Breast Flashcards
Indications for neoadjuvant chemo
- Locally advanced (T3/4) tumour
- cN1 nodes (try and avoid ALND)
- Increase chance of BCS
- Triple neg or ER/PR- HER2+
- Temporary contraindication to surgery (pregnancy, anticoagulation)
- Delay surgery while genetic testing undertaken (that may affect surgery chosen)
Indications for MRI
- Dense breast tissue/young women
- Lobular carcinoma
- Assess disease extent (esp if multicentric)
- Assess deep nodal involvement
- Assess chest wall invasion
- Assess response to neoadjuvant therapy
Disadvantages of MRI
Higher rates of false positives
No improvement in outcomes according to studies
Indications for adjuvant chemo?
Node + disease
Tumour >20mm (T2+)
Triple neg
High risk according to PREDICT or Adjuvant! calculators
High risk according to Oncotype DX or Mammaprint calculators
Indications for adjuvant radiotherapy?
Post wide local excision
- whole breast irradiation with boost to tumour bed
Nodes:
• Irradiate “regional nodes” (supra- and infraclavicular) if nodes positive at SLNB/ALND
• Irradiate axilla as well if no ALND performed (AMAROS trial)
• Irradiate axilla, supra and infraclavicular nodes post ALND if extensive axillary involvement (extranodal spread, >50% nodes involved)
After mastectomy, give if high chance of local recurrence
• Tumour >5cm (T3 - T4)
• >4 positive nodes - controversial, some say less
• Stage III disease
• Chest wall invasion/margin involvement
Adjuvant chemo after neo adj?
Not always necessary.
Give if:
- Residual disease post surgery (give Capecitabine)
- Didn’t complete neo adj regime -> continue regime (AC-T)
How do you assess grade of breast ca?
Bloom and Richardson classification
“TNM”
- Tubule formation
- Nuclear pleomorphism
- Mitotic count
How do you assess prognosis of breast ca?
Nottingham prognostic index
“SiNG”
- Size
- Nodal involvement
- Grade
The index is calculated using the formula:
NPI = [0.2 x S] + N + G
Where:
• S is the size of the index lesion in centimetres
• N is the node status: 0 nodes = 1, 1-3 nodes = 2, >3 nodes = 3
• G is the grade of tumour: Grade I =1, Grade II =2, Grade III =3
Gives survival at 10 years • 2 – 2.4 = 93% • 2.4 – 3.4 = 85% • 3.4 – 5.4 = 73% • >5.4 = 50%
Definition of ALH?
Atypical proliferation of monomorphic dyscohesive epithelial cells in a breast lobule
- with no/minor distortion of lobule (this is how it differs from LCIS)
Risk of ALH or LCIS on biopsy being upgraded to invasive cancer on excision?
<3%
Risk of ADH being upgraded to DCIS?
30%
Risk of DCIS being upgraded to invasive ductal carcinoma?
30%
Risk of overall malignancy in either breast when ALH or LCIS found?
ALH: 4-fold
LCIS: 8-fold
Types of LCIS? Why do these matter?
Classic
Pleomorphic
Mass-forming
Classic LCIS alone does not require excision but can be observed. Pleomorphic or mass-forming should be excised.
How does ADH differ from DCIS?
Both = atypical proliferation of epithelial cells arising from breast ducts, with no invasion of basement membrane
In DCIS the abnormal cells FILL the ducts
Subtypes of DCIS?
Papillary Comedo Solid Micropapillary Cribriform
Staging/prognosticating for DCIS?
Van Nuys index
"SMAG" Size Margins Age Grade
When should you perform SNB for DCIS?
If doing mastectomy
High suspicion of upgrading lesion (eg big - >5cm)
Mass-forming DCIS
Aetiology/classification of Nipple Discharge?
Normal (lactation)
Physiological (galactorrhoea)
- usually bilateral
- never bloody
- usually hyperPRL
Pathological
- Unilateral, persistent, spontaneous, bloody
- Papilloma >50%
- Duct ectasia
- Cancer
- Infection
Gynaecomastia aetiology?
