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Big Surgery > Breast > Flashcards

Breast Flashcards

1
Q

What are the two types of breast carcinomas?

A
  1. invasive ductal carcinoma

2. invasive lobular carcinoma

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2
Q

How often should women between 50-74 years old go to mammograms?

A

every 2 years

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3
Q

What are the aetiological factors of breast cancer?

A
  1. breast cancer in the contralateral breast
  2. increased oestrogen exposure-(early menarche and late menopause, nulliparity, having a baby after 35 years
  3. BRCA 1 and 2 gene mutations PREDISPOSES patients to 0% higher chance of breast and ovarian cancer
  4. Family History of first degree relatives
  5. obesity
  6. previous radiation
  7. previous history of benign breast conditions like fibroadenoma with atypical cellular involvement
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4
Q

What are the associated genetic conditions associated with breast cancer?

A
  1. P53 tumour suppressor gene mutataion
  2. Peutz-Jhegers syndrome
  3. Li-Fraumeni syndrome-SBLA-Sarcoma, breast, lymphoma, adrenal cancer syndrome
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5
Q

What type of cancer are breast cancers?

A

-adenocarcinoma

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6
Q

What are the characteristics of DCIS?

A
  • unifocal
  • pattern of grouped microcalcifications
  • higher risk of invasive carcinoma(ipsilateral)
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7
Q

What are the characteristics of LCIS?

A
  • microcalcifications are rare
  • multifocal
  • decreased chance of it becoming invasive carcinoma in both breasts
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8
Q

What are the characteristics of Invasive Ductal Carcinomas?

A
  • most common(70-80%)
  • unilateral localisation
  • unifocal tumours
  • most aggressive which easily cause Mets
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9
Q

What are the characteristics of Invasive lobular carcinoma?

A
  • not as aggressive

- bilateral or unilateral

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10
Q

What is the third type of invasive breast carcinoma?

A

-inflammatory

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11
Q

What are the clinical features of breast cancer?

A
  1. asymmetrical breast size
  2. nipple changes-discharge or inverted nipple
  3. palpable mass-usually a single, non tender mass with poorly defined margins
    - mostly in the upper outer quadrant(55%), then the inner upper quadrant(15%), nipple area(15%), lower inner area(10%), outer lower area(5%)
  4. Lymph node involvement(axilla), more than 1 cm
  5. Skin changes: peau’ d orange (redness, edema and pitting of hair follicles)
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12
Q

What causes peau’ d orange?

A

-It is caused by blocked lympatic channels

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13
Q

What is Paget’s disease of the breast?

A
  • a adenocarcinoma
  • either in-situ or invasive ductal carcinoma that infiltrates the nipple and areolar
  • it starts by affecting the nipple and then going out into the areolar
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14
Q

How does Paget’s disease present?

A
  • it looks like eczema

- it usually has erythema, itching, crusting and rawness

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15
Q

How do you diagnose and treat Pagets disease?

A
  • punch biopys

- a mastectomy is usually done

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16
Q

What is inflammatory breast cancer?

A

It is a advanced and invasive carcinoma associated with dermal lymphatic invasion of tumour cells
-it usually presents as a abscess or cellulitis

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17
Q

What are the clinical features of inflammatory breast cancer?

A

-25% have metastatic disease
-erythematous and oedematous (peau’ d orange) plaques appear over a rapidly growing mass
-tenderness
-axillary lympahdenopathy
-

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18
Q

What is the differential diagnosis for inflammatory breast cancer?

A
  • pagets disease of the breast
  • mastitis
  • breast abscess
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19
Q

What should you do if a woman comes to you with a palpable breast mass and they are less than 30 years?

A
  1. low probability- clinically assess them 3-10 days after their menstrual period
  2. high probability-do ultrasound or FNA
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20
Q

What should you do if a woman comes to you with a palpable breast mass and they are above the age of 30?

