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FRACS 2024 (Siobhan) > Breast > Flashcards

Breast Flashcards

1
Q

Breast anatomy

A
  • Modified sweat gland
  • Lies in superficial fascia anterior chest wall
  • From sternal edge to midaxillary lie
  • Overlies pec major/serratous anterior
  • 15-20 lactiferous ducts draining into a lobe —> converge as nipple with a sinus
    Held by ligament of Cooper (suspensory ligament)
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2
Q

Describe the axilla

A

Truncated cone

Apex clavicle/scapula/first rib

floor axillary fascia

Anterior pec major/ pec minor/ clavipectoral fascia

Posterior subscapularis/ teres major / latissimus dorsi

Medial serratus anterior to 4th rib

Lateral intertubercular (bicipital) groove, biceps tendon

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3
Q

Contents of axilla

A
  • axillary artery
  • axillary vein (from cephalon and basilic)
  • brachial plexus
  • axillary LNs
  • Biceps brachii (short head) and coracobrachialis
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4
Q

Blood supply to breast

A
  • Subclavian —> internal thoracic
  • Subclavian —> axillary —> acromiothoracic
  • Subclavian —> axillary —> lateral thoracic
  • Anterior intercostal

Veins follow arteries

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5
Q

Levels of axilla

A

Level 1 - lateral to pec minor

Level 2 - posterior to pec minor

Level 3 - medial to pec minor

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6
Q

Puberty effect on breast

A

Puberty —> puberty gonadotrophins

—> Oestrogen —> deposition of fat, beaching and elongation of ducts, formation of lobular units

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7
Q

What is ANDI

A

Abberations of normal development and involution

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8
Q

How do you classify breast lumps?

A

BENIGN
- Non-ANDI
- infection
- lipoma
- fat necrosis
- ANDI
- Non-proliferative
- duct ectasia
- fibrocystic change
- cysts
- Proliferative
- intraductal papilloma
- sclerosing adenosis
- radial scar
- fibroadenoma
- Dysplasia
- ADH
- ALH/LCIS

MALIGNANT
- DCIS
- Invasive breast cancer

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9
Q

What is duct ectasia

A

Benign dilatation and shortening of terminal ducts <cm from nipple

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10
Q

Define breast cyst

A

Abnormal, usually non-cancerous growth filled with liquid or semisolid substance, sometimes causing pain

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11
Q

What are fibrocystic breast changes?

A

Benign changes in breast characterised by fibrosis, breast cyst, and lumpy cobblestone texture of the breast

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12
Q

High risk features for nipple discharge

A

Blood stained
Persistent >2/52
Spontaneous
Single duct
Age >60 (32% malignancy)

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13
Q

Differential diagnosis for nipple discharge

A

Physiological

Galatorrhoea
- pituitary adenoma
- hypothyroidism
- medication

Duct ectasia

ANDI

Papilloma
- solitary duct discrete papilloma
- multiple papillomas
- junvenile papillomatosis

Inflammatory

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14
Q

Work up for nipple discharge

A

History
Examination
Mammogram
Ultrasound
Cytology

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15
Q

What is DCIS

A

Clonal proliferation of malignant epithelial cells confined within the basement membrane of the mammary ducts

33% —> invasive cancer over 20yrs
10yr survival >95%

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16
Q

What are the different views on a mammogram

A
  1. Mediolateral oblique (with pec major muscle triangle visible)
  2. Craniocaudal
17
Q

Features of benign calcifications

A

Macrocalcification
Popcorn calcifications (fibroadenoma)

Branching or linear are concerning
Microcalcifications

18
Q

When would you do Breast conserving surgery vs mastectomy for DCIS

A

Use Van Nuys Prognostic index

  • Age
  • Tumour size
  • Tumour growth pattern (histological grade)
  • Amount of healthy tissue surrounding tumour after removal (size of breast)

Low risk (4-6) —> BCS without radiotherapy
Intermediate risk (7-9) —> BCS + radiotherapy
High risk (10-12) —> mastectomy

19
Q

What margin do you aim for for BCS for DCIS

A

2mm

20
Q

When would you do a SLNB

A

T1/2 (consider T3) with clinically negative axillary nodes

DCIS - with mastectomy
DCIS - with suspicious features (large palpable mass)

Don’t if axillary status doesn’t affect adjuvant Mx e.g. elderly with early ER+ dx —> low recurrence rate

21
Q

Risk factors for DCIS

A

(Same as invasive breast cancer)

Female
>50
FHx BRCA1/2
Hx previous breast pathology
Lifetime oestrogen exposure
Obesity
Smoking

22
Q

Components of breast histo pathology report for DCIS

A

Size of lesion
Margin
Associated invasive ca or ADH
Nuclear grade (low/int/high)
Architectural pattern
Central necrosis
Calcification
Pagets dx of nipple
Hormone receptors

23
Q

BSC vs mastectomy (DCIS) not Van Nuy

A

Breast-to-tumour ratio
Contraindication to DXT
- previous DXT
- pregnant
- live remotely
Multicentric/multifocal
Known genetic mutation (BRCA1/2)
Patient preference

24
Q

When to do SLNB in DCIS

A

Multifocal
>3cm
Palpable (mass forming)
High grade
Suspicious node
Micro invasive dx
Mastectomy
(Upper outer quadrant)

25
Q

Who gets population breast cancer screening in Australia?

