Breast Cancer Flashcards
What is a bereavement?
A period after a loss
What is mourning?
A period after a berievement
What is grief?
The emotional reaction we go through during bereavement and mourning.
What are the five stages of grief?
Shock and denial
Anger - at themselves and at healthcare system
Bargaining
Depression - can last a year, give hope and can make it better
Acceptance
What three categories can breast lumps be divided into histologically?
Non-proliferative disorders - no increased risk
Proliferative disorders without atypia - mild to moderate risk
Atypical hyperplasias - substantial increase in risk
When do breasts grow?
Puberty - Breast enlargement, sometimes initially unilateral, is the fist obvious sign of puberty in girls. Breast buds may initially be unilateral.
Puberty breast development = thelarche
What is the most common benign breast disease?
Fibrocystic change.
This usually affects women aged 20-50 and appears tone hormonal in aetiology. Most often presents with pain and modularity.
When is breast disease rarely pathological?
If changes are bilaterally symmetrical.
If symptoms are greatest about 1 week before menstruation and decrease when it starts.
Examination may reveal an area of thickening or nodularity, poorly differentiated from the surrounding tissue and often in the upper outer quadrant of the breast.
What is cyclical mastalgia?
Tenderness and nodularity in the premenstrual phase that resolves as menstruation starts.
Breasts are active organs that change throughout the menstrual cycle. It affects 2/3 of menstruating women.
What are most palpable benign breast lumps?
FIroadeomas
Cysts
A benign mass is usually three-dimensional, mobile and smooth. It has regular borders and is solid or cystic in consistency.
In whom are cysts most common?
Most common between 35-50.
They are palpable as discrete lumps and may be recurrent.
They cannot be reliably be distinguished from solid tumours on examination.
What are fibroadenomas and in who are they most common?
Benign tumours that are common in young women, with incidence peaking at 20-24
They are the most common type of breast lesions.
Fibroadenomas arise in breast lobules and are composed of fibrous and epithelial tissue. They present as firm, non-tender, highly mobile, palpable lumps. Hormones seem to be involved in aetiology and HRT increases incidence.
What is mammary duct ectasia?
Unknown aetiology
Dilation of major ducts, filled with creamy secretion with periductal inflammation.
May be asymptomatic or -nipple discharge (bloody, serous, creamy white or yellow
- retracted nipple
- acute inflammation
- recurrent chronic inflammation with abscess formation
Treatment: Surgical excisions the major duct. Correction of nipple retraction.
What infections could occur in breasts?
Mastitis
Generalised cellulitis of the breasts
Treated with antibiotics
Can be a medical emergency
Breast abscess
Present with point tenderness, erythema and fever
Generally related to lactation
Non-lactational abscess more frequent in smokers
Caused by staph or strep
When do you refer?
Refer via two week wait to a breast clinic if:
Aged > 30 and unexplained breast lump with or without pain
Aged > 50 with any symptoms in one nipple only: Dischage, retraction, other changes of concern.
Consider a referral if:
skin changes that suggest breast cancer,
>30with unexplained axilla lump
Non-urgent referral if:
<30 and unexplained breast lump with or without pain.
What physiological changes are seen in breast tissue?
Prepubertal breasts - few lobules
Menarche - increase in number of lobules and increased volume of interlobular stroma
Menstrual cycle - follicular phase lobules quiescent, after ovulation cell proliferation and storms oedema, with menstruation see decrease in lobules
Pregnancy - increase in size and number of lobules, decrease in stroma, secretory changes.
Cessation of lactation - atrophy of lobules but not to former level
Increasing age terminal duct lobular units decrease in number and size, interlobular stroma replaced by adipose tissue
How can breast conditions present?
Pain Palpable masses Nipple discharge Skin lumps Lumpiness Mammographic abnormalities
What breast conditions cause palpable mass?
Normal nodularity
Invasive carcinoma
Fibroadenomas
Cysts
Most worrying if hard, craggy and fixed
What breast conditions can cause nipple discharge?
