Breast Flashcards
- How would you go about investigating a 60 year- old lady who presented to you having found a lump, about 2 cm across, in her left breast?
I would start off my investigation with the triple assessment which would include a clinical assessment, imaging and tissue biopsy.
The clinical assessment would involve a history of he presentation and a clinical examination.
This history would comprise of questions regarding the duration, changes (lump changes, skin changes, nipple changes and whether it changes with menstrual cycle), pain, systemic symptoms, recent trauma and risk factors.
The examination would include inspection of breast with the patients hands by their side and above their head looking for:
o Breast contour
o Skin changes: erythema, dimpling, puckering, peau d’orange
o Nipple changes: inversion, distortion, eczema, nodules, ulcers, discharge
AND palpation of :
o Four quadrants with a systematic approach
o Nipple
o Axillary tail
o Lymph nodes – axillary and supraclavicular.
Imaging can include mammography for patients over 30 or ultrasound for patients younger than 30 and MRI can be considered for high risk patients that may present with benign appearance on mammography.
Biopsy can include FNA or core biopsy. FNA can only provide information on the type of cells and whether they are dysplastic or not, whereas, core biopsy is able to determine the invasiveness of abnormal cells.
- What are the risk factors for breast cancer?
The risk factors can be categorised into modifiable and non-modifiable.
Non-modifiable include:
- age- incidence increases with age
- gender- male breast cancers account for less than 1%
- ethnicity- Caucasian women have higher risk
- previous hx of breast cancer or a high risk breast lesion
- FHx of breast cancer- esp first degree relative
- genetic mutations- e.g. BRCA1/BRCA2 mutations
- reproductive factors- early menarche (<12), late menopause (>55),
Modifiable risk factors include:
• Radiation exposure at a young age
• Obesity
o BMI > 30, especially in post-menopausal women
• Lifestyle factors
o Alcohol consumption
o Smoking (questionable)
• Hormonal therapy
o HRT and OCP
• Reproductive factors
o Nulliparity and late age of first full term pregnancy
- Describe the options for adjuvant treatment for breast cancer.
Adjuvant therapy is given after the primary treatment to lower the risk of recurrence. The primary treatment is usually surgery.
The management of all pts should be determined by a MDT.
Adjuvant therapy can be systemic or local.
Systemic therapy includes chemotherapy, hormonal therapy or biological therapy, whereas, radiotherapy is the local adjuvant therapy.
Chemotherapy – involves the use of combinations of cytotoxic agents given systemically to treat both local disease and any possible spread
o There are many different regimens of cytotoxic agents used to treat breast cancer
o Examples of cytotoxic drugs:
- Anthracyclines (affects DNA and RNA synthesis)– doxorubicin and epirubicin
- Alkylating Agents (affects DNA) – cyclophosphamide, carboplatin
- Antimetabolites (disrupts nucleic acid synthesis) – 5-fluorouracil, methotrexate
- Taxanes (disrupts microtubule action) – paclitaxel and docetaxel
Hormonal/ Biological therapy – requires immunohistochemically assessment of the tumour cells to determine receptor status and sensitivity to treatment.
ER positive tumors can be treated with Tamoxifen (SERM), aromatase inhibitors (can only be prescribed in post-menopausal women) or via ovarian ablations using LHRH analogues (Goserelin) or oophorectomy.
HER-2 positive tumors can be treated with Herceptin which is a monoclonal antibody to the HER-2 receptor.
Localised radiotherapy should be used in all women who have breast conserving therapy and also has a role for treatment of women who have mastectomy and a high risk of recurrence or nodal involvement
- 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?
The surgical options include a mastectomy or a lumpectomy (breast conserving surgery).
Breast conservation surgery involves removing the tumor with a margin of surrounds breast tissue via a wide local excision, followed by radiotherapy to the breast to minimize local recurrence.
Advantages include:
- the preservation of breast shape and skin whilst having similar survival benefits
- able to remove up to 20% breast volume and achieve reasonable cosmetic result
- patients report better body image and sexual functioning than those undergoing mastectomy
- less psychological impacts on pts when compared to mastectomy
- shorter operation with shorter recovery time
Disadvantages:
- there is a selection criteria that needs to be fulfilled. (E.g. has to be a single lesion, no larger than 3cm or 4cm in larger breast, has to be 2cm away from areola, lower histological grade lesion and no extensive nodal involvement)
- requires post op radiotherapy. Major issue in parts of the world where radiotherapy is unavailable
- higher risk of recurrence compared to mastectomy
A mastectomy is indicated for pts who aren’t candidates for BCT or prefer mastectomy.
