Breast Flashcards
how does density of breast tissue affect sensitivity of mammography
dense breast = more fibroglandular tissue compared to fat
denser breasts make mammography less sensitive
what age women is mammography used in
generally women over 40 unless malignancy highly suspected
1-5 scoring for P score/M score/ B score
1 - normal
2 - benign
3 - indeterminate/probably benign
4 - suspicious
5 - malignancy
when is USS used
alone useful in focal symptoms e.g. a lump and especially in younger patients/those with denser breasts
used with mammogram in those >40
how does a cyst appear on USS
fluid filled so a black distinct circle
distinguishing benign from malignant mass on USS
shape and margin
types of biopsy
fine needle aspiration cytology
core biopsy
C score for cytology scoring (FNA)
C1 insufficient sample
C2 benign
C3 indeterminate
C4 suspicious
C5 malignant
Biopsy scoring for B5
B5a non-invasive
B5b invasive
benefits of core biopsy over FNA
allows better assessment of malignancy including histological type, invasive or not and receptor status
how many cores are taken in a core biopsy
3
arterial supply of the breast
branches of the axillary artery
perforating branches of both the mammary artery and the intercostal arteries
lymphatic drainage of the breast
75% to the axillary nodes (levels 1-3)
rest to internal mammary nodes (more medial part of breast)
triple assessment
clinical assessment
imaging
needle biopsy
lymph node management if abnormal nodes on USS and biopsy
axillary node clearance
lymph node management if normal pre-op axillary assessment
sentinel node biopsy - nearest node to the cancer
grading of cancer
1-3 - shows aggressive potential
takes into account amount of gland formation, nuclear features and mitotic activity
what are the receptors in breast cancer
ER- oestrogen receptor +ve/-ve
PR - progesterone receptor; less important in deciding treatment
HER - +ve tend to grow and spread faster
treatments in ER +ve breast cancer
endocrine therapies that target the oestrogen such as aromatase inhibitors or tamoxifen
treatment in HER +ve breast cancer
monoclonal anti-HER2 therapy such as Herceptin (trastuzumab)
commonest type of breast cancer
second most
invasive ductal carcinoma
invasive lobular is second most - can be hard to detect because can present as thickening rather than lump - usually needs MRI
types of breast surgery
mastectomy
wide local excision with radiotherapy
lymphoedema
complication of lymph node clearance causing swelling of the arm as lymph accumulates
indications for mastectomy
multi-focality - >2 cancers in same breast
local recurrence
> 4cm lump
when is chemotherapy offered in breast cancer
usually adjuvant - after breast surgery
sometimes neoadjuvant - before breast surgery
not everyone is offered chemotherapy - depends on patient and tumour factors
what is the aim of adjuvant chemotherapy
to eradicate micrometastatic disease and increase chance of cure
T categories in breast cancer TNM staging
T0 - no evidence of tumour
Tis - carcinoma in situ or pagets with no mass
T1 - 2cm or less across
T2 - >2cm less than 5cm
T3- 5cm or more across
T4 - tumour of any size growing into the chest wall or skin
N categories TNM staging
N0 no nodes
N1 1-3 axillary nodes
N2 4-9 axillary nodes
N3 10 or more axillary nodes
predict tool
uses multiple patient and tumour factors to give percentage improved chance of survival with different therapies including adjuvant chemotherapy and hormone therapies
can radiotherapy be given again for a new primary
no - mastectomy usually performed if a new primary cancer develops in a same breast
radiotherapy shouldn’t be given twice
what types of breast cancer is chemotherapy usually used in
HER2 +ve cancers - anti-HER2 + chemotherapy
triple negative cancers always give chemotherapy
not indicated in Er+ve and PR+ve cancers
tamoxifen side effects
vaginal dryness
cataracts
endometrial thickening
DVT
what is mastitis
painful inflammatory condition of the breast
may or may not be associated with lactation
symptoms of pain, fever/general malaise, often wedge shaped area of tender, hard, red, swollen area of breast
breast abscess
collection of pus within the breast
a severe complication of mastitis
lactational mastitis cause
stasis in the milk ducts
may be infectious (if so usually staph aureus) or non-infectious
important factors to ask about breast pain
relationship to menstrual cycle; cyclical pain usually worse end of cycle (before menstruation)
any associated symptoms
uni or bilateral
PMH, FH, DH etc
cyclical breast pain
changes in hormones during menstrual cycle - luteal phase worst (before period)
common in premenopausal women
may radiate to axilla/arms
non-cyclical breast pain
- pain not related to menstrual cycle
or - extramammary pain; not from breast itself but rather chest wall/costochondiritis
cause often unclear but usually settles
breast density link to cancer
independently increases risk for cancer up to 5x
+ harder to detect in dense breasts
lactational mastitis risk factors
baby not attaching well + using dummies/bottles
nulliparity
a tight bra
imaging for suspected abscess/mastitis
USS to look for an abscess
if detected needs USS guided drainage
Abx of choice for mastitis/abscess in breastfeeding mothers
penicillins
physiological changes of the breast during lactation (hormones)
during pregnancy oestrogen stimulates ductal system growth and branching
progesterone causes alveolar cells to secrete
milk production begins after childbirth under prolactin influence
lactation is sustained by oxytocin and prolactin
breasts feel larger, firmer and more nodular, areolas may grow and darken
important mastitis differential
inflammatory breast cancer may present with skin changes of redness and inflammation as the cancer occurs along the lymph vessels
what medications may be used for severe cyclical breast pain
tamoxifen off license
Danazol (anti gonadotrophin) licensed for severe breast pain and tenderness in benign fibrocystic disease which has not responded to other treatments
breastfeding advice in mastitis
continue to breastfeed on demand from both breasts
non-lactational risk factors for mastitis/abscess
diabetes
immunocompromise
smoking
nipple piercing
PIP implants and removal if ruptured
a type of now banned silicone implants that are more likely to rupture than other types
the NHS will pay for removal but not for new implants
most common benign lump young woman
fibroadenoma - smooth, mobile, no skin tethering
USS performed to check whether cystic, or solid and confirm benign - on USS, solid with a defined margin
assessment of a presumed benign lump
triple assessment should still be performed if patient over 25 - USS guided core biopsy is best
if under then biopsy may not be done if benign on clinical examination and USS
excision of a fibroadenoma
only normally done if >4cm or growing
popcorn calcification
In postmenopausal women, fibroadenomas are prone to involution and often develop characteristic calcification known as ‘popcorn calcification’
most likely benign lump older woman
cyst
breast cysts management/transformation/new lump?
