Breast Conditions Flashcards
What is the fisherman paradigm?
That breast cancer is predominately a systemic disease at outset. It is neccessary to eradicate micro metastases with systemic therapies;
- hormonal
- chemo
- biological (herceptin)
What are the clincially relevant risk factors for breast cancer?
- female
- growing older
- gene mutations
- atypical ductal or lobular hyperplasia
- lobular carcinoma in sity
- atypical epithelial hyperplasia
What are the epidemiological risk factors for breast cancer?
- birth of first child after age of 30
- consumption of an alcoholic beverage one or more times per day
- early menarche
- FHx of breast cancer
- previous breast cancer
- nulliparity
- postmenopausal obesity
What are the most common symptoms of breast cancer?
Dimpled or depressed skin
Visible lump
Nipple chance e.g. inversion
Bloody discharge
Texture change
Colour change
_____ ________ is the most common histologic type of breast cancer, accounting for as many as __% of breast malignancies.
Ductal carcinoma is the most common histologic type of breast cancer, accounting for as many as 80% of breast malignancies.
What are the typical findings of ductal carcinoma?
Stellate solid mass or pleomorphic causing calcifications
Malignant solid mass may be circular and the calcifications may be non-casting
How is definitive diagnosis of ductal carcinoma made?
Image-guided tissue core biopsy
DCIS is most commonly _________ and perceived on screening mammography as malignant ________, usually ________ and of the ______ type
DCIS is most commonly nonpalpable and perceived on screening mammography as malignant calcifications, usually pleomorphic and of the noncasting type
How is definitive diagnosis of DCIS made?
Stereotatic vacuum assisted core biopsy
Invasive lobular carcinoma spreads diffusely with a typical histologic ____ ___ pattern
Invasive lobular carcinoma spreads diffusely with a typical histologic indian file pattern
LCIS is a risk factor for what?
Invasive carcinoma of the ductal type
What are the two variations of breast surgery?
Breast-conserving surgery (BCS)
Mastectomy
What is the preferred treatment for breast cancer?
Breast conserving surgery
What forms can BCS take?
Wide local excision with or without an oncoplastic procedure
What is an essential component of BCS?
Radiation therapy
How is irradiation used in breast conserving surgery?
total dose of whole breast irradiation of 4500–5000 centigrays is administered in fractions using opposed tangential fields
course usually administered in daily fractions (5 days per week) for 3–6 weeks.
A boost dose of irradiation to the tumor bed increases the target dosage to 6000–6500 centigrays.
What is a modified radical mastectomy?
Total mastectomy
Removes the entire breast, including the overlying skin and axillary lymph nodes
What is the modification with modified radical mastectomy?
Preservation of the pectoralis major muscle, facilitates improved wound healing and, potentially allows reconstruction
Who are candidates for breast reconstruction?
Most women who require or request mastectomy
Immediate or delayed breast reconstruction following conventional ___-____ _____ ________ (____) often results in prominent ____ on the new breast and a paddle of skin that is of a different ____ and ____.
Immediate or delayed breast reconstruction following conventional non-skin sparing mastectomy (NSSM) often results in prominent scars on the new breast and a paddle of skin that is of a different color and texture.
___-______ __________ (___) preserves most of the overlying skin during an immediate breast reconstruction (IBR) thus leading to a superior ______ outcome
Skin-sparing mastectomy (SSM) preserves most of the overlying skin during an immediate breast reconstruction (IBR) thus leading to a superior aesthetic outcome
How can breast reconstruction be achieved?
- breast prosthesis
- latissimus dorsi myocutaenous flap (usually plus a breast prosthesis)
- deep inferior epigastric perforator free flap (DIEP)
- transverse rectus abdominis myocutaenous (TRAM) flap
- superior/inferios gluteal artery perforator (S-GAP, I-GAP) free flaps
What determines choice of reconstruction method?
- body habitus
- co-morbidity
- smoking history
- size and shape of her breasts
- preference
- surgeons experience
What are the indications for post-mastectomy RT?
More than 3 nodes
+ve surgical margins
Tumours larger than 5cm
Adjuvant therapy;
_________ ____________, often called ___________, was found to be more effective than the single-drug therapies.
Adjuvant therapy;
multidrug chemotherapy, often called polychemotherapy, was found to be more effective than the single-drug therapies.
What adjuvant systemic therapies are available?
