Breast Flashcards
Breast exam: Why raise arms above head?
Strains ligaments of Astley Cooper and may bring to light a previously unnoticed skin dimple or inverison caused by an underlying breast cancer
How to check if a breast lump is tethered?
Ask pt to place hands on hip and push inwards - will tense pec major - if lump fixed to that, mobility when you move it will decrease.
Breast Cancer: Risk Factors
1) FH:
- 1st vs 2nd degree relative
- Uni vs bilateral
- Usually AD with variable penetrance
- BRCA1 (Chr17) - 2% Askenazi Jews, commoner with FH breast/ovarian cancer
- BRCA2 (Chr13)
2) Oestrogen exposure
- Late menarche, early menopause, young pregnancy, parity = lower risk
nb. Pregnancy >35 increased risk
- OCP
- HRT - taken beyond age of 55 = small risk, typically 3-5 extra cancers per 1000 women over 5 years (stops after)
- -> Oestrogen only HRT = smallest risk, Combined is largest
3) Previous Breast disease
4) Other:
- Obesity: Peripheral androgenisation of oestrigens
- High socioeconomic, sat fats, alcohol
Breast MDT team?
Consultant breast surgeon Consultant oncologist Breast care nurse/ CNS Radiologist Histopathologist Cytologist MDT coordinator. \+- Plastics, genetics, palliative care
Triple assessment?
History + Examination
Mammography (>40) / US (if under 40)
Painful vs Painless breast lumps?
Painless:
- cancers (painless + Unremitting growth)
- Cysts/fibroadenomas can also be painless
Painful: Lumpy breast tissue (fibrocystic disease) - Periductal mastitis - Benign cystic disease - Fibroadenomas
FNA?
- 10ml synringe + green needle inserted into lump
- Cyst will disappear as soon as aspirated
- Contents of needle expressed onto slide, smeard with another slide, air dried or fixed + sent to pathologist for H&E stain + interpretation
Cytology score from C1- C5 C1 - Insufficient material C2 - Benign C3 - Atypical cells, probably benign C4 - Suspicious of malignancy C5 - Malignant
Mammography - Breast views?
Breast cancer Px?
Which cancer is classically missed
Craniocaudal + oblique
Breast cancer - classically a white asymmetrical spiculated lesion containing microcalcification
DICS may just be a cluster of microcalcification
Lobular carcinoma (about 10% of all breast cancers) classically missed –> MRI more sensitive.
Core biopsy?
Performed in FNA score is C1-C3/ radiology/clinical examination suspicious of breast cancer
–> Can then be sent for histology and can differentiate between invasive and In situ cancer.
Breast Cancer stage General Mx
Stage I/II - Surgical resection
Stage III/IV - Avoid surgery unless to gain local control eg. fungating/ painful tumour
Conservation surgery for breast?
WLE + limited axillary surgery + radiotherapy
- For small primary tumours (
When would single masectomy be advised?
- Tumour >4cm
- Large tumour in small breast
- Won’t achieve good cosmetic result
- Nipple involvement
- Multifocal disease
- -> NB. all women must be counselled about reconstructive options
- Radiotherapy not necessary unless tumour close to chest wall or greater than >5cm. Radiotherapy compromises the subsequent quality of any reconstruction
Surgical Mx of impalpable cancer?
Stereotactic localisation under mammographic control
- Needle placed into area of microcalcification
- Pt has area of breast containing needle + margin excised
- Excised specimen X-rayed to ensure entire area of calcification removed
Single best predictor of survival from breast cancer?
Involvement of axillary lymph nodes
- No. of local nodes containing tumour reflects possibility of wide spread (micro)mets
Axillary Tx in Breast cancer?
Axillary clearance levels?
1) US guided FNA pre-op to sort out node-positive pts who need axillary node dissection
- -> If scan/FNA clear -> SNB
- If histology from SNB +ve - Second operation to clear rest from axilla
Axillary clearance: Removing nodes up to first axillary vein (level I)
- Medial border of pec minor (level 2)
- Border of first rib (level 3)
SNB procedure
1) Preoperative injection of radioisotope + blue dye into skin of breast
2) During surgery, combined use of radioisotope _ colour to track sentinal node(s). If histology +ve, second operation to clear rest from axilla
Axillary node clearance risks?
