Breast cancer Flashcards
Name some DDx for a breast lump presentation?
Benign
- fibroadenoma (oestrogen increases size/tenderness)
- fibrocystic change (cyst, fibrosis, ductal hyperplasia) (premenstrual, pain)
- sclerosing adenosis
- intraductal papilloma (nipple discharge serous fluid)
- epithelial hyperplasia
- phyllodes tumour (cysts)
- fat necrosis
- lactational mastitis
- gynaecomastia
Malignant
- Non-invasive: DCIS, Paget’s disease
Invasive: IDC (firm, sharp), invasive lobular ca (multiple, bilat), medullary ca, inflammatory breast ca
Other
- Infective: abscess
- Lymphadenopathy: axillary
- Subcut: cysts, skin infection, insect bite
Differentiate between breast imaging modalities.
- Breast US: younger women <35 yo (more glandular tissue), fails to detect microcalcification
- Mammogram: older women >35yo (less glandular tissue, more fat lobules), sensitivity and specificity increases with age
How is breast ca diagnosed?
Dx requires triple assessment:
1) Clinical examination
2) Imaging: US <35yo (more glandular tissue), mammogram >35yo (less glands, more fat lobules)
3) Tissue sampling: cytology or histology
What types of breast tissue biopsy are available?
- Fine needle aspiration (FNA)- small needle inserted into tumour, aspirated material examined for malignant cells (cytology)
- Core biopsy- large bore needle (14G) used to obtain tissue sample (histology and cytology)
- Excisional biopsy- mass removed via surgical excision
- Sentinel node biopsy- dye injected near tumour and uptake in nearby LN observed -> examines first LNs that would drain tumour
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What are the pros and cons of FNA?
Fine needle aspiration (FNA): small needle inserved into tumour, aspirated material examined for malignant cells (cytology)
- Pros: simple, minimally invasive, high sensitivity (98%), high specificity (97%), fast result (hours)
- Cons: user dependent, sampling error risk, no examination of tissue architecture (therefor only cytology, NOT histopathology too)
What are the pros and cons of core biopsies?
Core biopsy: large bore needle (14G) used to obtain tissue sample (histology and cytology)
- Pros: preserved architecture (can differentiate in situ from invasive), high sensitivity (98%), simple, minimally invasive, receptor status info possible
- Cons: more invasive than FNA, time consuming, user dependent, seeding risk
What are the pros and cons of excisional biopsy?
Excisional biopsy: mass removed via surgical excision
- Pros: entire mass removed (reducing time available to spread if malignant), pt peace of mind, tissue architecture, receptor status possible, good sensitivity and specificity
- Cons: very invasive, more time consuming
Describe the lymphatic drainage of the breast?
1) Ipsilateral axillary LNs (75%)- approx 35-50 contained in axilla fibrofatty tissue
i. Anterior (pectoral): lie along lateral thoracic a. -> drain lateral breast quadrants and upper half of anterior trunk
ii. Posterior (subscapular): lie along subscapular a. -> drain breast axillary tail and upper half of posterior trunk
iii. Lateral group: lie along axillary vein -> drain upper limb
iv. Central group: lie in axilla fat -> drain the above groups
v. Apical LNs: lie in clavipectoral fascia -> drain above groups and infraclavicular LN groups
L side: apical LNs -> subclavian trunk -> thoracic duct
R side: apical LNs -> subclavian trunk -> R lymphatic duct -> thoracic duct
2) Parasternal LNs (25%): run along internal thoracic a. -> drain medial areas
Describe the surgical classification of LNs.
Surgical LN classification: position relative to pectoralis minor
• Level 1: nodes inferior to inferolateral border of pec minor (lateral, anterior and posterior nodes)
• Level 2: nodes beneath pec minor (central, some apical)
• Level 3: nodes superior to superior pec minor border (remaining apical, some supraclavicular)
How is the concept of a “sentinel node” useful in the management of breast neoplasm?
Biopsy uses:
- Allows identification of any tumour cells -> staging tumour
- Avoids unnecessary axillary LN dissection (morbidity) -> lymphedema (disruption of normal lymph drainage causing swelling and pain)
Biopsy method:
- Radioactive marker or blue dye injected near tumour
- Sentinel LN identified as one which takes up marker
- LN then removed and analysed (macro and micro) -> histo, staging
- If carcinoma found, additional nodes may be dissected
Name some risk factors for breast cancer?
Modifiable:
- HRT (exogenous exposure to oestrogen)
- Nulliparity, or first pregnancy >30yo, or no breast feeding
- Obesity (hyper-oestrogenic state, due to increase aromatase activity)
- Smoking
- Liver disease- ETOH (state of hyper-oestrogenism)
Non-modifiable:
- Age
- Gender (F x100 risk)
- FMHx- first degree relative
- Genetics- BRACA1 and BRACA 2 (causes 5-10% breast ca), p53
- Early menarche, late menopause (long exposure to oestrogen)
- Proliferative fibrocystic change
- Past diagnosis DCIS
- Radiation
- Viruses (HPV, EBV)
