9.2 Breast disease Flashcards
Name five clinical presentations of breast conditions
- Palpable mass2. Pain (occasionally) 3. Nipple discharge4. Skin changes (depends on where the condition is located in the breast) 5. Mammographic abnormalities
Describe the most worrying types of lumps
Firm, fixed and craggy
When is nipple discharge the most concerning?
Spontaneous and unilateral
Name two findings that would be worrying in a mammogram and their associated conditions
- Densities (same as palpable mass)
2. Calcification: ductal carcinoma in situ (DCIS), benign changes
Which group of women is invited for regular mammograms and how often are they invited?
Women between 50-70 are invited for a mammogram every 3 years
What is the main inflammatory condition of the breast?
Describe its onset, how it affects the breast and 5 potential symptoms. Which population of women is it associated with?
Mastitis; breastfeeding mothers, unilateral and rapid onset
- Red swollen area on breast (may feel hot and painful)
- Wedge shaped lump
- Burning breast pain (constant or during breastfeeding)
- Nipple discharge
- Flu like symptoms
What can cause mastitis? Name four risks for mastitis identified by the CASTLE cohort study
Commonly associated with infection but can also just be inflammatory.
Nipple damage, oversupply of breast milk, using nipple shields, presence of S.aureus on the nipple or in breast milk
What are fibrocystic changes in the breast often associated with? How do they appear histologically?
Large cysts with fibrosis, associated with benign epithelial lesions
What are some complications of epithelial hyperplasia of the breast?
Blocks duct lumen -> pain and palpable mass -> increased risk of breast cancer
What are the most common stromal tumours in the breast? Describe their gross appearance and a primary characteristic
Fibroadenomas and phyllodes tumours. Rounded, multiple, large, surrounding mass of fat, mobile and can evade palpation!
What makes fibroadenomas and phyllode tumours so specific histologically? Describe their general histological appearance
Stromal proliferation; mixture of epithelia and basket weave stroma
What is a difference between fibroadenomas and phyllodes tumour?
Phyllodes rare <40, fibroadenomas more common in youngers
What happens if phyllodes tumours aren’t completely excised?
Aggressive local regrowth
What is gynecomastia and which population(s) is it more commonly seen?
Enlargement of male breast tissue
Puberty, elderly, neonates (excess circulating hormones via placenta)
What causes gynaecomastia in general? Name three things that could lead to it
Decreased androgen:estrogen ratio
Anabolic steroids, liver cirrhosis (estrogen can’t be metabolized), testicular cancers
Which group of women has the highest incidence of breast cancer?
> 50
Name 7 risk factors for breast cancer that are related to hormone exposure (estrogen and progesterone)
Gender, uninterrupted menses, early menarche, late menopause, breastfeeding, obesity and high fat diet, exogenous estrogens (i.e HRT and OCP)
Name two medically related things that increase risk of breast cancer
atypical changes on previous biopsy, previous breast cancer
Which genes are associated with most hereditary cases of breast cancer? What is their normal function and which other cancer type are they associated with?
BRCA1 and BRCA2; tumour suppressor genes. Ovarian cancer
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
How do mutations in the BRCA1 and BRCA 2 genes influence the age of diagnosis? What do many carriers of the gene undergo?
Much earlier (~20 years) than in sporadic cases, prophylactic mastectomies
What type of cancers are most breast carcinomas and where does breast cancer most often occur?
Adenocarcinomas, upper outer quadrant
How can carcinomas be divided and classified?
Divided: In situ and invasive
Classified: morphological microscopic subtypes
Which are the most prevalent morphological microscopic subtypes of breast cancer?
Ductal and lobular carcinomas
Define an ‘in situ carcinoma’
Cell expansion hasn’t penetrated basement membrane
What is Paget’s disease? Name a common symptom
In situ carcinoma with an intraepithelial spread. Unilateral red and crusting nipple with white areas in the epidermis
Define an invasive breast carcinoma, why is prognosis so much poorer at this point?
Invaded past BM into stroma, possibly involving vessels and lymph nodes.
High chance of axillary lymph node metastasis
Name two phenotypes that may be associated with invasive carcinomas, what is each indicative of?
- Peau d’orange lymphatic drainage problems in skin
2. Inverted nipple: structural damage
What are the three main groups of immunohistochemistry (IHC) subtypes?
- Hormone receptor positive (HR-positive); ER (estrogen) or PR (progesterone)
- HER2-positive
- Triple negative diseases (no ER and no HER2 in the sample)
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?
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)
What are the five main sites of breast cancer metastasis?
Axillary nodes, lung, liver, bone, brain
Describe the ‘triple approach’ used to investigate and diagnose breast cancer?
- Clinical: history, FH, examination
- Imaging; mammogram, USS, MMRI for lobular invasive
- Pathology; FNAC and core biopsy for histology and IHC
What is the ‘aim’ for mammographic screening?
Detect small impalpable cancers and pre-invasive cancers
What should you do to avoid unnecessary removal of multiple lymph nodes if there is a suspected or confirmed carcinoma?
Sentinel lymph node biopsy
*investigates most likely lymph node to contain breast cancer metastasis
What can be used to help establish a personal treatment approach in breast cancer?
Gene expression patterns
In a molecular classification that helps determine prognosis, what is the first, second and third method in which breast carcinomas are divided?
- ER-positive (better prognosis) or negative
- HER2?
- Divided based on 4 molecular subtypes
What are three ‘localized’ treatment approaches to breast cancer?
- Surgery: mastectomy or breast-conserving surgery
- Axillary surgery:
- Post-operative radiotherapy to chest and axilla *ensures removal of all malignant tissue
What are the three ‘systemic control’ therapeutic approaches to breast cancer
Chemo, hormonal treatment (ER+), herceptin treatment (HER2 receptor)
Name one hormonal treatment
Tamoxifen
Why is it especially hard to treat triple-negative breast cancer?
Since many effective treatments require a positive receptor
Name six overall factors that determine the prognosis of breast cancer
- In situ or invasive
- Histological subtype (IDC NST (of no special type) has the worst prognosis)
- Grade
- Stage
- Gene expression profiles
- Biomarkers
Describe four strategies to improve survival from breast cancer
- Early detection**
- Neoadjuvant chemo
- Newer therapies, i.e herceptin -> HER2 positive individuals
- Gene expression profiles; personalized treatments
What are the complications of ductal ectasia?
Milk duct in breast widens -> fills with fluid -> obstruction -> greenish discharge
Name four conditions that can mimic breast cancer
Ductal ectasia, gynecomastia, fat necrosis, benign epithelial hyperplasia
What is indicative of milky vs bloody/serous discharge?
Milky: endocrine disorders
Bloody or serous: benign lesions, ductal papillomas, malignancy
Which population group of women is it easiest to detect lesions in the breast?
Older women
What is the name of a tumour formed from mixed glandular and fibrous tissue?
Fibroadenoma
Name three non-hormonal related risk factors for breast cancer
- Geographic
Name another mutated gene that can cause breast cancer other than BRCA1 and BRCA2
p53
Which morphological microscopic subtype of breast cancer is the most common invasive carcinoma?
Invasive ductal carcinoma
Name two conditions which should be investigated to exclude Paget’s disease
Eczema or dermatitis (inflammatory nipple conditions)
Name three abnormalities looked for in a mammogram
Asymmetric densities, parenchymal deformities, calcification
Which molecular classification group of breast cancer has the worst prognosis?
ER negative, HER2 negative with basal-like phenotype/triple negative
Which biomarker of breast cancer is associated with a better prognosis?
ER positive
