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Surgery.(General 2).Breast > 3. Carcinoma of the female breast.(Clinical picture and investigations) > Flashcards

3. Carcinoma of the female breast.(Clinical picture and investigations) Flashcards

1
Q

Clinical picture of breast cancer

A
  • Symptoms

* Examination

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2
Q

Symptoms in Clinical picture of breast cancer

A

1- Mass : (commonest presentation)

2- Discharge per nipple :

3- Paget’s disease of the nipple.

4- Mastitis carcinomatosa.

5- Occult presentation :

6- Pain (10%)

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3
Q

Mass in Symptoms in Clinical picture of breast cancer

A
  • The commonest presentation

* Accidentally discovered painless mass in the breast

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4
Q

The commonest presentation of breast cancer

A

Accidentally discovered painless mass in the breast

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5
Q

Discharge per nipple in Symptoms in Clinical picture of breast cancer

A

Bloody commonly
or
thick greenish discharge

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6
Q

Clinical picture of Paget’s disease of the nipple in Symptoms in Clinical picture of breast cancer

A

Usually occurs at menopause [6th decade]

Pricking sensation of the nipple with erosions & ulcerations

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7
Q

Clinical picture of Mastitis carcinomatosa in Symptoms in Clinical picture of breast cancer

A
  • Occurs mostly during pregnancy and lactation (due to high hormonal level)
  • but may occur at any age unassociated with these events.
  • The overlying skin is red, warm & Swollen.
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8
Q

Occult presentation in Symptoms in Clinical picture of breast cancer

A

1- Dry irritative cough, haemoptysis & dyspnea.

2- Pathological fracture

3- Malignant jaundice or ascites.

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9
Q

Pathogenesis of Pain in Symptoms in Clinical picture of breast cancer

A

most of breast cancer is painless but pain occurs in
10%
1- Advanced cases after extensive local infiltration.
2- Mastitis carcinomatosa.

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10
Q

Examination in Clinical picture of breast cancer

A
  • General Examination

* Local Examination

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11
Q

General Examination in Clinical picture of breast cancer

A

Searching for signs suggestive of metastases:

1- Sclera examination

2- Chest examination

3- Abdominal examination

4- P.R. examination

5- Spine examination

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12
Q

The reason why we do Sclera examination in General Examination in Clinical picture of breast cancer

A

for Jaundice

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13
Q

The reason why we do Chest examination in General Examination in Clinical picture of breast cancer

A

for pleural effusion.

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14
Q

The reason why we do Abdominal examination in General Examination in Clinical picture of breast cancer

A

for liver nodules, ascites or umbilical nodules.

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15
Q

The reason why we search for ascitis in Abdominal examination in General Examination in Clinical picture of breast cancer

A

as liver secondaries cause ascitis

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16
Q

The reason why we do P.R examination in General Examination in Clinical picture of breast cancer

A

for peritoneal nodules and Douglas pouch

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17
Q

The reason why we do Spine examination in General Examination in Clinical picture of breast cancer

A

for bony metastasis.

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18
Q

Local Examination in Clinical picture of breast cancer

A
  • Inspection

* Palpation

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19
Q

Inspection in Local Examination in Clinical picture of breast cancer

A
  1. Dimpling
    2.Puckering.
    3.Nipple Retraction
  2. Peau d’orange
  3. Cancerous skin nodules (Sure sign of malignancy).
  4. Cancer en cuirasse (historical)
    7- Medullary carcinoma.
    8- Paget’s disease of nipple.
    9- Mastitis carcinomatosa.
    10- Dilated veins over the skin of the breast.
    11- Lymphoedema of the arm.
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20
Q

Dimpling in Inspection in Local Examination in Clinical picture of breast cancer

A
  • Pathogenesis of Dimpling
  • The reason why it’s Not pathognomonic
  • Significance
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21
Q

Pathogenesis of Dimpling in Inspection in Local Examination in Clinical picture of breast cancer

A

Contracture of Cooper’s ligaments

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22
Q

The attachments of cooper’s ligament

A

Between breast and pectoralis major muscle

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23
Q

The reason why Dimpling, in Inspection in Local Examination in Clinical picture of breast cancer, is Not pathognomonic

A

as it can occur in any fibrotic process e.g. chronic breast abscess & duct ectasia.

