Breast Flashcards
6 Ds of nipple changes in breast Ca
Discharge, deviation, depression, discoloration, destruction, dermatitis
Mx options of mastitis cx breast abscess
1) PO antibiotics(non teratogen)
2) Percutaneous aspiration
3) I & D
4) Stop breastfeeding
Red flags for nipple discharge
unilateral,uniductal, spontaneous(bra staining), persistent, bloody, elderly
Treatment for Pure Paget’s of the nipple without DCIS/IDC
Simple lumpectomy and remove Nipple Areolar Complex
Estrogen related RFs for breast cancer
Early menarche before 12?
Late menopause after 55
Nulliparity/ no children before age of 30
No breastfeeding
Hormone replacement therapy
OCPs
Genetic tests for Breast cancer
Invitae panel
BRCA 1/2 if young breast Ca < 50y.o or strong family Hx
Cowden syndrome(a/w breast,colon and thyroid Ca)
Hereditary Diffuse Gastric Ca( p53)
Indications for MRI Breast
Paget’s disease of the Nipple
- TRO concomitant lesions eg DCIS
Screening for high risk patients aged 35-40
- BRCA mutation
- First deg relative with BRCA
- Prev chest radiation
- Li Fraumeni or Cowden syndrome
- Nodal disease with occult primary
- Multifocal tumors
Breast Cancer TNM staging
Tis: DCIS/Paget’s disease of nipple
T1:
=<1mm
>1mm but <=5mm
>5mm but <=10mm
>10mm but <=20mm
T2: 20mm< and >50mm
T3: 50mm<
T4
Direct extension to chest wall ( Ribs, intercostal, serratus anterior, pectoralis minor NOT major ,muscle)
Extension to skin(Peau d’orange, ulceration, satellite skin nodule
T4a + T4b
d: Inflammatory Breast Cancer with lymphedema
3 components of curative breast cancer local mx
Breast surgery, Axilla surgery and Reconstruction
Curative options for breast surgery
1) Breast conserving therapy: Breast conserving surgery + whole breast RT
2) Simple mastectomy
3) Radical mastectomy
Reconstruction options post breast surgery
1) Grafts
-Implants: Silicone, Saline
Autologous
- Lat dorsi myocutaneous flap(LDMF)
- Transverse Rectus myocutaneous flap(TRAM)
- Deep Inferior Epigastric Perforator flap(DIEP), muscle sparing
2) Breast reconstruction
3) Nipple reconstruction
6 Ds of suspicious Nipple Areolar Complex changes
- Depression
- Discharge
- deviation
- discoloration
- destruction
- dermatitis
- Retraction
- Peau d orange(lymphoedema)
Red flags of nipple discharge
- unilateral
- uniductal
- spontaneous(bra staining)
- persistent
- serous and bloody
- elderly
Non Estrogen related risk factors for breast cancer
- BRCA 1/2 (a/w triple negative Breast Ca)
- FHx of Breast Ca
- Previous chest radiation
- High risk lesions
- Ductal Carcinoma in-situ(DCIS)
- Lobular carcinoma in-situ(LCIS)
- Atypical ductal hyperplasia(ADH) - Smoking
- Alcohol
Criteria for diagnosis of inflammatory breast cancer(T4d)
- Rapid onset of erythema, edema and peau d’orange appearance +- breast warmth and palpable lump
- Sx present for less than 6/12
- Erythema >⅓ of breast
- Histo showing poorly differentiated tumor diffusely invading breast parenchyma
Curative mx of inflammatory breast cancer
Chemo+RT+ Hormonal+ +surgery(including SLNB)
Suspicious features of BI RADS
- Skin and muscle involvement
- Vascularity
- Microcalcifications
Other suspicious features - Heterogenous
- Irregular borders
- Taller than wide
Indications for MRI Breast
- Paget’s disease of the Nipple
TRO concomitant lesions eg DCIS/IDC - Screening for high risk patients aged 35-40
- BRCA mutation
- First deg relative with BRCA
- Prev chest radiation
- Li Fraumeni or Cowden syndrome
- Nodal disease with occult primary
- Multifocal tumors
Options for histological dx of breast cancer
- Core biopsy
6-8x cores, may be done with MMG/US guidance
Histology and tumor architecture
Immunochemistry staining: Estrogen, Progesterone and Human epidermal growth factor receptors (ER, PR, HER2) - Punch biopsy
Especially for suspected inflammatory breast cancer, showing dermal lymphatic invasion by tumor cells - Vacuum Assisted Biopsy(VAB) for non palpable/ tumor surrounded by fluid
Contraindications to Breast Conserving therapy( Breast conserving surgery+ Whole breast RT)
- Poor tumor: breast ratio
- Multicentric disease
- Tumor >5cm
- RT contraindicated or patient not agreeable
Complications of Axillary clearance
- Thoracodorsal nerve injury
- Long thoracic nerve injury
- Lymphedema
- Joint stiffness
Mx of Atypical ductal hyperplasia
Microdochectomy kiv major duct excision
Mx of DCIS( Ductal carcinoma in situ)
BCS w/ WBRT and reconstruction
Unless multicentric disease or poor tumor:breast ratio
SLNB kiv AC only if specific indications
Hormonal therapy if ER/PR +ve, reduces recurrence
Indications for SLNB kiv axillary clearance for DCIS
- High grade tumor
- Comedo necrosis
- Mass forming
- Undergoing simple mastectomy( SLNB not accurate after)
Palliative options for breast cancer
Palliative chemotherapy for triple negative
Palliative RT
fungating mass
Bone mets
Surgical
Toilet mastectomy for sx of discharge
Prophylactic oophorectomy if chemotherapy and pt has not completed family
Enrolment in clinical trials for novel treatments
Adjuvant therapies for breast cancer
- Chemotherapy
- Radiotherapy
- Hormonal therapy for receptor positive tumors
- Immunotherapy/targeted therapy
- Clinical trials
Indications for neoadjuvant chemo for breast cancer
- Locally advanced tumor
- HER2+ and >1cm size
Contraindications to RT for breast cancer
Pregnancy, previous RT, Ataxia telangiectasia gene mutation
Side effects of breast cancer hormonal therapy
Hot flushes
Increased risk of endometrial ca
Increased VTE risk
SEs of breast cancer targeted therapy
cardiotoxicity and cardiomyopathy
