Breast Flashcards
Define breast cancer
- What are the key types of breast cancer
- Outline their progression
- How many are ER +ve
Main types:
1) Invasive ductal carcinoma (80% of all BC)
2) Invasive lobular carcinoma (5-15%)
See the anatomy of the alveoli to understand that the cancer can come from the epithelial cells lining either the lobule or the duct
The general picture for both types, is that they originate in the terminal duct/lobular unit, and progress from an initial hyperproliferative stage, to a pre-invasive stage (known as carcinoma in situ) to invasive BC.
In the in situ stage, the tumour cells are confined to the duct and have not invaded beyond the duct wall.
-About 80% are oestrogen receptor positive
Explain the aetiology / risk factors of breast cancer
Genetic and environmental
Most polygenic risk with 5-10% attributable to inherited factors.
BRCA-1 (17q) and BRCA-2 (13q) gene mutatons implicated in 2% of cases (carriers have lifetime risk up to 87%).
Associations/risk factors:
- Age
- Prolonged exposure to female sex hormones (oestrogen in particular)
- Nulliparity
- Early menarche
- Late menopause
- Menopausal HRT
- Obesity
- Alcohol
Summarise the epidemiology of breast cancer
Breast cancer is the most common cancer in the UK accounting for 31% of all new cancer diagnoses (2014).
Breast cancer is the leading female cancer, accounting for almost 1 in 5 cancer deaths among women.
Breast cancer mortality is falling.
In the UK breast cancer is the second most common cause of death from cancer in women after lung cancer
Recognise the presenting symptoms of breast cancer
- Primary cancer?
- With secondary spread?
Symptoms of primary:
- Breast lump (usually PAINLESS)
- Changes in breast shape
- Nipple discharge
Secondary spread:
-Axillary lump, bone pain, weight loss, paraneolastic syndromes (including cerebellar syndrome - paraneoplastic cerebellar syndrome occurs due to antibodies being produced against the breast tumour attacking the purkinje cells in the cerebellum)
Recognise the signs of breast cancer on physical examination
Inspect breasts with patients upright
Assess for:
- Asymmetry
- Peau d’orange (oedema in skin)
- Dimpling or tethering
- Nipple scaling or inversion or ulceration (in advanced cases)
-PALPATE USING CLOCKWISE RADIAL TECHNIQUE
Examination for palpable axillary, supraclavicular lymph nodes, chest abnormalities, hepatomegaly and bony tenderness
Identify appropriate investigations for breast cancer and interpret the results
What are the standard views on mammography
Which test is more useful in women older than and younger than 35.
Which tumour marker is used for breast cancer
Triple approach:
-Clinical examination, imaging (mammography, ultrasound, MRI) and tissue diagnosis (cytology or biopsy)
Mammogram (better in women >35) :
- Cranio-caudal
- Mediolateral oblique
Ultrasound (better in women <35):
-Identify benign cystic lesions from sinister solid lesions
Fine needle aspiration:
-minimally invasive, for cytology of discrete breast lump and drainage of cysts
Core biopsy:
-Can be image guided, enables histological diagnosis
Sentinel lymph node biopsy: radioactive tracer and/or blue die injected near breast lesion and a nuclear scan identifies if the sentinel node and the node is biopsied to detect spread
Staging: CT CAP, PET or bone scanning for mets
CA-15-3: Cancer antigen 15-3 (CA 15-3) is a normal product of breast cells. Concentrations of CA 15-3 in the blood are often increased in breast cancer.
Outline normal anatomy of the breast:
- Glands?
- Cell types
- Vasculature?
- Lymph drainage?
Overall, you have mammary gland (composed of lobules and lactiferous ducts) and connective issue.
Mammary gland:
1) 15-20 secretory lobules which each composed of many alveoli
2) network of lacterous ducts (one for the drainage of each lobule)
Connective tissue:
1) Fibrous component= suspensory ligaments of cooper. -Separate out lobules
- Attach and secure breast to dermis and underlying pectoral fascia
2) Fatty component
- —————————————————-
Medial part of breast supplied by internal thoracic artery (branch of subclavian)
Lateral part of breast supplied by:
1) Lateral thoracic and thoracoacromial branches – originate from the axillary artery.
2) Lateral mammary branches – originate from the posterior intercostal arteries (derived from the aorta).
3) Mammary branch – originates from the anterior intercostal artery.
Majority of lymph drained through the axillary lymph nodes (75%).