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24
Q

Significance of Dimpling in Inspection in Local Examination in Clinical picture of breast cancer

A

The earliest skin sign of breast cancer

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25
Q

Meaning of Puckering in Inspection in Local Examination in Clinical picture of breast cancer

A

Gathered into wrinkles or folds

Karmasha

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26
Q

Nipple Retraction in Inspection in Local Examination in Clinical picture of breast cancer

A
  • Pathogenesis

* The reason why it’s Not pathognomonic

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27
Q

Pathogenesis of Nipple Retraction in Inspection in Local Examination in Clinical picture of breast cancer

A

Infiltration and contracture of the main milk ducts

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28
Q

The reason why Nipple Retraction, in Inspection in Local Examination in Clinical picture of breast cancer, is Not pathognomonic

A

it can occur in any fibrotic lesion entangling the main milk ducts e.g. chronic breast abscess & duct ectasia.

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29
Q

peau d’orange in Inspection in Local Examination in Clinical picture of breast cancer

A
  • Definition
  • Pathogenesis
  • The reason why it’s Not pathognomonic
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30
Q

Definition of peau d’orange in Inspection in Local Examination in Clinical picture of breast cancer

A

It is a condition in which we get thick non-pitting edematous skin pitted at sites of hair follicles, sebaceous & sweat glands.

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31
Q

Pathogenesis of peau d’orange in Inspection in Local Examination in Clinical picture of breast cancer

A

due to obliteration & compression of the lymphatics of the skin by the tumour

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32
Q

The reason why peau d’orange, in Inspection in Local Examination in Clinical picture of breast cancer, is Not pathognomonic

A

as it can occur in any fibrotic mass causing obliteration & compression of the lymphatics of the skin

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33
Q

one of the following is pathognomonic for breast cancer:

  • Dimpling
  • Puckering
  • Nipple retraction
  • peau d’orange
  • Cancerous skin nodules
A

Cancerous skin nodules

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34
Q

Cancerous skin nodules in Inspection in Local Examination in Clinical picture of breast cancer

A
  • Definition
  • Pathogenesis
  • Significance
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35
Q

Definition of Cancerous skin nodules in Inspection in Local Examination in Clinical picture of breast cancer

A

They are Nodules may appear away from the mother carcinoma.

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36
Q

Pathogenesis of Cancerous skin nodules in Inspection in Local Examination in Clinical picture of breast cancer

A

Retrograde lymphatic permeation.

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37
Q

Significance of Cancerous skin nodules in Inspection in Local Examination in Clinical picture of breast cancer

A
  • They are specific & diagnostic

* Sure sign of malignancy

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38
Q

Cancer en cuirasse in Inspection in Local Examination in Clinical picture of breast cancer

A
  • Significance

* Morphology

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39
Q

Significance of Cancer en cuirasse in Inspection in Local Examination in Clinical picture of breast cancer

A
  • It’s a historical sign
  • It represents:
    1. very late stage of permeation
    2. advanced stage of nodulation
40
Q

Morphology of Cancer en cuirasse in Inspection in Local Examination in Clinical picture of breast cancer

A
  • The skin is very thick hard, stretched, leathery, indurated metallic, brownish
  • simulating shields of wars
  • Not localized to the breast but extends to the chest wall & back.
41
Q

Medullary carcinoma by Inspection in Local Examination in Clinical picture of breast cancer

A

Fungation & Ulceration is common with medullary carcinoma

42
Q

Paget’s disease of nipple by Inspection in Local Examination in Clinical picture of breast cancer

A

Superficial erosions, ulcerations & crustations

Edge of the ulcer is Well defined.

43
Q

Mastitis carcinomatosa by Inspection in Local Examination in Clinical picture of breast cancer

A

The overlying skin is red

44
Q

Palpation in Local Examination in Clinical picture of breast cancer

A
  1. Breast

2. Axillary Lymph nodes

45
Q

Breast Palpation in Local Examination in Clinical picture of breast cancer

A

Mass with the following criteria :

  1. Site
  2. Size
  3. Shape
  4. Mobility
  5. Consistency
  6. Edge
46
Q

Site of the mass in Breast Palpation in Local Examination in Clinical picture of breast cancer

A

commonly upper lateral quadrant .

47
Q

Size of the mass in Breast Palpation in Local Examination in Clinical picture of breast cancer

A
  • small or moderate in NOS carcinoma

* large in medullary carcinoma

48
Q

Shape of the mass in Breast Palpation in Local Examination in Clinical picture of breast cancer

A

Irregular

49
Q

Mobility of the mass in Breast Palpation in Local Examination in Clinical picture of breast cancer

A
  • Early it is mobile

* Late it becomes fixed.

