Breast Flashcards

1
Q

Indications for neoadjuvant chemo

A
  • 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)
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2
Q

Indications for MRI

A
  • 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
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3
Q

Disadvantages of MRI

A

Higher rates of false positives

No improvement in outcomes according to studies

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4
Q

Indications for adjuvant chemo?

A

Node + disease
Tumour >20mm (T2+)
Triple neg
High risk according to PREDICT or Adjuvant! calculators
High risk according to Oncotype DX or Mammaprint calculators

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5
Q

Indications for adjuvant radiotherapy?

A

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

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6
Q

Adjuvant chemo after neo adj?

A

Not always necessary.
Give if:
- Residual disease post surgery (give Capecitabine)
- Didn’t complete neo adj regime -> continue regime (AC-T)

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7
Q

How do you assess grade of breast ca?

A

Bloom and Richardson classification

“TNM”

  • Tubule formation
  • Nuclear pleomorphism
  • Mitotic count
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8
Q

How do you assess prognosis of breast ca?

A

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%
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9
Q

Definition of ALH?

A

Atypical proliferation of monomorphic dyscohesive epithelial cells in a breast lobule
- with no/minor distortion of lobule (this is how it differs from LCIS)

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10
Q

Risk of ALH or LCIS on biopsy being upgraded to invasive cancer on excision?

A

<3%

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11
Q

Risk of ADH being upgraded to DCIS?

A

30%

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12
Q

Risk of DCIS being upgraded to invasive ductal carcinoma?

A

30%

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13
Q

Risk of overall malignancy in either breast when ALH or LCIS found?

A

ALH: 4-fold
LCIS: 8-fold

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14
Q

Types of LCIS? Why do these matter?

A

Classic
Pleomorphic
Mass-forming

Classic LCIS alone does not require excision but can be observed. Pleomorphic or mass-forming should be excised.

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15
Q

How does ADH differ from DCIS?

A

Both = atypical proliferation of epithelial cells arising from breast ducts, with no invasion of basement membrane
In DCIS the abnormal cells FILL the ducts

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16
Q

Subtypes of DCIS?

A
Papillary
Comedo
Solid
Micropapillary
Cribriform
17
Q

Staging/prognosticating for DCIS?

A

Van Nuys index

"SMAG"
Size
Margins
Age
Grade
18
Q

When should you perform SNB for DCIS?

A

If doing mastectomy
High suspicion of upgrading lesion (eg big - >5cm)
Mass-forming DCIS

19
Q

Aetiology/classification of Nipple Discharge?

A

Normal (lactation)

Physiological (galactorrhoea)

  • usually bilateral
  • never bloody
  • usually hyperPRL

Pathological

  • Unilateral, persistent, spontaneous, bloody
  • Papilloma >50%
  • Duct ectasia
  • Cancer
  • Infection
20
Q

Gynaecomastia aetiology?

A

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
21
Q

Bloods for Gynaecomastia workup?

A
CBC
LFT
UEC
Prolactin
SHBG
Testosterone
Oestradiol
B-HCG
Cortisol
FSH+LH
22
Q

Classification of Phyllodes tumour

A

“MIPS”

Mitotic rate
Infiltration/invasion
Pure stromal overgrowth
Stromal atypia

Classifies into benign, borderline and malignant

23
Q
What margins will you accept?
DCIS
Invasive carcinoma
LCIS
Phyllodes
A

DCIS - 2mm
Invasive carcinoma - 1mm
LCIS - involved margin fine if classic LCIS
Phyllodes - 1cm

24
Q

Indications for frozen section

A

Evaluate nipple margin if planning nipple sparing mastectomy
Sentinel lymph node evaluation to determine need for ALND
Assess margins during BCS

25
Q

Flat Epithelial Hyperplasia

  • Definition
  • Risk of malignancy
  • Management
A

= 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

26
Q

Sclerosing Adenosis

  • Definition
  • Risk of malignancy
  • Management
A

= 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

27
Q

Radial scar

  • Definition
  • Risk of malignancy
  • Management
A

= 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

28
Q

Fibrocystic change

  • Definition
  • Risk of malignancy
  • Management
A

= 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

29
Q

Mild (usual) ductal hyperplasia

  • Definition
  • Risk of malignancy
  • Management
A

= 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)

30
Q

Florid ductal hyperplasia

A

= overgrowth of normal ductal epithelial cells that fill lumen

Two-fold increased risk of breast ca

Observe if imaging and path concordant

31
Q

What’s the difference between ADH and DCIS?

A

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

32
Q

What’s the difference between ALH and LCIS

A

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

33
Q

Breast pain

  • Classify aetiology
  • Management
A

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
34
Q

BIRADS classification

A

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

35
Q

Bethesda classification - breast

A
1 = insufficient
2 = benign
3 = atypical
4 = suspicious for malignancy
5 = malignant