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Surgery > Breast > Flashcards

Breast Flashcards

1
Q

Ductal carcinoma in situ characteristics

A

Arises from ductal atypia
Neoplastic cells fill ductal lumen but there is no BM penetration or lump formation

Unilateral and unifocal

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2
Q

How does DCIS appear on mammography

A

Microcalcifications

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3
Q

What is comedocarcinoma

A

Subtype of breast DCIS with central necrosis, dystrophic calcifications

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4
Q

Lobular carcinoma in situ characteristics

A

Neoplastic cells fill lobules. No BM penetration.

Multifocal and bilateral

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5
Q

LCIS mammogram appearance

A

Nothing at all (incidental biopsy finding)

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6
Q

Pagets disease of the breast characteristics

A

Spread of DCIS/invasive breast carcinoma that has spread through lactiferous duct to contiguous skin of nipple and areola producing eczematous lesions

Intraepithelial adenocarcinoma

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7
Q

Invasive ductal carcinoma

A

Glandular duct like aggressive malignant cells that have invaded BM in desmoplastic stroma producing a hard/firm/fibrous mass with sharp edges.

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8
Q

What is the MC kind of invasive breast cancer

A

Invasive ductal carcinoma

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9
Q

Invasive lobular carcinoma of breast characteristics

A

Malignant cells with low E cadherin expression forming orderly lines
No desmoplastic response or gland-like cells

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10
Q

Medullary breast cancer characteristics

A

Large anaplastic cells with associated plasma cells and LOs forming sheets and presenting as a well circumscribed soft mass with smooth edges + hyperplastic LNs

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11
Q

What is a DDx for medullary breast cancer

A

Fibroadenoma

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12
Q

What genes are associated with medullary breast cancer

A

BRCA1
Triple negative type

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13
Q

What causes inflammatory breast cancer and what is the prognosis

A

Tumour has invaded dermal lymphatics resulting in oedema, erythema, puckering and p’eau d’orange of the skin. Poor prognosis.

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14
Q

Mucinous breast cancer characteristics

A

Abundant extracellular mucin
Older women

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15
Q

Tubular breast cancer characteristics

A

Well differentiated tubules that lack myoepithelium

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16
Q

What are the molecular and biological subtypes of breast cancers

A

Luminal A = ER+/PR+/HER2-
Luminal B = ER+/PR+/HER2-
HER2 = HER2+ (+/- PR+ +/- ER+)
TNBC/Basal = HER2-/ER-/PR-

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17
Q

What is HER2

A

Human epidermal growth factor receptor 2

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18
Q

Who does luminal A type breast cancer effect
Where does it met
What is it’s prognosis and response to Tx

A

Older women

Bone > viscera > brain

Long survival
Poor chemo response but good endocrine therapy response

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19
Q

Who does luminal B type breast cancer effect
Where does it met
What is it’s prognosis and response to Tx

A

BRCA2 carriers
Bone > viscera > brain
Early recurrence at less < 10 years
Medium response to chemo and good response to endocrine therapy

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20
Q

Who does HER2 type breast cancer effect
Where does it met
What is it’s prognosis and response to Tx

A

Young women
Bone, brain and viscera
Good response to chemo but variable response to endocrine therapy
Bimodal recurrence (early and late)

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21
Q

Who does basal type breast cancer effect
Where does it met
What is it’s prognosis and response to Tx

A

Young women and BRCA1 holders

Bone, brain and viscera

Medullary and metaplastic cancer with a good response to chemo but poor response to endocrine therapy

Early recurrence and survival with mets is rare

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22
Q

Describe early stage breast cancer

A

Stage 0-2: confined to breast +/- up to 3 axillary/mammary LNs involved +/- micrometastases

0 = DCIS
1 = invasive carcinoma 2cm or less with no LN involvement or micromets to LNs
2 = invasive carcinoma > 2cm but < 5cm with 0-3 LNs involved

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23
Q

Describe locally advanced breast cancer

A

Stage 3
- Large size > 5cm +/- LNs
- Any size with skin/chest wall involvement
- Any size inflammatory carcinoma

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24
Q

Describe advanced breast cancer

A

Stage 4 = distant metastasis (bone, brain, lungs, liver)

