1
Q
Causes of a benign breast lump?
A
- fibroadenoma
- cyst
- sclerosing adenosis
- epithelial hyperplasia
- fat necrosis
- Duct papilloma
2
Q
Causes of breast discharge?
A
- Carcinoma
- Galactorrhea
- Hyperprolactinaemia
- Mammmary duct ectasia
- Intraductal papilloma
3
Q
What is a breast abscess? 2 types?
A
- A breast abscess is 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)
4
Q
What is mastitis?
A
inflammation of breast tissue.
Often this is related to breastfeeding (lactational mastitis), although it 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.
5
Q
Risk factors for infective masitis and breast abscesses?
A
Smoking, damage to the nipple, underlyiing breast disease e.g. cancer can affect the drainage of breast = predisposition to infection
6
Q
Most common causative bacteria for breast abscesses/ infective mastitis?
A
- Staphylococcus aureus (the most common)
- Streptococcal species
- Enterococcal species
- Anaerobic bacteria (such as Bacteroides species and anaerobic streptococci)
7
Q
Examples of gram positive bacteria and treatment used for this?
A
Staph aureus, streptococcal and enterococcal bacteria are gram positive, meaning that penicillins are likely to be effective.
Flucloxacillin, in particular, is used against staph aureus skin infections
7
Q
Examples of gram negative bacteria and treamtent for this?
A
E coli
Pseudomonas aeruginosa
Psuedomonas
cephalosporins (ceftriaxone-cefotaxime, ceftazidime, and others), fluoroquinolones (ciprofloxacin, levofloxacin), aminoglycosides (gentamicin, amikacin), imipenem, broad-spectrum penicillins with or without β-lactamase inhibitors (amoxicillin-clavulanic acid, piperacillin-tazobactam)
7
Q
Anaerobic bacteria - treatment?
A
. Co-amoxiclav (amoxicillin plus clavulanic acid) covers anaerobes.
Metronidazole
8
Q
Presentation of breast abscess/mastitis?
A
fast onset!!!!!
Nipple changes
◦ Purulent nipple discharge (pus from the nipple)
◦ Localised pain
◦ Tenderness
◦ Warmth
◦ Erythema (redness)
◦ Hardening of the skin or breast tissue
◦ Swelling
◦ swollen, fluctuant, tender lump within the breast..
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.
- Generalised symptoms of infection e.g. muscle aches, fatigue and fever
9
Q
Management of lactational masitis?
A
Blockage of ducts!
Continued breastfeeding, express milk, breast massage, heat packs, warm showers, simple analgesia
ABX when symptoms dont imrpove
10
Q
ABX - gram positive and what to do if penicillin allergy?
A
Fluclox
IF PENICILLIN ALLERGY —-> clarithromycin or erythromycin
11
Q
Managament of non lactational masitis ?
A
Analgesia, abx- CO amoxiclav ( broad spectrum), treatment for the underlying cause
12
Q
Managemenet of breast abscess?
A
- 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
13
Q
What is duct ectasia?
A
dilatation and shortening of the terminal breast ducts within 3cm of the nipple.
14
Q
Presentation of duct ectasia?
A
Nipple retraction and occasionally creamy nipple discharge.
Brown greeen discharge
15
Q
Periductal mastitis features?
A
Pressents in younger women - vast majoirty are smokers
Presents with periareolar or subareolar infections and may be reccurent
Differential for ductasia
16
Q
What is a fibroadenoma?
Who are they most common in?
A
Benign tumor of the stromal/epithelial breast duct tissue
Small and mobile, within the breast tissue
Younger women- 20-40 years old as respond to oestrogen and progresterone
17
Q
Presentation of fibroadenoma?
A
Painless
Smooth
Round
Well circumscribed (well-defined borders)
Firm!!!!!
Mobile (moves freely under the skin and above the chest wall)
Usually up to 3cm diameter
18
Q
Are fibroadenomas associated with cancer
A
NO
19
Q
Treatment for fibroadenoma?
A
if >3 cm surgical excision
20
Q
Mastalgia - types
A
Breast pain —-> Cyclical and non cyclical
21
Q
Cyclical mastaglia presentation?
A
More common and related to hormonal fluctuations during menstrual cycle
Typically occurs during 2 weeks before menstruation and settles during menstrual period.
May be other symptoms of premenstrual syndrome e.g. low mood, bloating, fatigue, headaches
22
Q
Symptoms of cyclical mastalgia?