The more extensive the node removal, the greater the risk of dmg to the sensory nerves of the axilla (intercostobrachial nerves)
- Lymphoedema of breast, hand, forearm and/or arm
Difference between in situ/ invasive breast cancer
In situ - has not breached the basement membrane of the duct and is a risk for the development of invasive disease
–> Surgery can eliminate the risk
Untreated DCIS risk rate?
What is the other type of carcinoma ins itu
20-30% of pts with untreated DCIS will progress to invasive breast cancer within 10 years
- Lobular carcinoma in situ
- Rarer and tends to be multi-focal
Most common type of invasive breast cancer? Other types?
80% are NOS (not otherwise specified) Other types are named based on morphology: - Lobular - Tubular - Medullary - Mucinous - Papillary
–> Special types tend to have a better prognosis than NOS
What is Paget’s disease of the nipple?
Unilateral, red, eczematous lesion of the nipple and area that may ulcerate and bleed.
- Histology shows infiltrating malignant cells
- Usually an underlying invasive/DCIS breast cancer
Tx: usually masectomy
Grading of breast cancer. Name & Components?
Other prognostic factors?
Bloom-Richardson method:
- Number of mitoses
- Tubule formation
- Degree off nuclear polymorphism
- -> total score assigned to appearance of tumour microscopically.
Grade influences prognosis:
- Grade I : good prognosis
- Grade II: intermediate
- Grade III: Poor
Other factors: max tumour diameter, no. of lymph nodes (most important)
Adjuvant vs neoadjuvant?
Neoadjuvant - before surgery, to shrink size of tumour
Adjuvant - after therapy, to reduce risk of recurrence and death (by 20%) due to micrometastases.
Adjuvant chemotherapy options
- Combination chemotherapy, particularly regimes containing anthracyclines are more effective than single0agent chemo. 6 cycles of cytotoxic chemo once a month is norm
Endo therapy in breast cancer?
- Adjuvant endo therapy not used if primary does not contain ER
- Optimal duration for endo tx is 5 yrs
Oestrogen-receptor antagonists (tamoxifen) in premenopausal women
Aromatase inhibitors (Arimidex) in postmenopausal women
nb. Ovarian ablation by chemical/oophorectomy also effective reduces the risk of recurrence and death from breast cancer in premenopausal but rarely used
Monoclonal therapy in breast cancer?
Herception - target HER2/neu oncoprotein
Tx of advanced (Stage III/IV/recurrent breast cancer)
1) Bone scan, CT scan of lungs/liver, FBC
2) Biopsy/histology to find out ER status
- -> Stage III with no evidence of mets can be treated with neoadjuvant therapy + surgical resection, followed by adjuvant chemo and radiotherapy
Local recurrence of previous WLE –> Masectomy if no mets
Mets: Tx generally palliative
- No sx - ?don’t treat
- Bone mets/pain –> bisphosphonates + radiotherapy
Breast cancer: routes of spread
1) Direct extension - muscle/chest wall, resulting in fixity, to skin (ulceration which may bleed/get infected)
2) Lymphatics (Oedema of overlying skin becomes pitted by adherence of sweat ducts and hair follicles - Peau d’orange + lymphoedema of arm)
3) Haematologically: Bones, lungs, liver
4) Transcoelomic spread - pleural seeding leading to malignant pleural effusion
DCIS Mx
Impalpable? WLE under stereotactic guidance
- Margins not clear? - Re-excision
IF grade II/III - Radiotherapy
IF extensive DCIS involving large areas of breast, >40mm or multifocal:
- Mastectomy +- reconstruction
Breast screening programme?
Women aged 47-73 invited every 3yrs for mammograms
- 60 cancers per 10 000 attendees picked up
- Mammography required highly trained radiologists and detects around 93% of breast cancers
Breast reconstruction types?
