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Overview •Breast anatomy •Breast examination •Referral criteria •Screening programs •Benign breast pathology •Breast cancerBreast anatomy Three components of the breast 1. Mammary glands 2. Connective tissue 3. Pectoral fascia Vasculature • Medial aspect – internal thoracic (nternal mammary artery) • Lateral aspect – lateral thoracic branch, thoracoacromial branch,lateral mammary branches and mammary branches.Lymphatics •Important to know for examination and understanding metastatic disease •Majority of the breast tissue drains to the axillary lymph nodesBreast examination •Prep:wash hands,PPE,explain the examination,get a chaperone,ask the patient to undress from the waist up and sit on the side of the bed 1.Looks:Inspect both breasts,do they look symmetrical? - any visible lumps - any scars? - any skin changes ? – scaling,erythema,puckering,peau d’orange - any nipple changes? – inversion,dischargePalpation of the breast tissue •Size •Shape •Location •Consistency •Mobility •Fluctuation •Overlying skin changes Question 1 A 34 year old woman comes to see you in the GP practice complaining of a lump in her right breast but is otherwise well.You examine her and she has symmetrical breasts,no skin or nipple changes. On palpation she has a firm nodule tethered to the chest wall.She has no lymphadenopathy.What is the best course of action? A. Reassure and send her home B. Send her home and review in 2 weeks in the GP clinic C. Give her a course of antibiotics D. Routine referral to the breast clinic E. Urgent referral to breast clinic under the suspected cancer pathway Answer 1 A. Reassure and send her home B. Send her home and review in 2 weeks in the GP clinic C. Give her a course of antibiotics D. Routine referral to the breast clinic E. Urgent referral to breast clinic under the suspected cancer pathwayReferral criteria Referral under the urgent suspected cancer if: •Aged over 30 with an unexplained breast lump (with or without pain) •Aged 50 years and over with unilateral nipple discharge,retraction or other changes of concern Consider referring under the urgent suspected cancer pathway: •Skin changes that suggest breast cancer •Aged 30 years or older 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. T riple assessment •Physical examination + imaging +/- biopsy •Patients < 35 🡪 ultrasound •Patients >35 🡪 mammogramQuestion 2 Which one of the following correctly describes the NHS breast cancer screening programme? A.Those aged 25–50 years,screen every 3 years,and those aged 50–64 years,screen every 5 years. B.Those aged 40–70 years,screen every 3 years. C.Those aged 45–65 years,screen every 5 years. D.Those aged 50–70 years,screen every 3 years. E.Those aged 50-70 years,screen every 5 years.Those aged 71 – 80 every 3 years.   •Answer 2 A.Those aged 25–50 years,screen every 3 years,and those aged 50–64 years,screen every 5 years. B.Those aged 40–70 years,screen every 3 years. C.Those aged 45–65 years,screen every 5 years. D.Those aged 50–70 years,screen every 3 years. E.Those aged 50-70 years, screen every 5 years.Those aged 71 – 80 every 3 years.Screening programmes •Aged 50– 70 🡪 mammogram every 3 years •>70 years – women can self-refer •Some women may be eligible for earlier screening • One first-degree female relative diagnosed with breast cancer under the age of 40 years. • One first-degree male relative diagnosed with breast cancer at any age. • Oage of 50 years.relative with bilateral breast cancer where the first primary was diagnosed under the • Two first-degree relatives,or one first-degree and one second-degree relative,diagnosed with breast cancer at any age. • One first-degree or second-degree relative diagnosed with breast cancer at any age and one first-degree or second-degree relative diagnosed with ovarian cancer at any age (one of these should be a first-degree relative). • Three first-degree or second-degree relatives diagnosed with breast cancer at any age.Benign breast lumps Question 3 A 24 year old female presents to the GP as she is worried about a painless lump she has felt in her left breast.There has been no trauma to the area,and has not experienced anything like this before. She is otherwise fit and well,is systemically well,and has not had any weight loss.She has no family history of breast cancer. On examination there is a firm,mobile,oval shaped 1.5cm lump in her left breast. You see no obvious skin or nipple changes to either breast.Y ou felt nothing abnormal in the left breast.No lymph nodes were palpable in the axilla.What is the most likely diagnosis? A. Duct ectasia B. Mastitis C. Fibroadenoma D. Ductal carcinoma in situ E. Fat necrosis Answer 3 A. Duct ectasia B. Mastitis C. Fibroadenoma D. Ductal carcinoma in situ E. Fat necrosisFibroadenoma •Caused by overgrowth of collagenous mesenchyme •Painless •On examination they are firm,smooth and mobile •Most regress •Sbe over 5cmadenomas usually 1-3cm in size,giant fibroadenomas can •Management:conservative management (observation and reassurance).If causing symptoms then can be surgically removed •If there is any diagnostic uncertainty then an ultrasound +/- fine needle aspiration Question 4 A 36 year old female presents to the GP as she is worried about a lump she has felt in her left breast.She has noticed that it has been there for the past 6 months and notices that it sometimes gets bigger around the time of her period.She is otherwise systemically well. On examination there is a fluctuant,mobile mass in the left breast.Y ou see no obvious skin or nipple changes to either breast.Y ou felt nothing abnormal in the right breast.No lymph nodes were palpable in the axilla. What is the most likely diagnosis? A. Ductal carcinoma in situ B. Breast cyst C. Breast abscess D. Fibroadenoma E. Fat necrosis Answer 4 A. Ductal carcinoma in