A
  1. Mammogram

then do core needle biopsy

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21
Q

What are features of a benign breast mass on a mammogram?

A
  1. well defined margins
  2. Halo sign- radiolucent circle around the lesion
  3. diffuse and coarse microcalcifications
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22
Q

What are the features of a malignant breast mass on a mammogram?

A
  1. focal mass or density with ill-derfined margins
  2. spiculated margins
  3. clustered microcalfications
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23
Q

When do we do FNA’s?

A

We do fine needle aspirations when we have a low probability of a lesion being malignant

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24
Q

What is the preferred test?

A

Core needle biopsy because it can help distinguish between invasive and non-invasive carcinoma

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25
Q

In which instances would we excise the mass?

A
  1. inconclusive results on core needle biopsy

2. if we are unable to do core needle biopsy

26
Q

What should we consider if there is axillary lymph node involvement?

A
  1. haematogenic spread has already ocured
27
Q

What is the workup of a breast cancer patient?

A
  1. We start with receptor testing of the biopsy samples
    - immunohistochemical testing of oestrogen and progesterone
    - FISH staining of HER2 positive receptors-in 20% of the cases
28
Q

What does triple negative mean?

A
  • It is a high grade and aggressive form

- oestrogen negative, progesterone negative and HER 2 negative

29
Q

What tests would you consider for checking mets?

A
  1. Bone mets- Contrast MRI scan to localise the pain, bone scan
  2. Liver mets- CT abdomen
  3. Lung mets- CXR and MRI of the lungs; thoracentesis is the case of pleural effusion
30
Q

How do we make a diagnosis of breast cancer?

A

Triple assessment-clinical assessment, radiology and tissue biopsy and confirmation

31
Q

What is a mammogram?

A

It is a special X-ray that can suggest but not make a diagnosis of breast cancer
-it is not useful in patients under 30 years because of the dense breast tissue that young people have

32
Q

In which cases would we use an ultrasound?

A
  • patients under the age of 30 because they have dense breast tissue
  • to determine whether the mass is cystic or solid
33
Q

Does an ultrasound help us determine whether the mass is benign or maligant?

A

No

34
Q

What is a FNA test?

A
  • cytological test that requires a 22 gauge needle and syringe
  • aspirate the mass in different directions and place on the slides to stick together
  • it is great to determine the type of cells but not enough to make a diagnosis of malignancy
35
Q

What is a Trucut/core needle biopsy?

A

It is a biopsy of the mass/tissue that is the sent for histopathological assessment
-it can give us info on the tumour type,biology and hormone receptor status

36
Q

What is the third and rare form of breast carcinoma?

A

mixed(both invasive and non-invasive)

-can include angiosarcomas and carcinosarcomas

37
Q

What is the most common type of invasive ductal carcinoma?

A

-Infiltrating ductal carcinoma(it affects 50-70%)

38
Q

What are some of the other invasive ductal carcinomas?

A
  • medullary carcinoma
  • mucinous carcinoma
  • tubular carcinoma
  • invasive cribriform carcinoma
  • invasive papillary carcinoma
39
Q

What do pathologists use to describe tumours?

A
  • size
  • grade
  • blood vessel or lymphatic invasion
  • PR(progsterone), ER(oestrogen), HER 2 receptors
40
Q

What is the first thing to do when you have a positive breast cancer diagnosis?

A
  1. check for metastases:
    - all patients must have CXR’s done, LFT’s done
    - If the LFT’S are abnormal or T3 means that they also need an ultrasound of the liver
    - patients must also have a bone scan done
41
Q

What works for ER and PR positive patients?

A

-Endocrine maneoveres such as Tamoxifen

42
Q

What seems to work for HER 2 positive patients?

A

Trastuzumab

43
Q

Name the 5 treatment options for breast cancer patients?

A
  1. surgery
  2. radiotherapy
  3. chemotherapy
  4. biological treatments
  5. endocrine manipulation
44
Q

What are the two surgical treatments for breast cancer?

