Assessment of Breast Lumps Flashcards
1
Q
Label 1-8
A
- Chest wall
- Pec major (breast sits on top of this)
- Lobule (gland that makes milk)
- Nipple
- Areola (more pigmented area around nipple)
- Lactiferous duct (ducts that converge and form a branched system connecting the nipple to the lobules)
- Adipose tissue
- Skin
2
Q
Histology of breast tissue
A
3
Q
Histology of breast tissue
A
4
Q
What % of breast lumps are due to benign breast disease?
A
80%
5
Q
What is the NICE guidance for breast lumps?
A
Refer using suspected cancer pathway (appointment within 2 weeks) if person 30 or older and has unexplained breast lump (consider referring if <30 years)
6
Q
What is the ‘triple assessment’ for breast lumps?
A
- Clinical –> examination
- Imaging –> ultrasound mammography
- Pathology –> biopsy and/or cytology
7
Q
What is a fibroadenoma?
A
Benign tumour composed of proliferation of glandular elements of the stroma
8
Q
What is a hamartoma?
A
Benign breast lump (normal elements in an unorganised way)
9
Q
What is a lipoma?
A
Benign tumour of fat
10
Q
Potential types of breast lumps:
A
- Fibroadenoma
- Hamartoma
- Lipoma
- Cyst
- Fibrocystic change
- Carcinoma (malignant)
11
Q
Features of a lump?
A
- Mobile or fixed?
- Well defined or not?
- Smooth or irregular?
- Firmness?
- Location?
12
Q
Defining location of lump
A
Breast split into quadrants and ‘oclock’
13
Q
How should the nipple be examined when assessing breast lumps?
A
- Inversion?
- Rash?
- Discharge? (blood, milky, greeny)
14
Q
What skin changes should be looked for during breast lump assessment?
A
- Tethering / retraction? (i.e. skin pulled in over lump)
- Oedema?
- Peau d’orange (looks like skin of orange)
- Ulceration / fungating lesion
15
Q
Clinical P code:
A
- P1 Normal
- P2 Benign lesion
- P3 Atypical, probably benign lesion
- P4 Atypical, probably malignant lesion
- P5 Malignant
16
Q
How does ultrasound imaging work?
A
- High frequency sound waves which bounce back (echo) from the various tissues
- Identify lesions:- size; solid or fluid-filled; shape; edge
17
Q
Appearance of fat during US?
A
Hypoechoic –> white
18
Q
What is a hypoechoic mass?
A
A hypoechoic mass is tissue in the body that’s more dense or solid than usual. This term is used to describe what is seen on an ultrasound scan.
19
Q
Appearance of fibroglandular breast tissue during US?
A
Echogenic –> black
20
Q
What does a mammogram involve?
A
- X-ray of breast from several angles
- Identifies masses/asymmetries, also calcifications
21
Q
Appearance of fat during mammogram?
A
Fat –> radiolucent –> black
22
Q
Appearance of solid masses during mammogram?
A
Solid masses –> radio opaque –> white
23
Q
Imaging R code:
A
- R1 Normal
- R2 Benign lesion
- R3 Atypical, probably benign lesion
- R4 Atypical, probably malignant lesion
- R5 Malignant
24
Q
After a biopsy is taken it is sent to pathology. What is the pathology B code? (biopsy)
A
- B1 Normal
- B2 Benign lesion
- B3 Atypical, probably benign lesion
- B4 Atypical, probably malignant lesion
- B5 Malignant
25
Pathology C code? (cytology specimen)
* C1 Insufficient
* C2 Normal or Benign lesion
* C3 Atypical, probably benign lesion
* C4 Atypical, probably malignant lesion
* C5 Malignant
26
Clinical Case:
* 40 year old lady
* GP referral with breast lump
* Clinical examination:
* 2cm **firm smooth mobile mass** in right breast UOQ
* No skin changes
* Longstanding **right nipple inversion**
* Ultrasound result:
* 15mm x 5mm well-defined lobulated lesion suggestive of a fibroadenoma
Diagnosis? What would then be suggested?
