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Phase 3a > Breast > Flashcards

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)
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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)
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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
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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)

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5
Q

How is triple assessment scored?

A

Score each out of 5…
- 1: normal
- 2: benign
- 3: indeterminate
- 4: suspicious
- 5: malignant

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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
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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
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8
Q

What are the suspicious cyst aspiration?

A
  • Blood stained
  • Does not fully aspirate
  • Reoccurs
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9
Q

What is the screening program for breast cancer?

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
  • Improves stage at diagnosis (picked up earlier)
  • Disadvantages: overdiagnosis of small low grade cancers, causes anxiety if recalled, uses X-ray radiation
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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
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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
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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
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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
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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
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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
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16
Q

What is the surgical 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 or 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
Q

What are the options for breast reconstruction?

A
  • 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
Q

What are some benign causes of nipple discharge?

A
  • Duct ectasia: yellow/green, thick, occasionally bloody, caused by build up of debris, prone to secondary infection
  • Papilloma: benign wart-like growth
  • Galactorrhoea: may be physiological or due to drugs
  • Purulent discharge (infection)
27
Q

Describe the causes and management of breast pain

A

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

28
Q

What are the benign causes of breast lumps?

A
  • ‘Normal’ nodularity: often cyclical, can be normal for some women
  • Fibroadenoma: benign lump, does not predispose to cancer, most common in younger women, 1/3 with shrink, 1/3 will stay the same, 1/3 will grow, only advised for surgical removal if large/prominent
  • Cyst: abnormal response to hormonal stimulation, most common in 40-60s, considered non-cancerous if not blood stained fluid, no residual lump, does not continually refill (if not then consider intracystic cancer)
29
Q

What are the different types of breast infection?

A

With lactation:
- associated with engorgement, redness, warmth
- may develop peripheral abscess and need aspiration
- treated with flucloxacillin

Without lactation:
- associated with ductal ectasia, so more central, and produces peri-areolar abscesses
- associated with diabetes and immunocompromised
- treated with augmentin or flucloxacillin plus metronidazole

  • incision and drainage is avoided as risk of mammary fistula, which would require surgical excision of underlying milk duct

Phase 3a (10 decks)

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