Breast Flashcards
63 How would you go about investigating a 60 year old lady who presented to you having found a lump, about 2cm across, in her left breast?
“Triple assessment” allows a rapid and comprehensive assessment of a breast lump. It is performed on the same day and when performed by experienced personnel, the chances of missing a cancer are <1%
Clinical examination + mammography + biopsy
Mammography (88% sn for women >40yo)
- Key features: mass lesion, microcalcification, architectural distortion, asymmetry
Microcalcifications:
- Granular and within spiculated lesion = virtually pathognomonic for cancer
- Coarse and clunky = benign
- Fine and linear/granular = malignant
Biopsy
- FNA (95% sn for malignancy) - can’t distinguish between invasive and in situ carcinoma
- Core biopsy (98% sn for malignancy) - diagnosis and grading on histology
USS may also be used to distinguish solid lesions from cysts, and is preferred in women <35yo due to greater breast tissue density
64 What are the risk factors for breast cancer?
1)Increasing age
2) Family history
- 2 x 1st-degree, 3 x 2-degree
- Age of onset
- Bilaterality
- BRCA1 or 2 mutations
3) Previous hx of breast cancer or carcinoma in situ
4) Reproductive factors
- Early menarche (<12yo)
- Late menopause (>55yo)
- Late age at first full term pregancy
- Nulliparity
5) Previous breast biopsies showing non-malignant abnormalities
6) Hormonal therapy (HRT, OCP) - i.e. high oestrogen levels (particular for ER+ cancer)
7) Radiation at young age
8) Obesity (BMI >30) in post-menopausal women
9) Lifestyle factors
- Alcohol consumption
- Smoking (results not uniform but suggestive)
- Night shift work
65 Describe the options for adjuvant treatment for breast cancer.
Aims of adjuvant systemic therapy:
• Delay or prevent metastasis
• Reduce mortality
Aims of adjuvant local therapy:
• Reduce the risk of cancer
• Control disease in the breast, chest wall, and axillary lymph nodes
• Cure (potentially, for small tumours of favourable grade)
Treatment options:
1) Radiation therapy
- Partial breast (reduce breast recurrence)
- Local regional (reduce chest wall/regional nodal relapse) - chest wall, supraclavicular fossa, axilla
2) Hormone therapy
- Triple negative = of no use
- ER/PR-positive
→ Pre-menopausal: tamoxifen (partial ER antagonist), goserelin (GnRH antagonist), oophrectomy
→ Post-menopausal: aromatase inhibitors (anastrazole, letrozole, exemestane)
- HER2-positive = Herceptin® (trastuzumab)
3) Chemotherapy (disrupt cell division/cause cell death)
- Docetaxel, paclitaxel (anti-tubulin)
- Doxorubicin, epirubicin (cytotoxic antibiotic)
- Cyclophosphamide (alkylating agent)
- 5-fluorouracil (pyrimidine analogue)
- Methotrexate (folate analogue)
- Carboplatin (platinum compound causing DNA cross-linking)
66 What are the surgical options for a small confirmed cancer which is sited laterally in the breast, is not fixed to the skin, deep tissue or nipple? What are the advantages and disadvantages of the options?
Mastectomy vs lumpectomy (breast-conserving therapy, BCT)
Mastectomy = removal of breast tissue and surrounding structures
- Radical = breast + axillary lymph nodes + pectoralis major + pectoralis minor
- Modified radical = excl. pectoralis major
- Simple = excl. pectoralis major and minor
Advantages: No post-op XRT, lower rate of local recurrence, psychological benefit if pt is fearful of recurrence, no future imaging required
Disadvantages: longer and more invasive operation, poorer cosmesis, additional reconstructive surgery may be desired, psychologically worse if impact on body image and sexuality predominates
BCT = removal of tumour with margin
- Wide local excision = 1cm macroscopic margin
- Quadrantectomy = removal of anatomical quadrant of breast tissue
Advantages: shorter and less invasive operation, better cosmesis and sensation preservation, psychologically better for body image/sexuality
Disadvantages: requires ~5 weeks post-op XRT, higher rate of local recurrence long-term, re-operation may be required
Criteria that preclude BCT:
- Multi-centric disease
- Large tumour size relative to breast size
- Presence of diffuse malignant-appearing calcifications on imaging
- Prior hx of chest RT
- Pregnancy
- Persistently positive margins despite attempts at re-excision
67 What are the important differential diagnoses for a breast lump?
Women 12-25
Inflammed cysts or ducts
Fibroadenomata
Hormonal thickening
Malignacy rare
Women 26-35
Classic fibroadenomata
Mammary dysplasia
Malignancy uncommon
Women 36-50 (premenopausal)
Cysts
Mammary dysplasia, discharges, duct papilloma
Malignancy
Inflammatory processes
Women 50 +
Malignancy
Duct ectasia
68 What is the influence of a patient’s age on the choice of imaging for breast cancer?
All women >30yo with a breast lump should have mammography performed
But for women <30yo, the diagnostic test of choice is USS. This is because:
1) Younger women have denser breast tissue which reduces the sensitivity of mammography (false positive rate of ~52% in patients <35yo)
2) USS is routinely available as an extension of the physical exam in an outpatient setting
69 A 26 yoa woman presents to the ED with a painful, hot, swollen left breast. She is 5 weeks post partum with her first child and has been breast feeding successfully. She was prescribed antibiotics for the problem 5 days ago by her GP but has been getting worse. She has no systemic previous medical history, takes no regular medication. On examination, she is febrile, and has a fluctuant swelling in the left lower quadrant of her left breast with overlying erythema. What is the diagnosis? What is the treatment?