A
  1. wide local excision

2. mastectomy

45
Q

What 6 factors do patients have to fulfill before they are allowed to do a wide local excision?

A
  1. no multifocal lesions
  2. no family hx
  3. < 5 cm mass
  4. radiotherapy for 6 weeks
  5. outer quadrants
  6. large breast
46
Q

What are the 2 surgical options for the axilla?

A
  1. sentinel lymph node biopsy

2. axillary nodal clearance

47
Q

Which 3 factors deem a patient appropriate for sentinel lymph node biopsy?

A
  1. Stage T1/T2
  2. no lymph node involvement
  3. no previous axilla surgery, irradiation or chemotherapy
48
Q

How is a sentinel lymph node biopsy done?

A
  • it is a minimally invasive procedure that involves removal of the first draining lymph node
  • The radioactive technetium is injected around the tumour 24 hours prior to surgery
  • the sentinel lymph node uptake is then detected with gamma rays
  • intraoperatively: they inject dye around the areolar around the same quadrant as the cancer
  • the node is removed and put in a frozen section
  • if cancerous: axillary node clearance is done
  • if not cancerous then nothing is done to the axilla
49
Q

Why do we need adjuvant therapy?

A

-We need it to ensure that we decrease the risk of women relapsing after 5 years

50
Q

Name the different types of adjuvant therapy?

A
  • radiotherapy
  • chemotherapy(eg. adriamycin and taxanes)
  • endocrine manipulation: entails changing the patients hormonal environment to cause tumour regression(progesterones and Tamoxifen)
  • biological modifiers (Trastuzumab working on HER 2)
51
Q

Name some of the hormonal or endocrine modifiers?

A
  1. premenopausal:
    - tamoxifen works on ER
    - progesterone
    - LHRH agonist
    - oopherectomy
  2. post menopausal
    - progesterone
    - tamoxifen
    - aromatase inhibitors
52
Q

How is breast cancer staged?

A

stage 0 to 4

53
Q

What is stage 0 and how do we treat it?

A
  • carcinoma in situ
  • if local: Wide local excision
  • if multifocal: mastectomy with axillary node clearance
54
Q

What is stage 1?

A

T1 without nodes

55
Q

What is stage 2?

What is the treatment options?

A

T1 or T2 with nodes OR T3 without nodes

  • the options include a total mastectomy with a sentinel lymph node biopsy or a wide local excision with a sentinel lymph node biopsy
  • axillary node clearance is done when the sentinel lymph node biopsy is positive
  • adjuvant therapy is needed
56
Q

What is stage 3?

-How do we treat it?

A

Locally advanced tumour(T4) or locally advanced node(N2,3)

  • Triple modality approach is needed: chemotherapy, surgery and radiotherapy
  • neoadjuvant (chemotherapy before the surgery to downsize the tumour is necessary)
57
Q

What is stage 4 and how do we treat it?

A

-metastatic disease
-palliation is the name of the game
Older, post-menopausal women-benefit from endocrine manipulation
younger women would benefit from chemotherapy

58
Q

What is the management for men that present with breast cancer?

A
  • mastectomy and axillary node clearance

- the incidence rate is 1%

59
Q

What are some of the side effects of chemotherapy?

A
  1. cardiotoxicity
  2. alopecia
  3. myelosupression
  4. hypersensitivity
  5. contra-indicated in first trimester of pregnancy
60
Q

What are he complications of breast cancer?

A
  • metastatic disease: bone, liver, lung, brain mets
  • recurrence: 40% in lymph nodes, chest wall
  • paraneoplastic syndrome
  • lymphedema of the arm is a side effect of treatment
61
Q

What are some of the factors that can prevent breast cancer?

A
  • mammograms every 2 years in women that are average risk between 50-74 years
  • breast feeding
  • early pregnancy

Big Surgery (21 decks)

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