Simple mastectomy is now the standard procedure for invasive breast cancer and involves the removal of the breast with preservation of pectoralis muscles and most of the axilla.
Advantages include:
- no post op RT needed unless high risk cancer that may require chest wall radiotherapy.
- no follow up imaging required
- lower rates of local recurrence
- can have reconstructive surgery
Disadvantages:
- longer operation
- poorer cosmetic outcome
- can have more psychological impacts on self image and sexual dysfunction
- may require further reconstructive surgery or prosthesis use
- What are the important differential diagnoses for a breast lump?
Differential diagnoses for a breast lump can be categorised into benign, pre-malignant or malignant.
Benign differentials include:
- abnormalities of normal development and involution which includes (fibroadenomas, fibroadenosis, intraductal papillomas, duct ectasia and cysts.)
- galactocele (milk cyst)
- fat necrosis due to trauma
- breast abscess
Pre-malignant include:
- ductal carcinoma in-situ
- lobular carcinoma in-situ
Malignant include:
- ductal carcinoma
- lobular carcinoma
- special types (tubular, mucoid, medullary and papillary carcinomas)
- sarcoma of breast
- phyllodes tumor ( rare but fast-growing masses that form from the periductal stromal cells of the breast)
The age of the patient greatly affects the most likely diagnosis of a breast lump:
• < 30 years – physiologically normal lumpy breast, fibroadenoma, fibroadenosis, abscess (if breast feeding), galactocele (if breast feeding)
• 30 – 45 years – fibroadenosis, cyst, abscess (especially smokers), carcinoma
• 45 – 60 years – cyst, abscess (especially smokers), carcinoma
• > 60 years - carcinoma
- What is the influence of a patient’s age on the choice of imaging for breast cancer?
• All women over the age of 30 years with a breast lump should have a diagnostic mammogram. If it is inconclusive, ultrasound can be done to increase the diagnostic accuracy, as it better characterise lesions and identify the presence of satellite lesions
Mammography has a high false positive rate in young patients
• In women < 30 years old USS is the investigation of choice because the presence of denser breast tissue make evaluation with mammography less useful. Another consideration is the radiation exposure to the breast tissue of younger women if mammography is performed.
o USS is most useful for the evaluation of cystic lesions
• MRI is the most sensitive investigation for breast cancer and the non-ionising nature makes it ideal for younger patients, however it is expensive and relatively less available and therefore not largely used
- A 26 year-old woman presents to the ED with a painful, hot, swollen left breast. She is five weeks post partum with her first child and has been breast feeding successfully. She was prescribed antibiotics for the problem five 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?
- The most likely diagnosis is lactational mastitis with breast abscess
- The treatment is:
• A Surgical consult:
o for aspiration under ultrasound or incision and drainage and MCS of the breast milk and pus
• Simple analgesia for the pain:
o Paracetamol or NSAIDs (ibuprofen)
• Continuing Antibiotics:
o Flucloxacillin
- Education and support to continue breast feeding
- Outpatient referral for lactation consultation
- How would you go about investigating a 16 year- old girl who presented to you having found a lump, about 2 cm across, in her left breast?
I would start with a clinical assessment.
I would take a history of the lump, when it appeared, the duration, whether there is pain, any changes to the skin, nipple, or lump, a menstrual history, family history, other risk factors and systemic symptoms.
I would then examine with a chaperone present. This would include inspection and palpation.
The result would be documented. If there are any red flags in the history or examination I would ultrasound (e.g. FHx), otherwise I would consider waiting and watching to see if the lump resolves over the period of 2-3 menstrual cycles keeping mind that cancers are rare in this age group and it is more likely to be a benign cause (e.g. fibroadenoma).
If the lump has not resolved then an ultrasound should be performed
- A 30 year-old woman presented with a painful lump in her left breast five days after childbirth.
This is a photograph of the breast.
What do you see?
Describe the lesion: • Location on a clock face or quadrant • Size and symmetry when compared to the other breast • Erythema • Purulence
Likely diagnoses:
• Lactation mastitis
• Lactation breast abscess
- What is the most likely organism that might be causing an acute, lactation associated, breast abscess?