Some lymph drains to following lymph nodes:
- Parasternal (20%)
- Posterior intercostal (5%)
Nipple and areola – drains to the subareolar lymphatic
plexus
Overall management of breast cancer
- Surgery
- Radiotherapy
- Chemotherapy
- Endocrine therapy
Outline the types of endocrine therapy used in breast cancer treatment
- Suppressing ovaries
- Blocking oestrogen production by enzymatic inhibition
- Inhibiting oestrogen action
Outline ovarian ablation
Previously was done surgically removing/by irradiation of ovary
Now can be done at the level of pituitary reversibly using LHRH AGONISTS
The reason it works is because it binds to LHRH receptors in the pituitary gland, leading to receptor down regulation and suppression of LH release and thus inhibition of ovarian function including oestrogen production
e.g. goserelin, leuprolide
Outline how breast cancer can be treated by inhibiting oestrogen action
Anti-oestrogens
Tamoxifen is a competitive inhibitor of estradiol binding to the ER
Antiestrogens negate the stimulatory effects of estrogen by blocking the ER, causing the cell to be held at the G1 phase of the cell cycle.
What is commonest side effect of tamoxifen
What are the negative effects
Few side effects reported - hot flushes (29%) most commonly reported during Tamoxifen therapy.
Increase incidence of endometrial cancer
Stroke
Deep Vein Thrombosis
Cataracts
Outline how oestrogen production can be reduced using enzymatic inhibition
This refers to the peripheral conversion of androgens into oestrogens in post menopausal women. In these women, aromatase inhibitors can be used to stop the production of the small amount of oestrogen usually converted from androgens
It isn’t used as much in pre-menopausal women, because most of their estrogen comes from the ovaries.
A 50-year-old woman comes to the physician’s office with a chronic eczematous dermatitis of the left nipple and areolar area for past 24 months. Her history reveals the lesion has been treated unsuccessfully with topical steroids and has progressively distorted the nipple, resulting in inversion of the nipple. Physical examination reveals scaly, crusted, and deformed left nipple with multiple plaques overlying the surrounding areola.
Paget’s disease of the breast
What is paget’s disease of the breast
Paget disease of the breast is a pathologic hallmark of malignant, intraepithelial adenocarcinoma cells within the epidermis of the nipple.
What is the diagnositc imaging for paget’s disease of breast
Diagnostic work-up should include a careful examination of both breast and mammography.
Presenting features of pagets disease of the breast
Eczematous changes of the nipple, along with distortion, scaling, crusting, and plaque formation are classic presenting features of this disease. The symptoms usually affect the nipple, then spread to the areola and eventually the breast. Symptoms commonly wax and wane.
How can you differentiate pagets disease of breast from eczema
Pagets: The symptoms usually affect the nipple, then spread to the areola and eventually the breast
Eczema tends to affect the areola first, then the nipple.
Outline investigation of a breast lump in a young demale
To confidently exclude breast cancer, lumps should under go triple assessment:
1) Clinical examination
2) Radiological examination
- YOUNG WOMEN <35 should be an USS
- WOMEN >35 should be a two view mammmogram
3) FNA
Define fibroadenoma
Non malignant lesion of the breast
Hyerplasia of a breast lobule, contains both normal epithelial and connective tissue elements
Explain the aetiology / risk factors of fibroadenoma
Most common breast mass in women <35 years old
Summarise the epidemiology of fibroadenoma
.
Recognise the presenting symptoms of fibroadenoma
A non-tender, mobile mass
Recognise the signs of fibroadenoma on physical examination
Fibroadenomas are usually smooth, well-circumscribed and mobile limbs (1-2cm in diabeter), a “ breast mouse”
Solitary, rubbery, mobile, non-tender
Identify appropriate investigations for fibroadenoma and interpret the results
Calficiation on imaging is more likely to suggest which kind of pathology
Triple assessment
1) Clinical examination
2) Mammography, or USS in younger patients (<35yo).
Benign masses are less likely to be calcified (microcalcifications are highly suggestive of MALIGNANCY)
3) Cytology/histology: by FNA cytology, or trucut or excision biopsy
If you’re under 30 and diagnosed with a fibroadenoma through ultrasound, biopsy might not be needed. Your doctor can check on it with physical exams and ultrasounds to see if it changes or grows. If you’re in your 30s or older, your doctor may recommend a needle biopsy to confirm the diagnosis.
Generate a management plan for fibroadenoma
They can be treated conservatively or removed surgically if large (or on request)
Conservative: REGULAR CHECK UPS
Identify the possible complications of fibroadenoma and its management
Pain, recurrence
Over time, a fibroadenoma may grow in size or even shrink and disappear. The average fibroadenoma is anywhere from the size of a marble up to 2.5 centimeters (cm) in diameter. If it grows to 5 cm or larger, it’s called a giant fibroadenoma.
