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Breast cancer Flashcards

1
Q

What should you note on initial presentation for breast mass/issues?

A

Age: <1% occur <30y, vast majority >50y

  • duration
  • change in size & time course
  • relationship to menstruation
  • tender?
  • mobile/fixed?
  • discharge? unilateral/bilateral? spontaneous/induced?
  • skin changes at nipple?
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2
Q

What are the three categories of benign breast lesions?

A
  • nonproliferative
  • proliferative without atypia
  • atypical hyperplasia
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3
Q

What is the DDx for benign breast masses?

A

Benign:

  • fibrocystic changes
  • fibroepithelial lesions (eg fibroadenoma)
  • fat necrosis
  • papilloma
  • galactocele
  • duct ectasia
  • ductal/lobular hyperplasia
  • sclerosing adenosis
  • lipoma
  • Neurofibroma
  • granulomatous mastitis
  • abscess
  • silicone implant
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4
Q

What is the DDx for malignant breast masses?

A

BrCA (likely invasive)
Malignant phyllodes
Angiosarcoma

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5
Q

What BrCA rarely forms a breast mass?

A

DCIS

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6
Q

What is the typical age of presentation with nonproliferative breast lesions?

A

30y to menopause (and after if on HRT)

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7
Q

What are the clinical features of benign nonproliferative breast lesions?

A
  • breast pain
  • focal nodularity or cysts; often upper outer quadrant, freq bilateral
  • mobile
  • varies with menstrual cycle
  • nipple discharge (straw-coloured, brown, or green)
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8
Q

What is the treatment of benign nonproliferative breast lesions?

A
  • evaluation of mass (U/S, mammography as indicated) and reassurance
  • analgesia (ibuprofen, ASA)
  • for severe Sx: OCP, danazol, bromocriptine
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9
Q

Name the types of benign nonproliferative breast lesions

A 
Most common: breast cysts
Other: 
- papillary apocrine changes
- epithelial-related calcifications
- mild hyperplasia "of the usual type"
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10
Q

How does having a benign nonproliferative breast lesion affect BrCA risk?

A

No change

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11
Q

What is the pathophys of benign nonproliferative breast lesion generally?

A

fibrous and cystic changes

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12
Q

Name the types of benign, proliferative without atypia, breast lesions

A

Fibroadenoma
Intraductal papilloma
Usual ductal hyperplasia
Sclerosing adenosis

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13
Q

What is the most common breast tumour in women < 30y?

A

Fibroadenoma

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14
Q

What is fibroadenoma? What are the clinical features? How is it diagnosed?

A

Benign breast tumour.
Presents with nodules:
firm, rubbery, discrete, well-circumscribed, non-tender, mobile, hormone-dependent

May do core or excisional biopsy if concerned re malignancy: U/S or FNA insufficient to differentiate

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15
Q

How is fibroadenoma treated, and how does it affect risk of BrCA?

A

Generally, conservative serial observation (US q6mo for 2y is typical)
Consider excision if
- 2-3cm and growing
- symptomatic
- formed after 35yo
- features on core biopsy suggest phyllodes tumour

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16
Q

What is one difference between cysts and fibroadenomas that you may elicit on history or Ix?

A

Cysts vary with menstrual cycle, fibroadenomas do not

FNA will not yield fluid in fibroadenoma, will in cysts

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17
Q

What is intraductal papilloma? What are the clinical features?

A

Solitary intraductal benign polyp

Can present as nipple discharge, breast mass, nodule on U/S

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18
Q

What is the most common cause of spontaneous, unilateral, bloody nipple discharge?

A

Intraductal papilloma

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19
Q

How is intraductal papilloma treated, and how does it affect risk of BrCA?

A

Involved duct is surgically excised (to ensure no atypia)

Can harbour areas of atypia or DCIS

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20
Q

What is usual ductal hyperplasia? What are the clinical features?

A

Increased cells within ductal space

Incidental finding, found on biopsy of mass or area of abn mammogram

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21
Q

How is usual ductal hyperplasia treated, and how does it affect risk of BrCA?

A

No treatment required

Generally low risk, slightly increased if moderate or florid hyperplasia

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22
Q

What is sclerosing adenosis? What are the clinical features?

A

Lobular lesions, with increased fibrous tissue and glandular cells

Presents as Mass or mammographic abnormality

23
Q

How is sclerosing adenosis treated, and how does it affect risk of BrCA?

A

No treatment required

Low risk for BrCA

24
Q

What are the levels of axillary lymph node involvement, and what do they imply?

