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Breast Flashcards

1
Q

Breast Cancer

A

Affects 1/10 women
 20 000 cases/yr in UK
 Commonest cause of cancer death in females 15-54
 Second commonest cause of cancer deaths overall

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2
Q

Breast Cancer RF aetiology

A

Family Hx
 10% Ca breast is familial
(One 1st degree relative = 2x risk)

5% assoc. c¯ BRCA mutations
 BRCA1 (17q) → 80% breast Ca, 40% + ov Ca
 BRCA2 (13q) → 80% breast Ca

Oestrogen Exposure 
 Early menarche, late menopause
 HRT, OCP (Million Women Study)
 First child >35yrs
 Obesity
Other RF
 Proliferative breast disease w atypia
 Previous Ca breast
 ↑ age (v. rare <30)
 Breast feeding is protective
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3
Q

Breast Cancer Types

DCIS/LCIS

A

 Non-invasive pre-malignant condition
 Microcalcification on mammography
 10x ↑ risk of invasive Ca

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4
Q

Breast Cancer Types Invasive Ductal Carcinoma

A

Invasive Ductal Carcinoma, NST/NOS
 Commonest: ~70% of cancers
 Feels hard (scirrhous)

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5
Q

Breast cancer Other subtypes (not DCIS, LCIS, Invasive ductal carcinoma)

A

 Invasive lobular: ~20% of cancers
 Medullary: affects younger pts, feels soft
 Colloid/mucinous: occur in elderly
 Inflammatory: pain, erythema, swelling, peau d’orange
 Papillary

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6
Q

Breast Cancer Types

Phyllodes Tumour

A

 Stromal tumour

 Large, non-tender mobile lump

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7
Q

Breast Cancer Spread

A

Direct extension → muscle and/or skin

Lymph → p’eau d’orange + arm oedema

Blood →
 Bones: bone pain, #, ↑Ca
 Lungs: dyspnoea, pleural effusion
 Liver: abdo pain, hepatic impairment
 Brain: headache, seizures
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8
Q

Breast Cancer Screening

A

 Every 3yrs from 47-73
 Craniocaudal and oblique views
 ↓ breast Ca deaths by 25%
 10% false negative rate.

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9
Q

Breast Cancer Presentation

A

Lump: commonest presentation of Ca breast
 Usually painless
 50% in upper outer quadrant
 ± axillary nodes

Skin changes
 Paget’s: persistent eczema
 Peau d’orange

Nipple
 Discharge
 Inversion

Mets
 Pathological #
 SOB
 Abdominal pain
 Seizures

May present through screening

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10
Q

Breast Cancer Skin changes

A

 Cysts
 Fibroadenomas
 DCIS
 Duct ectasia

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11
Q

Triple Assessment Breast Cancer

A

Any Breast Lump
Hx + Clinical Examination

Radiology
 <35yrs: US
 >35ys: US + mammography

Pathology
Solid lump: tru-cut core biopsy
Cystic lump: FNAC (green / 18G needle)
 Reassure if clear fluid
 Send cytology if bloody fluid
 Core biopsy residual mass
 Core biopsy if +ve cytology
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12
Q

Breast Cancer other Ix

A

Bloods
 FBC, LFTs, ESR, bone profile

Imaging: help staging
 CXR
 Liver US
 CT scan
 Breast MRI: multifocal disease or c¯ implants
 Bone scan and PET-CT

May need wire-guided excision biopsy

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13
Q

Breast Cancer Staging

A

Clinical Staging
 Stage 1: confined to breast, mobile, no LNs
 Stage 2: Stage 1 + nodes in ipsilateral axilla
 Stage 3: Stage 2 + fixation to muscle (not chest wall)
LNs matted and fixed, large skin involvement
 Stage 4: Complete fixation to chest wall + mets

TNM Staging
 Tis (no palpable tumour): CIS
 T1: <2cm, no skin fixation
 T2: 2-5cm, skin fixation
 T3: 5-10cm, ulceration + pectoral fixation
 T4: >10cm, chest wall extension, skin involved
 N1: mobile nodes
 N2: fixed nodes
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14
Q

Breast Cancer Management Surgery

A 
2 options
WLE + Radiotherapy (80% treated as such)
Mastectomy
 Typically large tumours >4cm
 Multifocal or central tumours
 Nipple involvement
 Pt. choice
 Not radical: no longer used
 Same survival, but WLE has ↑ recurrence rate
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15
Q

Breast Cancer Mx Sentinal Node Biopsy

A

Gold Standard
 Sentinal Node = first node that a section of breast drains to.
 If clinically –ve axillary LNs, no need for further dissection

Procedure
 Blue dye / radiocolloid injected into tumour
 Visual inspection / gamma probe @ surgery to ID SN
 SN removed and sent for frozen section
 If node +ve → axillary clearance or radiotherapy

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16
Q

Breast Cancer other axillary options (not sentinal node biopsy

A

Axillary sampling
 Removal of lower nodes
 Clearance or DXT if +ve

Axillary clearance
 Can be done to various levels

17
Q

Surgical Complications Breast Cancer

A 
Surgical Complications
 Haematoma, seroma
 Frozen shoulder
 Long-thoracic nerve palsy
 Lymphoedema
18
Q

Breast Cancer Systemic Rx

chemo/radio

A 
Radiotherapy
 Post-WLE: ↓ local recurrence
 Post-mastectomy: only if high risk of local recurrence
 Large, poorly differentiated, node +ve
 Axillary: node +ve disease
 Palliation: bone pain

