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Breast medicine DR REBECCA COOPER FY2 OBSTETRICS & GYNAECOLOGYThings you need to know u Screening u Examination technique + findings u Risk factors u Aetiology, common <30 vs >30 u Basic management – conservative / antibiotics / surgery / hormonal therapyToday’s session u Benign breast pathology – fibroadenomas, cysts, abscesses, ductal ectasia u Mastitis u Breast cancer screening u Malignancy u Exam style questions Fibroadenomas and cysts u Fibroadenomas u Cysts u Common in women <30 u Common in women 30-50 u Firm, well-circumscribed, mobile, u Firm, well-circumscribed mobile, smooth smooth lump on examination lump on examination u Send for triple assessment u May fluctuate in size u Management – remove if >3cm u Send for triple assessment u Management – aspiration/excision if painfulAbscesses and mastitis u Mastitis – inflammation of the breast, associated with lactation in postpartum women u Localised pain, tenderness, erythema, warmth, fever, often unilateral u Mx – continue breastfeeding, analgesia, manual expression of milk. May need oral abx if systemically unwell u Abscess – complication of untreated mastitis u Fluctuant, tender mass, overlying erythema _ systemically unwell u Mx – USS + pus biopsy, incision and drainage, abx u Periductal mastitis – strong association with smoking, abx +/- drainageBenign breast diseases u Fibrocystic breast disease – bilateral ‘lumpy’ breasts, mastalgia, worsen with menstruation, women 25-50. Triple Ax, NSAIDs, heat u Fat necrosis – painless, non-mobile mass, overlying skin inflammation. Following trauma, radiotherapy, surgery. More common in obese women. Triple Ax, no intervention. u Duct papilloma – bloody nipple discharge, no mass. Triple Ax, microdochectomy u Duct ectasia – nipple retraction, cream/green discharge. Microdochectomy / total duct excision u Cyclical mastalgia – tenderness fluctuating with menstrual cycle, can be associated with fibrocystic changes (breast lumps)Gynaecomastia u Enlargement of glandular tissue in males u Causes – puberty (hormone imbalance), obesity, chronic liver disease, drugs – spironolactone, testicular tumour (Leydig cell) u Management: u Testicular examination u Men >40 – exclude breast cancer u Reassure teenagers, tamoxifen or surgery may be consideredScreening u Ages 50-70, every 3 years u Dual view mammography u If abnormal -> biopsy u Triple screening – breast exam, imaging, biopsy u Pros – earlier detection, reduces mortality, fairly non-invasive u Cons – cancer can still be missed leading to false reassurance, false positives are distressing, ionizing radiation risk u Findings – mass, microcalcification, asymmetrical density, technical recall u High risk screening (BRCA) – annual MRI from 30, mammography from 40Epidemiology u 1 in 8 women will develop breast cancer in their lifetime u Most common cancer in women + second most common cause of deathBreast malignancy risk factors u Modifiable – obesity, smoking, alcohol, not breastfeeding u Increased hormone exposure - early menarche, late menopause, nulliparity, COCP or combined HRT u Genetic – FHx, female, BRCA 1 / 2, TP53, Peutz-Jeghers u BRCA 1 most common – chromosome 17 (60-80% increased lifetime risk) u BRCA 2 – chromosome 13 (45% increased lifetime risk) u Protective – breastfeeding, multiparity, late menarche, early menopausePresentation u Palpable, painless lump (often upper outer quadrant) – hard, irregular, tethered to chest wall u Nipple inversion, bloody nipple discharge, peau d’orange (oedema and pitting due to blockage of lymphatic drainage) u Palpable lymphadenopathy – axillary / supraclavicularAnatomy Condition Nipple Lump? Mobile? Painful? discharge Ductal carcinoma Bloody Yes No Maybe Lobular carcinoma No Yes No Maybe Ductal papilloma Bloody Minimal No No Duct ectasia Green No No No Cyst No Yes Yes Maybe Fibroadenoma No Yes Yes No Abscess No Yes No YesMalignant breast conditions u Ductal carcinoma in situ (DCIS) – premalignant, not yet invaded basement membrane u Identified on screening – microcalcification, unifocal lesion u 2 common types of invasive breast cancer u Invasive ductal carcinoma – abnormal proliferation of ductal cells + invaded basement membrane u Lobular carcinoma – more diffuse, frequently impalpable u Other u Medullary – younger patients, BRCA 1 u Inflammatory – presents like mastitis, no response to abx u Paget’s disease of the nipple – suspect if unresolved nipple eczema after steroid cream. 