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Jess Repro > 9.2: Breast Disease > Flashcards

9.2: Breast Disease Flashcards

1
Q

Name five clinical presentations of breast conditions

A
  1. Palpable mass
  2. Pain (occasionally)
  3. Nipple discharge
  4. Skin changes (depends on where the condition is located in the breast)
  5. Mammographic abnormalities
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2
Q

Describe the different types of pain that can be felt in the breasts and their associated breast conditions

A

Cyclical and diffuse: often physiological

Non-cyclical and focal; ruptured cysts, injury, inflammation

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3
Q

Name three causes for a palpable mass in the breast, is it always pathological? Which lumps are the most worrying?

A

Many are present normally but no woman should have a lump without a firm diagnosis. The most worrying lumps are firm, fixed and craggy

  1. Invasive carcinoma
  2. Fibroadenomas
  3. Cysts
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4
Q

When is nipple discharge the most concerning? Name two different types and their associated conditions

A

Most concerning if it is spontaneous and unilateral

  1. Milky: endocrine disorders
  2. Bloody or serous: benign lesions, ductal papillomas or malignant conditions
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5
Q

Name two findings that would be worrying in a mammogram and their associated conditions

A
  1. Densities (same as a palpable mass)

2. Calcification: ductal carcinoma in situ (DCIS), benign changes

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6
Q

Which population group of women is it easiest to detect lesions in the breast? Which group of women is invited for regular mammograms and how often are they invited?

A

It’s easiest to detect lesions in the breasts of older women. Women between 50-70 are invited for a mammogram every 3 years

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7
Q

What is the main inflammatory condition of the breast? Describe its onset of symptoms and how it affects the breast including 5 potential symptoms. Which population of women is it associated with?

A

Mastitis; usually affects one breast and symptoms often come on quickly, associated with breastfeeding mothers

  1. Red swollen area on the breast that may feel hot and painful to touch
  2. Wedge shaped breast lump or hard area on the breast
  3. Burning pain in the breast that is constant or only during breastfeeding
  4. Nipple discharge (may be white or contain streaks of blood)
  5. Flu like symptoms; aches, temperature, chills, fatigue
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8
Q

What can cause mastitis?

Name four risks for mastitis identified by the CASTLE cohort study

A

Commonly associated with an infection but it can also be just an inflammatory condition.

  1. Nipple damage
  2. Over supply of breast milk
  3. Use of nipple shields
  4. Presence of S.aureus on the nipple or in breast milk
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9
Q

What are fibrocystic changes in the breast often associated with? How do they appear histologically?

A

Often associated with benign epithelial lesions: a mass that resolves on needle aspiration and mimics breast cancer. Appears as large cysts with fibrosis

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10
Q

What is epithelial hyperplasia of the breast and what can it cause?

A

Expansion of the epithelial tissue in the ducts which can also block the lumen of the ducts. This can lead to pain and a palpable mass in the breast tissue, and it increases the risk of breast cancer

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11
Q

What are the most common stromal tumours in the breast? What are they associated with? Describe their gross appearance

A

Fibroadenomas (tumour formed of mixed fibrous and glandular tissue) and phyllodes tumours. Associated with a mobile mass that often evades palpation! They’re often rounded, multiple and large with a mass of fat surrounding them

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12
Q

Describe the histological appearance of fibroadenomas and phyllodes tumours, what makes them so specific?

A

Mixture of epithelium and basket weave stroma (the stromal proliferation is what makes them so specific)

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13
Q

What is a difference between fibroadenomas and phyllodes tumour?

A

Phyllodes tumour is rare before 40, fibroadenomas is more common in younger age groups

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14
Q

How would a phyllodes tumour present? What happens if they aren’t completely excised?

A

As a palpable mass or on a mammogram, there is an aggressive local regrowth if not completely excised

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15
Q

What is gynecomastia? Which population groups is it more commonly seen in and what causes it? Is there an associated risk of cancer?

A

Enlargement of male breast tissue, often seen at puberty or in elderly (uni or bilateral), and in neonates due to excess of circulating hormones from the placenta. Caused by a relative decrease in androgens or an increase in estrogen, no risk of cancer.

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16
Q

Name three things that can cause the hormonal imbalance which leads to gynaecomastia

A

Anabolic steroids, liver cirrhosis (estrogen can’t be metabolized), testicular cancers

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17
Q

What is the lifetime risk for breast cancer in women, which age group has the highest number of diagnoses and incidence? What % of all malignancies in women is breast cancer responsible for?

A

1/12, most diagnoses are made in the 50-75 range (higher incidence at an older age, 77% occurring in women over 50.)