Physiological
- Neonates, elderly, teenagers
Pathological
- Reduced oestrogren clearance (liver dis)
- Increased oestrogen production (testicular, pituitary, adrenal tumours, hepatoma)
- Decreased testosterone (klinefelters, cryptorchidism, hypopituitarism)
Drug-related
- Hormones
- Cimetidine
- Spironolactone
- Digoxin
- Phenothiazines
- Methyldopa
- Tricyclics
- Marijuana
Bloods for Gynaecomastia workup?
CBC LFT UEC Prolactin SHBG Testosterone Oestradiol B-HCG Cortisol FSH+LH
Classification of Phyllodes tumour
“MIPS”
Mitotic rate
Infiltration/invasion
Pure stromal overgrowth
Stromal atypia
Classifies into benign, borderline and malignant
What margins will you accept? DCIS Invasive carcinoma LCIS Phyllodes
DCIS - 2mm
Invasive carcinoma - 1mm
LCIS - involved margin fine if classic LCIS
Phyllodes - 1cm
Indications for frozen section
Evaluate nipple margin if planning nipple sparing mastectomy
Sentinel lymph node evaluation to determine need for ALND
Assess margins during BCS
Flat Epithelial Hyperplasia
- Definition
- Risk of malignancy
- Management
= Change in breast epithelial cells to columnar, in more than two layers, with cytological atypia
Risk of breast ca increased, though not to as great an extent as ADH or ALH
8-10% upgraded on excision to atypical hyperplasia or cancer
Manage with excision
Sclerosing Adenosis
- Definition
- Risk of malignancy
- Management
= benign proliferation of ductal elements (lobular acini, myoepithelial cells) and stromal tissue
Characterised by distorted breast lobules, a painful mass or calcs on mammo
No significant risk of malignancy
Observe if imaging and path concordant
Radial scar
- Definition
- Risk of malignancy
- Management
= dense collagenous fibroelastic core with trapped epithelial components
Aka complex sclerosing lesion if >1cm
Look very suspicious on imaging and can harbour cancers or premalignant lesions
Manage with excision biopsy
Fibrocystic change
- Definition
- Risk of malignancy
- Management
= Generalised involutional changes of breast characterised by shift from predominance of lobules and glands to increased fibrosis and cyst formation
Basically lumpy breasts in older women
Not premalignant/disease
Can leave alone
Mild (usual) ductal hyperplasia
- Definition
- Risk of malignancy
- Management
= increase in normal duct epithelial cells - >2 and <4 cells thick, not filling the lumen
Non-proliferative disease, no significant increased risk of breast ca
Observe if imaging and path concordant
cf florid (normal cells filling lumen) and atypical (atypical cells filling lumen)
Florid ductal hyperplasia
= overgrowth of normal ductal epithelial cells that fill lumen
Two-fold increased risk of breast ca
Observe if imaging and path concordant
What’s the difference between ADH and DCIS?
ADH is atypical cells that do not fill/distort a duct. Not more than 2 ducts and no more than 2mm in size
DCIS is atypical cells filling/distorting the ducts - >2mm in size or >2 ducts involved
What’s the difference between ALH and LCIS
Extent.
ALH = proliferation of monomorphic dyscohesive cells in a terminal ductal-lobular unit, either filling a lobule without distending and enlarging it; or some distension but only partial filling
LCIS = complete (rather than partial) involvement of terminal ductal-lobular unit, with much greater degree of expansion
Breast pain
- Classify aetiology
- Management
Cyclical vs non-cyclical (breast, non-breast)
Cyclical:
- Fibrocystic change
- Hormones (OCP, HRT)
Non-cyclical
- Mastitis
- Superficial thrombophlebitis
- Haematoma from trauma
- Fibroadenoma, lipoma
- Chest wall pain
- Coronary artery disease
- GI: hiatus hernia, GB disease
- Radiculopathy
Management
- Reassurance
- Supportive bra
- NSAIDs
- Tamoxifen
- Danazol
BIRADS classification
Breast imaging, reporting and data system
0 = inadequate 1 = normal 2 = benign lesion - 0% 3 = probably benign - <2% malignancy 4 = suspicious - 2-95% 5 = high suggestive of ca - >95% 6 = biopsy-proven ca
Closer surveillance for 3, surgical excision for 4-6
Bethesda classification - breast
1 = insufficient 2 = benign 3 = atypical 4 = suspicious for malignancy 5 = malignant