90% of patients will have an underlying invasive carcinoma. Investigations u 2WW urgent cancer referrals criteria; u >30 unexplained breast lump +/- pain u >50 with unilateral nipple changes u Triple assessment – 1-5, 1 = normal, 5 = malignant u Clinical assessment u Imaging (<40 USS due to dense tissue, >40 mammography) u Biopsy – core needle biopsy, fine needle aspiration u Hormonal receptors – oestrogen (ER), progesterone (PR), human epidermal growth factor 2 (HER2) u Ca 15-3 is used to monitor response to treatment + disease recurrence u CT CAP for TNM staging, Nottingham prognostic index scoring systemCancer treatment - surgical u Metastatic cancer – Lungs, liver, bones, brain. Spinal radiotherapy or bisphosphonates if bone mets u Chemotherapy may be used prior to surgery to reduce size u Wide local excision / lumpectomy – solitary lesion, peripheral, small lesion in large breast, DCIS <4cm u Mastectomy – multifocal / central tumour, large lesion in small breast, DCIS >4cm u Breast reconstruction surgery – immediate or delayedCancer treatment - radiotherapy u Whole breast radiotherapy can reduce the risk of recurrence of breast cancer following WLE by 2/3rds. u Some women will receive radiotherapy following a mastectomy, depending on tumour staging of disease and presence of nodal disease u Radiotherapy – SE: fibrosis, fat necrosis, fatigueCancer treatment u ER / PR +ve u Pre/perimenopausal – tamoxifen. SEs: menopausal, VTE + endometrial cancer risk u Post-menopausal – Anastrozole, letrozole, SEs: hot flushes, osteoporosis, fatigue u HER2 +ve u Trastuzumab (Herceptin). SEs: cardiac dysfunction, teratogenicity (contraindicated in patients with any cardiac medical history)Important things to remember - presentation u Mobile lump <30 – fibroadenoma u Breast lump >30 +/- pain – 2ww referral u Green nipple discharge – duct ectasia, more common in smokers u Bloody nipple discharge – duct papilloma, triple assessment -?Paget’s u Unresolving eczema on nipple - ?Paget’s u Gynaecomastia in men - ?testicular cancer, >40 ?breast cancerImportant things to remember - Management u Mastitis – CONTINUE breastfeeding u Triple screening – breast exam, imaging, biopsy u High risk screening (BRCA) – annual 30 years old (routine starts at 50) u Most malignancies = surgery first line, followed by radio + hormonal therapy u Pre/perimenopausal – tamoxifen u Post-menopausal – Anastrozole, letrozole (aromatase inhibitors)Exam style SBA questions (1) u A 42-year-old lady presents with a one week history of a lump in her breast. The lump is non-mobile, but does not appeared tethered to the tissue beneath. The lump is tender and there is some discoloration of the skin over the lump. She isn’t certain but thinks she may have lost some weight recently. She hit her days ago.ainst the handle bars of her bike after a minor accident around 10 u What is the most likely diagnosis? A. Ductal carcinoma in situ B. Paget’s disease C. Breast abscess D. Fat necrosis E. Breast cystExam style SBA questions (1) u Ductal carcinoma in situ u The history points away from the diagnosis of breast cancer due to the history of trauma, the bruising and there is no skin tethering. However all women with a breast lump should be referred for triple assessment. u Paget’s disease u Stem does not describe any association with the nipple u Breast abscess u Would be a hot, tender breast mass and is much more commonly associated with mastitis and breastfeeding. u Fat necrosis u The history of trauma is the biggest clue in the stem. They are non-mobile lumps but should be tethered, differing from a malignancy. There is also bruising around the area and tenderness u Breast cyst u Usually fluctuant and mobile, and softer to palpate (fluid filled) Exam style SBA questions (2) u A 52 year old woman presents to the GP with new redness and