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25
Q

What is neoadjuvant therapy and when is it used in breast cancer

A

Treatment delivered before primary Tx to reduce the size of the tumour or kill cancer cells that have spread

Neoadjuvant chemo is most commonly used with TNBC, HER2, type or locally advanced ER+/-PR+/HER2- cancers

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26
Q

What are the advantages of neoadjuvant therapy in breast cancer

A
  1. Making an inoperable tumour operable
  2. Making a large tumour small enough for breast conserving therapy
  3. Reducing risk of death from distant metastases
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27
Q

How does breast cancer staging occur

A
  1. Core biopsy with immunohistochemical staining for receptor status
  2. USS/CT/exam for LNs + intraoperative
  3. Distant metastasis
    - CXR
    - Abdo, chest, pelvis CT
    - Brain MRI
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28
Q

What are risk factors for male breast cancer

A

Most important = germline mutation in BRCA 2

Obesity
Infertility
Klinefelter syndrome
Exogenous oestrogen exposure
Prior benign breast disease
Chest wall radiation
Alcohol consumpion
Increasing age
First degree relative with breast cancer

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29
Q
A
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30
Q

Where does breast pain usually occur

A

Upper outer quadrant

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31
Q

Key features of mastalgia

A

Cyclical/non-cyclical
Focal/unilateral/bilateral

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32
Q

Causes of breast pain

A

Cyclical breast pain: hormones and menstrual cycle (can decrease with pregnancy/menopause)

Pregnancy

Menopause

Oestrogen/progesterone containing medications

Large breasts may produce non-cyclical breast pain

Non-cyclical breast pain may be from breat or referred from OA of thoracic spine or underlying MSK pain

Mastitis or breast abscess (redness/tender lump)

Males: physiological or diuretic related/medication related gynecomastia

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33
Q

Investigation of mastalgia

A

Imaging not indicated unless associated with lump or other signs raising suspicion of breast ca (eczematous rash/nipple retraction/bloody serous discharge/inflammation not responding to Tx etc.) or is a focal Sx in ppl > 50yo

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34
Q

Mx of mastalgia

A
  1. Reassurance
  2. Well fitted sports bra/non-underwire bra
  3. Topical NSAID gel
  4. Stopping/reducing hormonal meds
  5. Increasing soy, reducing caffeine and salt
  6. Evening primrose oil
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35
Q

How should a new breast Sx be investigated

A

The triple test
- Hx and clinical breast exam
- Imaging = mammography and/or USS
- Non-excisional biopsy = core biopsy and/or FNA cytology

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36
Q

Presenting symptoms of breast cancer

A

MC = new breast lump
Thickening or ridge
Breast of nipple asymmetry
Skin changes e.g., dimpling, redness,
Nipple changes
Nipple discharge
Unilateral breast pain

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37
Q

Next step: If on Hx and Ex there is no breast lump/discrete lesion and findings consistent with hormonal change:

A

Mammogram if DUE
Tx pain
Review in 6-8 weeks (immediately after period)
If problem persists refer for imaging

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38
Q

Next step: clinically benign breast mass/nipple change on Hx or Ex

A

Imaging

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39
Q

Next step: Clinically inconclusive on Hx and breast exam

A

Imaging

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40
Q

Next step: Suspicious or malignant breast or nipple change

A

Refer to breast surgeon and organise imaging

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41
Q

Next step: Normal breast tissue/no discrete lesion on imaging

A

If consistent with clinical findings:
- Reassure
- Advise RE breast awareness
- Advise RE future screening

If inconsistent with clinical findings:
- Non-excisional biopsy

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42
Q

Next step: If benign findings on breast imaging

A

Simple (asymptomatic) cyst: FNA
Solid lesion/complex cyst: Non-excisional biopsy = core or FNA cytology

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43
Q

Next step: FNA of simple breast cyst with normal fluid and no remaining lump

A

Send fluid for cytology if Dx uncertainty and review if lump returns
Refer to breast surgeon if persistent