A
Bilateral and generalised
Heaviness
Aching
23
Non cyclical mastalgia features?
More common in women aged 40-50
More likely to be localised than cyclical breast pain
Often no cause found
24
Non cyclical mastalgia features?
More common in women aged 40-50
More likely to be localised than cyclical breast pain
Often no cause found
25
Causes of non cyclical mastalgia?
Medications e.g. hromonal contraceptive
Infection e.g. mastitis
Pregnancy
Costochondritis
Skin - shingles or post herpetic neuralgia
26
Diagnosis for non cyclical mastalgia?
Breast diary
Exclude: preganncy, infection and cancer
27
Management of non cyclical mastalgia?
Wearing a supportive bra
Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (oral or topical)
Avoiding caffeine is commonly recommended
Applying heat to the area
Hormonal treatments (e.g., danazol and tamoxifen) under specialist guidance
28
Fibrocystic breast changes- what is it?
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.
Benign condiiton
Common in women of menstruating age
29
Symptoms of fibrocystic breast changes
Lumpiness
Breast pain or tenderness (mastalgia)
Fluctuation of breast size
Often occur prior to menstruating and resolve once menstrating benigns
Usually improve after menopause
30
Management of fibrocystic breast changes?
Wearing supportive bra
NSAIDS
Avoid caffeine
Apply heat to the area
Hormonal treatments e..g danaazol and tamoxifen
31
Breast cysts
Benign, individual, fluid filled lumps
30-50
PERIMENOPAUSAL PERIOD
Can be painfula dn may fluctuate in size over hte menstrual cycle
32
Examination - breast cysts?
Smooth, well circumscribed, mobile, possibly fluctuant
33
Treatment of breast cysts?
Require further assessment to exclude cancer - imaging and potenitally aspiraiton or excision
ASpiriation can reolve symptoms in patients with pain
May increased the risk of cancer
34
What is fat necrosis?
a benign lump formed by localised degeneration and scarring of fat tissue in the breast
35
Do breast cysts increase risk of cancer?
May slightly
36
Fat necrosis - associations/ triggers?
localised trauma, radiotherapy or surgery, with an inflammatory reaction resulting in fibrosis and necrosis (death) of the fat tissue.
37
Fat necrosis - on examination?
Painless
Firm
Irregular
Fixed in local structures
There may be skin dimpling or nipple inversion
38
Imaging and treatmetn for fat necrosis?
Ultrasound or mammogram can show a similar appearance to breast cancer. Histology (by fine needle aspiration or core biopsy) may be required to confirm the diagnosis and exclude breast cancer.
After excluding breast cancer, fat necrosis is usually treated conservatively. It may resolve spontaneously with time. Surgical excision may be used if required for symptoms.
39
Lipomas - what are they?
benign tumours of fat (adipose) tissue. They can occur almost anywhere on the body where there is adipose tissue, including the breasts.
40
On examination - lipomas?
Soft
Painles
Mobile
Do not cause skin changes
41
Galactocele - what are they?
They are breast milk filled cysts that occur when the lactiferous duct is blocked, preventing the gland from draining milk.
42
Who do galactoceles occur in?
Women who are lactating, often are they stop breastfeeding
43
Presentation of galactocele?
Firm, mobile, painless lump, usually beneath the areola
44
Treatment of galactocele?
Benign and usually resolve without any treatment.
possible to drain them with a needle.
Rarely, they can become infected and require antibiotics.
45
What is a phyllodes tumor?
Rare tumours of the connective tissue (stroma) of the breast, occurring most often between ages 40 and 50.
They are large and fast-growing.
They can be benign (~50%), borderline (~25%) or malignant (~25%).
Malignant phyllodes tumours can metastasise.
46
Treatment of phyllodes tumor?
Surgical excision
Chemo for malignant of metastatic tumours
47
What is gynaecomastia?
enlargement of the glandular breast tissue in males. Male breast enlargement is relatively common, particularly in adolescents and older men (aged over 50 years)
48
Why might gyaecomastia present in newborns?
s due to circulating maternal hormones, resolving as the maternal hormones are cleared.
49
Why do you get gynaecomastia?
