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Year 4 > breast > Flashcards

breast Flashcards

1
Q

risk factors for breast cancer (higher and lower risk)

A

higher risk:

  • age
  • alcohol
  • smoking (as a teenager)
  • oestrogen-progesterone pill + HRT
  • Xray and gamma radiation
  • obesity
  • easy menarche/late menopause
  • dense breasts

lower risk

  • longer duration of breastfeeding
  • early age at first child
  • increasing parity
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2
Q

what genes involved with breast cancer

A

BRCA1, BRCA2, p53

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3
Q

breast cancer symptoms/signs

A
  • lump
  • pain
  • skin changes (rash, nipple eczema, dimples, skin tethering, redness)
  • nipple discharge
  • inverted nipple
  • lymph node swelling
  • systemic symptoms
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4
Q

with breast lump, what investigations to do

A
  • if < 35 and P1-P3: ultrasound
  • if < 35 and P4-P5: ultrasound + mammography
  • if > 35: mammography, ultrasound and biopsy
  • if micro calcification on mammography: core biopsy
  • if lymph node involvement: ultrasound + biopsy + CT abode/thorax/pelvis (if >4 lymph nodes/big lump/specific symptoms
  • MR if no concordance
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5
Q

areas of metastasis of breast cancer

A

Bs and Ls:

bone, brain, liver ,lung

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6
Q

tool for prognosis?

worse and better prognosis of breast cancer

A

tool: PREDICT
worse prognosis: triple negative , HER2 pos, grade 3; Nodal/metastasis
- better prognosis: ER pos, low grade, primary cancer

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7
Q

meaning of primary/secondary breast cancer

A

primary: originates in breast, not spread
secondary: originates in breast and spread

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8
Q

what features determine the grade of breast cancer

A
  • differentiation
  • pleomorphism
  • mitotic activity
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9
Q

which biomarkers in breast cancer

A

ER
PR
HER2

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10
Q

treatment of breast cancer

A
  • if ER pos: tamoxifen + adjacent chemo
  • if HER2 pos: herceptin + chemo
  • surgical: wide excision + radiotherapy OR mastectomy (multifocal, local recurrence, DIS or invasion)
  • chemo: adjacent/neoadjuven, triple neg cancers, HER2 pos, node/metastasis
  • aromatase inhibitors (postmenopausal women)
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11
Q

morbidity of treatment of breast cancer

A

lymphedema

disfiguring surgery

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12
Q

what treatment to give for bone metastasis

A

denosumab

bisphosphonates (for prevention)

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13
Q

classification of breast pain

A

cyclical (linked to hormones)

non cyclical

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14
Q

investigations for breast pain

A

mammography

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15
Q

management of breast pain

A
  • reassurance
  • well fitted bra
  • diet and lifestyle changes (alcohol, caffeine, less fat/more fibre)
  • NSAIDs (topical)
  • change contraceptive pill
  • if severe and prolonged: hormone suppressing drugs (tamoxifen or danazol)
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16
Q

mastitis risk factors

A
  • tight bra
  • nulliparity
  • baby not attaching well to the breast
  • use of dummy/bottle
  • smoking
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17
Q

general symptoms/signs of mastitis

A

painful breast
fever/general malaise
tender, red, swollen and hard area of the great, in a wedge shaped distribution
greenish discharge

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18
Q

different types of mastitis

A

periductal
granulomatous
lactational

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19
Q

lactational mastitis features

A
  • inflam condition
  • milk statis due to overproduction or insufficient removal of milk
  • may be infective or non infective
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20
Q

management of lactational mastitis

A
  • analgesia and warm water
  • keep breastfeeding
  • ultrasound of breast to look for abscess
  • breast milk MS&C (if indicated)
  • if infective: prescribe flucloxacillin
  • urgent referral to secondary care if breast abscess (ultrasound guided drainage)
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21
Q

features suspicious of infection in mastitis

A
  • nipple fissure that looks infective
  • purulent discharge
  • influenza-like symptoms and pyrexia > 24h
  • considerable breast discomfort
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22
Q

differentials of mastitis

A
  • breast cancer
  • duct ectasia
  • cellulitis
  • fibroadenosis
  • blocked duct
  • galactocoele
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23
Q

signs and symptoms of implant rupture

A
  • lumpiness/swelling in and around the breast
  • change in shape of breast
  • redness
  • pain and tenderness
  • burning sensation
  • enlarged lymph nodes in the armpit
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24
Q

which type of implant is most likely to rupture

A

PIP

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25
Q

what is a fibroadenoma

A

benign breast tumour

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26
Q

how does fibroadenoma present on triple assessment

A
  • P2
  • U2 (pushing, not infiltrating margins and no shadowing behind the mass)
  • core biopsy (only if > 25yo)
27
Q

management of fibroadenoma

A
  • if diagnosis has been made through triple assessment, does not need treatment
  • if > 4cm, growing or patient requests it, can be excised
28
Q

prognosis of fibroadenoma

A
  • generally stays the same size, can get bigger or smaller

- does not increase risk of developing cancer

29
Q

def of breast cysts

A

benign fluid filled lobules

30
Q

epidemiology of breast cysts

A

women 35 yo- menopause

31
Q

cause of breast cyst

A

change in oestrogen levels

32
Q

treatment of breast cysts

A
  • no need for treatment

- if large or uncomfortable: fine needle aspiration (if blood stained: send for cytology)

33
Q

prognosis of breast cysts

A

does not increase risk of cancer

34
Q

when do women undergo breast screening

A

between 47-73 years old

every 3 years

35
Q

what tool(s) do you use for screening

A

mammography

36
Q

when can you start screening and why tools can you access if you have a high risk of breast cancer