44
Q

What does normal fluid on FNA of breast cyst look like

A

Straw to dark green

45
Q

Next step: FNA of simple breast cyst with bloody fluid and no remaining lump

A

Cytology and refer to breast surgeon

46
Q

Next step: FNA of simple breast cyst with remaining lump

A

Cytology and refer to breast surgeon

46
Q

Next step: Breast imaging indeterminate/equivocal or suspicious/malignant

A

Refer to breast surgeon and arrange non-excisional core biopsy or FNA cytology

47
Q

Next step: Non-excisional biopsy of breast lump shows benign findings

A

Reassure if consistent with clinical and imaging findings

48
Q

Next step: Non-excisional biopsy of breast lump shows atypical or suspiscious or malignant findings

A

Refer to breast surgeon

49
Q

What are benign nipple changes

A

Slit like retraction
Retraction that is easily everted

50
Q

What are clinically abnormal or suspicious nipple changes

A

colour change
fixed whole nipple inversion
ulceration/eczematous changes

51
Q

What kind of breast discharge is concerning for cancer

A

Unilateral
From a single duct
Serous
Bloody
Spontaneous
Woman > 60yo

52
Q

What happens if there is an abnormal result on any component of the triple test

A

Specialist referral and further investigation

53
Q

What breast imaging is indicated for women under 35 in Ix of new breast Sx

A

USS = first line
Mammogram used in addition to USS if clinical or USS findings are suspicious/malignant or indeterminate

54
Q

What breast imaging is indicated for women 35 and over in Ix of new breast Sx

A

Mammogram and USS both performed

55
Q

What breast imaging is indicated for women in pregnancy/lactation in Ix of new breast Sx

A

USS = most useful
Mammogram used in addition if clinical/USS findings are indeterminate, suspicious or malignant

56
Q

When should axillary imaging be performed and how

A

If mammogram/USS findings are suspicious or malignant

Ipsilateral axilla imaged with USS

57
Q

When is core biopsy indicated in Ix of new breast Sx

A

For Ix of suspicious lesions
When tumour type/histological grade/receptor status of Ca is required (esp. in pts being considered for neoadjuvant chemo)

58
Q

What is the advantage of core biopsy vs FNA cytology in Ix of breast lump

A

Core biopsy can differentiate bw in situ and invasive cancer

59
Q

When is FNA cytology useful in breast Ix

A

Confirmation of Dx of cystic lesion or fibroadenoma

60
Q

When is surgical referral to a breast surgeon indicated

A

Any one component of triple test +ve
Cyst aspiration with bloody aspirate or remaining lump
Spontaneous unilateral bloody or serous discharge from a single duct esp. in women > 60
Eczematoid nipple/areolar skin changes persisting > 1-2 weeks and not responding to topical Tx
Inflammtory breast conditions not resolving after 2 weeks of ABx

61
Q

What is a fibroadenoma

A

Benign breast tumour composed of fibrous and glandular tissue

62
Q

What promotes enlargement of fibroadenoma

A

Oestrogen (grows in pregnancy, reverts after menopause)

63
Q

Clinical features of fibroadenoma

A

Usually solitary, non-tender, rubbery consistency

64
Q

How does fibdroadenoma appear in imaging and tissue sample

A

USS: well defined mass

Mammogram: well defined mass +/- popcorn-like calcifications

Biopsy: glandular and fibrous tissue

65
Q

Palpable fibroadenoma Mx

A

> 40yo, palpable: consider for removal even if benign on triple test (likelihood of new lung being Ca increases with age)

< 40, palpable: surgical excision or regular clinical and USS review until stable over period of time

> 3-4cm diameter O=always consider for excision biopsy

Any lesion being followed which significantly increases in size/develops atypical features on imaging should undergo repeat biopsy or be considered for excision biopsy

66
Q

Impalpable fibroadenoma Mx

A

Benign features on imaging +/-: Mx with imaging surveillance 6-12monthly`

67
Q

What is galactorrhea and possible causes

A

Milk production in non-breastfeeding women or men

Primary hypothyroidism
Hyperprolactinaemia
Chronic nipple stimulation (piercings/tight clothing)

68
Q

What are pathological causes of nipple discharge

A

Intraductal papilloma
Mammary duct ectasia
Fibrocystic changes
Breast abscess
Malignancy esp. DCIS

