Breast Flashcards by Chandrakumar B.

What are the symptoms of bone metastases? (4)

Back pain
Hypercalcaemia
• constipation
• Abdominal pain
• disorientation

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** Breast metastases**

(4) in order, list most common breast metastases.

1) Lungs
2) Bone
3) Liver
4) Brain

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What does carcinoma in- situ mean?

Pre- invasive cancer that has not breached the epithelial BM

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DCIS

Is the most common type of non invasive breast cancer. (T/F)

True

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DCIS

Definition.

DCIS is the proliferation of malignant epithelial cells within the mammary ductal system.

No invasion into surrounding stroma

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DCIS

Progress of DCIS from normal cells. (3)

Ductal hyperplasia —> atypical ductal hyperplasia (ADH) —> DCIS

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DCIS

What is the risk of DCIS becoming malignant?

High risk for malignancy in next 10 years

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DCIS

What is the score used to prognosticate DCIS?

What are the parameters? (4)

Van Nuys prognostic Index

Size of lesion
Margin width
HPE classification (LG/HG)
Age

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DCIS

Mainstay management of DCIS?

What is breast conserving therapy (BCS)?

What endocrine therapy recommended for women who didn’t do bilateral mastectomy?

Surgery: Breast conserving therapy OR mastectomy

Local excision of tumour w/o complete removal of breast +/- neoadjuvant chemotherapy +/- radiotherapy

Tamoxifen for those who have not menopause; aromatase inhibitor for those who have menopause

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DCIS

What is Sentinel lymph node?

The sentinel Lymph node is the first LN that or group of nodes that drain lymph from the primary tumour

(axillary LN)

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DCIS

Why is SLNB not done (surgeon dependent) in DCIS? (3)

It is recommended to be done in patients with total mastectomy or wide local excision.

It is not recommended in BCS as DCIS is theoretically confined and metastases is unlikely to occur.

The risk of developing lymphedema from SLNB is higher than the risk of malignant transformation of DCIS

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DCIS

Is positive for E-cadherin. (Yes/No)

Yes

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LCIS

Is this pre-malignant? (yes/no)

Does it distort lobular architecture? (yes/no)

LC and LCIS are commonly multifocal and/or bilateral? (yes/no)

No, unlike DCIS, LCIS is not pre-malignant.

No, unlike DCIS, this does not distort lobular architecture.

Yes

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LCIS

treatment (3)

1) Lifelong close surveillance
2) Bilateral mastectomies
3) Prophylaxis with tamoxifen

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Ductal carcinoma

Age seen in?

Most common variant for invasive breast cancer (T/F)

Seen in Females >50
True

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Screening

Clinical breast examination (CBE) is advocated to start from what age?

From 35 years of age onwards

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Age Screening

Screening for general female population?

Screening for moderate risk females? (3)

What are RF for moderate risk? (3)

Screening for High risk but no genetic component?

What makes a strong family history for Br. Ca.? (2)

Screening for high risk with genetic risk (3)?

What are the genes for genetic risk for Breast cancer?qaqqq

General population: 50-74 years old (biannual)- every 6 months Mammogram (M)
40-49: Annual mammogram
50-59: Annual or biannual mammogram
60 & above: Biannual
Early menarche (<12)
Late menopause (>55)
Nulliparity
30-39: consider M
-40-59: Annual M
-60 or more: Biannual M
1st dgree relative
young age onset of breast cancer: <45
Annual MRI (30-49
Annual M (40-69)
Biannual (70 onwards)
BRCA1
BRCA 2
PALB2

Breast PE
Risk of Br Ca based on race?
Malay Chinese Indian?a

Chinese> Indian> Malay

Why do mammograms in patients with suspected Br Ca?

To look for early changes in the contralateral breast

4 common presentations of Br Ca.?

Asymptomatic early Br Ca
symptomatic Early Br Ca
locally advanced Br Ca
Mets Br Ca

Breast nipple discharge

4 suspicious signs (cancer).