Milky - endocrine disorders. e.g. pituitary adenoma; side effects of medication e.g. OCP
Bloody or serous - benign lesions e.g. papilloma, duct ectasia; occasionally malignant lesions
Most concerning if spontaneous and unilateral
What breast conditions cause mammography abnormalities?
Worrying findings include densities ad calcifications.
Densities - invasive carcinomas, fibroadenomas, cysts
Calcification - ductal carcinoma in situ. e.g benign changes
What is fat necrosis?
Presents as a mass, skin changes or mammographic abnormality.
Often history of trauma or surgery
Can mimic carcinoma clinically ad mammographically.
What physiological changes are seen in breast tissue?
Prepubertal breasts - few lobules
Menarche - increase number of lobules, increased volume of interlobular stroma
Menstrual cycle - follicular phase lobules, quiescent, after ovulation cell proliferation and stromal oedema, with menstruation see decrease in size of lobules.
Pregnancy - increase in size and number of lobules, decrease in stroma, secretory changes
Cessation of lactation - atrophy of lobules but not to former levels
Increasing age - terminal duct lobular units (TDLUs) decrease incumber and size, interlobular stroma replaced by adipose tissue
How can breast conditions present?
Pain Palpable mass Nipple discharge Skin changes Lumpiness Mommographic abnormalities
Which breast conditions cause pain?
If cyclical and diffuse, often physiological
Non-cyclical and focal - ruptured cysts, injury, inflammation
Occasionally presenting complaint in breast cancer
Which breast conditions cause a palpable mass?
Normal nodularity
Invasive carcinoma
Fibroadenomas
Cysts
Most worrying if hard, craggy and fixed
Which breast conditions cause nipple discharge?
Milky - endocrine disorders e.g. pituitary adenomas; side effect of mediation e.g. OCP
Blood or serous - benign lesions, e.g. papilloma, duct ectasia; occasionally malignant lesions
Most concerning if spontaneous and unilateral
Which breast conditions cause mammography abnormalities?
Worrying findings include: densities- invasive carcinomas, fibroadenomas, cysts
Calcifications - ductal carcinoma in situ (DCIS), benign changes
Found during mammography screening
Women between 47-73 invited every 3 years
Easier to detect lesions in breasts of older women
Are breast conditions common?
Breast symptoms and signs are common
Most will be benign
Fibroadenomas are most common
Breast cancer is most common non-skin malignancy in women
Mammographic screening increases detection of small invasive tumours and in situ carcinomas.
How do we classify pathological conditions of the breast?
Disorders of development Inflammatory conditions Benign epithelial lesions Stromal tumours Gynacomastia Breast carcinoma
What inflammatory conditions can be seen?
Acute mastitis - occurs during lactation, Staph infection from cracks or fissures, erythematous painful breast, may produce abscesses, treated by expressing milk and antibiotics
Fat necrosis - a mass, skin changes or mammography abnormalities, history of trauma or surgery, mimic carcinoma clinically and mammography
What are phyllodes tumours?
Rare before 40
Present as masses or as mammography abnormalities
Benign, borderline malignant types
Can be very large and involve the entire breast
Histology:
Nodules of proliferating stroma covered by epithelium
Stroma more cellular and typical than that in fibroadenomas.
Need to be excised with wide margin or may recur
Malignant type behave aggressively, recur locally and metastasize by blood stream.
Why is gynacomastia?
Enlargement of male breast
Unilateral or bilateral
Often seen at puberty and in the elderly.
Caused by relative decrease in androgen effect or increase in oestrogen effect
Can mimic male breast cancer, especially if unilateral
No increased risk of cancer
What causes gynaecomastia?
Occurs in most neonates secondary to circulating lateral and placental oestrogen and progesterone.
