Breast Flashcards
1
Q
What are the important features of a breast history
A
- Presenting complaint: duration, progression, associated symptoms, red flags
- Oestrogen history: age of menarche, menopause status, HRT, COCP, breastfeeding, nulliparity
- Family history: breast and ovarian cancer
- Drug history: HRT, COCP, anti-coagulants
- Past medical and surgical history: general history (to assess fitness for treatment), previous breast cancer and surgeries
- Social history: smoking, alcohol (risk factors), exercise (protective)
2
Q
What are the red flag symptoms suspicious of breast cancer?
A
- Painless, hard, fixed, irregular lump
- Skin distortion/tethering
- Ulceration
- Bloody nipple discharge
- Nipple inversion
- Axillary lymphadenopathy
- Secondary cancer (e.g. liver causing jaundice, bone causing pain or pathological fractures)
3
Q
What are the features of a breast examination?
A
- Inspection: first with arms by side then raised, look for lumps, distortion, tethering, asymmetry, and nipple retraction
- Palpation: cover all areas including subareolar and axillar, assess size, shape, consistency, mobility
4
Q
What investigations needed for a breast lump?
A
Triple assessment (ensures concordance):
- clinical assessment (history and examination)
- imaging (ultrasound and/or mammography)
- histology (core biopsy or fine needle aspiration)
5
Q
How is triple assessment scored?
A
Score each out of 5…
- 1: normal
- 2: benign
- 3: indeterminate
- 4: suspicious
- 5: malignant
6
Q
What are the indications for mammography versus ultrasound?
A
- If under 40: ultrasound (mammograms are not sensitive due to more dense tissue at this age)
- 40 and over: mammogram if suspicious of malignancy, and as screening, ultrasound may be used in diagnosis
7
Q
When is an MRI scan indicated as a breast investigation?
A
- Patients aged 25-60 years with BRCA gene may be offered annual MRI screening
- Evaluation of possible recurrent breast cancer, mammographically occult breast cancer
- Malignant axillary node with no palpable or imaging identified breast primary
8
Q
What are the suspicious cyst aspiration?
A
- Blood stained
- Does not fully aspirate
- Reoccurs
9
Q
Describe the screening program for breast cancer? (ages, advantages, disadvantages)
A
- All women aged between 50 and 71 have a mammogram every 3 years
- Women with increased familial risk (BRCA gene) start annual screening from aged 40
- Advantages: improves stage at diagnosis (picked up earlier)
- Disadvantages: overdiagnosis of small low grade cancers, causes anxiety if recalled, uses X-ray radiation
10
Q
What are the different histological types of breast cancer?
A
- Ductal carcinoma: either in situ (non-invasive, pre-cancerous), or invasive
- Lobular: invasive, more diffuse and prone to be multi-focal and more difficult to excise
- Rare subtypes: tubular, mucinous, inflammatory, Paget’s disease
11
Q
What dose the grade of a breast tumour mean?
A
- Varies from 1 (well differentiated, low mitotic rate) to 3 (abnormal differentiation, high mitotic rate, gene mutations)
- Important prognostic marker to determine treatment
12
Q
What hormone receptors are important in breast tumours and what do they mean?
A
- Oestrogen: expressed in 70%, oestrogen stimulates tumour growth, and will respond to anti-oestrogen therapy
- Progesterone: also indicates sensitivity to anti-oestrogen therapy
- HER2: over expressed in 15%, means that growth pathway is up-regulated, poor prognostic factor
- Triple negative cancers: do not express any hormone receptors (15% of cases), very aggressive subtype of cancer, may be linked to BRAC-1 mutation
13
Q
Describe the different techniques of tissue diagnosis for breast cancer
A
- Fine needle aspiration cytology: small needle passed through lump many times and aspirate is tested to be acellular, benign, or malignant, quick and cheap but low sensitivity/specificity
- Core biopsy: under local anaesthesia, small needle on spring-loaded biopsy gun to remove ‘apple core’ of lesion, increased accuracy of diagnosis (e.g. invasive vs DCIS) and tumour typing
- Vacuum assisted biopsy: larger needle shaves off larger volumes of lesion, can remove smaller lesions entirely
- Open biopsy: surgical removal of biopsy for diagnostic purposes, used in skin lesions or when other methods failed
14
Q
What is the surgical management for breast surgery?