Generally caused by hormonal imbalance between oestrogens and androgens - higher oestrogen and lower androgen
Raised oestrogen = breast development, whilst androgens have inhibitory effect on breast development
Raised prolactin - can cause
Reduction in testosterone
Medications
50
Drug interactions with prolactin
Dopamine has an inhibitory effect on prolactin
Dopamine antagonists e.g. antipsychotics block dopamine production = prolactin levels to rise adn cause gyanecomastia and galactorrhea
51
What can cause high oestrogen?
Phsyiological in adolescents
Obesity - enzyme found in adipose tissue that converts androgens to oestrogen
Testicular cancer - oestrogen secretion from leydig cell tumour
Liver cirrhosis and failure
Hyperthyroidism
HCG secreting tumor e.g. Small cell lung cancer
52
Conditions that can reduce testosterone and cause gyneocomastia?
Testosterone deficiency in older age
Hypothalamus or pituitary conditions that reduce LH and FSH levels (e.g., tumours, radiotherapy or surgery)
Klinefelter syndrome (XXY sex chromosomes)
Orchitis (inflammation of the testicles, e.g., infection with mumps)
Testicular damage (e.g., secondary to trauma or torsion)
53
Medications that can cause gynaecomastia?
Antipsychotics (increase prolactin levels)
Digoxin (stimulates oestrogen receptors)
Spironolactone (inhibits testosterone production and blocks testosterone receptors)
Gonadotrophin-releasing hormone (GnRH) agonists (e.g., goserelin used to treat prostate cancer)
Opiates (e.g., illicit heroin use, Marijuana ) and Alcohol
54
Gynaecomastia vs pseudogynaecomastia ( breast enlargement due to obesity)- on examination?
On palpation, there will be firm tissue behind the areolas in gynaecomastia, representing growth of the gland and duct tissue. This is different to simple adipose (fat) tissue, which is soft and more evenly distributed.
55
History - gyaecomastia ... working out the cause?
Age of onset, duration and change over time
Associated sexual dysfunction (indicating low testosterone)
Any palpable breast lumps or skin changes (exclude breast cancer)
Associated symptoms that may indicate the cause (e.g., testicular lumps or symptoms of hyperthyroidism)
Prescription medication (e.g., antipsychotics, spironolactone or GnRH agonists)
Use of anabolic steroids, illicit drugs or alcohol
56
Examination- gyaencomastia... what are the causes?
True gynaecomastia versus simple adipose tissue
Unilateral or bilateral
Any palpable lumps, skin changes or lymphadenopathy (exclude breast cancer)
Body mass index (BMI)
Testicular examination (e.g., lumps, atrophy or absence)
Signs of testosterone deficiency (e.g., reduced body and pubic hair)
Signs of liver disease (e.g., jaundice, hepatomegaly, spider naevi and ascites)
Signs of hyperthyroidism (e.g., sweating, tachycardia and weight loss)
57
Investigations for gynaecomastia?
Determined by history and examination findings. Simple gynaecomastia in an otherwise healthy adolescent may be managed with watchful waiting.
Unexplained rapid-onset gynaecomastia in a 30 year old male with no apparent cause may require in-depth investigations.
58
Bloods for gynaecomastia
Renal profile (U&Es), Liver function tests (LFTs), Thyroid function tests (TFTs)
Testosterone, Sex hormone-binding globulin (SHBG)
Oestrogen Prolactin (hyperprolactinaemia)
Luteinising hormone (LH) and follicle-stimulating hormone (FSH)
Alpha-fetoprotein and beta-hCG (testicular cancer) Genetic karyotyping (if Klinefelter’s syndrome is suspected)
59
Imaging for gynaecomastia?
Breast ultrasound (may help assess the extent of gynaecomastia)
Mammogram (if cancer is suspected)
Biopsy (if cancer is suspected)
Testicular ultrasound (if cancer is suspected)
Chest x-ray (if lung cancer is suspected)
60
Managing for gynaecomastia?
Depends on the underlying cause. Gynaecomastia almost always resolves with time in adolescents.
Stopping a causative drug (e.g., anabolic steroids or spironolactone) will usually resolve the symptoms. Patients may be referred to the specialist breast clinic where the cause is unclear or cancer is suspected.
Treatment options in problematic cases (e.g., pain or psychological distress) include:
Tamoxifen (a selective oestrogen receptor modulator that reduces the effect of oestrogen on the breast tissue)
Surgery
61
Intraductal papilloma - what is it?
Warty lesion that grows within one of the ducts in the breast.
