20- Breast & Endocraniology Explains Flashcards
What is the indication for endocrine therapy in breast cancer treatment?
Endocrine therapy is indicated for oestrogen receptor positive tumours, downstaging primary lesions, and as definitive treatment in old or infirm patients.
When is irradiation and wide local excision used in breast cancer treatment?
Irradiation and wide local excision are used in cases of large lesions, high grade or marked vascular invasion following mastectomy.
When is chemotherapy used in breast cancer treatment?
Chemotherapy is used to downstage advanced lesions to facilitate breast-conserving surgery, and for patients with grade 3 lesions or axillary nodal disease.
What are the endocrine agents used in breast cancer treatment?
Tamoxifen is commonly used as a partial oestrogen receptor agonist. Aromatase inhibitors are the preferred agents in postmenopausal women. Perimenopausal women start on tamoxifen and may switch to aromatase inhibitors after 3 years.
What is the most commonly used chemotherapy regime in breast cancer treatment?
The FEC regime (Fluorouracil, epirubicin, and cyclophosphamide) is the most commonly used chemotherapy regime. Taxanes are commonly used in high-risk patients.
What limits the use of anthracycline class drugs in chemotherapy?
Anthracycline class drugs have marked cardiotoxicity, which can limit their use. This property is shared with trastuzumab.
What is gynaecomastia?
Gynaecomastia is the presence of abnormal breast tissue in males, typically caused by an increased oestrogen to androgen ratio.
What syndromes with androgen deficiency can cause gynaecomastia?
Kallman’s syndrome and Klinefelter’s syndrome are examples of syndromes with androgen deficiency that can cause gynaecomastia.
What are some medical conditions that can cause gynaecomastia?
Medical conditions such as testicular failure (e.g., mumps), liver disease, testicular cancer (e.g., Seminoma secreting HCG), ectopic tumour secretion, hyperthyroidism, and undergoing haemodialysis can cause gynaecomastia.
What are some very rare drug causes of gynaecomastia?
Very rare drug causes of gynaecomastia include tricyclic antidepressants, isoniazid, calcium channel blockers, heroin, busulfan, and methyldopa.
Which drugs are commonly associated with gynaecomastia?
Common drug causes of gynaecomastia include spironolactone (most common), cimetidine, digoxin, cannabis, finasteride, oestrogens, and anabolic steroids.
What are the treatment options for gynaecomastia?
The treatment options for gynaecomastia include identifying and managing any underlying causes and considering liposuction for the best cosmetic outcome.
What is a fibroadenoma?
A fibroadenoma is a type of breast lesion that commonly occurs in young females under the age of 25. It is characterized by the formation of dense stroma within the breast tissue, resulting in the development of palpable lumps.
What percentage of palpable breast lesions do fibroadenomas account for?
Fibroadenomas account for approximately 13% of all palpable breast lesions. However, in women aged 18-25, they constitute up to 60% of all palpable breast lesions.
What are the different classifications of fibroadenomas?
Fibroadenomas are classified as juvenile, common, and giant. Juvenile fibroadenomas occur in early adolescence, while giant fibroadenomas are characterized by a size greater than 4cm.
What is the recommended approach for small fibroadenomas in young females?
For young females with small fibroadenomas (less than 3cm on imaging), a policy of watchful waiting without biopsy may be adopted.
When is a core biopsy recommended for fibroadenomas?
A core biopsy is recommended for fibroadenomas that exceed a size of 4cm to exclude the possibility of a phyllodes tumor.
What is the natural history of fibroadenomas?
In the natural history of fibroadenomas, approximately 10% will increase in size, 30% will regress, and the remaining will stay the same. However, during pregnancy and lactation, fibroadenomas may increase in size substantially and sequester milk.
What are the treatment options for fibroadenomas?
Some women may choose to have their fibroadenomas excised. They can usually be removed through a circumareolar incision. Smaller lesions may be removed using a mammotome.
What are breast cysts?
Breast cysts are fluid-filled sacs that make up approximately 15% of all breast lumps. They are most common in perimenopausal females and are caused by distended and involuted lobules.
How can breast cysts be identified on clinical examination?
Breast cysts can be readily apparent on clinical examination as soft, fluctuant swellings. It’s important to exclude the presence of an underlying mass lesion.
What imaging findings are associated with breast cysts?
On mammography, breast cysts usually show a “halo appearance.” Ultrasound can confirm the fluid-filled nature of the cyst.
What is the recommended approach for symptomatic breast cysts?
Symptomatic breast cysts may be aspirated, and following aspiration, the breast should be re-examined to ensure that the lump has disappeared.