Summarise the prognosis for patients with fibroadenoma
T/F there is a small risk of a fibroadenoma becoming cancerius
Good prognosis.
Fibroadenomas have NO increased risk of cancer in women with a simple fibroadenoma AND no family history of breast cancer
Higher estrogen levels due to pregnancy or hormone therapy can cause a fibroadenoma to get bigger, while menopause often causes it to get smaller
However, there appears to be a slight increase in risk with a “complex fibroadenoma.” This is a fibroadenoma that includes one or more of the following benign elements: cysts larger than 3 millimeters; sclerosing adenosis; epithelial calcifications; or papillary apocrine change.
Smoking is a risk factor for which benign breast conditions
Periductal MASTITIS
Benign breast lumps are less common in which patients
Those on the contraceptive pill
Lumpy breasts which can be painful, especially just before the period
Fibrocystic disease is a very common benign breast condition characterised by
lumpy breasts which can be painful. The pain is typically at its worst immediately
before the patient’s period and is relieved when the period arrives.
Breast abscesses are associated with which risk factorrs
Breastfeeding and smoking
Duct ectasia key buzzword?
Duct ectasia is a
condition in which the lactiferous ducts get blocked. The classic SBA buzzword of
duct ectasia is a ‘cheesy yellow/green discharge’.
In breast cancer biopsy, are core biopsies or FNAs more commonly performed
Core biopsies are usually performed instead of FNA’s as more detailed information such as ER and PR status and HER2 can be obtained.
T/F a full staging assessment is required in patients with early stage breast cancer
Most patients with early stage breast cancer do not require baseline staging tests, as the detection rate is very small. If however, the patient has symptoms that may be suspicious for possible metastases then a FBC, U&Es, LFTs and bone profile would be appropriate.
T/F the age of the patient is an important consideration in assessing breast cancer patients for surgery
F
The age of a patient is irrelevant when planning surgical treatment. The patient has to be assessed as to their physical fitness
Which additional therapy is given to cancer patients following wide local excisios
A wide local excision involves excising the tumour with surrounding normal breast tissue to ensure good margins are achieved (breast conservation surgery). Radiotherapy is given to the breast tissues as an adjuvant post-surgery to prevent local recurrence
How does lobular carcinoma act differently to ductal?
Invasive lobular carcinoma is less common accounting for 15% of cases. It behaves in the same way as ductal carcinoma although it has the tendency to be bilateral and multi-focal.
How do breast cysts present
Can be tender lump, appearing suddenly. Mobile and smooth, may or may not be fluctuant.
Cysts are often an incidental finding during the screening process.
What is the cause of a cyst
Risk factors for breast cyst
They are distended and involuted lobules.
Cysts account for around 15% of all discrete breast masses and are more common in perimenopausal women. They are uncommon after the menopause.
T/F carcinomas can appear within cysts. USS is good at visualising this
T
The proportion of cystic lumps which contain an intracystic carcinoma is relatively low and ultrasound is now of such high quality that it would be unusual to miss an intracystic carcinoma at ultrasound examination.
What does a breast cyst look like on mammography
Cysts have a characteristic halo on mammography and have a smooth round appearance. They are often multiple and bilateral.
What are the investigations for breast cyst
- Clinical examination
2. Mammography –> USS.
What do breasts cysts look like on USS
Differentiate it to fibroadenoma
Cysts show up as transparent objects. They have well demarcated edges and have posterior acoustic enhancement
Benign solid lumps, such as fibroadenomas, show as having well defined edges with internal echoes
How are symptoms relieved from a painful breast cyst
Fine needle aspirations of a cystic lesion will relieve symptoms. It is often done under ultrasound guidance
Whilst cysts can be safely left in situ, it is best practice to aspirate the cyst at first presentation as this will not only confirm the diagnosis but also give the patient relief from both the physical symptoms and also from the anxiety of having a breast lump
T/F aspirated fluid from symptomatic cysts should be sent for cytology
Cyst fluid is not sent for cytology unless uniformly bloodstained
T/F HRT can worse breast cyst symtpoms
T
HRT would not resolve the symptoms of breast cysts. HRT can in fact exacerbate the symptoms. Cysts are common breast lumps in perimenopausal women and are uncommon after the menopause. Therefore HRT would just prolong the symptoms.
t/f breast cysts are usually hormone dependenT
T
“Smooth mobile and painless lump” most likely differential
Fibroadenoma
Uusal presentation of a fibroadenoma
The usual age of first presentation of a fibroadenoma is adolescence to around 30 years but patients may notice a fibroadenoma when some of the glandular tissue starts to decrease from around the age of 35 years