Chemotherapy
Hormonal therapy
Targeted therapy
What is the most commonly used hormonal therapy?
Tamoxifen
What is herceptin (trastuzumab,TZ)?
Recombinant humanized monoclonal antibody which targets HER-2
What is bevacizumab
Recombinant humanized monoclonal antibody against vascular endothelial growth factor
First line therapy for metastatic breast cancer
What is lapatinib?
Dual inhibitor of epidermal growth factor receptor (EGFR) and human epidermal growth factor receptor 2 (HER-2) tyrosine kinases
When is lapatinib indicated for use?
It is indicated for use in combination with capecitabine for the treatment of patients with advanced breast cancer or metastatic breast cancer (MBC) whose tumors overexpress HER-2 (ErbB2) and who have received previous treatment that included an anthracycline, a taxane, and herceptin.
What is the commonest benign neoplasm of the breast and how is it usually diagnosed?
Fibroadenoma
Diagnosed as palpable mass (1-3cm) in the early reproductive years
Confirmed with US core biopsy
How are fibroadenomas usually described by examination?
typically rubbery to firm, mobile, smooth with distinct borders, and is usually nontender
When and how are fibroadenomas removed?
Electively if womans preference
Lumpectomy or percutaenous vacuum assisted core biopsy as out-patient under local anaesthesia
How can phyllodes tumours be differentiated from fibroadenomas?
Often larger (3-6cm)
Tend to occur in older women (35-45 y/o)
Tend to increase in size
Requires histologic verficiation
How are phyllodes tumours treated?
Excised with wide (1cm), clear, surgical margins and caredully followed up
What is mastalgia?
Pain
How does mastalgia present?
- women during reproductive years
- usually cyclic but can be noncyclic
- diffuse and most intense in immediate premenstrual phase
- usually bulateral
Noncyclic mastalgia is usually ______, often ______, and ____ responsive to treatment than ____ mastalgia.
Noncyclic mastalgia is usually localized, often persistent, and less responsive to treatment than cyclic mastalgia.
What is it imperative to ascertain in mastalgia?
That pain is not of nonbreast etiology affecting the anterior chest wall
List some etiologies of anterior chest wall pain
- Achalasia
- Angina
- Cervical radiculitis
- Cholecystitis
- Cholelithiasis
- Coronary artery disease
- Costochondritis (Tietze syndrome)
- Fibromyositis
- Hiatal hernia
- Myalgia
- Neuralgia
- Osteomalacia
- Phantom pain
- Pleurisy
- Psychological pain
- Pulmonary embolus
- Pulmonary infarct
- Rib fracture
- Sickle cell disease
- Trauma
- Tuberculosis
What dp most women with cyclic mastalgia have?
An intense varient of physiologic breast changes that occur during the menstrual cycle
When can a woman with mastalgia be reassured that her symptoms are physiologic?
After complete evaluation and examination including a mammogram for a woman >35 years
What may improve mastalgia?
- well-fitting bra
- regular exercise
- evening primrose oil
- tamixofen
- topical NSAIDs
*
When do breast cysts appear?
occur during the late reproductive years of a woman’s life
Describe a cyst on examination
- typically palpable, clearly defined, soft, mobile, and smooth
- borders are distinct.
- often somewhat tender, especially before menstruation.
- may be multiple and/or bilateral
What is an effective way of diagnosing and treating a cyst?
FNA
What fluid aspirated from a cyst must be sent for cytological evaluation?
Only grossly bloody fluid
What can occur within a cyst and is associated with bloody cyst fluid?
Benign intracystic papillary proliferation calles a papilloma
When is pappiloma suspected clinically?
Cyst aspirate grossly bloody
Residual mass after aspiration
What is recommended for papilloma diagnosis?
Ultrasound-guided core biopsy of any intra-cystic solid lesion or iregular cystic wall
What is physiologic nipple discharge?
- Clear, yellow and watery in women of reproductive age
- Physiologic
What is pathologic nipple discharge?
Bloody discharge, particularly from a single duct
What is the commonest etiology of spontaenous nipple discharge?
Intraductal papilloma or papillomas- BENIGN
What is the management for intraductal lesions causing nipple discharge?
Excision and histological evaluation
What are the investigations of pathological nipple discharge?
- mammography
- Ultrasonography
- surgical excision of discharging ducts
What is paget’s disease of the nipple?