What is duct ectasia?
Duct ectasia is a condition that occurs as women progress through menopause. It is characterized by the shortening and dilation of breast ducts. Some women may experience a cheese-like nipple discharge and slit-like retraction of the nipple. No specific treatment is required for duct ectasia.
What imaging modalities are typically used for breast imaging?
Breast imaging is typically performed using a combination of ultrasound (USS) and mammography, especially in women presenting with a palpable lump.
Why may mammography be less informative in younger patients?
In younger patients, the denser breast tissue encountered in this age group may make mammography less informative.
What imaging modality is recommended for women with breast implants and a palpable lump?
For women with breast implants and a palpable lump, the imaging modality of choice remains the same, which is a combination of USS and mammography. However, specialized imaging techniques may be needed to obtain optimal mammographic views.
When is MRI scanning the preferred imaging modality for breast concerns?
If there are specific concerns about a breast implant, rather than a lump, MRI scanning is the preferred imaging modality. It is also beneficial in screening younger patients with a family history and in patients with lobular cancers who are being considered for breast-conserving surgery.
What are the features of fibroadenomas?
Fibroadenomas are mobile, firm breast lumps that develop from a whole lobule. They account for 12% of all breast masses and have no increase in the risk of malignancy. Over a 2-year period, up to 30% of fibroadenomas will get smaller. If a fibroadenoma is larger than 3cm, surgical excision is usually performed. Phyllodes tumors should be widely excised, and mastectomy may be necessary for large lesions.
What are the characteristics of breast cysts?
Breast cysts are present in 7% of all Western females and usually manifest as a smooth, discrete lump that may be fluctuant. There is a small increased risk of breast cancer, especially in younger individuals. Cysts should be aspirated, and those that are blood-stained or persistently refill should be biopsied or excised.
What are sclerosing adenosis, radial scars, and complex sclerosing lesions?
Sclerosing adenosis, radial scars, and complex sclerosing lesions typically present as breast lumps or breast pain. They cause mammographic changes that may mimic carcinoma. These lesions distort the distal lobular unit without hyperplasia, although complex lesions may show hyperplasia. They are considered disorders of involution and do not increase the risk of malignancy. Biopsy is recommended, but excision is not mandatory for these lesions.
What is epithelial hyperplasia?
Epithelial hyperplasia has a variable clinical presentation ranging from generalised lumpiness to discrete lumps. It is characterized by increased cellularity of the terminal lobular unit, and atypical features may be present. Individuals with atypical features and a family history of breast cancer have a significantly increased risk of malignancy. Treatment depends on the presence of atypical features, with conservative management or surgical resection being options. Close monitoring is also recommended for those with atypical features.
What is fat necrosis?
Fat necrosis is a condition that usually has a traumatic cause in up to 40% of cases. Its physical features often mimic carcinoma, and the mass may initially increase in size. Imaging and core biopsy are used for diagnosis.
What are duct papillomas?
Duct papillomas commonly present with nipple discharge, while large papillomas may present as a mass. The discharge usually originates from a single duct. Duct papillomas do not increase the risk of malignancy. Treatment typically involves microdochectomy.
Why is accurate staging of the axilla important in breast cancer management?
Accurate staging of the axilla is essential in breast cancer management because involvement of the axillary nodes has an adverse effect on prognosis. The 10-year survival rate is reduced from 75% to 25% in cases where the axillary nodes are involved.
What is the worst prognosis regarding axillary node involvement?
Involvement of level 3 nodes carries the worst prognosis in terms of breast cancer.
What are the historical approaches to axilla management in breast cancer?
Historically, management of the axilla ranged from limited level 1 axillary node excision to full level 3 axillary nodal clearances.
What are the targeted operations for axillary node management?
To minimize the morbidity of axillary node clearance, targeted operations have been developed, including axillary nodal sampling and sentinel lymph node biopsy.
What is the debate regarding axillary nodal micrometastasis?
There is debate regarding the presence of axillary nodal micrometastasis and its impact on survival. Some studies suggest that it confers an increased risk of locoregional recurrence and a reduction in disease-free survival, while others show no overall impact. It is important to distinguish between micrometastasis and isolated tumor cells, as the latter do not have an adverse impact on prognosis.
What was the finding of the ASCOG Z0011 trial?
The ASCOG Z0011 trial addressed the need for definitive treatment of the axilla in women with positive sentinel nodes. The trial found no survival benefit in routinely undertaking axillary node clearance when axillary nodal disease was limited in its extent.
What is the recommended treatment for individuals with overt evidence of axillary nodal involvement?