Breast cancer is responsible for 20% of all malignancies in women.

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18
Q

Name 8 risk factors for breast cancer that are related to hormone exposure (estrogen and progesterone) and 3 risk factors that aren’t.

A

Risk factors are related to hormone exposure (estrogen and progesterone)

  1. Gender
  2. Uninterrupted menses
  3. Early menarche (<11)
  4. Late menopause
  5. Reproductive history: i.e increased age at first full term pregnancy
  6. Breastfeeding
  7. Obesity and high fat diet
  8. Exogenous estrogens (i.e HRT and OCP have slight increase in risk)

Non-hormonal related:

  1. Geographic influence; higher incidence in US and Northern Europe; likely related to lifestyle
  2. Radiation
  3. Hereditary
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19
Q

How do atypical changes on previous biopsies and previous breast cancers influence the risk of getting breast cancer (either for the first time or again)

A

Atypical changes: increase risk X4-5

Previous breast cancer: increases risk X10

20
Q

Which genes are most hereditary cases of breast cancer associated with and what is their normal function? How much does a mutation in these genes increase the individual lifetime risk of breast cancer and what other cancer is associated with them?

Bonus: name another mutated gene that can cause breast cancer

A

BRCA1 and BRCA2 which are normally tumour suppressor genes (they repair damaged DNA). Carriers have a 60-85% increase in breast cancer and the % is similar for ovarian cancer.

Another gene that can be involved is p53 - cell checkpoint

21
Q

How do mutations in the BRCA1 and BRCA 2 genes influence the age of diagnosis? What do many carriers of the gene undergo?

A

~20 years earlier than in sporadic cases

Many carriers undergo prophylactic mastectomies (breast reduction)

22
Q

What type of cancers are most breast carcinomas and where does breast cancer most often occur?

A

95% are adenocarcinomas, ~50% occur in the upper outer quadrant

23
Q

How can carcinomas be divided and classified?

A
  1. Divided into in situ and invasive (invades normal tissues within or beyond the breast)
  2. Classified according to morphological microscopic subtypes
24
Q

Which are the most prevalent morphological microscopic subtypes of breast cancer? Name their four main types

Which subtype is the most common invasive carcinoma?

A

Ductal and lobular carcinomas are most prevalent

  1. Ductal carcinoma in situ (DCIS)
  2. Lobular carcinoma in situ (LCIS)
  3. Invasive lobular carcinoma (ILC)
  4. Invasive ductal carcinoma (IDC) (85% of invasive carcinomas)
25
Q

Define an ‘in situ carcinoma’

A

The expansion of cells hasn’t penetrated the basement membrane (no blood vessel or lymph node involvement, cannot metastasize)

26
Q

What is Paget’s disease? Describe it, including a common symptom. Name the two differentials for this disease

A

Form of in situ carcinoma with an intraepithelial spread: cells can extend to the nipple skin without crossing the basement membrane that causes a unilateral red and crusting nipple with white areas in the epidermis (where the carcinoma cells have invaded into a different portion of epithelium but still haven’t moved past the BM)

The differential is eczema or dermatitis (inflammatory nipple condition) and both should be investigated to exclude paget’s

27
Q

Define an invasive breast carcinoma, why is prognosis so much poorer at this point?

A

Carcinoma has invaded the BM into the stroma, possibly involving vessels and lymph nodes. Prognosis worsens as by the time the cancer is palpable over half the patients will have axillary lymph node metastasis

28
Q

Name two phenotypes that may be associated with invasive carcinomas

A
  1. Peau d’orange: particular phenotype where breast skin appears like an orange, means there is lymphatic drainage problems in the skin
  2. Inverted nipple: implies there is structural damage
29
Q

What are the three main groups of immunohistochemistry (IHC) subtypes? How are they identified and how do they differentiate?

A

Differentiated by the presence/absences of different receptors, identified using antibodies

  1. Hormone receptor positive (HR-positive); estrogen (ER) or progesterone (PR) receptor positive
  2. Human epidermal growth factor receptor 2 (HER2-positive)
  3. Triple negative diseases (no ER and no HER2 in the sample)
30
Q

What are the four molecular subtypes of breast cancer and which IHC subtypes is each associated with? Which do most BRCA1 and BRCA2 patients have?

A

Luminal A and B groups: estrogen and/or progesterone but difference in HER2 and Ki-67 (a marker of proliferation)

HER2/NEU: ER and PR negative but HER2 positive

Basal-Like: Triple negative (most BRCA1 and 2 patients)

31
Q

What are the five main sites of breast cancer metastasis?

