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Reproductive System > Breast Cancer + Benign Pathologies - Treatment, Investigation (Cytology & Biopsy) > Flashcards

Breast Cancer + Benign Pathologies - Treatment, Investigation (Cytology & Biopsy) Flashcards

1
Q

risk factors for breast cancer (9)

A
  1. increasing age (MAIN)
  2. previous breast cancer
  3. genetics: BRCA 1/2 (5%)
  4. HRT use > 10 yrs
  5. early menarche and late menopause
  6. late pregnancy
  7. alcohol > 14 units per week
  8. high weight (more adipose = more estrogen storage)
  9. post RT for hodgkin’s lymphoma
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2
Q

presentation of breast cancer (5)

A
  1. lump (MAIN) - usually painless
  2. mastalgia - persistent unilateral pain
  3. nipple changes/discharge
  4. change in breast size, shape, contour
  5. DVT, lymphedema
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3
Q

what is peau d’orange and what is it a sign of?

A

redness of pitting of the skin over the breast - like orange
sign of inflammatory breast cancer, the worst kind

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4
Q

3 stages of diagnosing breast cancer

A
  1. history and examination
  2. radiological: mammogram, USS, MRI
  3. cytopathological: a. FNA, b. core biopsy
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5
Q

what is the main difference between FNA and core biopsy?

A
  1. FNA - cell sample, cytology

2. core biopsy - tissue sample, histopathology (ER/PR, HER2 receptor status)

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6
Q

when is MRI used in breast imaging?

A
  • risk of lobular cancer
  • dense breast (younger)
  • benign disease
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7
Q

which breast imaging is the most sensitive in older women?

A

mammogram

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8
Q

what is the difference between invasive and in situ disease and what investigation is needed to find out?

A

core biopsy needed

  • in situ: within the basement membrane
  • invasive: breached basement membrane
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9
Q

what are some of the further investigations you will do after core biopsy? (3)

A
  • ER positivity
  • PR positivity
  • HER2 receptor status –> gives prognostic indication
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10
Q

neo-adjuvant vs adjuvant

A

neo-adjuvant: before surgery

adjuvant: after surgery

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11
Q

what are some of the adverse prognostic factors (that worsens prognosis and increases the chance of recurrence) (6)

A
  1. node involvement +
  2. tumor grade 3
  3. tumor type
  4. ER/PR -
  5. HER 2 +
  6. lymphovascular invasion
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12
Q

what prognostic factors are included int he nottingham prognostic index (NPI)? (3)

A
  1. node involvement
  2. tumor grade
  3. tumor type
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13
Q

what are the different types of breast cancer? divide it into invasive and non-invasive cancer, which is the most common?

A
  1. invasive - most common type:
    • ductal carcinoma (75-80%)
    • lobular carcinoma (10%)
    • others (10%)
  2. non invasive:
    • ductal carcinoma in situ
    • lobular carcinoma in situ
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14
Q

what are the different methods of staging breast cancer?

A
  1. bloods: FBC, U&Es, LFTs (check liver spread), Ca2+/PCO2 (check bone spread)
  2. imaging: mammogram, USS, MRI
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15
Q

are tumor markers useful in breast cancer?

A

no, there is no tumor marker in breast cancer

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16
Q

what are the common locations of local and distant mets (for distant list them in order)

A

local - chest wall, nipples, skin, underlying muscle

distant:
1. bone
2. lung
3. liver
4. brain (esp HER2+)
5. bone marrow

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17
Q

what are some of the treatments for breast cancer?

A
  1. surgery:
    • breast conservative surgery
    • mastectomy
    • axilla surgery
  2. RT
  3. chemo
  4. hormone therapy
  5. targeted therapy (HER2) - trastuzumab/herceptin, pertuzumab
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18
Q

what should you do after a routine or pre-operative USS axilla? (what happens when it is or isn’t normal)

A
  1. normal –> sentinel node biopsy

2. abnormal –> FNA

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19
Q

what should you do if an FNA result of axilla is negative or positive?

A
  1. negative –> sentinel node biopsy

2. positive –> axillary clearance or RT

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20
Q

what are the 2 dyes use in the duo technique for sentinel node biopsy?

A
  1. tachnetium 99

2. evans blue

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21
Q

what are some of the complications of axillary clearance? (5)

A
  • lymphedema (10-17%)
  • nerve damage and altered sensations
  • reduced shoulder joint ROM
  • vascular damage
  • radiation induced sarcoma
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22
Q

when are patients given RT and what are the exceptions?

A

ALL patients after wide local excision need RT unless:

  • > 60 yrs
  • T1, N0
  • low Ki67 < 25 (stained tumor cells in the total number of malignant cels)
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23
Q

what is the recommended regimen for RT?

A

3 weeks

- boosts effective in preventing local recurrence in young ppl

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24
Q

what are some of the complications of RT?