Individuals with overt evidence of axillary nodal involvement, either through positive sentinel lymph node biopsy or preoperative ultrasound and fine-needle aspiration, should still receive complete axillary treatment, either through clearance or radiotherapy.
What are the common treatments for breast cancer?
The common treatments for breast cancer include surgery, chemotherapy, hormonal therapy, and radiotherapy.
What is the purpose of chemotherapy in breast cancer management?
Chemotherapy may be used to downstage tumors and allow for breast-conserving surgery.
What is the role of hormonal therapy in breast cancer management?
Hormonal therapy can also be used to downstage tumors and enable breast-conserving surgery.
When is radiotherapy given to patients with breast cancer?
Radiotherapy is given to most patients who have undergone breast-conserving surgery. However, some older patients receiving hormone treatment and who have small, low-grade tumors may safely avoid radiotherapy.
What is therapeutic mammoplasty?
Therapeutic mammoplasty is an option for some patients and involves symmetrizing surgery in most cases.
What options are available for patients who have undergone mastectomy?
Patients who have undergone mastectomy may be offered a reconstructive procedure either in conjunction with their primary resection or at a later stage.
How is axillary disease managed in breast cancer patients?
As a minimum, all patients with invasive breast cancer should have their axilla staged. This can be done using sentinel lymph node biopsy for those without overt evidence of axillary nodal involvement. Patients with a positive sentinel lymph node biopsy or evidence of axillary nodal metastasis should undergo axillary node clearance or axillary irradiation.
What are the surgical options for breast cancer?
The surgical options for breast cancer include mastectomy and wide local excision. The choice between the two depends on factors such as tumor characteristics, breast size, and patient preference.
What are the risks associated with axillary node clearance?
Axillary node clearance is associated with the development of lymphedema, an increased risk of cellulitis, and frozen shoulder.
How are thyroid function test results interpreted for thyrotoxicosis (e.g. Graves’ disease)?
In cases of thyrotoxicosis, the TSH levels are low while the free T4 levels are high. It is important to note that in T3 thyrotoxicosis, the free T4 levels may still be within the normal range.
What are the thyroid function test results for primary hypothyroidism?
Primary hypothyroidism is characterized by high TSH levels and low free T4 levels.
What are the thyroid function test results for secondary hypothyroidism?
Secondary hypothyroidism is characterized by low TSH levels and low free T4 levels. In such cases, replacement steroid therapy is required before initiating thyroxine treatment.
What are the thyroid function test results for sick euthyroid syndrome?
In sick euthyroid syndrome (non-thyroidal illness), both TSH and free T4 levels are low. This condition is commonly observed in hospitalized patients.
What are the thyroid function test results for poor compliance with thyroxine medication?
In cases of poor compliance with thyroxine medication, TSH levels are high, while free T4 levels are either normal or high.
What is the alternative term for sick euthyroid syndrome?
Sick euthyroid syndrome is now referred to as non-thyroidal illness.
Yes, TSH levels may be normal in some cases of sick euthyroid syndrome.
What are the thyroid function test results for steroid therapy?
Steroid therapy can result in high TSH levels and normal or high free T4 levels.
What is the most common subtype of thyroid malignancy?
The most common subtype of thyroid malignancy is papillary carcinoma.
How is papillary carcinoma accurately diagnosed?
Papillary carcinoma is accurately diagnosed through fine needle aspiration cytology.
How does papillary carcinoma typically metastasize?
Papillary carcinoma typically metastasizes via the lymphatics, which is why laterally located apparently ectopic thyroid tissue is usually a metastasis from a well-differentiated papillary carcinoma.
What histological features may be present in papillary carcinoma?
Histologically, papillary carcinoma may demonstrate psammoma bodies (areas of calcification) and “orphan Annie” nuclei.
What are the characteristics of follicular carcinoma?
Follicular carcinoma is less common than papillary lesions. While they may present as a discrete nodule, microscopic evaluation reveals invasion despite appearing well encapsulated macroscopically. Lymph node metastases are uncommon, and these tumors tend to spread hematogenously, resulting in a higher mortality rate.
How is follicular carcinoma diagnosed?
Follicular lesions cannot be accurately diagnosed on fine needle aspiration cytology. Therefore, all follicular FNAs (THY 3f) will require at least a hemithyroidectomy.
What are the characteristics of anaplastic carcinoma?
Anaplastic carcinoma is less common and tends to occur in elderly females. The disease is usually advanced at presentation, and only palliative decompression and radiotherapy can be offered.
What are the characteristics of medullary carcinoma?
