Breast Flashcards
Until what age is the breast classified as undergoing development?
25
How do fibroadenomas develop and appear?
- as lobular units and dense stroma are being formed within the breast tissue
- mobile, firm breast lumps
- 12% of masses
Classifications of fibroadenomas?
- juvenile
- common
- giant (>4cm)
Investigations of fibroadenomas?
- young and small <3cm on imaging - watchful waiting
- > 4cm - core biopsy to exclude phyllodes tumour
- very large - mastectomy
How do fibroadenomas change?
- 10% increase in size
- 30% regress
- rest remain same
How can fibroadenomas be excised?
- shelled out through circumareolar incision
- smaller lesions - mammotome
In whom are breast cysts most common?
perimenopausal women caused by distended and involuted lobules
How do breast cysts appear?
- soft, fluctuant swellings
- halo appearance on mammography
- US: fluid filled
Management of breast cysts:
symptomatic may be aspirated
What is duct ectasia?
- as women progress through menopause
- ducts shorten and dilate
- cheese like nipple discharge
- slit like retraction of nipple
- no treatment
Selective Oestrogen Receptor Modulators (SERM) - MOA, ADR
- Tamoxifen
- oestrogen receptor antagonist and partial agonist
- management of oestrogen receptor positive breast cancer
- ADR: menstrual disturbance, hot flushes, VTE, endometrial cancer
Aromatase inhibitors - examples, MOA, ADR
- anastrozole, letrozole
- reduce peripheral oestrogen synthesis
- ER positive breast cancer
- ADR: osteoporosis (DEXA scan when initiating), hot flushes, arthralgia, myalgia, insomnia
Is there increased risk of malignancy with fibroadenomas?
no
Is there increased risk of breast cancer with breast cysts?
small , especially if younger
Management of breast cysts:
- aspiration
- if blood stained or persistently refill - biopsy or excision
What are sclerosing adenosis, radial scars and complex sclerosing lesions?
- breast lump or pain
- mammographic changes which mimic carcinoma
- distortion of distal lobular unit without hyperplasia
- disorder of involution
Is there increased risk of malignancy with sclerosis adenosis?
no
Management of sclerosing adenosis:
biopsy, excision not mandatory
What is epithelial hyperplasia?
- ranges from generalised lumpiness to discrete lump
- increased cellularity of terminal lobular unit
- atypical features and family history of breast cancer - greatly increased risk of malignancy
Management of epithelial hyperplasia:
no atypical features - conservative
atypical features - close monitoring or surgical resection
What is fat necrosis?
- 40% traumatic
- physical features mimic carcinoma
- mass may increase in size initially
Management of fat necrosis:
imaging and core biopsy
What is a duct papilloma?
- present with nipple discharge
- large papillomas - mass
- discharge from single duct
Is there increased risk of malignancy with duct papillomas?
no
Management of duct papillomas:
microdochectomy
Most common type of breast cancer:
invasive ductal carcinomas
some arise as result of ductal carcinoma in situ
Pathological assessment of breast cancer:
- assessment of tumour and lymph nodes
- sentinel lymph node biopsy to minimise morbidity of axillary dissection
Main breast cancer reconstruction type:
latissimus dorsi myocutaneous flap and sub pectoral implants
Indications for mastectomy:
- multifocal tumour
- central tumour
- large lesion in small breasts
- DCIS >4cm
- patient choice
Indications for wide local excision of breast cancer:
- solitary lesion
- peripheral tumour
- small lesion in large breast
- DCIS <4cm
- patient choice
What scoring system is used for breast cancer prognosis?
Nottingham Prognostic Index
Calculation of NPI:
tumour size x 0.2 + lymph node score + grade score
How does axillary lymphadenopathy determine surgical management of breast cancer?
- no palpable axillary lymphadenopathy: pre-operative axillary ultrasound before primary surgery (if positive - sentinel node biopsy to asses burden)
- palpable lymphadenopathy: axillary node clearance indicated at primary surgery (may lead to arm lymphedema and functional arm impairment)
When is radiotherapy used in breast cancer?
- whole radiotherapy recommended after wide local excision (reduce risk of recurrence in 2/3)
- mastectomy for T3-4 tumours or >=4 positive axillary nodes
When is hormonal therapy indicated for breast cancer?
- if positive for hormone receptors
- tamoxifen pre- and peri-menopausal women
- post-menopausal: aromatase inhibitors
How is biological therapy used in breast cancer management:
- most common: trastuzumab (Herceptin)
- only in HER2 positive
- not if history of heart disorders
How is chemotherapy used in breast cancer?
- prior to surgery to downstage primary lesion
- or after surgery e.g. axillary node disease (FEC-D used)
When should you refer people using suspected cancer pathway referral for an appointment within 2 weeks for breast cancer?
- > =30yo with unexplained breast lump with or without pain
- >=50yo with symptoms in one nipple of: discharge, retraction or other changes
When should referral for appointment in 2 weeks be considered for breast cancer?
- skin changes that suggest breast cancer
- or aged 30 and over with an unexplained lump in axilla
What qualifies as a non-urgent referral for breast cancer?
under 30 with unexplained breast lump with or without pain
Predisposing factors breast cancer:
- BRCA1 and 2 (40% lifetime risk)
- 1st degree relative premenopausal breast cnacer
- nulliparity (1st pregnancy >30yo)
- early menarche, late menopause
- combined hormone replacement therapy, COCP
- past breast cancer
- ionising radiation
- p53 gene mutations
- obesity
- previous surgery for benign disease
NHS breast screening programme:
- 47-73 yo
- mammogram every 3 years
Who is offered breast cancer screening:
one first or second degree relative WITH:
- age of diagnosis <40yo
- bilateral breast cancer
- male breast cancer
- ovarian cancer
- Jewish
- sarcoma in relative younger than 45yo
- glioma or childhood adrenal cortical carcinomas
- complicated patterns of multiple cancers at young age
- paternal history of breast cancer
Go study the anatomy of the breast
on google images
Most breast cancers arise from what tissue?
- duct tissue
- lobular tissue
All the most common types of breast cancer:
- invasive ductal carcinoma (most common)
- invasive lobular carcinoma
- ductal carcinoma in situ
- lobular carcinoma in situ
Rare types of breast cancer:
- medullary
- mucinous
- tubular
- adenoid cystic carcinoma
- metaplastic
- lymphoma
- basal type
- phyllodes or cyst-sarcoma phyllodes
- papillary
What is paget’s disease of the nipple:
- eczematoid change of nipple
- underlying breast malignancy
- 1-2% patients with breast cnacer
- mostly with invasive carcinoma
What is inflammatory breast cancer?
- cancerous cells block lymph drainage
- inflamed appearance of breast