69
Q

Ix of nipple discharge that is bilateral and/or only on expression

A

If no discrete lesion and no blood on clinical exam: - advise to cease expression
- do mammogram if due
- review in 2-3 mo (if continues –> breast surgeon)

If clinically abnormal:
- imaging with mammogram and USS
- refer to breast surgeon

70
Q

Ix of nipple discharge that is unilateral, spontaneous or > 60yo

A

Do imaging with mammogram and USS and refer to breast surgeon

71
Q

Tx for galactorrhea

A

Cabergoline single dose 1mg PO

72
Q

What is a mammary fistula and how does it occur

A

Abnormal communication bw mammary duct epithelium with peri-areola skin

2˚ to I&D of central breast abscess, mastitis, duct ectasia

73
Q

Ix and Mx for mammary fistula

A

Rule out carcinoma
Excision of involved duct system, antibiotics, primary closure

74
Q

What is mastitis

A

Inflammatory process affecting parenchyma of lactating breast MCly bacterial in aetiology

75
Q

MC pathogen causing mastitis

A

Staph aureus
Breast abscesses: mixed flora including anaerobic organisms

76
Q

Lactational mastitis Sx

A

Localised pain and tenderness
Erythema
Engorgement
Initially localised to one segment of breast –> can spread to affect whole breast if untreated
Signs of nipple damage
+/- systemic: fever, malaise, rigors, N&V

77
Q

What is a breast abscess

A

Localised collection in breast tissue resulting in painful breast lump possibly 2˚ to bacterial mastitis that is rapidly progressive or not managed quickly

78
Q

When is mastitis most common

A

First 6 weeks of breastfeeding esp. 2nd and 3rd weeks

79
Q

Risk factors for mastitis

A

Breastfeeding in early postpartum period
Milk stasis (engorgement/insufficient drainage)
Cracked nipples (entry of bacteria)

80
Q

Clinical features of breast abscess

A

Similar to mastitis + discrete tender lump (tense or fluctuant)

81
Q

Assessment of pt with suspected mastitis

A

Clinical diagnosis
- Hx and breast Ex
- Examine infant to ensure adequate growth and hydration
- Examine attachment to breast
- Exclude conditions that may interfere with attachment (oral candida, tongue tie, cleft palate)
- Consider lactation consultant

Breast infection that does not improve with ABx –> USS and guided aspiration for drainage and MC&S

82
Q

Mx of mastitis

A

Symptom control:
- regular oral paracetamol and NSAIDs
- gentle massage and warm compress prior to feeding
- cold pack after feeding

Antibiotics
- flucloxacillin/dicloxacillin 500mg QID for at least 5 days

Support continued breastfeeding:
- education and reassurance
- regular and complete drainage of breast
- consider lactation consultant referral

Review in 24 - 48 hours and USS if not settling

83
Q

Mx of breast abscess

A

USS guided aspiration and MC&S
ABx guided by culture

84
Q

What is gynaecomastia

A

Development of breast tissue in male due to imbalance bw free oestrogen and free androgen effects on breast tissue

85
Q

Causes of gynaecomastia

A

Physiological: neonatal (maternal hormones), pubertal (relative oestrogen excess), old age (increased aromatase activity)

Hyperprolactinaemia
Liver disease
Oestrogen/HCG producing tumours
Hyperthyroidism
Breast carcinoma
Klinefelter syndrome/hypogonadism

Digoxin
Spironolactone
Cannabis

86
Q

Ix Mx of gynaecomastia

A

Puberty: usually spontaneously resolves but if persists > 6-18mo may respond to tamoxifen or require surgical removal due to fibrosis

Older age: Ix for bronchial carcinoma, testicular tumours etc, exclude significant liver disease
- consider tamoxifen if painful (3-6mo trial) +/- surgery if Sx/cosmetics unacceptable

87
Q

Risk factors breast carcinoma

A

Increased exposure to oestrogen
- Nulliparity/1st viable pregnancy after 35yo
- Never breastfed
- Early menarche/late menopause
- Postmenopausal obesity
- HRT after menopause

Increasing age
Smoking and alcohol
Previous breast cancer (endometrial/ovarian/colorectal Ca)
Breast conditions with cellular atypia (fibrocystic change)
Childhood radiation