dryness to her left nipple. She has a past medical history of eczema. Despite her usual emollient eczema creams, there are changes to her areola that are not resolving after 5 days. The GP examines her and cannot feel any breast lumps. u What is the next step in management? A. Trial with a steroid cream and book a follow up in 7 days B. Provide reassurance that it will get better with more time C. Refer to the breast clinic D. Request a mammogram E. Treat as cellulitis with oral antibiotics Exam style SBA questions (2) u A Trial with a steroid cream and book a follow up in 7 days u Unless it is definitely clear that the skin changes are simply eczema, any unilateral nipple changes in persons older than 50 should be referred to the breast clinic u Provide reassurance that it will get better with more time u This will cause delays in treatment. Any unilateral nipple changes in women >50 should be referred to the breast clinic u Refer to the breast clinic u This is the 2 week wait pathway. This is likely Paget’s diease of the nipple which is associated with breast carcinoma. u Request a mammogram u Although she will likely need a mammogram, this should be as part of the triple assessment, which will be completed upon referral to the breast clinic u Treat as cellulitis with oral antibiotics u Cellulitis would not cause changes to the nipple itself, rather just erythema around the area and is not particularly common on the breastExam style SBA questions (3) u A 67 year old woman undergoes a wide local excision for an ER +VE T1N0M0 malignancy in her left breast. u What treatment is she most likely to be offered following her surgery? A. Whole breast radiotherapy + Herceptin B. Whole breast radiotherapy + Tamoxifen C. Whole breast radiotherapy + Anastrozole D. No radiotherapy + Tamoxifen E. No radiotherapy + Anastrozole.Exam style SBA questions (3) u Whole breast radiotherapy + Herceptin u Herceptin is used for HER +ve cancers u Whole breast radiotherapy + Tamoxifen u Tamoxifen is used for pre-menopausal women u Whole breast radiotherapy + Anastrozole u As she is 67 years old you can safely assume she is post-menopausal. Aromatase inhibitors are used in post-menopausal women as this enzyme prevents oestrogen production. u No radiotherapy + Tamoxifen u Women will generally be offered radiotherapy following WLE, as it is well proven to greatly reduce risk of recurrence. Tamoxifen is for use in pre-menopausal women u No radiotherapy + Anastrozole. u As above. Anastrozole would be correct however she would also be offered radiotherapyExam style SBA questions (4) u A 45 year old woman visits her GP as she is worried she is at increased risk of breast cancer and is wondering if she needs any extra screening. u Which of the following is an indication for referral to the breast clinic prior to routine screening from 50-70? A. Mother diagnosed with breast cancer at 50 B. Dad diagnosed with breast cancer at 60 C. Mother and grandmother both diagnosed with endometrial cancer D. Personal history of fibroadenoma as a teenager E. Personal history of premature ovarian failure Exam style SBA questions (4) u Mother diagnosed with breast cancer at 50 u Only if diagnosed <40 u Dad diagnosed with breast cancer at 60 u Paternal breast cancer at any age of diagnosis increases risk u Mother and grandmother both diagnosed with endometrial cancer u Endometrial cancer not linked to breast cancer, strong history of ovarian cancer would increase risk of breast cancer u Personal history of fibroadenoma as a teenager u No increased risk of malignancy u Personal history of premature ovarian failure u Actually a protective factor – reduces hormonal exposure Exam style SBA questions (5) u A 59 year old woman is referred to the breast clinic due to some unilateral nipple inversion and a thick, green nipple discharge. She has a 30 pack year smoking history. She has nil other past medical history. She undergoes triple assessment, and is not found to have a cancer, but does report the condition to be causing significant distress due to pain and discharge which stains her clothes in public. u What treatment option is she most likely to be