Breast Flashcards
Breast cancer metastasises to bone in one spot vs several spots in the bones
Best Management?
One spot: Radiation Therapy (relieves pain and prevents fractures)
Several Spots: Anticancer therapy (hormonal treatment [tamoxifen] or chemotherapy)
Extra:
Bone pain — NSAIDS and opioid drugs; radioactive therapy (strontium or samarium)
May give bisphosphonate to slow cancer
First line investigation for breast symptoms for
< 35y/o vs > 35 y/o
< 35 y/o: ultrasound (use MMG when US findings not consistent to clinical findings)
> 35 y/o: combination of MMG + breast US
Pregnant or lactating with breast symptoms
1st line IX?
US preferred over MMG
MMG can be used only if US inconsistent with clinical findings
Still safe to use MMG (can detect most breast CAs well during pregnancy)
Obesity premenopausal vs post menopausal risk for breast CA
Early life obesity in premenopausal — decreases risk (protective!)
Post menopausal obesity — increases risk of breast CA!
How often should MMG be done as per Cancer Council Australia?
Every 2 years for all women aged 50-74 years old
If => 40 years old and concerned (i.e. due to family history), can perform MMG
Paget’s Disease vs Eczema
Paget’s Disease (eczematous-looking, dry scabbing red rash of the nipple with ulceration of nipple and areola — always due to malignancy)
- unilateral
- older patients
- possible nipple discharge
- not pruritic/pustules
- deformity of nipple
- possible palpable lump
Eczema
- bilateral
- reproductive years/lactation
- no discharge
- pruritic + pustules
- normal nipple
- no lump
Paget’s Disease
Treatment?
Breast-conserving surgery (lumpectomy/partial mastectomy/WLE)
OR a mastectomy
Total mastectomy for advanced cancers
Arrange from good prognosis to worst prognosis:
Metastatic breast CA
Hodgkin Lymphoma
Non-Hodgkin Lymphoma
Metastatic Choriocarcinoma
Metastatic Seminoma
Good prognosis to worst prognosis:
- Metastatic seminoma of the testis (5-year survival rate of 95-100%)
- Hodgkin Lymphoma (5-year survival rate of 87%)
- Metastatic Choriocarcinoma (5-year survival rate of 80%)
- Non-Hodgkin Lymphoma (5-year survival rate of 71%)
- Metastatic breast CA (18-24 months) (5-year survival rate of 40%)
Red Flags for Breast Cancer
Management?
- Hard and irregular lump
- Skin dimpling and puckering
- Skin oedema (‘peau d’ orange’)
- Nipple discharge
- Nipple distortion
- Nipple eczema (Paget’s disease)
MMG+US/FNAC/Excision Biopsy(!!) even if cytology is normal
What to consider for patients with high-risk family history of breast and ovarian cancer?
- Refer to cancer specialist or family cancer clinic for risk assessment, 2. genetic testing (BRCA gene screening) and management plan
- Surveillance: regular clinical breast examination + annual breast imaging with MMG/MRI/US
After doing US (< 40 y/o) or MMG (> 40y/o), refer to breast cancer screening clinic or surgeon?
Refer to breast surgeon for further evaluation once US/MMG report is received
Vitamin A deficiency leads to what breast diseases?
Periductal Mastitis
AKA subareolar abscess
- affects young women / men,
- vitamin A (retinoids) deficiency and smoking — potential causes
[DIFFERENT FROM ductal ectasia (younger women, dilated ducts, toothpaste-like discharge)]
Aromatase Inhibitors:
- Arimidex (anatrozole)
- Femara (letrozole)
- Aromasin (exemestane)
Used to treat breast CA and ovarian CA in post menopausal women.
- blocks aromatase (enzyme that converts androgen to estrogen)
Side effects?
MOST COMMON side effects are symptoms of menopause:
Hot flashes
Night sweats
Vaginal dryness
Other possible side effects:
Muscle and joint pain
Speeds up bone thinning —> osteoporosis
May raise cholesterol
Compared to tamoxifen and raloxifene:
DVT (less than tamoxifen)
Stroke (less than tamoxifen)
Endometrial cancer (less than tamoxifen)
Osteoporosis (MORE THAN TAMOXIFEN)
Triple Test
- Clinical exam
- Imaging: MMG +/- breast US
- FNAC +/- Core Biopsy
Intermittent thin or milky discharge or nonlactational (usually serous) nipple discharge is…
Usually physiological
Frequently bilateral and arises from multiple ducts
Cause: stimulation of the nipple or to drugs (estrogen, tranquillisers)
Galactorrhea
Common cause?
Hormonal imbalance (hyperprolactinanemia, hypothyroidism)
Drugs (OCPs, phenothiazine, antihypertensive, tranquillisers)
Trauma to chest
Nature: bilateral, arising from multiple ducts
Pathologic Nipple Discharge
Bloody, serous, green-grey, yellow
Spontaneous, unilateral, often localised to a single nipple duct
Identify the source:
If mass noted > biopsy
If no mass > terminal duct excision of the involve duct(s)
What are the characteristics of a malignant breast lesion on ultrasound?
- Hypoechogenicity
- Irregular and ill-defined border
- Spiculated margins
- Being taller than broader
- Posterior acoustic shadowing
- Microcalcifications
If any above is seen, proceed
Does FNAC or Core Biopsy offer a more definitive diagnosis?
Core Biopsy
- avoids inadequate sampling
- usually able to distinguish between invasive vs in situ cancer
However, FNAC is more convenient and minimally invasive.
Advice for asymptomatic woman, 50-69 years old on HRT for breast cancer screening?
ALL asymptomatic women, 50-69 years old»_space; (MMG) screen every 2 years
Regardless of whether on HRT or not
40s and 70s are eligible to attend for FREE breast screening as well
Quickest and most effective way to diagnose a breast cancer?
FNAC
Most accurate when experienced cytologists are available
Although less sensitive than core biopsy.
CB is ix of choice in evaluation of microcalcifications or if FNAC provides scarce material
MMG and US is mainstay for screening, not for definitive diagnosis.
Ultrasound is preferred for the initial diagnosis of breast abnormalities for patient 30 years and younger because of…?
Dense breast tissue
MMG will not be able to detect small lesions and can lead to false negative results
How long should a patient wait to do MMG/US if FNA was done first? Why wait?
2-weeks should be waited because small hematomas from needle aspiration can cause false-positive
Is nipple discharge always an abnormal finding?
Always an abnormal finding EXCEPT in late pregnancy or the postpartum period
7 types of nipple discharge
(MPlusX)
Milky: white discharges sometimes fat globules seen under microscopy
Multicoloured gummous: sticky discharge
Purulent: pus with white cells seen under microscopy
Watery: colourless
Serous: faintly thin discharge
Serosanguineous: thin, clear discharge with pink tint, RBCs seen under microscopy
Bloody (sanguinous): pure blood
Watery, serous, serosanguinous or bloody nipple discharge
Intraductal papillomas — most common cause of these discharges
Nipple discharge seen in ductal ectasia
Multicoloured and sticky discharge
Toothpaste like discharge (classic description)
