Breast Flashcards
Breast lump differentials
Painful
- CA
- fibroadenosis, abscess, mastitis, galactocele, fat necrosis, cyst
Painless
- CA
- cyst, fibroadenoma, phyllodes tumour, fibroadenosis
Scoring for breast radio imaging (mammogram)
BIRADS - Breast Imaging - Reporting and Data System
0 : incomplete, further imaging or information is required.
1 : negative – symmetrical, no masses, architectural disturbances, calcifications
2 : benign findings, e.g. fibroadenomas, simple cyst, lipomas
3 : probably benign; short interval follow-up needed
4 : suspicious for malignancy
5 : highly suspicious for malignancy
6 : known biopsy-proven malignancy
Management of breast cyst
asymp: watch and wait
symptomatic: aspirate
- not palpable after aspiration - TCU 1/12
- if (1) recur (2) does not resolve completely with aspiration (3) yield bloody aspiration»_space; send for MMG + US TRO intra-cystic tumour
Fibroadenoma
- features
- mgx
smooth, firm, rubbery, v mobile no pain enlarge during pregnancy, involute during menopause if <2cm leave >2cm/ enlarge: excise
Fibrocystic change AKA firbroadenosis
- features
- mgx
smooth, lumpy/ cobblestone, mobile
change with menstrual cycle
pain +/-
re-examine on day 10 of menses
persistent dominant mass > MMG+US+biopsy TRO CA
Differentials for nipple discharge
- bloody
- straw/ serous
- green/brown/black
- purulent
- white/milky
- blood stained
blood: intraductal papilloma, ductal CA, fibroadenosis
straw/serous: ductal papilloma, CA, or mammary ductal ectasia
green/brown: mammary ductal ectasia
purulent: lactational mastitis, breast abscess
white: drug related galactorrhea, spontanous galactorrhea, lactation
blood stain: Paget, dermatitis
intraductal papilloma mgx
inx: ductogram
tx: microdochectomy, major duct excision
Mammogram findings
- DCIS
- IDC
DCIS: clustered pleomorphic calcifications, straight line
IDC: spiculated mass
Causes of galactorrhea
drug causes:
- delete dopamine: TCA, methyldopa, benzo
- block dopamine R: haloperidol
- estrogen effect: digitalis
Pit prolactinoma
IX: serum prolactin, CT/MRI
TX: bromocriptine, resect prolactinoma
Vasculature of breast
Arterial supply
- int thoracic artery
- axillary artery
- subscapular artery
- IC arteries
Venous supply
- int thoracic vein
- long thoracic vein
- axillary vein
- IC vein
Lymphatic of breast
Axillary nodes 75%
- level I, II, III in relation to pec minor
Internal mammary nodes 20%
Inter-pectoral nodes (rotter)
RF Breast CA
BREAST BRCA Radiation Estrogen (early menarche, late menopause, child >30, nulliparity, HRT - E&P >5y) Age/ alcohol Size Tx cancer/ previous biopsy
Triple assessment
- clinical exam
- radiological: MMG/US/MRI
- Histopatho: cytology/ biopsy
all 3 concordant for benign >99% rule out CA
Common areas of CA on MMG
CC view: upper lateral quadrant
MLO: oblique milky way
MMG findings
- malignant
- benign
malignant:
- spiculation
- linear, small, thin, branching calcificatoins
- irregular borders
- archi distortion
- ductal asymmetry
- asym density
- multiple clusters
Benign:
- radial scar
- fat necrosis (oil cyst)
- milk of calcium (microcalcifications appear discoid on cc view, sickle shaped on MLO)
Breast US findings
- malignant
- benign
malignant: BITCH
- borders: spiculated, microlobulation, angular margins