• Usually caused by commensal skin bacteria – MOST commonly Staphylococcus Aureus. It enter the breast through lactiferous duct or nipple trauma (cracks, fissures)
EXTRA
Less commonly Candida Albicans or Escherichia Coli
- What is the management of an acute lactation associated breast abscess?
Management:
Aspiration with USS guidance or surgical incision and drainage – milk and pus aspirated should be sent for MCS
• Continued breast feeding/ expression of milk
• Simple analgesia
• Education and reassurance
• Antibiotics (flucloxacillin)
- A 30 year-old woman presented with a painful lump in her left breast five days after childbirth.
This is a photograph of the breast.
What is the likely diagnosis and what is the management?
Describe the lesion:
• Location on a clock face or quadrant
• Size and symmetry when compared to the other breast
• Erythema
• Purulence
Likely diagnosis – Lactation mastitis +/- breast abscess
DDx: Galactocele (usually non-painful), Inflammatory breast cancer
Management:
Aspiration with USS guidance or surgical incision and drainage – milk and pus aspirated should be sent for MCS
• Continued breast feeding/ expression of milk
• Simple analgesia
• Education and reassurance
• Antibiotics (flucloxacillin)
- 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.
Q1. Describe three “adjuvant” treatments that would be potentially beneficial to her referring to the aims of each treatment and distinguishing between the aims of adjuvant systemic therapy and adjuvant local therapy.
3 adjuvant therapies that would be potentially beneficial for this pt include: - adjuvant radiotherapy - adjuvant hormonal therapy AND -adjuvant chemotherapy.
External beam radiation therapy is aimed at achieving local disease control by using high dose (40-50Gy) radiation to kill cancer cells. In the case of lumpectomy adjuvamt radiotherapy is indicated.
This woman’s tumour is ER +ve / PR +ve / HER2 -ve, therefore she should be given hormonal treatment to target the ER (e.g. SERM-Tamoxifen or aromatase inhibitor, depending on whether she is pre- or post-menopausal).
If she is premenopauseal tamoxifen can be used as it o competitively binds to the oestrogen receptor and therefore limits the stimulation of cancer growth (antagonist in the breast but agonist in the bone and endometrium).
Aromatase inhibitors should only be used in postmenopausal women.
Ovarian suppresion via GnRH agonist-Goserelin, or oophorectomy can also be used for used in treatment of pre- and perimenopausal women.
Adjuvant systemic chemotherapy should be considered due to the high grade of the lesion, even though the Sentinel Node Biopsy was negative. The treatment here aims to disrupt the cell cycle. Examples include anthracyclines, alkylating agents, antimetabolites, taxanes.
EXTRA The use of adjuvant chemotherapy is usually reserved for those patients with poor prognostic indicators such as: o Large tumour size o Node positivity o Grade 3 tumours o Extensive lymphovascular invasion
- 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?
Arguments for axillary clearance are:
- There is a high risk of micrometastases in other lymph nodes and therefore completion lymph node dissection should be performed over partial dissection or sampling.
- There are improved mortality rates for patients that undergo axillary dissection, compared to those who don’t.
- Completion lymph-node dissection has improved regional disease control and allows more precise staging and prognostic information which will influence decisions regarding adjuvant systemic therapy
Arguments Against Axillary Clearance are that:
• the MSLT-II trial showed no survival benefit for patients who underwent immediate completion lymph node dissection, when compared to patients who had nodal observation with ultrasonography and only underwent operation when lymph node involvement was clinically detectable
AND
- there are side effects with axillary clearance and they include: wound infection, seroma formation, shoulder dysfunction, lymphoedema, paraesthesia
- 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 six weeks”. It is bleeding when he rubs it with a towel.
Q1. How should you mange this problem?
This sounds like a nodular BCC which usually presents as a pearly nodule with possible central ulceration, telangiectasia and bleeding with excoriation.
This patient should be investigated with a thorough history and clinical exam and an excision bipsy (gold standard) can be done.
Non Melanoma Skin Cancers can be treated with elliptical excision.
Other treatment options include curettage and diathermy, liquid nitrogen, imiquimod (acts as an immune response modifier) or fluorouracil, radiotherapy or excision and flap repair or graft.