It is the result of the proliferation of epithelial cells. T
he typical presentation is with clear or blood-stained nipple discharge.
Intraductal papillomas are benign tumours; however, they can be associated with atypical hyperplasia or breast cancer.
62
Presentation of intraductal papilloma?
Can occur at any age, but most often occur between 35-55 years.
Often asymptomatic. They may be picked up incidentally on mammograms or ultrasound.
They may present with:
Nipple discharge (clear or blood-stained)
Tenderness or pain
A palpable lump
63
Diagnosis for intraductal papilloedema?
Triple assessment
Ductography - injecting contrast into the abnormal duct and perfroming mammograms to visualise that duct
Seen as an area that does not fill with contrast - filling defect
64
Management for intraductal papilloedema
Complete surgical excision
Tissue examined for atypical hyperplasia or cancer
65
Pagets disease of the nipple - features
Eczematoid change of the nipple associated with an underlying breast malignancy and it is present in 1-2% of patients with breast cancer.
66
How is pagets different from eczema
it involves the nipple primarily and only latterly spreads to the areolar (the opposite occurs in eczema).
67
Diagnosis and treatment of pagets?
Diagnosis is made by punch biopsy, mammography and ultrasound of the breast.
Treatment will depend on the underlying lesion.
68
Breast cancer - risk factors?
* 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)
Genetics
69
Genetics of breast cancer - increased risk
BReast CAncer gene
The BRCA1 gene is on chromosome 17
The BRCA2 gene is on chromosome 13.
70
Types of breast cancer?
Ductal carinoma in situ
Lobular carcinoma in situ
Invasive ductal carcinoma
Invasive lobular carcinoma
Inflammatory breast cancer
71
Ductal carcinoma in situ
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
72
Invasive ductal carcinoma NST
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
Can be seen on mammograms
73
Invasive lobular carcinoma
Around 10% of invasive breast cancers
Originate in cells from the breast lobules
Not always visible on mammograms
74
Inflammatory breast cancer?
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
75
Pagets disease of nipple - what might it represent?
Breast cancer involving the nipple
76
Breast cancer screening
Mammogram every 3 years to women aged 50 – 70 years
High risk - may have mammogram more often
77
High risk patients for breast cancer - 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
78
What is chemoprevention?
May be offered to women at high risk of breast cancer
Tamoxifen if pre-menopausal
Anastrozole if postmenopausal
79
Presentation for breast cancer?
ps 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)-
* Lymphadenopathy, particularly in the axilla
80
Referral criteria - breast cancer ?
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)
Consider for:
An unexplained lump in the axilla in patients aged 30 or above
Skin changes suggestive of breast cancer
Consider non-urgent referral for unexplained breast lumps in patients under 30 years.
81
Imaging for breast cancer
* Younger women generally have more dense breasts with more glandular tissue.
* Ultrasound scans are typically used to assess lumps in younger women (e.g., under 30 years). They are helpful in distinguishing solid lumps (e.g., fibroadenoma or cancer) from cystic (fluid-filled) lumps.
* Mammograms are generally more effective in older women. They can pick up calcifications missed by ultrasound.
MRI may be used for further information
82
Lymph node assessment - breast cancer?
* Women diagnosed with breast cancer require an assessment to see if cancer has spread to the lymph nodes. All women are offered an 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.
83
Breast cancer receptors - types
* Oestrogen receptors (ER)
* Progesterone receptors (PR)
* Human epidermal growth factor (HER2)
84
What is triple negative breast cancer?
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.
85
Gene expression profiling - breast cancer-- when to do this?
assessing which genes are present within the breast cancer on a histology sample.
helps predict the probability that the breast cancer will reoccur as a distal metastasis (away from the original cancer site) within 10 years.
recommend this for women with early breast cancers that are ER positive but HER2 and lymph node negative.
It helps guide whether to give additional chemotherapy.
86
Metastastitis for breast cancer - key places it goes ot?
2 Ls and 2 Bs
Lungs, liver, bones and brain
87
Staging for breast cancer? What investigations do you do?