Chemotherapy
 Pre-menopausal, node +ve, high grade or recurrent
tumours.
 Neo-adjuvant chemo improves survival in large tumours
 6 x FEC: 5-FU, Epirubicin, Cyclophosphamide
 Trastuzumab (anti-Her2) is used if Her2+ve
 SE: cardiac toxicity

19
Q

Breast Cancer Systemic Rx

Endocrine

A

Used in ER or PR +ve disease: ↓ recurrence, ↑ survival
 5yrs of adjuvant therapy

Tamoxifen
 SERM: antagonist @ breast, agonist @ uterus
 SE: menopausal symptoms, endometrial Ca

Anastrazole
 Aromatase inhibitor → ↓ oestrogen
 Better cf. tamoxifen if post-men (ATAC trial)
 SE: menopausal symptoms

If pre-menopausal and ER+ve may consider ovarian
ablation or GnRH analogues (e.g. goserelin)

20
Q

Treating Advanced Disease (Stage 3-4) Breast Cancer

A

 Tamoxifen if ER+ve
 Chemo for relapse
 Her2+ve tumours may respond to trastuzumab

Supportive
 Bone pain: DXT, bisphosphonates, analgesia
 Brain: occasional surgery, DXT, steroids, AEDs
 Lymphoedema: decongestion, compression

21
Q

Breast Cancer Reconstruction

A

Offered either at 1O surgery or as delayed procedure.

Implants - silastic or saline inflatable

Lat dorsi myocutaneous flap
 Pedicled flap: skin, fat, muscle and blood supply
 Supplied by thoracodorsal A. via subscapular A.
 Usually used w an implant

Transverse rectus abdominis myocutaneous flap
 Gold-standard
 Pedicled (inf. epigastric A.)
 Or free: attached to internal thoracic A
 No implant necessary and combined tummy tuck
 CI if poor circulation: smokers, obese, PVD, DM
 Risk of abdominal hernia

Nipple Tattoo

22
Q

Mastalgia

A 
Cyclical 
 ~35yrs
 Pre-menstrual pain
 Relieved by menstruation
 Commonly in upper outer quadrants bilaterally

Non-cyclical
 ~45yrs
 Severe lancing breast pain (often left)
 May be assw back pain

Rx
 Reassurance + good bra for most
 1st line: EPO (contains gamma-linoleic acid)
 OCP
 Topical NSAIDs (e.g. ibuprofen)
 Bromocriptine
 Danazol
 Tamoxifen
23
Q

Acute Mastitis

A

Usually lactating

Presents - painful, red breast
May > abscess (lump near nipple)

Rx - fluclox alone in early stages
Fluclox + I&D if fluctuant abscess

24
Q

Fat necrosis

A

Assw previous trauma
painless,palpable, non-mobile mass
May calcify > simulating cancer

Rx - Analgesia, no follow up needed

25
Q

Duct Ectasia

A

Post menopausal 50-60

Slit like nipple (oft bilateral)
+/- periareolar mass
thick white green discharge
may be calcified on mammography

Rx
Need to distinguish from Ca
Surgical duct excision if mass present or discharge troublesome

Close follow up

26
Q

Periductal Mastitis

A

Smokers 30y

Painful erythematous subarealar mass
assw inverted nipple +/- purulent discharge
May > abscess or discharging fistula

Rx - broad spectrum abx

27
Q

Benign mammary dysplasia

A

30-50y benign

Pre-menstrual breast nodularity + pain, often in upper outer quadrant
> tender lumpy breasts

Aberration of normal development + involution

  • Fibroadenosis
  • Cyst formation
  • Epitheliosis (hyperplasia)
  • Papillomatosis

Rx
Triple assessment

reassurance, analgesia, good bra, evening primrose oil

Danazol occasionally

28
Q

Cystic Disease (benign breast lesions)

A

perimenopausal >40 benign

Distinct, fluctuant round mass, oft painful

Rx
- aspiration gree, brown fluid persistence or blood > triple assessment

29
Q

Duct papilloma

A

40-50 years benign

Common cause of bloody discharge - not usually palpable

Triple assessment

Excise due to ^risk of ca

30
Q

Fibroadenoma (breast)

A

<35 years (rare postmenopause) ^black

Commonest benign tumour
Stromal tumour
painless mobile rubbery mass, oft multiple + bilateral

popcorn calcification

Rx
Reassure + follow up if <2.5cm

Shell out surgically

  • > 2.5cm
  • FH breast Ca
  • Pt choice
31
Q

Phyllodes tumour

A

50+ stromal tumour

Large, fast growing mass
mobile, non-tender
Epithelial + connective tissue elements

Rx
- Wide local excision

32
Q

Ductal Carcinoma In Situ (malignant)

A

Presents as Microcalcification on mammogram
Rarely assoc. with symptoms:
- lump
- discharge
- eczematous change = Paget’s disease
→ Ca @ 1%/yr (10x ↑ risk) in ipsilateral breast

Rx - WLE + radio
- Extensive or multifocal > mastectomy + reconstruction + SNB

33
Q

Paget’s Disease of the breast

A

Unilateral, scaly, erythematous, itchy +/- palpable mass (invasive carcinomas)

Rx

  • usually underlying invasive or DCIS breast cancer
  • mastectomy + radio +/- chemo/endo
34
Q

Lobular Carcinoma In situ

A

Incidental biopsy finding (no calcification)
oft bilateral (20-40%)
young women
^risk ca in both breasts

Rx
Bilateral prophylactic mastectomy or lose watching w mammographic screening

D3 (14 decks)

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