Breast Conditions Flashcards
How common is breast cancer?
Most common cancer in women = most common type is ductal (80%)
What are the clinical risk factors for breast cancer?
Female gender, older age, gene mutations, atypical ductal/lobular hyperplasia, lobular carcinoma in-situ, atypical epithelial hyperplasia
What are the epidemiological risk factors for breast cancer?
Birth of first child > age 30, alcohol >1-2x daily, early menarche, family history, previous breast cancer, nulliparity, postmenopausal obesity
What are the protective factors against breast cancer?
Routine vigorous exercise, maintaining healthy weight
What are the symptoms of breast cancer?
Dimpled/depressed skin, visible lump, nipple change, bloody discharge, texture change, colour change
What is the presentation of breast cancer?
Stellate solid mass or pleomorphic casting microcalcifications, may be circular and calcification may be non-casting
When is US useful for diagnosing breast cancer?
Young women or those with mammographically dense breasts = not useful for evaluating calcifications
How is breast cancer diagnosed definitively?
Image guided tissue core needle biopsy
How is ductal carcinoma in-situ detected?
Detected by screening mammography as non-palpable
How is ductal carcinoma in-situ definitively diagnosed?
Stereotactic vacuum-assisted core biopsy
How are invasive lobular carcinomas diagnosed?
Not apparent by palpation or imaging until advanced
Lobular carcinoma in-situ can be used as tumour marker
How do invasive lobular carcinomas spread?
Spread diffusely with typical Indian file pattern
What is the preferred treatment for breast cancer?
Breast conserving surgery = may be wide local excision +/- oncoplastic procedure to shape breast
What is an essential component of breast conserving surgery for breast cancer?
Irradiation = usually performed in oncologic radiation therapy centre
How is irradiation delivered during breast conserving surgery for breast cancer treatment?
Total dose of 4500-5000 centigrays administered in fractions using opposed tangential fields = usually given 5 days per week for 3-6 weeks
What is a modified radical mastectomy?
Removal of entire breast including overlying skin and axillary lymph nodes
Why is the pectoralis major preserved during a modified radical mastectomy?
Facilitates improved wound healing and potentially allows reconstruction
Which women are candidates for breast reconstruction?
Most women who undergo mastectomy are candidates for reconstruction
What are the types of breast reconstruction?
Prosthetic and autologous = both can be performed immediately or be delayed until later
What are some features of breast reconstruction following non-skin sparing mastectomies?
Often results in prominent scars on new breast and paddle of skin that is different from rest of breast
What are some features of breast reconstruction after a skin sparing mastectomy?
Has better aesthetic outcomes as most of overlying skin preserved
What are the methods of breast reconstruction?
Breast prosthesis
Latissimus dorsi myocutaneous flap
Deep inferior epigastric perforator free flap
Rectus abdominis myocutaneous flap
Superior/inferior gluteal artery perforator free flap
What are the indications for radiation therapy to treat breast cancer?
Involvement >3 nodes, tumour >5cm, positive surgical margins
When can partial breast irradiation for breast cancer be given?
Intra or post-operatively through special catheter following breast conserving surgery
What are some adjuvant therapies for breast cancer?
Chemotherapy = individualised therapy, may offer clinical trials if patient qualifies
Hormonal therapy = most commonly tamoxifen
What are some targeted therapies for breast cancer?
Trastuzumab = targets HER2, effective as adjuvant Bevacizumab = targets vascular endothelial growth factor, 1st line for metastatic disease Lapatinib = dual inhibitor of EGFR and HER2
What are the indications for using lapatinib to treat breast cancer?
Use alongside capecitabine = advanced/metastatic disease whose tumours overexpress HER2
What must a breast cancer patient have previously been treated with in order to qualify for lapatinib?
Must have been previously treated with an anthracycline, a taxane and herceptin
What is the most common benign tumour of the breast?
Fibroadenomas
How are fibroadenomas diagnosed?
Presence of palpable mass in young women and confirmed by US
What are the features of fibroadenomas?
Rubbery or firm, mobile, non-tender and smooth with distinct borders
How do fibroadenomas change around menopause?
Tend to remain unchanged or shrink approaching menopause and become non-palpable after menopause
How are fibroadenomas managed?
Usually don’t need removal but can be done electively = open lumpectomy or percutaneous vacuum-assisted core biopsy
What do Phyllodes tumours resemble?
Resemble fibroadenomas clinically and cytologically
How do Phyllodes tumours differ from fibroadenomas?
Often larger = 3-6cm
Occur in older women aged 35-45
Tend to increase in size and require histologic verification
What are the histological types of Phyllodes tumours?
Benign, indeterminate or malignant
How are Phyllodes tumours managed?
Excise with 1cm clear margins and carefully follow up
What are the types of mastalgia?
Cyclic and non-cyclic
What are the features of cyclic mastalgia?
More common = diffuse and most intense during intermediate premenstrual phase, tends to be bilateral
What are the features of non-cyclic mastalgia?
Localised and persistent, less responsive to treatment
Is mastalgia a feature of breast malignancy?
Rarely = more common if it is associated with a palpable breast mass
What are some causes of anterior chest wall pain that don’t originate from the breast?