A
- Mastectomy: about 1/3rd of patients, with or without reconstruction
- Conservation surgery: lumpectomy, wide local excision, with radiotherapy
15
Q
What are the indications for mastectomy?
A
- Patient choice
- Large tumour relative to breast volume (where conservation surgery would remove more than 20%)
- Multifocal or multicentric disease
- Sub-areolar tumour
- Contraindication for radiotherapy
- Failed conservation surgery
- Risk reduction in BRCA gene carrier
- Local recurrence after WLE
16
Q
What is the management to the axilla in breast cancer?
A
- Aim is to remove cancer deposits (local disease control) and to provide prognostic information to determine further treatment
- Sentinel node biopsy: identification with radioisotope of the first node affected in the drainage chain, removal for histology
- Axillary node clearance: if known axillary nodal disease, or positive sentinel node biopsy, removal of all axillary nodes, with low recurrence rates but more complications
- Radiotherapy: in low risk women after positive sentinel node biopsy instead of full clearance, or given at the same time as breast radiotherapy
17
Q
What staging classification is used for breast cancer?
A
- TNM classification
- Stage 1: primary 2cm or less (T1), no nodes (N0), no mets (M0)
- Stage 2: primary 2-5cm (T2), ipsilateral axially node (N1), tumour more than 5cm with no skin/chest wall involvement (T3)
- Stage 3: anything more (T4, N>1, but always M0)
- Stage 4: distant metastases
18
Q
What are the indications for radiotherapy for breast cancer?
A
- Always given after wide local excision
- After some mastectomies if high risk or poor prognosis
- As palliative care for large or inoperable primary cancer
- Treatment of symptomatic bone metastases
- Treatment for axillary node disease instead of clearance surgery
19
Q
What is the use of chemotherapy in breast cancer?
A
- Most likely to be beneficial in more aggressive tumours, which means younger patients
- Mainly given to patients with poor prognosis tumours (ER-ve, HER2+ve, node +ve, large tumour, high grade)
- Standard drug is epirubicin, fluorouracil, and cyclophosphamide, or cisplatinum for triple negative cancers
- Can use neoadjuvant to shrink tumour before surgery
20
Q
What is the use of hormone therapy in breast cancer?
A
Antioestrogens (for 5/10 years)…
- premenopausal: tamoxifen (selective oestrogen receptor modulator)
- postmenopausal: letrozole (aromatase inhibitors)
Ovarian suppression…
- Goserelin (Zoladex)
- stops ovaries producing oestrogen
- for premenopausal women with ER +ve tumour
- may prevent infertility caused by chemotherapy
HER2 targeting therapies…
- trastuzumab (neutralises adverse effect of HER2 expression)
- pertuzumab (added if high risk node positive)
21
Q
What is the use of bisphosphonates in breast cancer?
A
- Reduces the rate of developing bone metastases
- Only approved for post menopausal women with intermediate or high risk cancers
22
Q
Describe Paget’s disease of the nipple
A
- Eczematous change of the nipple due to underlying malignancy
- Should be suspected in apparent nipple eczema does not resolve with 2 weeks of steroid/anti-fungal cream
- Caused by infiltration of tumour cells through the ducts onto the nipple surface where they infiltrate the epidermis
- Treatment removal by mastectomy, or central (nipple excising) wide local excision
23
Q
What are the common metastases of breast cancer?