FHx
BRCA1 or 2

88
Q

What is Breast Conserving Treatment (BCT) in breast cancer and examples

A

Removal of cancerous breast tissue only
- wide local excision = remove tumour + 1cm of normal breast tissue
- segmental mastectomy/quadrantectomy

Must be done with adjuvant radiotherapy

Usually combined with axillary surgery
Usually for tumours < 3cm in diameter

89
Q

CI to Breast Conserving Surgery

A

Multifocal
Large tumour to breast ratio
Fixation to chest wall
Involvement of skin/nipple
Subareolar location
Hx of chest radiation
Excision with negative tumour margins not guaranteed (> 2mm)
Clustered microcalcifications on imaging

90
Q

In Breast Conserving Surgery how are negative tumour margins ID’d

A

Mark margin of resected tissue with ink –> tumour at ink = not a negative margin –> repeat resection/consider mastectomy

91
Q

Complications of Breast Conserving Surgery

A
  • Local recurrence but unchanged longterm survival outlook
  • Excision without radiotherapy has unacceptable local recurrence rate
  • Fear of recurrence
92
Q

What is lumpectomy performed

A

Benign breast tumour only (large amount of normal breast tissue not resected i.e., no need for margins)

93
Q

What is a mastectomy and when is it indicated

A

Removal of entire breast +/- other structures (LNs/muscles)

Indications
- unable to undergo BCT
- pts who request more aggressive Mx/pt preference
- large tumour relative to breast size
- central tumour beneath/involving nipple
- multifocal
- local recurrence
- local

94
Q

Types of mastectomy

A

Modified Radical
- breast, skin overlying tumour always including nipple, fat, underlying pectoralis fascia, level I and II axillary LNs (originally used to remove pec msc)
Simple = breast only removed
Double = both breasts removed

95
Q

Complications of mastectomy

A

Damage to long thoracic nerve in radical mastectomy –> scapula winging

96
Q

What is the most useful prognostic marker in breast cancer

A

Presence of metastatic disease in axillar LNs

97
Q

What is a Sentinel Node biopsy in breast cancer and who is it for

A

Who: All patients with clinically node-negative breast cancer and must be performed in breast conserving surgery or mastectomy

What: localisation of sentinel node peroperatively with injection of blue dye and radio-isotype labelled albumin into subdermal plexus around nipple –> node is ID’d visually and with gamma camera –> node is removed and histopathologically analysed for presence of cancerous cells

If nodal disease found –> axillary clearance

98
Q

What is an axillary dissection and when is it performed in breast ca pts

A

Removal of 10+ LNs during surgery for pts with clinical signs of LN infiltration

Axillary radiotherapy is equally effective but NEVER both (lymphoedema risk too high)

99
Q

Complications of axillary dissection

A

Secondary lymphoedema of arm (also with axillary radiation)

100
Q

Clinical features and complications of upper limb lymphoedema

A

Immobility of limb
Swelling
Feeling of tightness
Increased infection risk
Poor wound healing
Cosmetic disfigurement

Risk of angiosarcoma of breast

101
Q

Risk of tamoxifen therapy in breast ca

A

Endometrial cancer

102
Q

When is radiotherapy used in breast ca Tx

A

To conserved breast after BCT
To chest wall after mastectomy if risk factors for recurrence
To axilla if nodal disease (or dissection)

103
Q

Endocrine Tx in breast ca

A

Pre-menopausal:
- Tamoxifen (mixed action on oestrogen R) as adjuvant for 5 years in R positive disease
- Oophorectomy or GnRH analogue (goserelin) for anti-oestrogenic effects
- Synthetic progestogens act on progesterone Rs

Post-menopausal
- Aromatase inhibitors (anastrazole, letrozole) reduce circulating oestrogen levels as adjuvant for 5 years in R positive disease

SEs = oestrogen deprivation Sx

104
Q

Why are aromatase inhibitors preferred to tamoxifen in postmenopausal women in R +ve breast cancer

A

Risks of VTE and endometrial carcinoma

105
Q

When is chemo used in breast ca

A

High risk pts
R- disease
Failure to respond to endocrine therapy
Require rapid response
Palliation

Surgery (17 decks)

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