Breast Disease Flashcards
the breast lies in
subcutaneous tissue of the anterior thoracic wall
extent of the breast base
sternal edge to mid-axillary line from 2nd to 6th ribs
the breast overlies
pectoralis major, overlapping into serrates and to a small extent, supper rectus and external oblique
axillary tail
small part of the outer quadrant that is prolonged toward the axilla
blood supply of breasts
mainly lateral thoracic artery
also internal thoracic, posterior intercostal arteries (perforating branches) and thoracic-acromial artery
all arterial supply forms an anastomosing network
venous drainage of breasts
circus areolar venous plexus and glandular tissue venous plexus to internal thoracic and axillary veins
lymph drainage
subareolar plexus communicated with breast lymphatics
75% drains to axillary nodes
25% to parasternal nodes
occasional drainage to intraclavicular
lactiferous ducts
about 15-20
each drains a lobe of the breast
each has a dilated sinus at its terminal portion in the nipple
areola
pigmented skin with smooth muscle
contraction causes nipple erection
the skin of the areola
large sebaceous glands, sweat glands and areolar glands are present
areolar glands form small elevations
areolar glands
form small elevations called tubercles of Montgomery
ligaments of Cooper
fibrous strands connecting dermis of skin to ducts and fascia
cancers may attach to these fibres which is what causes dimpling
how is paeu d’orange created
the appearance of orange peel
cancer obstructs dermal lymphatics causing appearance
crucial points to ask on history
history of the symptom
reproductive history (menarche, menopause, pregnancies, lactation, HRT, OCP, age of first full term pregnancy)
previous breast exams
smoking, alcohol, injectables
family Hx
when to use MRI
for high risk screening and complex cases only
types of benign breast disease
hormonal benign breast change
fibroadenomas
inflammation
cysts
papillomas
fat necrosis
screen detected lesions
some screen detected lesions
radial scars - benign
atypical ductal hyperplasia - increased risk of cancer
LCIS or lobular neoplasia - risk lesion
mammography density
women with extensive mammography density are 4-6 times more likely to develop breast cancer than women of the same age with little or no mammography density
people with first degree relatives who ha breast cancer
2-3x higher risk
higher is relatives has premenopausal onset/bilateral breast cancer
people with second degree relatives who had breast cancer
not increased
?? except paternal aunts
people with multiple affected family members
absolute risk approaches 50%
if women have BRCA1 or BRCA2
45% lifetime risk ovarian cancer
other genes increasing risk of breast cancer
TP53
PALB2
PTEN
CHEK2 associated with moderate increase
signs and symptoms of breast cancer
lump or lumpiness in the breast or axilla, especially if its only on one breast
breast lump and pain
changes in nipple appearance eg. retraction, scaliness, inversion, redness
discharge from nipple
breast pain, particularly localised with or without cyclic variation
change in shape or appearance of breast eg. dimpling, redness
triple test includes
- clinical examination
- imaging (mammography and/or ultrasound
- non-excision biopsy (FNA and/or core biopsy)
if any of the triple tests results are abnormal, refer to breast assessment clinic
national breast cancer screening program
women between the ages of 50-74 years are invited every two years for free mammograms
women ages 40-49 and 75 and over are also eligible to receive free mammograms
Ductal carcinoma in situ
more morphologically heterogenous
discrete spaces filled with malignant cells, rarely single subtypes
as lesions grow, the centre tends to necroses, undergoing coagulation and calcifying towards the nipple (segmental calcifications)
four subtypes of DCIS
papillary, cribriform, solid and comedo
invasive ductal cancer
grows as a cohesive mass with mammography abnormalities
usually a palpable lump
most common
3 subtypes of invasive ductal cancer
infiltrating
mutinous
colloid
invasive lobular cancer
permeates in single file
escapes physical examination and early detection on mammography
variable prognosis
breast cancer mets
advanced, metastatic stage 4 breast cancer
aim of treatment of distant mets is usually palliative
common places for breast cancer to go
lung
bone
liver
brain
breast conservation surgery
survival is the same as mastectomy
aims for better cosmetic outcome
WILL need radiotherapy
once more than 30% of breast needs to be removed, cosmetic outcome is worse
oncoplastic surgery
breast reshaping
reduction techniques
volume replacement
augmentation or reduction contralateral side
radiotherapy
usually even after breast conserving surgery
or to chest wall after mastectomy
chemotherapy
mainly anthracycline and taxmen containing regimens
neo-adjuvnant therapy
hormone blocking therapy
tamoxifen
aromatase inhibitors
ovarian function suppression
targeted therapy
Herceptin and pertuzumab for HER2 over expressing tumours
CDK4/6 inhibitor for ER+ tumours
treatment for ER+ slow growing cancers
hormone therapy
treatment for ER+ fast growing cancers
hormone therapy plus chemo
treatment for HER2+ breast cancer
chemo
Herceptin (Trastuzumab)
hormone therapy (if ER+ as well)
treatment for triple negative breast cancer
chemo
molecular profiling for breast cancer
analysis of multiple genes to develop an individual signature prognostic indicators so may suggest whether chemo is needed
oncotype DX
tests for 21 genes
predicts risk of cancer recurrence and likely benefit of chemotherapy in lymph node negative breast cancer
what is used for anti-HER2 therapy
Herceptin
tamoxifen
selective oestrogen receptor modulator
used in pre and post menopausal women
aromatase inhibitors
eg. anastrazole and letrozole block oestrogen production in liver and fat
only for post menopausal women
side effects of hormonal therapy
hot flushes
joint pains and stiffness
mood disturbance
sexual dysfunction