Affects more than 1/2 boys in puberty as oestrogen peaks before testosterone
Klinefelter’s syndrome
Oestrogen excess - liver cirrhosis
Gonadotrophin excess - testicular tumour (e.g. Leydig and Sertoli cells)
Drug related - spironolactone, chlorpromazine, alcohol, steroids
What are the risk factors for breast cancer?
Gender Uninterrupted menses Early menarche Late menopause Reproductive history - parity and age at first full term pregnancy Breast-feeding (protective) Obesity and high fat diet (protective up to 40) Exogenous oestrogen - HRT increases risk a bit Geography - higher in US and Europe Atypical changes on previous biopsy Previous breast cancer Radiation
How do we classify breast carcinoma?
carcinomas can be in situ or invasive.
They can then be lobular or ductal.
What is in situ carcinoma?
Neoplastic population of cells limited to ducts and lobules by basement membrane (BM), myoepithelial cells are preserved.
Does not invade into vessels and therefore cannot metastasise or kill the patient.
Why is DCIS a problem?
Non-obligate pre-cursor of invasive carcinoma
Most often present as mammography calcifications (clusters or liner and branching) but can present as a mass.
Can spread through ducts and lobules and be very extensive.
Histologically often shows central necrosis with calcification
What is Paget’s disease?
Cells can extend to nipple skin without crossing BM
Unilateral, red and crusting nipple.
Eczematous or inflammatory conditions of the nipple should be regraded as suspicious and biopsy performed to exclude Paget’s disease.
How does invasive carcinoma differ from DCIS?
Neoplastic cells have invaded beyond the BM into stoma
Can invade into vessels and can therefore metastasize to lymph nodes and other sites
Usually presents as a mass or as mammography abnormalities.
By the time a cancer is palpable, more than half of the patients will have axillary lymph node metastases
P’eau d’orange - imvolvement of the lymphatic drainage of the skin
How is invasive breast carcinoma classified?
Invasive ductal cell carcinoma
Invasive lobular carcinoma
Tubular carcinoma
Mucinous carcinoma
How does breast cancer spread?
Lymph nodes via lymphatics - usually in the ipsilateral axilla
Distant metastases via blood vessels - bones, lungs, liver, brain
Invasive lobular carcinoma can spread to odd sites - peritoneum, retroperitoneum, leptomeninges, gastrointestinal tract, ovaries, uterus
What factors determine the prognosis in breast cancer?
In situ disease or invasive carcinoma
TNM stage
Tumour grade
Histological subtype
Molecular classification and gene expression profile
How do we investigate and diagnose breast cancer?
Triple approach:
Clinical - history, family history, examination
Radiographic imaging - Mammogram and USS
Pathology - Core biopsy, fine needle aspiration cytology
What is mammographic screening?
Started in late 1980s
Women ages 47-73yrs old
2 view mammogram every 3 years
Aim to detect small, impalpable and pre-invasive cancers
Look for asymmetric densities, parenchymaldeformites and calcofications
Assess abnormality using further imaging, biopsy and FNAC
What are the therapeutic approaches to breast cancer for local and regional control?
Breast surgery - mastectomy or breast conservation surgery
Axillary surgery
Post-operative radiotherapy to chest and axilla
What is sentinel lymph node biopsy?
Reduces the risk of post-operative morbidity
Intraoperative lymphatic mapping with dye and/or radioactivity of the draining or ‘sentinel’ lymph node(s) - one most likely to have metastasis
If negative, axillary dissection can be avoided
What are the therapeutic approaches to breast cancer for systemic control?
Chemotherapy -if benefits outweigh the risks
Hormonal treatment - e.g. Tamoxifen (if ER positive)
Herceptin - (if HER positive)
How do we improve survival from breast cancer?
Early detection - awareness of disease, importance of family history, self-examination, mammography screening
Neoadjuvent chemotherapy - early treatment of metastatic disease
Use of newer therapies - e.g. Herceptin
Gene expression profiles
Prevention in familial cases - genetic screening, prophylactic mastectomies
