ovarian cancer
66
Is a mutation in BRCA1 or BRCA2 a higher risk for breast cancer?
BRCA1
67
Breast carcinomas can be divided into 5 main categories. What are these?
1. **Carcinoma in situ** 2. **Invasive breast cancers** 3. **Inflammatory breast cancer** 4. **Paget's disease of the nipple**
68
What is the most common type of **non-invasive** breast malignancy?
Ductal carcinoma in situ (DCIS) (20% of all breast cancer diagnoses)
69
What are the 2 types of breast carcinoma in situ?
1. Ductal carcinoma in situ (DCIS) 2. Lobular carcinoma in situ (LCIS)
70
What is DCIS? What cells?
Pre-cancerous or cancerous epithelial cells of the **ductal tissue** of the breast
71
Can DCIS spread?
* Potential to spread **locally** over years * Potential to become an **_invasive_** breast cancer (around 30%)
72
How is DCIS often picked up?
Mammogram screning
73
Prognosis of DCIS?
Good if fully excised and adjuvant treatment is used
74
Is DCIS or LCIS more common?
LCIS
75
What LCIS? Where does it arise from?
A pre-cancerous condition of the **secretory lobules**
76
Who does LCIS typically occur in?
Occurs typically in **pre-menopausal** women (90%)
77
How is LCIS often picked up?
* Often **_asymptomatic**_ and _**undetectable_** on a mammogram * Usually diagnosed incidentally on a **breast** **biopsy**
78
Prognosis of LCIS?
Higher risk of **invasive** malignancy in the future (around 30%)
79
Management of LCIS?
Often close monitoring (e.g. 6 monthly examination and yearly mammograms)
80
What defines an **invasive** cancer?
Has invaded the **basement membrane**
81
What are the 2 types of invasive breast cancer?
1. **Invasive ductal carcinoma** 2. **Invasive lobular carcinoma**
82
Give some subtypes of invasive ductal carcinomas
Tubular, cribiform, papillary, mucinous/colloid, medullary (have distinct patterns of growth)
83
Where do invasive ductal carcinomas originate?
Originate in cells from the **breast ducts**
84
What is the most common type of invasive breast cancer?
Invasive ductal carcinoma
85
How are invasive ductal carcinomas often picked up?
Can be seen on mammograms
86
Who are invasive lobular carcinomas normally seen in?
Much more common in **older women**
87
Where do invasive lobular carcinomas arise from?
Originate in cells from **breast lobules**
88
How are invasive ductal carcinomas often picked up?
Not always visible on mammograms * **Diffuse** **spread** makes detection more difficult * Tumours often quite **_large_** by the time they’re detected
89
What is inflammatory breast cancer?
Cancer cells block **lymph** **vessels** in skin of breast, causing breast to appear swollen and red or inflamed.
90
What age group is inflammatory breast cancer typically seen in?
Younger women (\<40 y/o)
91
What does inflammatory breast cancer present **similarly** to?
Presents similar to a **breast abscess** or **mastitis** → swollen, warm, tender breast with pitting skin (peau d’orange) BUT does not respond to Abx
92
What type of cancer does peau d'orange of the breast indicate?
Inflammatory breast cancer
93
Prognosis of inflammatory breast cancer?
* Worse than other breast cancers as tends to be more **_aggressive_** and spread more quickly * Typically at a locally advanced stage when 1st diagnosed * 1/3 cases have already metastasised
94
What is Paget's disease of the breast?
A rare condition associated with breast cancer
95
Is Paget's disease of the breast related to Paget's disease of the bone?
No
96
Presentation of Paget's disease of the breast?
* Looks like **eczema** of nipple/areolar * Erythematous, scaly rash
97
What may Paget's disease of the nipple indicate?
May represent DCIS or invasive breast cancer
98
Who is offered mammograms and how often?
Women aged 50-70 y/o every 3 years
99
What is the aim of mammograms?
Detect breast cancer **early** – roughly 1 in 100 women are diagnosed with breast cancer after going for a mammogram
100
Disadvantages of breast cancer screening?
* Anxiety & stress * Exposure to radiation, with very small risk of causing breast cancer * Missing cancer – false reassurance * Unnecessary further tests or treatment where findings would not have otherwise caused harm Generally, the benefits far outweigh the downsides and screening IS recommended
101
Genetic testing for breast cancer can be performed in high risk patients. What must happen first?
Genetic counselling & pre-test counselling to discuss benefits and drawbacks of genetic testing .g. implications for family members and offspring.