- Internal calcifications
- taller than wide
- central vascularity
- hypo echoic nodule/ pos acoustic shadowing
benign
- ellipsoid
- macrolobulations
- hyperechoic
- smooth, well circumscribed
- thin echogenic capsule
ductal vs lobular carcinoma insitu
BOTH: malignant cells arising from terminal duct-lobular unit, confined by BM
ductal:
- positive for E cadherin
- distort lobular architecture
- low recurrence rate
lobular
- neg for E cadherin
- do not distort lobular architecture
- not considered premalignant but inc risk of ca
- bilateral, multicentric
Mgx of DCIS
lumpectomy + rad
partial mastec
simple mastec
adjuvant RT, hormone therapy
Krukenburg tumour
CA in ovary mets from GI source/ pylorus but sometimes from breast
Criteria for wide excision breast sx
- T2 or below (<5cm), no skin or chest wall involvement
- only 1 tumor (not multicentric)
- no mets
- appropriate tumor size to breast ratio (cosmesis)
- MUST agree to post op RT (no CI: pregnancy, previous breast RT, severe collagen tissue disorder)
blue dye (methylene blue) vs radioisotope dye (technetium 99) in pregnancy
do not use blue dye
- teratogenic
(side note: blue dye on breast last for 4w, first few days, post op urine may be green - normal)
(pps: dual method give the highest accuracy)
Options for breast reconstruction
prosthesis/ implant
muscle flap from rectus abdominis (TRAM) or latissimus dorsi myocutaneous flap (LDMF)
Cx of mastectomy and axillary clearance
Immediate
- injury to axillary vessels
- injury to nerve (long thoracic n - scapula winging from serratus anterior weakness, thoracodorsal n - lat dorsi, medial pectoral nerve)
Early
- axillary nerve thrombosis
- haemorrhage, hematoma
- wound infx
- seromas
- flap necrosis
- pain and numbness in upper arm and axilla
- restricted shoulder mobility
Late
- lymphatic fibrosis
- lymphedema
SE of radiotherapy
ST:
- skin irritation
- tiredness
- breast swelling
- cough
LT:
- skin pigmentation
- rib #
- angiosarcoma
- RT induced CA
Rad to axilla:
- lymphedema
- axillary fibrosis
SE of Chemo
NandV myelosuppression oral mucositis cardiomyopathy peripheral sensory neuropathy
Hormonal therapy
- classes
- MOA
- SE
- Selective Estrogen Receptor Modulators (SERMS): Tamoxifen
SE:
- menopausal symptoms: hot flushes, HR rise, sweating)
- endometrial ca
- DVT, PE
- stroke
use daily for 5 years, with carry on effect after - Aromatase inhibitors: lanastrazole, letrozole, exemestane
- inhibit peripheral conversion of testosterone and androstenedione to estrodiol
- only for post menopausal women
- SE: msk pain, osteoporosis, HLD (give bisphosphonates)
Targeted therapy in breast CA
- name
- MOA
- SE
- Herceptin (trastuzumab)
- IV for 1 year
- target Her2neu
- SE:
cardiomyopathy,
pulmonary toxicity
infusion reactions
febrile neutropenia - Avastin - VEGF receptors
- Lapatinib (her1/ her2)
mgx of lobular ca in situ (LCIS)
risk inc 1%/ year
- life long surveillance: annual mammogram + PE
- chemoprevention with tamoxifen (5y)
- b/l total mastec
Screening for breast CA
- what about high risk groups
MMG
40-49: yearly
>50: once every 2 years
High risk:
- start 5-10y before youngest member
- 25-30yo for BRCA
- screen: mthly BSE, 6mthly CBE, US, MRI, annual mammogram
Pagets vs eczema
- investigation?