A
- Bone (may cause pain, pathological fracture, spinal cord compression)
- Lung (pleural effusions, lung masses)
- Liver (worse outlook)
- Brain (worst prognosis)
24
Q
Describe ductal carcinoma in situ
A
- Pre-malignant condition that is asymptomatic and detected on breast screening
- The epithelial cells lining the ducts becomes thickened as malignant cells proliferate, but they cannot invade the basement membrane to metastasise
- Most present as microcalcifications on mammography, but some as lumps
- Natural course depends on grade and how larger the affected area is, but up to half evolve into invasive cancer in 5-10 years
- Treatment involves wide local excision with radiotherapy, or mastectomy if more extensive
25
What are the options for breast reconstruction?
- External prosthesis
- Implant or expander
- Acellular dermal matrix and dermal sling
- Latissimus dorsi flap (+/- implant)
- TRAM/DIEP flap (transverse rectus abdominus myocutaneous/deep inferior epigastric perforator)
- Nipple reconstruction
26
Describe the causes and management of breast pain
Cyclical:
- often worse prior to period and resolves after
- reassurance and simple analgesia is often all that is needed
- can use danazol (weak androgen, but can cause breast shrinkage, hirsutism and weight gain), or tamoxifen (not used long term due to risk of endometrial cancer)
Non-cyclical:
- often treated most effectively with NSAIDs
- could be non- breast cause e.g. cardiac, MSK
27
Describe fibroadenoma of the breast (epidemiology, features, prognosis, management)
- Benign breast lump, most common cause of breast lesion in younger women, with no increased risk of malignancy
- Firm, non-tender, highly mobile lump arising within breast lobule
- 1/3 will shrink, 1/3 will stay the same, 1/3 will grow
- Management with surgical excision only if >3cm
28
Describe breast nodularity
- Fibrocystic changes associated with pain and nodularity
- Affects women aged 20-50 related to hormonal changes as symptoms are worse just before menstruation
- Persistent or bilateral changes should prompt referral as proliferative changes have a slight increased chance of developing malignancy
- Treatment is with analgesia and supportive bra
29
Describe breast cysts
- Common in middle aged women, with a small increased risk of malignancy
- Presents as a smooth discrete lump which may fluctuant or be recurrent, not distinguishable from solid tumours on examination
- May resolve by itself or need aspirating (investigate for malignancy if blood stained or persistently refill)
30
Describe duct papilloma
- Benign warty lesion presenting with nipple discharge (possible blood stained) originating from a single duct, or a mass if large
- Needs triple assessment (but no increased risk of malignancy), and managed with surgical excision of duct
31
Describe fat necrosis
- Most have a traumatic cause (e.g. history of injury)
- More likely to occur in women with larger, fatty breasts who are overweight
- Features my mimic carcinoma (painless lump, skin changes of redness, bruises, dimple)
- Biopsy may be required but no further treatment
32
Describe duct ectasia
- Dilation and shortening of the terminal breast ducts
- Most common in menopausal women and smokers
- Presents with nipple retraction, and creamy, thick, and green nipple discharge
- May be treated with duct excision if troublesome
33
Describe mastitis
- Inflammation of the breast tissue due to blocked milk ducts and/or bacterial infection, most common in lactating women
- Symptoms include pain, swelling, redness, warmth, flu-like symptoms (e.g. fever), and may have nipple discharge
- Management with continue breastfeeding, simple analgesia, warm compress, and flucloxacillin if systemically unwell
34
Describe breast abscess
- Complication of infectious mastitis, most common in breastfeeding women infected with staph. aureus
- May develop in non-lactating women, with higher risk in diabetes, immunosuppression, or nipple piercings, likely to be sub-areolar
- Symptoms of pain, distinct swelling/lump, redness, warmth, nipple discharge/retraction, lymphadenopathy, and systemic features of fever, malaise, tachycardia
- Managed with continuing breastfeeding, needle aspiration and flucloxacillin, or surgical drainage if large