102
Give some management options for high risk breast cancer patients
1. **Annual** mammogram screening (as opposed to every 3 years) 2. Chemoprevention 3. Bilateral mastectomy or bilateral oophorectomy → significant counselling required
103
What is the pharmacological agent for **chemoprevention** of breast cancer in **premenopausal** women?
Tamoxifen
104
What is the pharmacological agent for **chemoprevention** of breast cancer in **postmenopausal** women?
Anastrozole
105
What is the main contraindication for anastrozole?
severe osteoporosis
106
What is the NICE criteria for a 2 week wait referral for suspected breast cancer?
* **Unexplained** **breast** **lump** in patients aged **_30_** and above * **Unilateral** **nipple** **changes** in patients aged **_50_** and above e.g. discharge, retraction or other changes * **Unexplained** **lump** **in** **axilla** in patients aged **_30_** and above * **Skin changes** suggestive of breast cancer
107
What imaging modality is used for breast cancer assessment in younger women (\<30)? Why?
Ultrasound as more dense breasts (more glandular tissue)
108
What imaging modality is used for breast cancer assessment in older women (\<30)?
Mammogram
109
What can mammograms pick up that may be missed by US?
Calcifications
110
What is US of the breast useful in differentiating?
Helpful in distinguishing **solid** **lumps** (e.g. fibroadenoma or cancer) from **cystic** **lumps** (fluid-filled)
111
What imaging may be recommended **after** a mammogram?
MRI
112
What staging system is used in breast cancer?
TNM
113
What are the 4 most common sites for breast cancer to metastasise to?
1. Bone (hypercalcaemia) 2. Lungs 3. Liver 4. Brain
114
What are the 3 types of breast cancer receptors?
1. Oestrogen (ER) 2. Progesterone (PR) 3. Human epidermal growth factor (HER2)
115
What is **triple negative** breast cancer?
*Triple-negative breast cancer* is where the breast cancer cells do NOT express ANY of these three receptors (ER, PR, HER2)
116
Prognosis of triple negative breast cancer?
This carries a **worse prognosis** as it limits treatment options.
117
Give some management options for breast cancer
1. Surgery 2. Radiotherapy 3. Chemotherapy 4. Hormone therapy
118
What biopsy is typically done prior to breast cancer surgery?
Sentinel node biopsy to assess if there has been any lymphatic spread
119
What is the 1st line pharmacological option for **hormone therapy** in _ER-positive_ breast cancer in **premenopausal** women?
Tamoxifen
120
What class of drug are indicated in **hormone therapy** in _ER-positive_ breast cancer in **premenopausal** women?
**Aromatase** **inhibitors** (e.g. letrozole, anastrozole, exemestane)
121
What is the 1st line pharmacological option for **hormone therapy** in _HER2-positive_ breast cancer in **premenopausal** women?
Trastuzumab (Herceptin) → immunotherapy (monoclonal antibody)
122
Give the 2 fist line pharmacological options in **oestrogen-receptor** positive breast cancers
1. Tamoxifen 2. Aromatase inhibitors
123
Who is tamoxifen indicated in?
Oestrogen-receptor positive breast cancer in **_pre-menopausal_** women
124
Who are aromatase inhibitors indicated in?
Post-menopausal women
125
Give some examples of aromatase inhibitors
Anastrozole, letrozole, exemestane
126
What is aromatase? Function?
Aromatase in an **enzyme found in fat** (adipose) tissue that **converts androgens to oestrogen** in _post-menopausal women_ – after menopause, the action of aromatase in fat tissue is the **primary source of oestrogen**
127
After menopause, what is the primary source of oestrogen in women?
Action of aromatase converted androgens to oestrogen in fat tissue
128
Mechanism of aromatase inhibitors?
Aromatase inhibitors block the creation of oestrogen in fat tissue
129
What is the 1st line pharmacological option for **hormone therapy** in _HER2-positive_ breast cancer in **premenopausal** women?
Trastuzumab
130
What is another name for Trastuzumab?
Herceptin
131
What class of drug is Trastuzumab?
Monoclonal antibody (immunotherapy)
132
Mechanism of Trastuzumab (Herceptin)?
Cell signalling inhibitor: 1) Blocking **HER-2 activating ligand** from binding 2) Activating the body’s own immune response against these cells
133
Main side effect of Trastuzumab (Herceptin)?
Can affect heart function (**cardiotoxicity**) so initial & close monitoring of heart function is required.
Yr 3 - Core Conditions
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