Medullary carcinoma is a tumor of the parafollicular cells (C Cells) and has a neural crest origin. Serum calcitonin levels may be elevated, which is useful for monitoring recurrence. It may be familial and occur as part of the MEN-2A disease spectrum. These tumors can spread via lymphatic or hematogenous routes and are not responsive to radioiodine as they are not derived primarily from thyroid cells.
How do lymphomas of the thyroid respond to treatment?
Lymphomas of the thyroid respond well to combined chemoradiotherapy. Radical surgery is unnecessary once the disease has been diagnosed on biopsy material, which is obtained through a core biopsy (with care!) rather than fine needle aspiration.
What is the recommended management for a large multinodular goiter?
For a large multinodular goiter, surgery is recommended if there are pressure symptoms. The treatment of choice is a total thyroidectomy.
What is the management approach for a toxic nodule?
A hemithyroidectomy is the management approach for a toxic nodule.
What is the recommended management for a follicular lesion (THY 3f)?
To establish a diagnosis for a follicular lesion (THY 3f), a hemithyroidectomy is recommended.
What is the management approach for papillary thyroid cancer?
The management approach for papillary thyroid cancer is a total thyroidectomy and central compartment nodal dissection. An extended lymphadenectomy may be required.
What is the management approach for follicular thyroid cancer?
For follicular thyroid cancer, a total thyroidectomy is usually performed, especially if the patient has already undergone a hemithyroidectomy.
What is the recommended management for anaplastic thyroid cancer?
Palliative radiotherapy is the recommended management for anaplastic thyroid cancer.
What should be considered in the management of lymphoma of the thyroid?
In the management of lymphoma of the thyroid, a core biopsy should be considered.
What is the management approach for medullary thyroid cancer?
The management approach for medullary thyroid cancer is a total thyroidectomy. Screening for other MEN (multiple endocrine neoplasia) tumors should also be conducted.
What is the recommended management for persistent refilling cysts?
For persistent refilling cysts, injection sclerotherapy is the initial approach. If this fails, surgery may be required.
What is the management approach for Graves disease with significant eye signs?
The management approach for Graves disease with significant eye signs is a total thyroidectomy.
What are the management options for Graves disease without significant eye signs?
For Graves disease without significant eye signs, the management options include patient choice between radioiodine treatment and surgery.
What is the significance of thyroid peroxidase (microsomal) antibodies in blood testing?
Thyroid peroxidase antibodies are found in autoimmune diseases that affect the thyroid, such as Hashimoto’s disease (100%) and Graves’ disease (70%).
Who usually has antibodies to the TSH receptor in their blood?
Individuals with Graves’ disease typically have antibodies to the TSH receptor in their blood (95%).
What does the presence of calcitonin in blood indicate?
Calcitonin is released from the parafollicular cells and is usually found in patients with medullary carcinoma of the thyroid. Its presence in blood testing can be indicative of this type of thyroid cancer.
What is the usefulness of thyroglobulin in clinically distinguishing between different types of thyroid disease?
Thyroglobulin is not useful for clinically distinguishing between different types of thyroid disease. However, it may be used as part of thyroid cancer follow-up.
What are the causes of nipple discharge?
The causes of nipple discharge include physiological changes during breastfeeding, galactorrhea (often due to emotional events or certain drugs), hyperprolactinemia (commonly caused by pituitary tumors), mammary duct ectasia (most common in menopausal women), carcinoma (often blood-stained discharge with underlying mass or lymphadenopathy), and intraductal papilloma (more common in younger patients with blood-stained discharge and no palpable lump).
What is the commonest cause of galactorrhea?
The commonest cause of galactorrhea may be a response to emotional events. Certain drugs, such as histamine receptor antagonists, are also implicated.
What is the most common type of pituitary tumor causing hyperprolactinemia?
The most common type of pituitary tumor causing hyperprolactinemia is microadenomas, which are less than 1cm in diameter. Macroadenomas, which are larger than 1cm in diameter, can cause pressure on the optic chiasm and result in bitemporal hemianopia.
What is mammary duct ectasia?
Mammary duct ectasia refers to the dilatation of breast ducts. It is most common in menopausal women and is characterized by thick and green-colored discharge. It is more frequently seen in smokers.
What are the characteristics of nipple discharge in carcinoma?
Nipple discharge in carcinoma is often blood-stained. It may be associated with an underlying mass or axillary lymphadenopathy.
How does intraductal papilloma typically present?
Intraductal papilloma is more common in younger patients. It may cause blood-stained discharge, but there is usually no palpable lump.
What is the recommended assessment for patients with nipple discharge and a mass lesion?
Patients with nipple discharge and a mass lesion should undergo triple assessment, which involves examining the breast and determining the presence of a mass lesion.