Variant of ductal carcinoma, intraductal, and/or invasive
How does paget’s disease of the nipple present?
Erythematous weeping lesion on the surface of the nipple and the areola
Usually presents as dry, scaly, eczematous lesion
How is paget’s disease diagnosed?
Histologic tissue biopsy (incisional or punch)
Often underlying palpable mass or radiological abnormality
What is the treatment for puerperal mastitis?
- course of antibiotics effective for Staphylococcus aureus;
- flucloxacillin 500 mg orally every 6 hours
or
- augmentin 625 mg every 8 hours for 7 days
- should be administered as soon as clinical signs of mastitis;
- fever, erythema, induration, tenderness, and swelling
Describe ongoing management of mastitis?
Patient should be examined every 3 days to be certain the infection is responding to therapy and that there is no abscess formation
If there is lack of response to mastitis antibiotics what should be done?
It should be changed
What is the advice regarding breastfeeding and mastitis?
Breastfeeding should be continued if already begun and/or the infected breast can be pumped until the mastitis clears
How does a breast abscess present?
a flocculent sometimes-bulging mass usually located in the central area of the mastitis
How can a breast abscess be verified?
. Focused ultrasound can verify a fluid-filled (pus) center
What is diagnostic (and therapeutic) of a breast abscess?
- Aspiration with a number 18-gauge needle using local anesthesia is diagnostic and can be therapeutic if all the pus is aspirated.
- The aspirate is sent for microbiological analysis
When might the aspiration of a breast cyst have to be repeated?
every 3 days, particularly if there is more than 10 milliliters of pus initially aspirated
If repeated aspirations are not effective in clearing an abscess what should be done?
Open surgical dependent drainage under GA
Antibiotics continued until evidence of cellulitis has cleared
Nonpuerperal mastitis is uncommon and even rare in postmenopausal women.
What are the usual pathogens?
- S. aureus
- Peptostreptococcus magnus
- Bacteroides fragilisare
What is the treatment for nonpeurperal mastitis?
- re-examined every 3 days until the infection clears.
- Augmentin 625 mg orally every 8 hours for 7 days as initial therapy is usually effective.
- Alternately, cephalexin 500 mg orally every 6 hours for 7 days can be prescribed.
What is chronic mastitis associated with?
Subareolar abscess
What can occur in chronic mastitis and what should be done?
Periareolar fistulae, should be surgically exicsed with inflammation is quiescent
What should be considered in chronic mastitis that is unresponsive to antibiotic therapy?
Inflammatory carcinoma
How does an adenolipoma usually present?
As a smooth palpable mass with a characteristic mammographic pattern
When does apocrine metaplasia of epithelial cells occur?
Apocrine metaplasia of the epithelial cells, which enlarge and are eosinophilic are histologically noted in the lining of a cyst
Ductal hyperplasia is a _____ histologic process, but when the hyperplasia is ______ it is associated with an increased risk of ________ and thought potentially to be the beginning of ____________ to ______ carcinoma __ ___ and eventually ______ ______ carcinoma.
Ductal hyperplasia is a benign histologic process, but when the hyperplasia is atypical it is associated with an increased risk of carcinoma and thought potentially to be the beginning of transformation to ductal carcinoma in situ and eventually invasive ductal carcinoma.
Fat necrosis can mimic _____ by _________ but has a distinct ___________ appearance and is often secondary to ______ ______. Fat necrosis usually subsides __________ but may leave a residual _____________ _______.
Fat necrosis can mimic cancer by examination but has a distinct mammographic appearance and is often secondary to breast trauma. Fat necrosis usually subsides spontaneously but may leave a residual mammographic lesion.
A galactocele is a _____ ____-____ ____ most commonly associated with _______ or ______. ___ can diagnose and drain a galactocele.
A galactocele is a palpable milk-filled cyst most commonly associated with pregnancy or lactation. FNA can diagnose and drain a galactocele.
A lipoma has a ___, _____ border on mammography, can be _______, and reveals only ______ cells by ______.
A lipoma has a thin, smooth border on mammography, can be palpable, and reveals only adipose cells by biopsy.
What is mondor’s disease?
Phlebitis and subsequent clot formation in the superficial (skin) veins of the breast
How does mondor’s disease present?
Phlebitis as firm, vertical, cord-like structure usually associated witha history of trauma to the breast
How does mondor’s disease resolve?
Sponaneously in 8-12 weeks