Diagnosis: lactation mastitis leading to secondary breast abscess
Two key elements of the pathogenesis:
1) Milk stasis or overproduction
2) Bacteria enters the breast via traumatised nipple or from the infant’s mouth (most commonly S. Aureus responsible)
Treatment for lactation mastitis:
1) Antibiotic therapy (di/flucloxacillin or cephalexin/clindamycin)
- Indications: acute pain, >12-24hrs, fever or systemic symptoms of infection, positive microbiology
2) Effective milk removal
3) Warm compress
4) Symptomatic relief
5) Supportive counselling
Treatment for (fluctuant) breast abscess:
1) Surgical intervention (needle aspiration or incision + drainage if >5cm)
2) Antibiotic therapy
70 How would you go about investigating a 16 year old girl who presented to you having found a lump, about 2cm across, in her left breast?
History
- HPC: duration, fluctuant or constant, precipitating event/trauma, changes with menstrual cycle
- PMH: medications, gynae history incl. menstruation, obstetric history (if any), previous cancers
- Fx: breast or ovarian cancer in the family
71 A 30 yoa woman presented with a painful lump in her left breast 5 days after childbirth. This is a photograph of the breast. What do you see?
Describe the lesion using:
- Location/position
- Size and asymmetry compared to other breast
- Erythema
- Purulence
?Lactational mastitis with secondary breast abscess, presenting clinically with:
- Hx: decreased milk outflow, breast pain
- Inspection: erythema, swelling, fistula
- Palpation: tenderness, firmness, mass, lymphadenopathy
72 What is the most likely organism that might be causing an acute, lactation associated, breast abscess?
Usually caused by commensal skin bacteria, most commonly by S. Aureus
Enter breast through milk duct or nipple trauma (cracks, fissures)
73 What is the management of an acute lactation associated breast abscess?
Management of primary breast abscess (developing from failure of mastitis or cellulitis to respond to antibiotic therapy) consists of drainage + antibiotic therapy
1) Drainage
- Decision on technique is based on the state of the overlying skin
a) Needle aspiration using local anaesthetic
- Appropriate initial approach when overlying skin is intact
- Use of USS guidance ensures complete drainage and aspiration of loculated areas
- Infiltration of local anaesthetic through a small area of skin some distance away from the abscess; gentle injection directly into abscess cavity if pus is thick
- Repeat every 2-3 days until no collection remains
b) Surgical drainage (usually with local anaesthetic in most cases)
- Warranted where overlying skin is compromised or abscess is not responsive to needle aspiration + antibiotics
- Small stab incision, irrigation of abscess cavity with local anaesthetic + adrenaline solution until all pus is evacuated
Note:
• Aspirated material should be sent for culture
• Patient should be re-examined every 2-3 days, cavity imaged with USS and irrigated as appropriate
2) Antibiotics
• Empirical = cephalexin, flucloxacillin (gram-negative cover for staph and strep)
• Adjust according to microbial sensitivities
Additional lactational mastitis treatment:
• Symptomatic treatment to reduce pain and swelling (NSAIDs, cold compress)
• Complete emptying of the breast (via breastfeeding, pumping, or hand expression)
74 A 30 yoa woman presented with a painful lump in her left breast 5 days after childbirth. This is a photograph of the breast. What is the likely diagnosis and what is the management?
