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Clinical Years / Progress Test > Breast > Flashcards

Breast Flashcards

1
Q

how does density of breast tissue affect sensitivity of mammography

A

dense breast = more fibroglandular tissue compared to fat

denser breasts make mammography less sensitive

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2
Q

what age women is mammography used in

A

generally women over 40 unless malignancy highly suspected

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3
Q

1-5 scoring for P score/M score/ B score

A

1 - normal
2 - benign
3 - indeterminate/probably benign
4 - suspicious
5 - malignancy

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4
Q

when is USS used

A

alone useful in focal symptoms e.g. a lump and especially in younger patients/those with denser breasts

used with mammogram in those >40

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5
Q

how does a cyst appear on USS

A

fluid filled so a black distinct circle

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6
Q

distinguishing benign from malignant mass on USS

A

shape and margin

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7
Q

types of biopsy

A

fine needle aspiration cytology

core biopsy

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8
Q

C score for cytology scoring (FNA)

A

C1 insufficient sample
C2 benign
C3 indeterminate
C4 suspicious
C5 malignant

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9
Q

Biopsy scoring for B5

A

B5a non-invasive
B5b invasive

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10
Q

benefits of core biopsy over FNA

A

allows better assessment of malignancy including histological type, invasive or not and receptor status

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11
Q

how many cores are taken in a core biopsy

A

3

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12
Q

arterial supply of the breast

A

branches of the axillary artery

perforating branches of both the mammary artery and the intercostal arteries

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13
Q

lymphatic drainage of the breast

A

75% to the axillary nodes (levels 1-3)

rest to internal mammary nodes (more medial part of breast)

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14
Q

triple assessment

A

clinical assessment
imaging
needle biopsy

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15
Q

lymph node management if abnormal nodes on USS and biopsy

A

axillary node clearance

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16
Q

lymph node management if normal pre-op axillary assessment

A

sentinel node biopsy - nearest node to the cancer

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17
Q

grading of cancer

A

1-3 - shows aggressive potential

takes into account amount of gland formation, nuclear features and mitotic activity

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18
Q

what are the receptors in breast cancer

A

ER- oestrogen receptor +ve/-ve

PR - progesterone receptor; less important in deciding treatment

HER - +ve tend to grow and spread faster

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19
Q

treatments in ER +ve breast cancer

A

endocrine therapies that target the oestrogen such as aromatase inhibitors or tamoxifen

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20
Q

treatment in HER +ve breast cancer

A

monoclonal anti-HER2 therapy such as Herceptin (trastuzumab)

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21
Q

commonest type of breast cancer

second most

A

invasive ductal carcinoma

invasive lobular is second most - can be hard to detect because can present as thickening rather than lump - usually needs MRI

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22
Q

types of breast surgery

A

mastectomy

wide local excision with radiotherapy

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23
Q

lymphoedema

A

complication of lymph node clearance causing swelling of the arm as lymph accumulates

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24
Q

indications for mastectomy

A

multi-focality - >2 cancers in same breast

local recurrence

> 4cm lump

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25
Q

when is chemotherapy offered in breast cancer

A

usually adjuvant - after breast surgery

sometimes neoadjuvant - before breast surgery

not everyone is offered chemotherapy - depends on patient and tumour factors

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26
Q

what is the aim of adjuvant chemotherapy

A

to eradicate micrometastatic disease and increase chance of cure

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27
Q

T categories in breast cancer TNM staging

A

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

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28
Q

N categories TNM staging

A

N0 no nodes
N1 1-3 axillary nodes
N2 4-9 axillary nodes
N3 10 or more axillary nodes

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29
Q

predict tool

A

uses multiple patient and tumour factors to give percentage improved chance of survival with different therapies including adjuvant chemotherapy and hormone therapies

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30
Q

can radiotherapy be given again for a new primary

A

no - mastectomy usually performed if a new primary cancer develops in a same breast
radiotherapy shouldn’t be given twice

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31
Q

what types of breast cancer is chemotherapy usually used in

A

HER2 +ve cancers - anti-HER2 + chemotherapy

triple negative cancers always give chemotherapy

not indicated in Er+ve and PR+ve cancers

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32
Q

tamoxifen side effects

A

vaginal dryness
cataracts
endometrial thickening
DVT

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33
Q

what is mastitis

A

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

34
Q

breast abscess

A

collection of pus within the breast
a severe complication of mastitis

35
Q

lactational mastitis cause

A

stasis in the milk ducts
may be infectious (if so usually staph aureus) or non-infectious

36
Q

important factors to ask about breast pain

A

relationship to menstrual cycle; cyclical pain usually worse end of cycle (before menstruation)
any associated symptoms
uni or bilateral
PMH, FH, DH etc

37
Q

cyclical breast pain

A

changes in hormones during menstrual cycle - luteal phase worst (before period)
common in premenopausal women
may radiate to axilla/arms

