Breast Flashcards
What are the important features of a breast history
- 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)
What are the red flag symptoms suspicious of breast cancer?
- 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)
What are the features of a breast examination?
- 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
What investigations needed for a breast lump?
Triple assessment (ensures concordance):
- clinical assessment (history and examination)
- imaging (ultrasound and/or mammography)
- histology (core biopsy or fine needle aspiration)
How is triple assessment scored?
Score each out of 5…
- 1: normal
- 2: benign
- 3: indeterminate
- 4: suspicious
- 5: malignant
What are the indications for mammography versus ultrasound?
- 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
When is an MRI scan indicated as a breast investigation?
- 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
What are the suspicious cyst aspiration?
- Blood stained
- Does not fully aspirate
- Reoccurs
Describe the screening program for breast cancer? (ages, advantages, disadvantages)
- 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
What are the different histological types of breast cancer?
- 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
What dose the grade of a breast tumour mean?
- Varies from 1 (well differentiated, low mitotic rate) to 3 (abnormal differentiation, high mitotic rate, gene mutations)
- Important prognostic marker to determine treatment
What hormone receptors are important in breast tumours and what do they mean?
- 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
Describe the different techniques of tissue diagnosis for breast cancer
- 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
What is the surgical management for breast surgery?
- Mastectomy: about 1/3rd of patients, with or without reconstruction
- Conservation surgery: lumpectomy, wide local excision, with radiotherapy
What are the indications for mastectomy?
- 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