Lymph node asessment and biopsy
MRI of the breast and axilla
Liver ultrasound for metastasis
CT of the thorax, abdomen, pelbis
Isotopic bone scan for bony metastisis
88
Chronic lymhoedema in relation to breast cancer
Chronic condition caused by impaired lymphatic drainage of an area
Can occur in an entire arm after breast cancer surgery on that side
89
Management for lymphoedema ( chronic)
Massage techniques to manually drain the lymphatic system (manual lymphatic drainage)
Compression bandages
Specific lymphoedema exercises to improve lymph drainage
Weight loss if overweight
Good skin care
AVOID PUTTING CANNULA/TAKING BLOOD OUT OF THAT ARM- higher risk of complications and infection due to the impaired lymphatic drainage on that side
90
Radiotherapy - breast cancer?
Used in patients with breast conserving surgery to reduce the risk of reoccurence
91
Common radiotherapy side effects
General fatigue from the radiation
Local skin and tissue irritation and swelling
Fibrosis of breast tissue
Shrinking of breast tissue
Long term skin colour changes (usually darker)
92
Chemotherapy - when is it used?
Neoadjuvant therapy – intended to shrink the tumour before surgery
Adjuvant chemotherapy – given after surgery to reduce recurrence
Treatment of metastatic or recurrent breast cancer
93
Hormone treatment - oestrogen receptor positive breast cancer
Treatment that disrupts the oestroge sitmulating the breast cancer
Tamoxifen for premonopausal women
Aromatase inhibitors for postmenopausal women e.g. letrozole, anastrozole, exemestane
94
What is tamoxifen?
Selective oestrogen recetor modulator
Either blocks or stimulates oestrogen receptors depending on site of action
- Blcoks receptors in breast, stimulates receptors in uterus in bones
Helps prevents osteoporosis but increases risk of endometrial cancer
95
What are aromatase inhibitors/ what does aromatase do?
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 work by blocking the creation of oestrogen in fat tissue
95
What are aromatase inhibitors/ what does aromatase do?
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 work by blocking the creation of oestrogen in fat tissue
96
How long are aromatase imhibits/ tamoxifen given to women wtih oestrogen receptor positive breastcncaer?
5-10 years
97
Targeted treatment for breast cancer-HERpositive
Trastuzumab (Herceptin) is a monoclonal antibody that targets the HER2 receptor. It may be used in patients with HER2 positive breast cancer. Notably, it can affect heart function; therefore, initial and close monitoring of heart function is required.
Pertuzumab (Perjeta) is another monoclonal antibody that targets the HER2 receptor. It may be used in patients with HER2 positive breast cancer. This is used in combination with trastuzumab (Herceptin).
Neratinib (Nerlynx) is a tyrosine kinase inhibitor, reducing the growth of breast cancers. It may be used in patients with HER2 positive breast cancer.
98
Followups for breast cancer
Mammograms yearly for 5 years
99
Adverse effects of SERMs
e.g. tamoxifen
menstrual disturbance: vaginal bleeding, amenorrhoea
hot flushes - 3% of patients stop taking tamoxifen due to climacteric side-effects
venous thromboembolism
endometrial cancer
100
Adverse effects of aromatase inhibitors?
osteoporosis
NICE recommends a DEXA scan when initiating a patient on aromatase inhibitors for breast cancer
hot flushes
arthralgia, myalgia
insomnia
101
What is sclerosing adenosis?
Presents as breast lump/pain
Mammographic changes which mimic a carcinoma
Disortion of the distal lobular unit without hyperplasia
Disorder of involution, no increase in malignancy
AAAMedicine
flashcards
Decks in class (42)
# Cards
-
Respiratory Conditions237
-
Renal327
-
Gastro conditions396
-
Neurology conditions326
-
Cardiology Conditions281
-
Endocrine286
-
Breast104
-
murmurs and arrythmias21
-
Psych192
-
Neonates69
-
Paediatrics495
-
Drugs2
-
Rheumatology199
-
Opthalmology conditions141
-
Ortho206
-
Anaesthetics127
-
ENT Conditions104
-
Dermatology conditions225
-
Vascular conditions113
-
Haematology196
-
Infectious diseases31
-
quick Acute + Pharma68
-
Pharma2
-
Resp quick80
-
Renal quick7
-
Cardio quick49
-
Neuro quick66
-
Older person - dementia, palliative29
-
Dermy quick39
-
Renal quick54
-
Endo quick38
-
Oppy quick34
-
GI quick56
-
MSK quick61
-
Paeds quick72
-
ENT quick26
-
O+G and sex health quick3
-
Other quick60
-
Psychy quick41
-
Gynaecology171
-
OBS263
-
Sexual Health & Contraception116