A
  • skin telangiectasia
  • radiation pneumonitis
  • cutaneous radionecrosis, osteonecrosis
  • angiosarcoma
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25
Q

what type of breast cancer patient is chemo most effective in? What is oncotype testing and how is this related to chemo?

A

< 50 yrs and have the adverse prognostic factors
oncotype testing done for those who are ER+/HER2- and have no nodal involvement to see whether chemo would still be effective for them despite not having the adverse prognostic factors

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26
Q

what are the 3 types of hormone and therapy used (drug names) - tell their mechanism of action, dosage, differences in benefits and side effects

A
  1. tamoxifen
    • 20 mg once daily for 5-10 yrs
    • blocks ER receptor directly
    • effective in all age groups
    • effective after chemo
    • side effects: thromboembolism, avoid in PE/DVT
  2. AI (letrozole, arimidex) - inhibits ER synthesis
    • 2.5 and 1 mg respectively, once daily for 5 yrs
    • inhibits ER synthesis
    • used in postmenopausal women
    • improves disease survival if switching drugs
    • side effects: osteoporosis
  3. zoladex - blocks FSH/LH
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27
Q

what receptor does hormone therapy target?

A

ER, FSH and LH (hormones), enzymes used in the synthesis of ER

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28
Q

what are the 2nd and 3rd generation drugs in chemo?

A

3rd gen: docetaxel - MOST potent

2nd gen: doxorubicin, epirubicin

29
Q

what is the most effective treatment for HER2+ breast cancer?

A

trastuzumab (herceptin), pertuzumab

30
Q

what is the follow up like after diagnosis of breast cancer?

A

0-5 yrs after diag: annual clinical examination check

5-10 yrs after diag: annual mammo

31
Q

what is included in the triple assessment in symptomatic clinic for breast cancer?

A
  1. surgeon (examination)
  2. radiologist (scans)
  3. cytopathologists (FNA/biopsy)
32
Q

what is the difference in cell arrangement between lobular and tubular carcinoma?

A
  1. lobular carcinoma - cytoplasmic vacuole arrangement

2. tubular carcinoma - cells arranged in tubes

33
Q

what are some of the findings of benign vs malignancy cytology? (4 points)

A
  1. cellularity
    • B: low/moderate cellularity
    • M: high cellularity
  2. cell groups
    • B: cohesive group of cells, flat sheet, uniform in size
    • M: crowding/overlapping of cells, loss of cohesion
  3. appearance of nucleus
    • B: oval (bare) nuclei
    • M: nuclear pleomorphism, loss of bipolar nuclei
  4. chromosome pattern
    • B: uniform
    • M: hyperchromasia
34
Q

can aspiration cure cysts?

A

yes, aspiration is curative for cysts, unless there is blood or residual mass in the aspirated fluid.

35
Q

what would cytology find in ductus ectasia?

A

macrophages only

36
Q

what will nipple scrape find in Paget’s disease?

A

squamous cells + malignant cells

37
Q

what are some of the things that can be confirmed with core biopsy but not with FNA?

A
  • grading

- confirm invasion (staging)

38
Q

list some of the benign conditions of the breast - which of these is the most common? (6)

A
  1. fibrocystic change
  2. fibroadenoma (MOST COMMON)
  3. intraductal papilloma
  4. fat necrosis
  5. phyllodes tunmor
  6. dut ectasia
39
Q

fibrocystic change presentation

A
  • can be typical or atypical
  • painful lump area
  • fluctuate with menstrual cycle
40
Q

what are the different types of fibrocystic change? (5)

A
  1. fibrosis
  2. adenosis: increased gland formation
  3. cysts: dilated ducts
  4. apocrine metaplasia: special epithelium with pink cytoplast and brown nuclei
  5. ductal epithelial hyperplasia
41
Q

presentation of firboadenoma (4) - what is the peak age of onset?

A

most common in adolescents or young adult - peak age 3rd decade

  • painless
  • freely mobile
  • well circumscribed
  • may naturally regress with age even if left untreated
42
Q

what are the 2 different types of fibroadenoma and how are they different?

A
  1. intracanalicular growth pattern: elongated ducts into slits due to surrounding fibrous tissue
  2. pericanalicular growth pattern: ducts not compresed by fibrous tissue
43
Q

presentation of intraductal papilloma - what is the age for this?

A
  • middle aged women
  • lactiferous duct and nipple discharge
  • papillary structure
  • can show typical or atypical hyperplasia –> malignancy
44
Q

what is the most common cause of fat necrosis? (expected to see this in their history) - explain the process of how this leads to fat necrosis

A

trauma - RT, surgery

trauma –> dead breast tissue –> healing and calcification of fibrous tissue –> mass

45
Q

presentation of fat necrosis

A
  • mimics radiological and clinical symptoms of carcinoma
  • lipid filled cysts
  • histiocytes with foamy cytoplasm
  • fibrosis and calcifications –> characteristic egg shell appearance on mammo
46
Q

phyllodes tumor - what are its 2 components?