situ B. Breast cyst C. Breast abscess D. Fibroadenoma E. Fat necrosisBreast cysts •Common in patients above the age of 35 •Benign •Fluid filled sacs •Mobile and fluctuant •Usually painful,especially around mensesQuestion 5 A 28 year old female presents to the GP with a painful breast.She is 4 weeks post-partum and is currently breast feeding.On examination she has a tender,red swollen left nipple.She is otherwise well,her observations are stable.Y ou suspect she has mastitis. Which of the questions below are not part of the treatment of mastitis? A.Analgesics B.Antibiotics if infective mastitis C.Gentle hand expression to promote drainage D.Local measures like hot and cold compress E.Stopping breastfeedingAnswer 5 A. Analgesics B. Antibiotics if infective mastitis C.Gentle hand expression to promote drainage D.Local measures like hot and cold compress E.Stopping breastfeedingMastitis/breast abscess •Infection of the mammary ducts,most commonly associated with lactation •Can lead to formation of abscess •Most common organism staph aureus •Symptoms:painful,immobile,tethered to overlying skin,maybe erythematous and warm •T reatment:antibiotics •Patients may become unwell and develop a fever and this may lead to them needing to be drainedDuct ectasia •Blockage of mammary ducts by stagnant secretions •Develops around menopause •Common in smokers •Symptoms:green nipple/brown/blood discharge from the nipple,may have some nipple retraction,there may be a lump present under the nipple •Investigations:ultrasound •Management:no specific management,can give smoking cessation Question 6 An 18 year old female has come to the GP as she has noticed a lump in her breast.She has noticed it has come on in the last 2 days.She is otherwise well with no past medical history and no history of breast cancer in the family.She mentions she has just started playing rugby and played her first rugby game 3 days ago.On examination there is a tender,firm lump in the left breast with an overlying bruise.What is the most likely diagnosis? A. Ductal carcinoma in situ B. Breast cyst C. Breast abscess D. Fibroadenoma E. Fat necrosis Answer 6 A. Ductal carcinoma in situ B. Breast cyst C. Breast abscess D. Fibroadenoma E. Fat necrosisFat necrosis •T rauma leading to fibrosis and calcification of the breast •Symptoms:immobile,firm lumps,may be some bruising present •Investigations:need to confirm diagnosis with triple therapy,no specific management requiredPhyllodes •Rare (mostly) benign tumour arising from the breast stroma which has the potential to become malignant – 70% are benign •If they are malignant then they are classed as soft tissue sarcomas •Occur in patients in their 40’s •Symptoms:Discrete,rubbery breast lumps,sometimes painful. Typically a history of rapid growth •Investigations:Triple assessment •Management:Surgical excision with 5mm marginBreast cancer •Invasive v non-invasive •Ductal v lobular •Rare breast cancers • Inflammatory breast cancers • Paget’s disease of the nippleRisk factors •Increased exposure to oestrogen •Age •Female gender •First degree relative with breast cancer •Prev.breast cancer •Genetics – BRCA1 BRCA2 mutations •Radiation therapy to the chest •Not having breastfed •Lifestyle – excessive alcohol and fat intakeNon-invasive breast cancer Ductal carcinoma in situ •Abnormal cells inside the mammary glands •Confined to the breast tissue •Four subtypes (papillary,cribiform,solid,comedo) •T ypically,no mass,may have some nipple discharge and overlying breast skin crusting •T ypically,slow growingNon-invasive breast cancer Lobular carcinoma in situ •Cellular changes inside the breast lobule •If untreated,20-30% will become invasive •Symptoms:may be asymptomatic,may have a breast lumpInvasive breast cancer •Invasive ductal carcinoma – most common •Invasive lobular carcinomaRare breast cancer •Inflammatory breast cancer • Subtype of locally advanced breast cancer • May present with an erythematous,oedematous breast • Sometimes mistaken for mastitis/breast abscess but the patient will systemically well •Paget’s disease of the nipple • Malignant form of breast cancer • Commonly associated with a ductal carcinoma in situ • Presents with eczematous-like rash,itchy inflamed nipple,burning sensation and discharge from the affected area and an inverted nipple Question 7 A 72-year-old woman presents to her general practitioner after noticing a lump in her right breast and after investigations she is diagnosed with breast cancer. Biopsies are done which reveal the following: Oestrogen receptor (ER) Positive Progesterone receptor (PR) Negative Human epidermal growth factor receptor 2 (HER2) Negative What treatment is she likely to be offered? A. Anastrozole B. Goserelin C. Pembrolizumab D. Tamoxifen E. Trastuzumab Answer 7 A. Anastrozole B. Goserelin C. Pembrolizumab D. T amoxifen E. T rastuzumabManagement Considerations: •Staging –TNM staging used •Receptor status • Progesterone receptors • Oestrogen receptors • HER2 receptors • riple negativeMedical management •Preferred if surgery not appropriate •Endocrine • Aromatase inhibitors (letrozole,anastrozole,exemestane) – post-menopausal ER+ve •Biologics • Trastuzumab (Herceptin)- HER2 +ve •Chemotherapy • Neoadjuvant – prior to surgery to shrink the tumour • Adjuvant – after surgery to prevent recurrence •ovariestropin-releasing hormone agonists (goserelin) – premenopausal to protect •RWLEotherapy – recommended in most patients with invasive cancer afterSurgical management •Wide local excision • Removes the breast cancer with a margin of healthy tissue • Used if the cancer is small •Mastectomy • Involves removing the entire breast and skin overlying it • Larger cancers or multifocal cancer •Sentinel node sampling • Intraoperatively to rule out lymphatic involvement •Reconstruction •Ovarian ablation • To stop oestrogen synthesisThank-you!