A

can start earlier (from 20y if gene involvement)

- annual MR and mammography

37
Q

disadvantages of breast screening

A
  • mammography is uncomfortable and involves small amount of radiation (few months-years of background radiation)
  • false pos results (unnecessary anxiety)
  • occasionally miss cancer
  • breast cancer may occur between screening appointments
  • screening may diagnose a cancer which never needed treating
38
Q

explain process of breast screening

A
  • mammography every 3 years between age 47-73
  • prep: undress from waist down, do not wear talcum powder or deodorant , need to know about previous breast cancer Hx, HRT, FH
  • mammography done by female mamographer, need to compress breast
  • interpretation: read by two trained film readers (radiologists, breast physician or radiographers)
  • results: by post within 2 weeks
  • may have recall (one in 4 women) and do magnification view
39
Q

def ductal carcinoma in situ

A

cancer cells have formed within the milk ducts but have not invaded through the basement membrane to surrounding breast tissue

40
Q

symptoms of DCIS

A

breast mass
nipple discharge
paget’s disease

41
Q

how does DCIS appear on mammography

A

pattern of micro calcification following a linear branching pattern of milk ducts

42
Q

management of DCIS

A
  • wide local excision and radiotherapy
  • mastectomy
  • post surgical hormonal treatment (if pos)
  • annual mammogram and clinical examination for 5 years
43
Q

def familial breast cancer

A

occurs more frequently in a family than would be expected in the general population

44
Q

who do you refer to secondary care for breast cancer (FH wise)

A
  • one 1st degree relative < 40
  • two 1st/2nd degree relatives at any age

or FH of:

  • bilateral breast cancer
  • male breast cancer
  • ovarian cancer
  • jewish ancestry
  • complicated cancer in young relatives
  • 2+ cancers on father’s side
45
Q

how do you manage familial breast cancer

A
  • screening from a young age (MRI and mammograms annually)
  • prophylaxis mastectomy
  • prophylaxis oophorectomy
  • chemoprevention (tamoxifen and raloxifene)
46
Q

doctor confidentiality with familial breast cancer genetic testing

A
  • doctor cannot tell anyone without your consent
  • can share with family members that have undergone genetic testing to understand their risk (but should discuss this with you first)
    look up more
47
Q

tripple assessment components

A
  • clinical assessment (history and examination)
  • imaging (mammography/ultrasound)
  • needle biopsy (FNA/core biopsy)
48
Q

triple assessment scoring (1-5)

A
  1. normal
  2. benign
  3. indeterminate/probably benign
  4. suspicious
  5. malignant
P: palpation 
U: ultrasound 
M: mammography 
B: biopsy 
C: cytology
49
Q

different views of a mammogram

A
  • mediolateral oblique (MLO) view (to include axillary tail)

- craniocaudal (CC) view

50
Q

why compress breast in mammogram

A
  • spreads our glandular tissue (reduce overlap)
  • decreases risk of blurring
  • helps thin breast: avoids over/underexposure of certain parts
  • reduces radiation dose
51
Q

how do you describe a mammography in terms of parts

A

R/L breast
lower/upper
inner/outer
mass

52
Q

findings on ultrasound for malignancy

A
  • irregular borders
  • star shaped, spiked finger like projection
  • enlarged ducts
  • unusual tissue structures
  • invasion through tissue plane
  • dense shadowing behind it
53
Q

benign findings on ultrasound

A
  • round or oval shaped
  • well defined borders that are easily distinguished from surrounding tissue
  • tissue plane pushed away (but not invaded)
54
Q

appearance of fluid, soft and dense tissue on ultrasound

A

fluid appears black
soft tissue is varying shade of grey
dense tissue appears white

55
Q

advantages of FNA over core biopsy

A
  • FNA quick and easy to perform
  • processing times are rapid (FNA: 30 mins, core biopsy, several days)
  • low cost procedure
  • few complications
56
Q

disadvantages of FNA over core biopsy

A
  • FNA interpretation requires highly trained and experienced pathologist
  • difficult to classify malignant lesions as evasive or non invasive
  • cytology prep does not require as much tissue in core biopsy
  • cytology preps cannot ascertain receptor status of a cancer
57
Q

differentials for breast erythema

A

infection
trauma
underlying breast pathology (inflammatory)

58
Q

cause of puckering of the breast

A

associated with invasion of suspensory ligaments of the breast
underlying malignancy

59
Q

cause of peau d’orange

A
  • dimpling of skin due to cutaneous lymphatic oedema
  • tethering of swollen skin ti hair follicles and sweat glands
  • typically associated with inflammatory breast cancer
60
Q

difference between skin tethering and skin fixation

A

skin tethering: lump is attached to the skin but can be moved in an arc without moving the skin. if moved outside arc, skin indents

skin fixation: lump cannot be moved without moving the skin

61
Q

paget’s disease

A

eczematoid change in nipple associated with underlying breast malignancy

differs from eczema of nipple as mainly involve nipple and then laterally spreads to alveolar

62
Q

nipple eczema

A

nipple and or areolar associated with erythema and pruritus

63
Q

differentials of lump presentation through the ages

A

20s: benign modularity or fibroadenoma
30s: benign modularity
40s: benign modularity or increasing risk of cyst (or cancer)
50s: cysts, benign nodular or cancer
60s: cancer

64
Q

differentials of microcalcifications

A
  • fibroadenomas
  • cysts
  • response to trauma or surgery
  • DCIS

Year 4 (13 decks)

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