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Surgery > Breast cancer > Flashcards

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
Q

What is atypical hyperplasia? How does it present? How is it diagnosed?

A

… what it sounds like. Ductal or lobular. Cells lose apical-basal orientation.

Presents as breast lump.
Dx is by core or excisional biopsy

26
Q

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

A

Tx is complete resection, risk factor modification(eg exogenous hormones), and close follow-up

Increased risk of BrCA.

27
Q

Name 3 other benign breast lesions

A
  • fat necrosis
  • mammary duct ectasia (obstruction of subareolar duct)
  • abscess (lactational, non-lactational)
28
Q

How does fat necrosis present, and how is it treated?

A

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
Q

What are the two greatest risk factors for BrCA?

A

Gender and age

30
Q

What are phyllodes tumours?

A

Rare fibroepithelial breast tumours
Benign or malignant
Mostly affect women 35-55

31
Q

What should you ask about on history for ?BrCA, so assess risk factors?

A
  • 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
Q

What should you assess for on exam for ?BrCA?

A
  • 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
Q

What are the main categories of malignant masses?

A
  • ductal (invasive or in situ)
  • lobular (invasive or in situ)
  • inflammatory
34
Q

What are the investigations for BrCA?

A

Imaging

  • Mammogram (screening or focused)
  • U/S
35
Q

What are the guidelines for screening mammography?

A

Screen women q2y starting age 50

40 in US – and do yearly, due to more rapid growth in 40s

36
Q

When should a focused mammogram be done? What else may be done?

A

Abn clinically or on screening mammogram

May also do guided biopsy

37
Q

What imaging is done in younger women with breast concerns?

A

U/S – breast tissue denser

Can determine if solid or cystic, guide biopsy

38
Q

What features on FNA Dx simple cyst?

A

Aspiration of non-bloody fluid from a mass

39
Q

What should be done if FNA returns bloody fluid?

A

Incisional biopsy

40
Q

What is LCIS? How is it Dx, and what are the implications for BrCA?

A

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
Q

How is LCIS managed?

A
  • excision (if Dx on core biopsy; if excisional, already excised)
  • surveillance
  • consider chemoprevention (eg tamoxifen for 5y)
42
Q

What is DCIS? How is it Dx, and what are the implications for BrCA?

A

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
Q

How is DCIS managed?

A
  • 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
Q

What Ix should be done for staging, once someone is Dx with invasive BrCA?

A
  • CXR (?not CT)
  • Mammography
  • CT abdo
  • Neuro Sx: CT brain
  • Bone pain: bone scan
45
Q

How is staging done of BrCA?

A

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
Q

How are stage I and II BrCA treated?

A

Modified radical mastectomy
Lumpectomy (to negative margins) + radiation
Both have comparable 5y survival

47
Q

What are the contraindications to lumpectomy + radiation?

A
  • 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
Q

What is a sentinel lymph node biopsy work?

A

Biopsy first lymph node, see if there, if present then dissect all lymph nodes
If not there, no need to dissect

49
Q

When is chemo offered for BrCA?

A

Node-positive

Node-negative with high-risk primary

50
Q

What is important to know about breast tumour biology?

A

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
Q

What is inflammatory BrCA?

A

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
Q

How is inflammatory BrCA Dx? Tx?

A

Dx: biopsy of affected skin
If +, referral for urgent treatment

Mastectomy + axillary lymph node dissection + radiotherapy
+ adjuvant therapy

53
Q

What should you do if presumed mastitis does not resolve with Abx?

A

Assess for inflammatory BrCA!

could alternately be abscess

Surgery (11 decks)

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