38
Q

non-cyclical breast pain

A
  • pain not related to menstrual cycle
    or
  • extramammary pain; not from breast itself but rather chest wall/costochondiritis
    cause often unclear but usually settles
39
Q

breast density link to cancer

A

independently increases risk for cancer up to 5x
+ harder to detect in dense breasts

40
Q

lactational mastitis risk factors

A

baby not attaching well + using dummies/bottles
nulliparity
a tight bra

41
Q

imaging for suspected abscess/mastitis

A

USS to look for an abscess

if detected needs USS guided drainage

42
Q

Abx of choice for mastitis/abscess in breastfeeding mothers

A

penicillins

43
Q

physiological changes of the breast during lactation (hormones)

A

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

44
Q

important mastitis differential

A

inflammatory breast cancer may present with skin changes of redness and inflammation as the cancer occurs along the lymph vessels

45
Q

what medications may be used for severe cyclical breast pain

A

tamoxifen off license

Danazol (anti gonadotrophin) licensed for severe breast pain and tenderness in benign fibrocystic disease which has not responded to other treatments

46
Q

breastfeding advice in mastitis

A

continue to breastfeed on demand from both breasts

47
Q

non-lactational risk factors for mastitis/abscess

A

diabetes
immunocompromise
smoking
nipple piercing

48
Q

PIP implants and removal if ruptured

A

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

49
Q

most common benign lump young woman

A

fibroadenoma - smooth, mobile, no skin tethering

USS performed to check whether cystic, or solid and confirm benign - on USS, solid with a defined margin

50
Q

assessment of a presumed benign lump

A

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

51
Q

excision of a fibroadenoma

A

only normally done if >4cm or growing

52
Q

popcorn calcification

A

In postmenopausal women, fibroadenomas are prone to involution and often develop characteristic calcification known as ‘popcorn calcification’

53
Q

most likely benign lump older woman

A

cyst

54
Q

breast cysts management/transformation/new lump?

A

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

55
Q

does cystic fluid need cytology when drained

A

only if blood stained

56
Q

screening mammograms

A

aged 50-70 every 3 years

over 70 on request

all are read by two interpreters

57
Q

microcalcification
- what is it
- causes

A

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

58
Q

investigation of microcalcification

A

stereotactic guided core biopsy - doesn’t show well on USS

59
Q

ductal carcinoma in situ

A

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

60
Q

spread of ductal carcinoma in situ

A

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

61
Q

localising DCIS for surgery

A

stereotactic wire localisation using X-ray guidance done before surgery then removed with surgical specimen

62
Q

reasons for repeat surgery/mastectomy after wide excision for DCIS

A
  • adequate margin of healthy tissue not achieved
  • area of invasive cancer found within the DCIS
63
Q

DCIS follow up

A

annual mammogram and clinical examination for 5 years

64
Q

breast arterial calcification

A

tramline appearance - lots of lines of calcification
associated with increasing age, diabetes and cardiovascular disease

65
Q

screening for women of high risk

what defines high risk

A

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

66
Q

what proportion of breast cancers are due to genetics

A

1 in 20 associated with genes such as BRCA1 or 2

67
Q

normal function of BRCA genes

A

DNA repair genes

68
Q

male breast cancer risk BRCA genes

A

BRCA 1 slightly increased risk
BRCA 2 more increased risk

69
Q

risk reducing options

A

enhanced screening

risk reducing surgery (mastectomy, oophorectomy)

risk reducing drugs e.g. tamoxifen

70
Q

BRCA genes
- inheritance
- chromosomal locations

A

autosomal dominant inheritance

BRCA 1 chromosome 17 long arm
BRCA 2 chromosome 13 long arm

71
Q

prophylactic mastectomy risk reduction

A

90%

72
Q

duct ectasia

A

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

73
Q

aromatase inhibitors
- examples
- side effects

A

anastrozole
letrozole

used in ER+ve

side effects;
osteoporosis
hot flushes
arthralgia, myalgia
insomnia

74
Q

adjuvant hormonal therapy

A

if hormone receptor positive
tamoxifen is pre and peri menopausal women
aromatase inhibitors in post menopausal women

75
Q

2ww breast referral guidelines

A

30+ with a lump
50+ with unilateral nipple discharge, retraction or other concerning change

76
Q

Paget’s disease of the nipple

A

eczematous change of the nipple associated with an underlying breast malignancy

77
Q

fat necrosis of the breast

A

more common in obese women/large breasts
may follow trivial trauma
initial inflammatory response followed by hard irregular lump
warrants further investigation

78
Q

tamoxifen action

A

selective oestrogen receptor modulator - works in premenopausal women

79
Q

aromatase inhibitors action

A

block peripheral conversion of androgens to oestrogens so only effective in post menopausal women

80
Q

worrying features of nipple discharge

A

unilateral
spontaneous
uni ductal
blood stained
serous

81
Q

2WW breast cancer

A

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

Clinical Years / Progress Test (24 decks)

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