50
Q

Consistency of the mass in Breast Palpation in Local Examination in Clinical picture of breast cancer

A
  • hard in NOS carcinoma
  • soft in medullary carcinoma.
  • Cystic in mucinous carcinoma
51
Q

Edge of the mass in Breast Palpation in Local Examination in Clinical picture of breast cancer

A
  • Early well defined edge

* but late ill defined after infiltration of deeper structures.

52
Q

Axillary Lymph nodes Palpation in Local Examination in Clinical picture of breast cancer

A

If enlarged they are:

  • Hard
  • Early mobile & later on fixed.
53
Q

Investigations of breast cancer

A

A- Investigations for the primary lesion :

B- Investigations for metastases :

54
Q

Investigations for the primary lesion in Investigations of breast cancer

A

1- Biopsy:

2- Mammography:

3- Breast ultrasound : complementary

4- MRI

5- Tumour markers

55
Q

The most important single diagnostic investigation for the primary lesion in a case of breast cancer

A

Biopsy

56
Q

Investigations for metastases in Investigations of breast cancer

A
  • Chest : Plain X - ray chest.
  • Liver : Gamma GT, ALP & abdominal U.S.
  • Bone : Bone scan (99Tcm).
57
Q

which is better? to do abdominal U/S or order liver enzymes to detect liver secondaries

A

order liver enzymes as they inc before mass is seen by US

58
Q

Biopsy in Investigations for the primary lesion in Investigations of breast cancer

A
  • Significance

* Types

59
Q

Significance of Biopsy in Investigations for the primary lesion in Investigations of breast cancer

A

The most important single diagnostic investigation for the primary lesion in a case of breast cancer

60
Q

Types of Biopsy in Investigations for the primary lesion in Investigations of breast cancer

A

a) Fine Needle Aspiration Cytology (FNAC)
b) Tru cut needle biopsy
c) Frozen section biopsy
d) Excision biopsy
e) Image guided biopsy.

61
Q

Fine Needle Aspiration Cytology (FNAC) in Types of Biopsy in Investigations for the primary lesion in Investigations of breast cancer

A
  • Advantages

* Disadvantages

62
Q

Advantages of Fine Needle Aspiration Cytology (FNAC) in Types of Biopsy in Investigations for the primary lesion in Investigations of breast cancer

A
  • Has got excellent patient compliance Simple

* Quick to perform in out patient clinic “OPC’’

63
Q

Disadvantages of Fine Needle Aspiration Cytology (FNAC) in Types of Biopsy in Investigations for the primary lesion in Investigations of breast cancer

A
  • Does not differentiate between invasive carcinoma & carcinoma in situ.
  • Good (+ve) but bad (- ve).
64
Q

Tru cut needle biopsy in Types of Biopsy in Investigations for the primary lesion in Investigations of breast cancer

A
  • Alternative name
  • Procedures
  • Advantages
65
Q

Alternative name of Tru cut needle biopsy in Types of Biopsy in Investigations for the primary lesion in Investigations of breast cancer

A

Core needle biopsy

66
Q

Procedures of Tru cut needle biopsy in Types of Biopsy in Investigations for the primary lesion in Investigations of breast cancer

A
  • It is done under local anesthesia

* Done by a special needle that cut a core of tissue out of the tumour

67
Q

Advantages of Tru cut needle biopsy in Types of Biopsy in Investigations for the primary lesion in Investigations of breast cancer

A
  • Done by a special needle that cut a core of tissue out of the tumour
  • Does not cause dissemination of malignant cells
68
Q

Frozen section biopsy in Types of Biopsy in Investigations for the primary lesion in Investigations of breast cancer

A
  • Procedures
  • Advantages
  • Disadvantages
69
Q

Procedures of Frozen section biopsy in Types of Biopsy in Investigations for the primary lesion in Investigations of breast cancer

A
  • Done intraoperative.

* The mass is excised, the specimen is frozen and slides are prepared from the frozen block.

70
Q

Advantages of Frozen section biopsy in Types of Biopsy in Investigations for the primary lesion in Investigations of breast cancer

A
  • A diagnosis is obtained within 20-30 minutes.

* If it was +ve for malignancy, the surgeon proceeds for radical surgery.

71
Q

Disadvantages of Frozen section biopsy in Types of Biopsy in Investigations for the primary lesion in Investigations of breast cancer

A

Sometimes a firm diagnosis can not be obtained by frozen biopsy and the surgeon should wait for the result of the paraffin section

72
Q

Procedures of Excision biopsy in Types of Biopsy in Investigations for the primary lesion in Investigations of breast cancer

A

Excision of the mass and is sent for paraffin section.

73
Q

Image guided biopsy in Types of Biopsy in Investigations for the primary lesion in Investigations of breast cancer

A
  • U.S. or MRI guided biopsy.