Pagets: - unilateral - destroy nipple - underlying DCIS or invasive CA - often negative PE/ MMG > do MRI, punch/ full wedge biopsy - if lump felt: ICA - if no lump: DCIS Eczema: - bilateral - nipple normal - no underlying lump - dramatic improvement with steroids
(do punch biopsy or full thickness wedge biopsy of nipple)
Gynaecomastia
- causes
- inx
DOPING NO
Drugs - spironolactone, cimetidine, TCAs
Organ failure - liver, renal failure, hyperthyroidism
Physiological - neonates, puberty, elderly
Idiopathic
Nutrition - malnutrition
G-hypogonadism - klinefelter
Neoplasm - male breast ca - testicular ca - bronchial ca - prolactinoma Others
INX
- MMG, u/s, biopsy
- testicular u/s, AFP, beta HCG
- liver panel, renal panel, thyroid panel
- test, estradiol, LH/FSH/ prolactin
What are you looking for on breast biopsy
- features of malignancy
- breach of basement membrane
- histological subtype
- degree of differentiation
- immunohistochemistry: HER2 and ER status
Skin changes in breast CA
F+PURE fixation of skin to lump peau d orange ulcerating, fungating retraction of skin/ dimpling (invasion into Cooper ligament) erythema
Nipple changes in breast CA
discharge (bloody) deviation depression destruction discolouration displacement dermatitis
BRCA 1 and 2
- genetics
- what is the risk like
tumor suppressor gene a/w 80% of hered breast CA but only 5% of all breast CA
AD inheritance
incomplete penetrance
BRCA 1
- breast cancer features
- what other cancers
ER/PR neg (triple neg), high grade, poorly diff
Other CA: ovarian, endometrial, prostate
BRCA 2
- breast cancer features
- what other cancers
ER/PR positive
well differentiated
Other CA: male breast CA, colon, pancreatic, stomach, gall bladder, malenoma, prostate CA
Risk reduction strategies for BRCA 1 and 2
- bilateral salpingo-oophorectomy (red risk of ovarian CA)
- bilateral prophylactic mastectomy
- chemoprophylaxis (tamoxifen): red risk by 50%
Criteria for genetic counselling
- Family History
≥ 2 relatives with breast cancer, one under 50
≥ 3 relatives with breast cancer, any age
Previously identified BRCA 1 / 2 mutation in the family
Pancreatic cancer with breast and/or ovarian in same side of family
Ashkenazi Jewish ancestry (1-3% incidence) - Personal History
Breast cancer diagnosed ≤ 40 years or younger (regardless of tumour sub-type) Ovarian / Fallopian Tube cancer
Male breast cancer**
Triple negative breast cancer diagnosed at age ≤ 60 years
Staging for Breast Ca
- T stage
T1: <2cm T2: 2-5cm T3: >5cm T4: a chest wall b skin (peau, ulcer, satellite lesion) d inflam breast CA
Staging for Breast CA
- DCIS
- Early Breast CA
- Locally Advanced BC
- Advanced BC
DCIS: Tis
EBC: Stage I, II
LA: Stage III
ABC: Stage IV
Staging for Breast CA
0, I, II, III, IV
0: Tis I: T1 N0 II: T1,2,3, N0 T0,1,2 N1 III: T3N1 anyT, N2/3 T4 any N IV: M1
Cx of axillary clearance
- nerve injury: thoracodorsal nerve (weak arm adduction), long thoracic nerve, intercostobrachial nerve (numb to medial arm and axilla)
- axillary vein thrombosis (swelling of arm)
- lymphatic fibrosis
- lymphedema/ lymphangiosarcoma
- frozen shoulder
- bleeding/ infection
Indication for post op radio
- ALL BCT
- Mastec: size >5, T4, positive sx margins, >4 axillary LN, chest wall involvement
- > 4 pathologically involved nodes
Indication for
- neoadjuvant chemo
- adjuvant chemo
Neo:
- downsize for BCT
- Stage II/ III HER2 pos or triple neg cancer
Ad chemo:
- stage III or Local advanced BC
phyllodes
- how many malignant
- mgx
10% malignant
Tx: WLE with 1cm margin
no role for ALND and chemoradiation
follow up for breast CA
- post tx mammogram 1y after initial mammogram
- annual mammogram for c/l breast
- regular gyne f/u