A
  1. Axillary nodes
  2. Lung
  3. Liver
  4. Bone
  5. Brain
32
Q

Name five “odd sites” an invasive lobular carcinoma can spread to (often seen in patients with a recurrent invasive lobular carcinoma)

A
  1. Peritoneum
  2. Retroperitoneum
  3. GI tract
  4. Ovaries
  5. Uterus
33
Q

Describe the ‘triple approach’ used to investigate and diagnose breast cancer?

A
  1. Clinical; history, FH, examination
  2. Radio graphic imaging; mammogram and ultrasound scan (and MMRI for lobular invasive)
  3. Pathology, provide material for histology and IHC: FNAC (fine needle aspiration cytology) and core biopsy
34
Q

What is the ‘aim’ for mammographic screening? Name three abnormalities looked for in a mammogram

A

To detect small impalpable cancers and pre-invasive cancers. Look for asymmetric densities, parenchymal deformities, calcification, etc

35
Q

Why and how are sentinel lymph node biopsies performed if there is a suspected or confirmed carcinoma?

A

Can inject a dye to identify the most likely lymph node to contain a breast cancer metastasis, and if its negative dissection of multiple lymph nodes can be avoided

36
Q

How are gene expression patterns used in the treatment of breast cancer patients?

A

Microarrays have been used to examine patterns of gene expression in the tissues of breast cancer patients.

A 17 marker panel has been found that can correctly identify women that could eventually develop metastasis and therefore a personal approach can be taken with their treatment

37
Q

In a molecular classification that helps determine prognosis, what is the first, second and third method in which breast carcinomas are divided? Which subsequent group has the best and the worst prognosis?

A
  1. First divided based on being ER-positive or negative, with a better prognosis associated with the ER-positive group
  2. Groups are then divided based on the presence of HER2, and then divided based on the four molecular subtypes

The worst prognosis is given to the group that is ER negative, HER2 negative with a basal-like phenotype/triple negative

38
Q

What are three ‘localized’ treatment approaches to breast cancer

A
  1. Breast surgery: mastectomy (preventative or post-diagnosis) or breast-conserving surgery (only areas of the breast requiring surgical excision)
  2. Axillary surgery: depending on whether there are involved nodes (sentinel node sampling or axillary dissection will determine whether this is necessary)
  3. Post-operative radiotherapy to chest and axilla; ensures that all malignant tissue has been removed in case any was missed in surgery
39
Q

What are the three ‘systemic control’ therapeutic approaches to breast cancer

Bonus: how common are 2/3 required?

A
  1. Chemotherapy; neoadjuvant or whole treatment
  2. Hormonal treatment; appropriate for ER positive tumours (~80%)
  3. Herceptin treatment; depending on HER2 receptor status (~20%)
40
Q

Name one hormonal treatment

A

Tamoxifen

41
Q

Why is it especially hard to treat triple-negative breast cancer? How are they initially divided to determine the best treatment option?

A

Since many effective treatments require a positive receptor, stratified initially based on whether there is lymph node involvement.

42
Q

Name six overall factors that determine the prognosis of breast cancer (and specify which ‘type’ of each factor has the worst or better prognosis)

A
  1. In situ or invasive*
  2. Histological subtype (IDC NST (of no special type) has the worst prognosis)
  3. Tumour grade (how differentiated from parent tissue, higher grade = worst prognosis)
  4. Tumour stage (tumour size, how locally advanced, lymph node and distant (blood) metastasis)
  5. Gene expression profiles; divides individuals into risk groups
  6. Biomarkers; ER-positive has a better prognosis
43
Q

Describe four strategies to improve survival from breast cancer

A
  1. Early detection**: awareness, FH (genetic screening, prophylactic mastectomies) self-examination, mammographic screening
  2. Neoadjuvant chemo: early treatment for metastatic disease
  3. Using newer therapies, i.e herceptin to target HER2 positive individuals
  4. Gene expression profiles; personalized treatments
44
Q

What is the Predict online tool?

A

Patients and clinicians can talk through different treatments for early invasive breast cancer and think about associated survival rates

45
Q

Other than mastitis, what other inflammatory condition leads to the blockage of ducts? What does it cause and what is it most commonly associated with?

A

Ductal ectasia; a milk duct beneath the nipple widens, thickens and fills with fluid. The most common cause of greenish discharge.

46
Q

Name four conditions that can mimic breast cancer

A
  1. Ductal ectasia
  2. Gynecomastia
  3. Fat necrosis
  4. Benign epithelial hyperplasia

Jess Repro (18 decks)

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