benign - don’t need treatment but aspirate if painful or causing discomfort
do not transform to cancer
if new lump always return don’t presume cyst
does cystic fluid need cytology when drained
only if blood stained
screening mammograms
aged 50-70 every 3 years
over 70 on request
all are read by two interpreters
microcalcification
- what is it
- causes
small specks on calcium salts too small to feel or call pain
common
sometimes associated with fibroadenomas, cysts and trauma
most important cause - due to ductal carcinoma in situ (DCIS)
difficult to differentiate cause- all need further assessment
investigation of microcalcification
stereotactic guided core biopsy - doesn’t show well on USS
ductal carcinoma in situ
cancer cells within the milk ducts but not invaded the basement membrane
necrotic cells at the centre often calcify and can follow a linear pattern of microcalcificaiton
spread of ductal carcinoma in situ
initially confined to ducts so doesn’t have potential to spread
can eventually invade the basement membrane and become invasive and then have potential to metastasise
more likely to spread if high grade on biopsy
localising DCIS for surgery
stereotactic wire localisation using X-ray guidance done before surgery then removed with surgical specimen
reasons for repeat surgery/mastectomy after wide excision for DCIS
- adequate margin of healthy tissue not achieved
- area of invasive cancer found within the DCIS
DCIS follow up
annual mammogram and clinical examination for 5 years
breast arterial calcification
tramline appearance - lots of lines of calcification
associated with increasing age, diabetes and cardiovascular disease
screening for women of high risk
what defines high risk
BRCA gene mutations, tp53 gene mutation and previous supradiaphragmatic radiotherapy
annual MR and mammography from age 40
high risk is 30%+ lifetime risk of breast cancer
what proportion of breast cancers are due to genetics
1 in 20 associated with genes such as BRCA1 or 2
normal function of BRCA genes
DNA repair genes
male breast cancer risk BRCA genes
BRCA 1 slightly increased risk
BRCA 2 more increased risk
risk reducing options
enhanced screening
risk reducing surgery (mastectomy, oophorectomy)
risk reducing drugs e.g. tamoxifen
BRCA genes
- inheritance
- chromosomal locations
autosomal dominant inheritance
BRCA 1 chromosome 17 long arm
BRCA 2 chromosome 13 long arm
prophylactic mastectomy risk reduction
90%
duct ectasia
usually post menopausal
ducts shorten and dilate
may cause a cheese like nipple discharge and slit like retraction of the nipple
no specific treatment required
aromatase inhibitors
- examples
- side effects
anastrozole
letrozole
used in ER+ve
side effects;
osteoporosis
hot flushes
arthralgia, myalgia
insomnia
adjuvant hormonal therapy
if hormone receptor positive
tamoxifen is pre and peri menopausal women
aromatase inhibitors in post menopausal women
2ww breast referral guidelines
30+ with a lump
50+ with unilateral nipple discharge, retraction or other concerning change
Paget’s disease of the nipple
eczematous change of the nipple associated with an underlying breast malignancy
fat necrosis of the breast
more common in obese women/large breasts
may follow trivial trauma
initial inflammatory response followed by hard irregular lump
warrants further investigation
tamoxifen action
selective oestrogen receptor modulator - works in premenopausal women
aromatase inhibitors action
block peripheral conversion of androgens to oestrogens so only effective in post menopausal women
worrying features of nipple discharge
unilateral
spontaneous
uni ductal
blood stained
serous
2WW breast cancer
aged 30 and over and have an unexplained breast lump with or without pain or
aged 50 and over with any of the following symptoms in one nipple only: discharge, retraction or other changes of concern
consider in
with skin changes that suggest breast cancer or
aged 30 and over with an unexplained lump in the axilla