Achalasia, angina, cervical radiculitis, cholecystitis, cholelithiasis, coronary artery disease, costochondritis, fibromyositis, hiatal hernia, myalgia, neuralgia, osteomalacia, phantom pain, pluerisy, PE, rib fracture, sickle cell disease, TB
What is the cause of most cyclic mastalgia?
Intense variant of physiological breast changes that occur during menstrual cycle
What women with mastalgia should be investigated for cancer?
Those over 35 = need evaluation and mammogram
What are some management options for mastalgia?
Well fitting firm bra and regular exercise
Evening primrose oil, tamoxifen and topical NSAIDs
When do palpable cysts tend to occur?
During the late reproductive years
What are the features of cysts?
Palpable, clearly defined, soft, mobile, smooth with distinct borders, multiple and/or bilateral
When may cysts become tender?
Before menstruation
How are cysts diagnosed?
Fine needle aspiration = only grossly bloody fluid should be sent for cytological evaluation
What must be done following fine needle aspiration of a cyst?
Palpate the area of the cyst to ensure there is no residual fluid
What is a papilloma?
Benign intracystic papillary proliferation = often associated with blood cyst fluid
When should you suspect a papilloma of being an intracystic carcinoma?
If fluid is grossly bloody or there is residual mass after aspiration
How are papillomas diagnosed histologically?
US-guided core biopsy
What is the appearance of physiological nipple discharge?
Clear, yellow and watery
What is the most common cause of nipple discharge?
Intraductal papilloma
Should bloody nipple discharge be investigated?
Yes = always pathologic, especially when from single duct
Is nipple discharge a sign of malignancy?
Rarely = more common if associated with palpable mass
What is the management for all intraductal lesions?
Should be excised and evaluated
What investigations are done for nipple discharge?
Mammography, US, surgical excision
What is Paget’s disease of the nipple?
Variant of ductal carcinoma = intraductal and/or invasive
What is the usual presentation of Paget’s disease of the nipple?
Dry and scaly erythematous lesion = often underlying palpable mass or radiological abnormality
Why can Paget’s disease of the nipple be mistaken for nipple discharge?
Can present as erythematous weeping lesion on nipple surface and areola
How is Paget’s disease of the nipple diagnosed?
Incisional or punch biopsy
What is puerperal mastitis related to?
Pregnancy or lactation = common and usually responds quickly
What are the signs of puerperal mastitis?
Fever, erythema, induration, tenderness, swelling
What organism most commonly causes puerperal mastitis?
Staph aureus
How is puerperal mastitis treated?
Flucloxacillin 500mg orally every 6hrs or augmentin 625mg every 8hrs for 7 days
What is the management of puerperal mastitis?
Examine patient every 3 days and change antibiotic if no response to treatment
No need for cultures = not rewarding
Continue breastfeeding until infection clears
Is non-puerperal mastitis common ?
No = uncommon and rare in postmenopausal women
What organisms cause non-puerperal mastitis?
Staph aureus, peptostreptococcus magnus, bacteroides fragilis
What is the treatment of non-puerperal mastitis?
1st line = augmentin 625mg orally every 8hrs for 7 days
2nd line = cephalexin 500mg orally every 6hrs for 7 days
What are some features of chronic mastitis?
Uncommon = may be associated with subareolar abscess
What can chronic mastitis lead to?
Periareolar fistulae = surgically excise when inflammation is quiescent
When should you consider inflammatory carcinoma as a cause of chronic mastitis?
When mastitis is unresponsive to treatment and spreads over entire breast
How do breast abscesses present?
Flocculent, sometimes bulging, mass usually located in central area of mastitis
How are breast abscesses diagnosed?
Focused US can verify pus-filled centre
Aspiration with 18-gauge needle using local anaesthetic is diagnostic
Microbiological analysis of aspirate
How are breast abscesses treated?
Aspiration may be therapeutic if all pus aspirated
May need to repeat aspiration every 3 days = especially if >10ml of pus is initially aspirated
How are breast abscesses that haven’t cleared by repeated aspiration treated?
Open surgical drainage under general anaesthesia
Continue antibiotics until all evidence of inflammation has cleared
What are some features of adenolipomas?
Presents as smooth palpable mass
Has characteristic mammographic pattern
Where is apocrine metaplasia of epithelial cells found?
Histologically noted in lining of cysts = cells enlarge and are eosinophilic
What is ductal hyperplasia?
Benign histologic process
What is atypical ductal hyperplasia associated with?
Increased risk of carcinoma = beginning of transformation to ductal carcinoma in-situ and eventually invasive ductal carcinoma
What can fat necrosis mimic?
Cancer
What are some features of fat necrosis?
Has distinct mammographic appearance
Often secondary to breast trauma
Usually resolves spontaneously but may leave residual mammographic lesion
What is a galactocele?
Palpable milk filled cyst = commonly associated with pregnancy or lactation, diagnoses and drained by FNA
What are some features of lipomas?
Thin smooth border on mammography, may be palpable, reveals only adipose cells on biopsy
What is Mondor’s disease?
Phlebitis and subsequent clot formation in superficial veins of breast = usually resolves spontaneously in 8-12 weeks
How does Mondor’s disease present?
Firm, vertical cord-like structure = usually associated with history or trauma to breast