- Becker prosthesis placed under Pec Major (Simplest)
- Autologous tissue flaps (lat dorsi/rectus) can be combined with implants to increase breast volume - useful where skin replacement needed
- nipple reconstructed in subsequent operation.
Aim of reconstruction is to create symmetry so augmentation or reduction of opposite breast may be necessary
Lumpy breast tissue cause?
Benign fibrocystic breast disease
- Oestrogen/progesterone during luteal phase –> Epithelial proliferation & increased vascularity - lumpy tender breast tissue
Benign cystic disease of breast - PC 5/10 years before menopause when terminal ducts undergo apoptosis and leave an isolated TLAU which continues to produce fluid
Fibroadenoma of breast?
Tx
Benign discrete lumps in breast
- Overgrowth of collagenous mesenchyme which surrounds each terminal lobuloalveolar unit (TLAU) and usually presents before the age of 30.
Tx: Conservatively, or excised as day case
Occasionally grow to great size (Giant fibroadenoma)
Mastalgia
Either:
1) Cyclical, occurring in the week prior to menses
- Common, lasts 4-5/7
- Evening primrose oil may help, if taken for ATLEAST 2/12
2) Unrelated to menstrual cycle
- pain down breast and nipple associated with pain in axilla and radiation down arm
- Associated with back pain in 15%
Nb: Tietze’s - costochondritis may present similarly –> Classic sign = pain on pressing costal cartilage
- NSAID
Mastitis
- Epidemiology
- Types
- organism
- Mx
- Commonly affects women of childbearing age
Lactational infection:
- During breast feed
- PC: pain + swelling + tenderness
- Usually S.aureus Tx. Fluclox
- Treat abscesses with repeated aspiration + Abx so women can continue to breastfeed.
If abscess persist - breastfeeding should be stopped by switching baby to bottle + surgical I+D
Non-lactational aka. periductal mastitis:
- Periareolar region
- Complications commoner in smokers
- Major ducts under areola become dilated (duct ectasia)
- May be interstitial lymphocytic infiltrate
- Major Complication: Rupture of one or more ducts
–> Rupture through skin : mammillary fistula
Mx: Difficult. Excision of whole major duct system
Nipple discharge
- Physiological discharge common: ranges from white-green-black
- Other non-malignant cause = duct papilloma
- -> blood stained d/c from single duct
DDx:
- underlying carcinoma
- if sinister causes ruled out, tx is duct excision (hatfield’s procedure)
‘if you imagine your nipple is a clockface, how many hours is it coming out from’
- Is it spontaenous or on squeezing
Breast screening
- All women aged 47-70
- 2 views every 3 years
- Double reporting
- Recall to screening unit for further views or additional imaging
How does paget’s differ from nipple eczema?
It involves the nipple primarily and only latterly spreads to the areolar (the opposite occurs in eczema).
Diagnosis is made by punch biopsy, mammography and ultrasound of the breast.
Fibroadenomas?
Under the age of 25 years the breast is usually classified as undergoing development. Lobular units are being formed and a dense stroma is formed within the breast tissue. This may result in the development of fibroadenomas.
As a group fibroadenomas account for 13% of all palpable breast lesions. However, in women aged 18-25 they constitute up to 60% of all palpable breast lesions. The are classified as juvenile, common and giant. The former occur in early adolescence and the latter are characterised by a size greater than 4cm. In young females with small fibroadenomas (less than 3cm on imaging) a policy of watchful waiting without biopsy may be adopted. A size of greater than 4cm attracts a recommendation for core biopsy to exclude a phyllodes tumour. The natural history of fibroadenomas is that 10% will increase in size, 30% regress and the remainder stay the same. This does not apply during pregnancy and lactation when they may increase in size substantially and subsequently sequester milk.
Some women may wish to have their fibroadenomas excised, they can usually be shelled out through a circumareolar incision. Smaller lesions may be removed using a mammotome.
Mondor’s disease?
A rare condition which involves thrombophlebitis of the superficial veins of the breast and anterior chest wall. It sometimes occurs in the arm or penis. In axilla, this condition is known as axillary web syndrome