* Mammography guided stereotactic biopsy

74
Q

Advantages Mammography guided stereotactic biopsy in Image guided biopsy in Types of Biopsy in Investigations for the primary lesion in Investigations of breast cancer

A

stereotactics provide us with coordinates ( W H D ) to locate exact location in case of impalpable masses

75
Q

what should be done in cases of impalpable masses in breast cancer

A

Do either:

Mammographic guided stereo-tactic biopsy: stereotactics provide us with coordinates ( W H D ) to locate exact location

Or

Mammographic guided wiring : then intraoperative remove wire with safety margin

76
Q

Mammography in Investigations for the primary lesion in Investigations of breast cancer

A
  • Definition
  • Findings suggestive of malignancy
  • Normal variation Findings
  • Advantages
  • Disadvantages
77
Q

Definition of Mammography in Investigations for the primary lesion in Investigations of breast cancer

A

It is a soft tissue X- ray

78
Q

Findings suggestive of malignancy in Mammography in Investigations for the primary lesion in Investigations of breast cancer

A

a. Asymmetry or distortion of breast outline.
b. Increased skin thickness.
c. High density mass with inc. Vascularity.

d. Mass with speculations & stellate configuration
.
e. Micro-calcification

79
Q

Micro-calcification in Findings suggestive of malignancy in Mammography in Investigations for the primary lesion in Investigations of breast cancer

A
  • Morphology

* Pathogenesis

80
Q

Morphology of Micro-calcification in Findings suggestive of malignancy in Mammography in Investigations for the primary lesion in Investigations of breast cancer

A

1- clustered

2- Linear or branching

3- Pleomorphic.

4- Opaque center (radiolucent center is benign).

81
Q

what is the meaning of clustered in mammography of breast cancer

A

not diffuse

82
Q

Pathogenesis of Micro-calcification in Findings suggestive of malignancy in Mammography in Investigations for the primary lesion in Investigations of breast cancer

A

cell death

83
Q

Normal variation Findings in Mammography in Investigations for the primary lesion in Investigations of breast cancer

A
  • Dense breast ( inc. glandular element) in young female appear white
  • Fatty breast in old female appear grey
84
Q

Advantages of Mammography in Investigations for the primary lesion in Investigations of breast cancer

A

1- It can detect non palpable mass (detects carcinoma 2 years before clinical manifestations with accuracy rate 90%).

2- Evaluates other breast even after biopsy

3- screen occult breast cancer in patients with axillary lymph node enlargement

85
Q

Disadvantages of Mammography in Investigations for the primary lesion in Investigations of breast cancer

A

1- It is not a substitute for biopsy.

2- Doesn’t differentiate between solid and cystic

3- False - ve results in : Medullary & lobular carcinoma.

4- can’t be used for Dense breast in young females

86
Q

Breast ultrasound in Investigations for the primary lesion in Investigations of breast cancer

A
  • Significance

* Advantages

87
Q

Significance of Breast ultrasound in Investigations for the primary lesion in Investigations of breast cancer

A

It’s complementary to the mammography

88
Q

Advantages of Breast ultrasound in Investigations for the primary lesion in Investigations of breast cancer

A

1- Useful in dense breast.

2- Can distinguish between solid and cystic lesions
.
3- We can do U.S guided biopsy.

89
Q

Advantages of MRI in Investigations for the primary lesion in Investigations of breast cancer

A

1- It is the gold standard for imaging the breasts of women with implants.

2- Screening of patients with LN and no breast masses detected clinically or by mammography

3- Assessment of the axilla for non palpable L.N

4- Useful to distinguish scar from recurrence in women who have had previous conservative breast therapy 6 month before

90
Q

The reason why women with breast implants shouldn’t do mammography or ultrasound

A

because implants mask breast cancer and they should do MRI instead

91
Q

postoperative scar in women who have had previous conservative breast therapy

A
  • may be a scar from fibrotic hematoma

or

  • recurrence distinguished by MRI
92
Q

Tumour markers in Investigations for the primary lesion in Investigations of breast cancer

A

CA 15.3

93
Q

what is Triple assessment?

A
  • Indication:
  • Procedures
  • The accuracy
94
Q

Indication of Triple assessment

A

Any patient who presents with breast lump

95
Q

Procedures of Triple assessment

A

The diagnosis should be made by a combination of:

1- Clinical assessment

2- Radiological imaging (mammography and complementary breast U/S)

3- Biopsy

96
Q

The accuracy of Triple assessment

A

99.9%

Surgery.(General 2).Breast (8 decks)

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