Likely diagnosis = lactational mastitis with secondary breast lump OR primary breast abscess
Management of primary breast abscess (developing from failure of mastitis or cellulitis to respond to antibiotic therapy) consists of drainage + antibiotic therapy
1) Drainage
- Decision on technique is based on the state of the overlying skin
a) Needle aspiration using local anaesthetic
- Appropriate initial approach when overlying skin is intact
- Use of USS guidance ensures complete drainage and aspiration of loculated areas
- Infiltration of local anaesthetic through a small area of skin some distance away from the abscess; gentle injection directly into abscess cavity if pus is thick
- Repeat every 2-3 days until no collection remains
b) Surgical drainage (usually with local anaesthetic in most cases)
- Warranted where overlying skin is compromised or abscess is not responsive to needle aspiration + antibiotics
- Small stab incision, irrigation of abscess cavity with local anaesthetic + adrenaline solution until all pus is evacuated
Note:
• Aspirated material should be sent for culture
• Patient should be re-examined every 2-3 days, cavity imaged with USS and irrigated as appropriate
2) Antibiotics
• Empirical = cephalexin, flucloxacillin (cover for staph and strep)
• Adjust according to microbial sensitivities
Additional lactational mastitis treatment:
• Symptomatic treatment to reduce pain and swelling (NSAIDs, cold compress)
• Complete emptying of the breast (via breastfeeding, pumping, or hand expression)
75 A 50 year old woman is diagnosed with breast cancer. Her surgeon recommends a “lumpectomy” and sentinel node biopsy. The pathology report shows a 20 mm grade 3 ER positive, PR positive, Her-2 negative cancer, without lymphovascular invasion, and a negative sentinel node biopsy. a) Describe three “adjuvant” treatments that would be potentially beneficial to her b) referring to the aims of each treatment and distinguishing between the aims of adjuvant systemic therapy and adjuvant local therapy.
Aims of adjuvant systemic therapy:
• Delay or prevent metastasis
• Reduce mortality
Aims of adjuvant local therapy:
• Reduce the risk of cancer
• Control disease in the breast, chest wall, and axillary lymph nodes
• Cure (potentially, for small tumours of favourable grade)
Treatment options:
1) Radiation therapy
- Partial breast (reduce breast recurrence)
- Local regional (reduce chest wall/regional nodal relapse) - chest wall, supraclavicular fossa, axilla
2) Hormone therapy
- Triple negative = of no use
- ER/PR-positive
→ Pre-menopausal: tamoxifen (partial ER antagonist), goserelin (GnRH antagonist), oophrectomy
→ Post-menopausal: aromatase inhibitors (anastrazole, letrozole, exemestane)
- HER2-positive = Herceptin® (trastuzumab)
3) Chemotherapy (disrupt cell division/cause cell death)
- Docetaxel, paclitaxel (anti-tubulin)
- Doxorubicin, epirubicin (cytotoxic antibiotic)
- Cyclophosphamide (alkylating agent)
- 5-fluorouracil (pyrimidine analogue)
- Methotrexate (folate analogue)
- Carboplatin (platinum compound causing DNA cross-linking)
76 A 30 year old man presents with a 3.2 mm melanoma on his right arm. A wide excision and sentinel node biopsy is performed. One node is removed from the right axilla as part of the sentinel node procedure. It contains a 0.3 mm deposit of melanoma. Q1. What are the biological arguments for and against proceeding to an axillary clearance?
Although resection usually controls the primary lesion, melanoma often metastasizes through lymphatic channels to regional lymph nodes
Arguments for axillary clearance:
1) Complete regional lymphadenectomy, rather than partial dissection or sampling, is necessary for melanoma because of the high risk of involvement of other lymph nodes within the basin or of extra-nodal spread
2) Preferred treatment for clinically detectable and cytologically/pathologically proven regional lymph node involvement in melanoma - associated with long-term disease free survival
- ~20-40% 10-year survival for patients with metastatic involvement of regional nodes
- The number of metastatic lymph nodes is a significant prognostic factor; patients with only 1 positive node have a better prognosis (40-50%) than those with >1 positive node
3) Even if patients subsequently develop distant metastases, aggressive regional therapy at presentation can prevent morbidity caused by mass effect from involved nodes or skin breakdown
Common short-term complications:
• Wound infection (15%)
• Wound necrosis or separation (3%)
• Seroma formation (17%)
• Shoulder dysfunction (4%)
Common long-term complications
• Lymphedema (12%)
• Paraesthesia
77 A 53 year old man presents with a pearly nodule on his back that has, according to the patient “come up fairly quickly in the last 6 weeks”. It is bleeding when he rubs it with a towel. Q1. How should you mange this problem?
The description of this man’s skin nodule as “pearly” and “bleeding when he rubs it” are characteristic for a basal cell carcinoma (BCC). Although BCCs are typically slow growing, this patient’s description of it having “come up fairly quickly” could be a result of having not noticed it initially due to its location on his back.
BCCs are a common skin cancer that arise from the basal layer of epidermis and have low metastatic potential. BCC accounts for around 70% of non-melanoma skin cancers in Australia.
Features of nodular BCC
- Shiny pearly nodules or papules
- Surface telangiectasia
- Slow enlargement
- Bleeding and ulceration (when left untreated)
How to manage this presentation:
1) Confirm clinical diagnosis
- Shave/punch biopsy (diagnostic only)
- Excision biopsy (diagnosis + definitive treatment)
2) Definitive treatment
- Excision biopsy
- Mohs surgery
→ Not indicated for small primary BCCs on trunk/extremities that lack aggressive features
-Curettage and electrodissection
→ Useful for small, primary BCC with discrete borders on the trunk/extremity
- Cyrotherapy (liquid nitrogen)
- Topical therapies
→ 5-flurouracil
→ Imiquimod