* Diagnosis: P2 lump, likely fibroadenoma, R2 benign
* Referred for ultrasound guided core biopsy
* B2
27
Clinical Case:
* 35 year old lady
* GP referral with breast lump
* 3cm **firm smooth mobile mass** in left breast LIQ
* Unremarkable overlying skin and nipple
* No lymph nodes palpable in axilla
* Though to be P2 lump, likely large fibroadenoma
* Ultrasound:
* 32mm well-defined solid lesion, consistent with a fibroadenoma
* R2 benign
* Referred for ultrasound guided core biopsy
* Then found to be **malignant**
Diagnosis?
* 1st likely diagnosis from clinical examination: P2 lump, likely large fibroadenoma
* 2nd likely diagnosis from ultrasound: R2 benign
* Actual diagnosis from biopsy: malignant B5
* Plan: Review in clinic; assess axilla radiologically
* Discuss surgical options with patient and assess for family history
28
What are the BRCA genes?
•Genes that encode tumour suppressor proteins which are critical for cells to repair damaged DNA
29
How does a mutation in BRCA gene affect its function?
* Gene mutation – proteins not made or don’t work properly – DNA damage in cells not repaired properly
* ~70% change of developing BC by 80
30
Clinical Case:
* 47 year old lady
* GP referral with breast lump
* 2.6cm **firm irregular mass** in the central area of the right breast with some **indrawing of the nipple**
* No definite lymph nodes felt in axilla
* Mammogram:
* Irregular 3.5cm mass with **coarse calcifications**
* Ultrasound:
* Equivocal node in axilla
* Clinical core biopsy of breast and US-guided FNAC of axilla
1st likely diagnosis from clinical examination: P5 malignant
2nd likely diagnosis from imaging: R5 malignant
3rd final diagnosis from biopsy: invasive carcinoma B5 and metastatic carcinoma in lymph node C5
31
How does oestrogen play a key role in the development of breast cancer?
Stimulates the growth of tumours that express oestrogen receptors (ER positive)
32
What % of breast cancers are ER positive?
Around 80%
33
What is endocrine therapy?
Hormone therapy (for ER positive). There are two types of hormone therapy for breast cancer:
* Drugs that stop estrogen and progesterone from helping breast cancer cells grow
* Drugs or surgery to keep the ovaries from making the hormones
34
How does tamoxifen work?
A hormone therapy --\> block the effect of oestrogen on the tumour cells and improve prognosis
35
What is Her2?
* Her2 is one of the human epidermal growth factor receptors
* The Her2 gene is amplified in 20-25% of breast cancers and predicts poorer prognosis
36
What is Trastuzamab (Herceptin)?
An antibody that targets and blocks the receptors improving prognosis in Her2 positive cases
37
What does the MDTM discussion involve?
* Pre-operative chemotherapy or not
* Type of surgery
* Wide local excision vs mastectomy (whole breast)
* Sentinel lymph node biopsy vs axillary node clearance
38
What is axillary node clearance?
Axillary Node Clearance is an operation to remove the lymph nodes under the armpit. Breast cancer sometimes spreads to the lymph nodes, and if this has happened it is important to remove the lymph nodes to remove the cancer in your armpit.
39
What is Sentinel lymph node biopsy?
Sentinel node biopsy is a surgical procedure used to determine whether **cancer has spread beyond a primary tumor into your lymphatic system**. It's used most commonly in evaluating breast cancer and melanoma. The sentinel nodes are the first few lymph nodes into which a tumor drains.
40
What does a sentintel lymph node biopsy involve?
Injecting radioactive blue dye into region of tumour and tracking the radioactivity (and visibily the blue ink) to indentify which node drains the tumour first
* If there is no tumour spread to the very first node that drains the tumour then the rest of the lymph nodes furher upstream will also be free of tumour
* If tumour IS found in lymph node, the patient may require an operation to take out other lymph nodes