A
  • Biennial screening age 50-74yo
  • 40-49yrs at request
  • asymptomatic

Mammo sensitivity 80%, specificity 90%

26
Q

What are the WHO principles of screening?

A

CONDITION
- important health problem
- natural history understood
- recognisable latent/early symptomatic phase

TEST
- suitable test with:
-high sensitivity and specificity
-validated
-safe

TREATMENT
- accepted treatment for pts with disease
- treatment effective, available and accessible

SCREENING PROGRAMME
- agreed policy on who to treat
- facilities for diagnosis and treatment
- economically balanced in relation to health budget expenditure
- case findings should be a continuous process

POPULATION SCREENING - test offered systematically to all individuals in the defined target group within a framework of agreed policy, protocols, quality management, monitoring and evaluation

27
Q

What are the most significant risk factors for breast cancer?

A

4 RR
- Female sex >50years
- carrier of known genetic mutation associated with BC
- history of previous breast cancer or DCIS

Other risk factors:

2-4 RR
- FHx BC/ovarian
- Hx other proliferative breast pathology

1.25-2 RR
- lifetime oestrogen exposure (early menarche, late menopause, nulliparity; OCP or HRT)
- body size and lifestyle (post-menopausal obesity, ETOH >3 drinks/day)
-Other medical history (other ca including ovary, thyroid, endometrium, colon; high dose radiation esp <20yrs, in utero diethylstilbestrol exposure)

28
Q

Describe the different types of hereditary breast cancers

A

BRCA 1 and 2
- TSG
- Autosomal dominant
- Breast, ovarian, prostate, pancreas
Breast -
BRCA1 55-70%
BRCA2 45-70%

Ovarian
BRCA1 40%
BRCA2 15%

Prostate
BRCA1 20%
BRCA2 40%

Pancreatic
BRCA1 2-4%
BRCA2 5%

BRCA1 - younger, ‘medullary-like”, high-grade, ER/PR-ve

Li Fraumeni
- TP53
- Breast, bone/soft tissue sarcoma, CNS tumour, adrenal cortex
- 50% lifetime risk
- high rate HER2+ve
Risk ++ with radiation

Cowden Dx
- PTEN
- multiple hamartomas, breast, thyroid, endometrial
- 50% risk

Peutz-jeghers
-STK11
- CRC, gastric, SB, pancreatic, biliary, GB, oesophagus, ovaries, cervix, Sertoli cell
- CRC 40%
- gastric 30%
- SB 10%
- pancreatic 10-25%

Hereditart diffuse gastric cancer syndrome
- CDH1
- loss of e-cadherin
- 50-60% risk LOBULAR BC

PALB2
- 45% risk BC

CHECK2
- Li Fraumeni variant
- 30% risk

ATM
- 30% risk

29
Q
A
30
Q

What are the different stages of breast cancer?

A

Early breast cancer - T1/2, N0/N1, no Mets

Locally-advanced - T3/4 or N2/3, M0

Advanced - metastatic disease

31
Q

Describe the TNM for breast cancer

A

T
Tis- carcinoma in situ
Tis (DCIS)
Tis (Pagets)
T1 - <2cm
T2 - 2-5cm
T3 - >5cm
T4 - involving chest wall/skin (ulceration/nodules)
T4a chest wall
T4b ulceration, peau d’orange, ipislateral nodules
T4c both T4a and b
T4d inflammatory (dermal lymphatic invasion)

N - clinical
N1 - mobile level 1/2
N2 - matted/fixed level 1/2 or IM LN
N3 - supraclavicular/infraclavicular

N -pathological
N1 - micromets or 1-3 axillary LN
N2 - 4-9 LN
N3 - >10 LN

M
Cervical or contralateral axillary LN
Distant Mets

32
Q

Ultrasound findings suspicious for breast cancer

A

Lesion taller than wide
Irregular/poorly defined margin
Invasion of tissue planes
Hypoechoic
Microlobulation
Internal calcification
Posterior acoustic shadowing
Internal vascularity

LN suspicious features:
Thickened cortex
Eccentric rounded node
Loss of cortico-medullary differentiation

33
Q

Systemic staging

A

For locally advanced
CT chest and abdo
CT brain
Bone scan
FDG-PET

LA = T3/4 or N2/3
T3 >5cm
T4 chest wall/skin/inflammatory

FRACS 2024 (Siobhan) (5 decks)

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