A
  1. fibrous

2. epithelial

47
Q

presentation of phyllodes tumor

A
  • fleshy tumor with leaf like pattern and cysts on cut surface
  • hard to differentiate from fibroadenoma
  • 1-15 cm well-circumscribed lesion
  • can be benign, borderline, malignant (mets are hematogenous)
48
Q

duct ectasia presentation

A
  • nipple discharge

- macrophages on cytology

49
Q

what is the best prognostic indicator of breast cancer?

A

node status

50
Q

what is the overall prognosis for breast cancer?

A

64% 5 yr survival

51
Q

what is Ki67, and is a low Ki67 good?

A

Ki67 is a marker of proliferative activity and influences prognosis (low Ki67 = good)

52
Q

what is the difference between histological and molecular classification of breast cancer?

A

histological: invasive/in situ, ductal/lobular
molecular: tumors with the same grade can behave differently, respond to different treatment, and have different prognosis depending on their molecular subtypes (IHC)

53
Q

why does triple negative cancer have worse prognosis/

A

doens’t respond to receptor-targeted treatments –> high rates of recurrence and worse prognosis

54
Q

which one has a worse prognosis between recurrence and new primary cancer?

A

recurrence - because it means that it did not respond well to the treatment the first time

55
Q

histological presentation of DCIS

A
  • cribriform architecture
  • comedo necrosis, calcification
  • grade based on nuclear morphology
56
Q

histological presentation of LCIS

A
  • multicentric, may be bilateral
  • lobules affected and distended, ducts not affected and becomes squished
  • characteristic intracytoplasmis spaces due to negative staining (DCIS would be +)
57
Q

what are the chances of DCIS and LCIS becoming invasive? which one has a higher risk?

A
  • DCIS: high risk
    • 30% chance in 15 yrs if low grade
    • 50% chance in 8 yrs if high grade
  • LCIS:
    • 19% chance in 25 yrs (but can be bilateral and not on the same side)
58
Q

how come LCIS cannot be excised?

A

because it is multicentric and can be bilateral

59
Q

how many percent of special type cells will nee to be present for the tumor to be considered no special type (ductal carcinoma), special type (lobular), or mixed?

A
  1. no special type: < 50% special type cells
  2. mixed: > 90%
  3. special type: 50-90%
60
Q

list the different prognostic indicators for breast cancer (10) - which of this is the MAIN one?

hint: start with NPI

A
  • node status (MAIN)
  • tumor size (< 2cm good prognosis)
  • tumor grade
  • tumor type (ductal worse prognosis - NST)
  • age
  • lymphovascular space invasion lowers prognosis
  • ER/PR, HER2 negative
  • proliferative rate
  • gene expression profiling (oncotyping) - determines whether it is suitable for chemo
61
Q

what are the 4 molecular subtypes of breast cancer and describe the IHC findings of each

A
  1. luminal A
    • ER+
    • HER2 -
    • low Ki67
  2. luminal B
    • ER+
    • HER+/HER2- with high Ki67
  3. basal/triple negative - worst prognosis
    • ER/PR, HER2 -
  4. HER2: aggressive, but responds well to treatment
    • ER/PR -
    • HER2 +
62
Q

what is the rate of recurrence and new primary cancer after the initial diagnosis? which of this is worse and why?

A

there is 10% recurrence within 10 yrs of diagnosis

  1. < 10 yrs after diag: true recurrences
  2. 10 yrs after diag: 50-50
  3. > 10 yrs after diag: new primary
63
Q

define paget’s disease and list out its presentations (5)

A

intraepithelial spread of intraductal carcinoma, underlying DCIS or invasive disease

  • large pale staining cells infiltrating in the epidermis of nipple
  • limited to the nipple/extends to alveolar
  • ulceration, crusting, redness, pain, scaling, itching - presents like eczema
  • serous or bloody discharge
  • peau d’orang
64
Q

what is the most common male breast pathology? name percentage

A

gynecomastia (10-30% men)

65
Q

gynecomastia presentation

A
  • increased subareolar tissue (firm disc)
  • can be bilateral
  • not malignant
66
Q

what is the most common molecular subtype of breast carcinoma in men?

A

male carcinoma < 1% breast cancer, usually luminal subtype invasive with ER positivity

67
Q

what are some things that can cause gynecomastia outside of breast pathology?

A
  • hyperthyroid
  • hypogonadism
  • estrogen and androgen hormone use
  • liver cirrhosis
  • chornic kidney failure
  • COPD
68
Q

what type of breast cancer is paget’s disease associated with and how does it spread to the dermis?

A

associated with underlying ductal or invasive carcinoma which involves the dermis by spreading along the lactiferous duct

Reproductive System (7 decks)

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