offered? A. Conservative management – observation and reassurance B. Mastectomy C. Nipple removal of the affected breast D. Microdochectomy E. NSAIDs and advice to hand express the discharge every morning to avoid it staining clothes Exam style SBA questions (5) u Conservative management – observation and reassurance u Duct ectasia can be managed conservatively, but not when it is causing significant symptoms affecting quality of life u Mastectomy u This would be obviously inappropriate u Nipple removal of the affected breast u This would not be favourable for cosmetic reasons, and unless the milk ducts are also removed the problem will not be resolved u Microdochectomy (total duct excision) u The correct answer – due to how symptomatic this patient is, and is usually fit and well, she is likely to be offered surgical management for this, which is to remove the milk ducts which are causing the pain and discharge. u NSAIDs and advice to hand express the discharge every morning to avoid it staining clothes u NSAIDs may help the pain but expressing the discharge is not advised Exam style SBA questions (6) u A 26 year old woman visits the emergency department with fever and pain in her left breast. She is 8 weeks post partum and has been breastfeeding. She has had some redness and tenderness around her left nipple for the last 2 weeks, but was encouraged by the midwife to keep breastfeeding. It has now become more painful and she thinks she can now feel a small lump, as well as feeling feverish and lethargic. u What is the first line management of this patient? A. Oral antibiotics alone B. Oral antibiotics and needle aspiration C. IV antibiotics alone D. IV antibiotics and needle aspiration E. Needle aspiration alone Exam style SBA questions (6) u Oral antibiotics alone u First line is needle aspiration, and she will need IV antibiotics as she is systemically unwell with fever u Oral antibiotics and needle aspiration u As above u IV antibiotics alone u She will need IV antibiotics as an adjuvant to needle aspiration, however aspiration is first line u IV antibiotics and needle aspiration u Correct. She will need needle aspiration a it is a small lump. Although not given a measurement in this stem, breast abscess under 5cm will be suitable for needle aspiration, and larger abscesses will require incision and drainage u Needle aspiration alone u She will require antibiotics as well, IV in this case as she is systemically unwell. Exam style SBA questions (7) u Which of these characteristics is not always an indication for mastectomy? A. Peripheral tumour B. Central tumour C. Multifocal tumour D. Ductal carcinoma in situ >4cm E. Large lesion in a small breast Exam style SBA questions (7) u Peripheral tumour u Depending on the size of the breast, this may be suitable for wide local excision u Central tumour u These are usually more difficult to remove via wide local excision and will require mastectomy u Multifocal tumour u Will require a mastectomy u Ductal carcinoma in situ >4cm u Will require a mastectomy u Large lesion in a small breast u Will require a mastectomyExam style SAQ (1) u What is involved in ‘triple screening’ for breast cancer? (3)Exam style SAQ (1) u What is involved in ‘triple screening’ for breast cancer? u Clinical assessment – history and examination u Mammography, or USS <40 u BiopsyExam style SAQ (2) u Name 4 risk factors for breast cancer other than the BRCA gene. (4)Exam style SAQ (2) u Name 4 risk factors for breast cancer other than the BRCA gene. u Female, strong family history u Modifiable – obesity, smoking, alcohol, not breastfeeding u Increased hormone exposure - early menarche, late menopause, nulliparity, COCP or combined HRTExam style SAQ (3) u Name 5 symptoms/signs of breast carcinomas (5)Exam style SAQ (3) u Name 5 symptoms/signs of breast carcinomas u Breast lump, typically hard, irregular, non-mobile u Erythema, peau d’orange (skin induration), nipple inversion, nipple ‘eczema’, bloody nipple discharge u Axillary lymphadenopathy u Chest pain due to chest wall invasion u Signs of metastases – bone pain, SOB or chest pain, headache u Weight loss, fatigueAny questions?