1) Single duct discharge
2) spontaneous discharge
3) Copious
4) Serous to Bloody

What age is considered early onset Br CA?

< 40 Y/O

6 Risk Factors for Br Ca.

Early menarche (<12 y/o)
Late menopause (>55 y/o)
Late age @ first full term pregnancy (first birth after 30– risk X2 compared to first birth before 18)
Nulliparity
HRT (risk disappears w/in 5Y of ceasing HRT)
Oestrogen based OCP

Protective factors against Br Ca?

-Breastfeeding, how long? (@ least 6 months)
- Healthy lifestyle (physical activity)

Other risk factors for br ca. (5)

-Age -Fam Hx ( at least 2 generations of breast or gynecologic ca) • Age at Dx. U • 1° relative w/ BrCa= risk x2 • Risk increases if relative had early onset Ca or BILATERAL disease •Associated ca.; ovary, Colon, prostate, gastric, pancreatic - Previous breast disease: • Previously treated Br Ca • Breast biopsy ° Adenosis, cysts, apocrine metaplasia (no increased risk) ° Atypical ductal hyperplasia or Atypical lobular hyperplasia (high risk) ° Previous mammogram results - ionising radiation (RT for previous breast Dz or lymphoma) - Daily alcohol intake (before age 30)

What is a triple assessment?

Triple assessment for Br Ca: 1) Physical examination (CBE) 2) Imaging (mammogram) 3) Biopsy (FNAC VS Core biopsy)

Indications for hook wire biopsy?

- Non palpable Lump

Difference between stereotactic VS US guided biopsy?

Stereotactic uses X-ray (mammogram) US guided uses ultrasound - US is faster - More Comfortable for patient

What kind of gland is the breast?

- Modified sweat gland

Breast is located between subcutaneous fat and the fascia of the pectoralis muscle and serratus anterior Muscle (T/F)

True

What is the pathophysiology behind skin dimpling?

Malignant infiltration and the contraction of Cooper's Ligament

**Breast Anatomy** Areola is lubricated by?

Glands of Montgomery (large modified sebaceous gland)

**Breast Lymphatic drainage** Where does 75% of breast lymph drain into? 20%? Balance?

- Axillary nodes- 75% of ipsilateral breast drains to Axillary nodes - Into ipsilateral internal mammary nodes - into inter pectoral nodes (Rotter's nodes)

**Breast Anatomy** Anatomical/surgical division of axillary nodes? (Relative to Pec minor)

Level I: lateral to Pec minor Level II: posterior to Pec minor Level III: medial to Pec minor, extending to apex of axilla

If carcinoma of breast is confirmed, what Blood tests to be done (2) What imaging? (1) Additional for staging purposes?

- CBC - LFT - CXR - CT of chest and abdomen - PET CT of Chest abdomen

Describe sentinal lymph node.

First LN in the LN basin draining a tumor

Can FNA differentiate between invasive VS in situ Br. Ca? (yes/no)

No, thus need to do core biopsy

What can a core needle biopsy determine? (3)

- Tumor histology - Assess receptor status (ER/PR/HER2-neu) - Tumor biology

What imaging (2) is recommended for patients with invasive cancer for systemic staging?

PET scan Brain MRI

What are the Indications for mastectomy for Stage 4 Breast cancer? (3)

- Bleeding - Pain - Ulceration/ Fungating

**Breast surgery complications** Mastectomy and Axillary node clearance, nerve injury (3) What are the symptoms seen in patients based on each nerve?

1) Long thoracic nerve 2) Thoracodorsal nerve (innervates Latissimus dorsi) 3) Intercostobrachial nerve 1) Cause weakness to serratus anterior & dynamic winging of scapula 2) Pain that shoot( zaps) Tingling sensation Weakness and loss of function of lat dorsi, wrist drop fingerdrop 3) Intercostobrachial nerve injury signs: constricting, burning and lancinating sensations and sensory loss in axilla, posteromedial upper arm and ant. chest wall. Can develop frozen shoulder