Breast Flashcards by Pamudi Pannilavithana

PC - extremely mobile, smooth and firm breast lumps
younger patient
“breast mouse”

fibroadenoma

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How would you manage a fibroadenoma?

> 3cm surgical excision

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PC - smooth, discrete and fluctuant breast mass
peri-menopausal woman

Breast cyst

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How would a breast cyst be managed?

aspirated as small risk of cancer, esp if young
*if blood stained or persistently refilling biopsy and excise

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PC - breast lump or pain, mammographic changes that mimic cancer
*distortion of lobular unit without hyperplasia

sclerosing adenosis

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PC - hard, irregular lump. dimpling of skin, nipple changes
obese woman, mechanical trauma, recent surgery

fat necrosis - imaging and core biopsy

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PC - tender lump, green-brown discharge

mammary duct ectasia

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how do you manage mammary duct ectasia?

none
microdochetomy if young

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What are some differentials for nipple discharge?

physiological breast feeding
galactorrhoea
hyperprolactinaemia
mammary duct ectasia - thick and green, smoker
carcinoma - blood stained
intraductal papilloma - blood stained, no lump, young

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PC - painless, hard, ,irregular lump, nipple inversion or skin tethering

breast cancer

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PC - dry, reddening and thickening, eczematous changes of breast and areola

pagets disease of the breast
*associated with underlying malignancy

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PC - progressive erythema and oedema of breast in absence of signs of infection, WCC & CRP etc

inflammatory BC

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What is the most common type of breast cancer?

invasive ductal carcinoma

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Where does ductal carcinoma in situ arise from?

epithelial cells lining the ducts
*no BM invasion, u/L

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where does lobular carcinoma in-situ arise from?

epithelial cells inside the lobules (secretory units made of many acini cells) confined to the acini cells
*pre-menopausal women. b/L usually

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What are the 2 types of cancers that have invaded the BM?

invasive ductal carcinoma - cells have no particular features under microscope
invasive lobular carcinoma

What is the pathophysiology of breast cancer?

BRCA 1, BRCA 2 mutations –> acquired or inherited
- glandular cells become malignant with oncogene mutations
- HER2 oncogene overexpression - for cell survival

What is BRCA 1 associated with?

*chromosome 7
increased risk of bowel, prostate and breast cancer

What is BRCA 2 associated with?

*chromosome 13
increases men’s risk of BC, lower risk than BRCA 1

What are some risk factors for developing BC?

oestrogen exposure - nulliparity, combined HRT, COCP, early menarche, late menopause
high BMI
FHx
age
female
alcohol intake, smoking

How might breast cancer present?

lump - painless, irregular, craggy, hard
nipple changes - dimpling, skin changes, Peau d orange, discharge
constitutional sx
mets sx
pagets disease!

How does breast screening work?

females
50-71 y/o –> mammogram
30 - BRCA + MRI
20 - p53 + MRI

What are some risks with the breast cancer screening programme?

male patients
trans patients
homeless people may not hear about from GP

What are the urgent 2ww referral criteria for BC?

30+ unexplained lump with or without pain
50+ nipple discharge, retraction or other concerning changes

What is included in the triple assessment for BC?

clinical assessment and hx imaging - b/L USS <30 and mammo >30 biopsy - fine needle, sentinel node or USS guided

What other investigations are needed in suspected BC?

FBC for anaemia, infection, neutropenia LFT - mets CRP - infection U&E - renal function pre imaging and management bone profile - hypercalcaemia and mets imaging - CT thorax, abdo, pelvis, PET, CXR, CT head hormone receptors - oestrogen, progesterone, HER2

What is the relevance of hormone receptors in BC management?

oestrogen - binds to nucleus on cancer cell and causes proliferation, if negative prognosis worse as less like parent cell HER2 - proliferative and anti-apoptosis signals hence prognostically worse *can target in treatment!

What methods of surgery can be offered in BC?

wide local with 1cm margin - solitary, peripheral, small mastectomy - multifocal, central, large sentinel node - prevent spread

What are the risks of breast cancer surgery?

- infection, anaesthetic risk, nerve or vessel damage, bleeding risk, VTE, body image - Seroma - collection of serous fluid which could become infected - Lymphoedema - swelling due to impaired lymph drainage, difficult to treat so avoid!! - avoid cannulation, BP measurement and blood taking on the arm on the side of mastectomy as further contributing

What kind of chemo regimens can be given in BC?

neo-adjuvant to allow for WLE > mastectomy adjuvant - reduce recurrence and destroy any micro-mets preventative in hormone negative disease

What are the risks with chemo?

short term - hair loss, fatigue, N+V, infection risk long term - infertility, osteoporosis, cardiac, leukaemia

What is the consideration for radiotherapy in BC?

adjuvant - target residual cells axillary nodes bony mets reduce risk of recurrence in WLE

What are some risks with radiotherapy?

CVS risks lung pneumonitis radiation dermatitis rib #

What hormone therapies are considered in BC? + what are some risks?

aromatase inhibitor - post-menopausal women to prevent peripheral conversion of fat to oestrogen tamoxifen - competitive oestrogen inhibition, in pre-menopausal *VTE and endometrial cancer risk

What is the implication of immunotherapy in BC? + risk?

HER2 proto-oncogene mutations and MAB target *skin toxicity, hepatotoxicity, GI tox, pneumonitis

What are some indications for poor prognosis in BC?

- short disease free interval - triple negative cancers - BRCA 1+2 - brain and spine metastases - lack of response to previous cancer treatments