A

Level I: lateral to pectoralis minor
Level II: deep to pectoralis minor
Level III: medial to pectoralis minor

Higher level of nodal involvement = worse prognosis

25
What is atypical hyperplasia? How does it present? How is it diagnosed?
... what it sounds like. Ductal or lobular. Cells lose apical-basal orientation. Presents as breast lump. Dx is by core or excisional biopsy
26
How is atypical hyperplasia treated, and how does it affect risk of BrCA?
Tx is complete resection, risk factor modification(eg exogenous hormones), and close follow-up Increased risk of BrCA.
27
Name 3 other benign breast lesions
- fat necrosis - mammary duct ectasia (obstruction of subareolar duct) - abscess (lactational, non-lactational)
28
How does fat necrosis present, and how is it treated?
Uncommon. Result of trauma (may be minor, positive history in only 50%), after breast surgery (i.e. reduction) Firm, ill-defined mass with skin or nipple retraction, ±tenderness Regress spontaneously, but complete imaging ± biopsy to rule out carcinoma
29
What are the two greatest risk factors for BrCA?
Gender and age
30
What are phyllodes tumours?
Rare fibroepithelial breast tumours Benign or malignant Mostly affect women 35-55
31
What should you ask about on history for ?BrCA, so assess risk factors?
- menarche, menopause ages - children, age at birth of 1st child - previous masses and whether biopsied (& results) - prev Dx of benign or malignant breast condition - prev Br Surgery - Hx of non-Br CA - Medications (particularly hormonal contraception, HRT) - FHx BrCA mother/aunts/daughters - FHx other CA -- esp ovarian, prostate, colon - consitutional Sx - metastatic Sx: cough, uro Sx, bony pain
32
What should you assess for on exam for ?BrCA?
- symmetry - skin changes - nipple retraction - excoriation Inspect sitting with hands on hips, and raised above head, also supine Sitting: palpate axillae Supine: systematic palpation - expressible discharge? - masses? - location, consistency - well-defined & smooth, or poorly defined & irregular - tender/not
33
What are the main categories of malignant masses?
- ductal (invasive or in situ) - lobular (invasive or in situ) - inflammatory
34
What are the investigations for BrCA?
Imaging - Mammogram (screening or focused) - U/S Biopsy -
35
What are the guidelines for screening mammography?
Screen women q2y starting age 50 | 40 in US -- and do yearly, due to more rapid growth in 40s
36
When should a focused mammogram be done? What else may be done?
Abn clinically or on screening mammogram May also do guided biopsy
37
What imaging is done in younger women with breast concerns?
U/S -- breast tissue denser Can determine if solid or cystic, guide biopsy
38
What features on FNA Dx simple cyst?
Aspiration of non-bloody fluid from a mass
39
What should be done if FNA returns bloody fluid?
Incisional biopsy
40
What is LCIS? How is it Dx, and what are the implications for BrCA?
Lobular carcinoma in situ Neoplastic cells contained within lobule Usually incidental finding on biopsy for another indication: no palpable mass, no mammography findings But, increases risk for BrCA
41
How is LCIS managed?
- excision (if Dx on core biopsy; if excisional, already excised) - surveillance - consider chemoprevention (eg tamoxifen for 5y)
42
What is DCIS? How is it Dx, and what are the implications for BrCA?
Ductal carcinoma in situ • proliferation of malignant ductal epithelial cells completely contained within breast ducts, often multifocal • 80% non-palpable, detected by screening mammogram • risk of invasive ductal carcinoma in same breast up to 35% in 10yr
43
How is DCIS managed?
- lumpectomy with wide excision margins + radiation (5-10% risk of invasive cancer) - mastectomy if large area of disease, high grade, or multifocal (risk of invasive cancer reduced to 1%) - possibly tamoxifen as an adjuvant treatment - 99% 5 yr survival
44
What Ix should be done for staging, once someone is Dx with invasive BrCA?
- CXR (?not CT) - Mammography - CT abdo - Neuro Sx: CT brain - Bone pain: bone scan
45
How is staging done of BrCA?
TNM (see a table) ``` Otherwise, I-IV: IV: distant mets III: - >5cm, or involving adjacent structures - fixation or matting of axillary lymph nodes, or involvement of nodes in internal mammary chain or supraclavicular fossae ``` Roughly 85% are stage I or II
46
How are stage I and II BrCA treated?
Modified radical mastectomy Lumpectomy (to negative margins) + radiation Both have comparable 5y survival
47
What are the contraindications to lumpectomy + radiation?
- large or multiple tumours - diffuse microcalcifications - prior radiation therapy to breast or chest wall - pregnancy (though could be done if preg near term, with radiation after delivery) relative: collagen/vascular disease, eg scleroderma
48
What is a sentinel lymph node biopsy work?
Biopsy first lymph node, see if there, if present then dissect all lymph nodes If not there, no need to dissect
49
When is chemo offered for BrCA?
Node-positive | Node-negative with high-risk primary
50
What is important to know about breast tumour biology?
If tumour has certain receptor(s), can use adjuvant therapy: - estrogen or progesterone receptor positive (ER, PR): can offer estrogen receptor modifiers, or aromatase inhibitors - HER2/neu: growth factor receptor. Can be treated with transtuzimab (receptin)
51
What is inflammatory BrCA?
Most aggressive form of BrCA ductal carcinoma that grows in nests (vs solid tumour); invades and blocks dermal lymphatics Presents as erythema, edema, warm, swollen, tender breast, ± lump, nipple changes peau d'orange indicates advanced disease
52
How is inflammatory BrCA Dx? Tx?
Dx: biopsy of affected skin If +, referral for urgent treatment Mastectomy + axillary lymph node dissection + radiotherapy + adjuvant therapy
53
What should you do if presumed mastitis does not resolve with Abx?
Assess for inflammatory BrCA! | could alternately be abscess

Surgery (11 decks)

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