Breast Disease Flashcards
What are the differentials for breast pain?
Cyclical & diffuse = often physiological
Non-cyclical & focal = ruptured cysts, injury, inflammation
Presenting complaint in breast cancer
What are the differentials for a palpable mass in the breast?
Could be normal nodularity
Hard, craggy, fixed —> worrying sign (cancer)
Invasive carcinoma, fibroadenoma, cysts
note: no woman should be allowed to have a lump in the breast without a firm diagnosis
What are the differentials for nipple discharge?
Most concerning if spontaneous & unilateral
Milky = endocrine disorder e.g. pituitary adenoma, OCP
Bloody/serous = benign lesions e.g. papilloma, duct ectasia; occasionally malignant
When are women invited for mammographic screening? What are some worrying findings?
Women between 50yrs & 70yrs (extended to 47yrs and 73yrs) invited every 3yrs
Worrying findings = asymmetric densities, parenchymal deformities, calcifications
note: easier to detect lesions in the breasts of older women (more adipose tissue)
What is the incidence of breast cancer?
Rare before 25yrs (except for some familial cases)
Incidence rises with age:
- average age at diagnosis = 64yrs
- 77% of cases in women over 50yrs
Most common non-skin malignancy in women (20%)
1/12 women will develop breast cancer at some point
10% of cases are hereditary (3% of overall are BRCA1/2)
Male breast cancers = 1%; increased risk in Klinefelter’s, male to female transsexuals, men treated with oestrogen for breast cancer
What are some disorders of breast development?
Polythelia (accessory breast tissue) = excess nipples
Occur along line of milk line remnants (axilla —> breasts —> thorax —-> labia —> inner thighs)
Therefore breast cancer can occur in the axilla/labia
What is acute mastitis?
Almost always occurs during lactation, usually Staph. aureus, entering through the nipple cracks & fissures
- erythematous, painful breasts + pyrexia
- may produce abscesses
- antibiotics + express milk
What is duct ectasia?
Blockage of lactiferous duct
Usually occurs around menopausal age (50yrs-60yrs)
- may have periareolar mass +/- nipple discharge
- duct dilatation & inflammation
- can mimic carcinoma clinically
What is fat necrosis?
Presents as mass, skin changes, or mammographic abnormalities
History of trauma or surgery e.g. seatbelt injury
Can mimic carcinoma clinically & mammographically
What is fibrocystic change of the breast?
Commonest breast lesion
May present as a mass or mammographic abnormality
- mass often “disappears” after fine needle aspiration (cyst collapses)
- histology = cyst formation, fibrosis, apocrine metaplasia (pink colour)
- can mimic carcinoma clinically and mammographically
What is epithelial hyperplasia of the breast?
Proliferation of epithelial cells which fill and distend ducts and lobules
Slight increase in risk of carcinoma (esp. if atypical)
Incidental finding in biopsy/mammogram
What is a papilloma of the breast?
Intraduct lesion consisting of multiple branching fibrovascular cores covered by myoepithelial & epithelial cells
Small duct = multiple & deeper in the breast, slight increased risk of carcinoma, less common than solitary carcinomas
Large duct = lactiferous ducts near nipples
May present with nipple discharge (may be bloody), small palpable mass, or mammographic abnormality
What is a fibroadenoma of the breast?
Most common benign tumour of the breast
Can occur at any reproductive age (often “breast mouse”) or mammographic abnormality
- can be multiple & bilateral
- can grow very large and replace most of the breast
- macroscopic = well circumscribed, rubbery, greyish/white
- histology = mixture if stromal & epithelial elements
- localised hyperplasia rather than true neoplasm
- can mimic carcinoma clinically & mammographically
What is a phyllodes tumour?
Rare before 40yrs
Presents as rapidly growing masses (months)
More commonly benign; rarely malignant
- can be very large and involve the whole breast
- malignant types behave aggressively, recur locally, & metastasise by blood stream
- need to excise with a wide margin due to risk of recurrence
Histology = nodules of proliferating stroma covered by epithelium (leaf vein appearance)
note: stroma more cellular & atypical than that in adenomas
What is gynaecomastia?
Unilateral or bilateral enlargement of the male breast
Caused by relative decrease in androgen effect or increase in oestrogen effect
- puberty & elderly
- can mimic male breast cancer (esp. if unilateral) but has no increased risk of cancer
- occurs in most neonates secondary to circulating maternal & placental oestrogens & progesterone
- transient gynaecomastia occurs in 50% of boys at puberty due to peak in oestrogen production occurring earlier than the testosterone peak
Also occurs in:
- Klinefelter’s syndrome
- cirrhosis of liver (excess of oestrogen)
- gonadotrophin excess (functioning testicular tumour)
- drug-related e.g. spironolactone, alcohol
What is the aetiology of breast cancer?
95% are adenocarcinomas
Most common in upper outer quadrant (50%)
Risk factors:
- gender
- uninterrupted menses
- early menarche (
What are the genetic mutations associated with breast cancer?
BRCA 1/2 = tumour suppressor genes
- 60%-85% lifetime risk of breast cancer in women
- median age at diagnosis is 20yrs earlier
- prophylactic mastectomies
p53 (Li-Fraumeni syndrome)
How can breast cancer be classified?
In situ v.s. invasive
Ductal v.s. lobular
Describe in situ breast carcinoma. Give some examples.
Neoplastic population of cells limited to ducts & lobules by basement membrane (does not invade vessels, therefore cannot metastasise) - myoepithelial cells are preserved
Ductal carcinoma in situ (DCIS):
- mammographic calcifications
- can present as mass
- can spread extensively through ducts and lobules
- central (comedo) necrosis with calcification
- non-obligate precursor of invasive carcinoma
Paget’s disease of the breast:
- cells can extend to nipple skin without crossing the basement membrane —> unilateral red and crusting nipple
- any eczematous/inflammatory conditions of the nipple should be biopsied to exclude Paget’s disease
Describe invasive carcinoma of the breast. Give some examples.
Invaded beyond basement membrane into stroma, therefore can invade blood vessels and metastasise to lymph nodes and other sites
- usually presents as mass or mammographic abnormality
- by the time cancer is palpable, more than 50% will have axillary lymph node metastases
- peau d’orange = involvement of lymphatic drainage of skin —> blocks drainage —> oedema formation —> hair follicles held in place & rest of breast expands outwards —> resembles orange skin
Invasive ductal carcinoma:
- 70%-80% incidence
- lined by atypical cells when well-differentiated
- lined by sheets of pleiomorphic cells when poorly differentiated
- 10yrs survival = 35%-50%
Invasive lobular carcinoma:
- 5%-15% incidence
- infiltrating cells in single file
- cells lack cohesion (lack of E-cadherin)
How does breast cancer tend to metastasise?
Lymphatics —> lymph nodes (usually ipsilateral axilla)
Blood vessels —>
- > bones (most freq.)
- > lungs, liver, brain
Invasive lobular carcinoma can spread to peritoneum, retroperitoneum, leptomeninges, GI tract, ovaries, uterus
note: poorer prognosis with oestrogen receptor negative, HER2 negative carcinomas
How is breast cancer diagnosed and treated?
Diagnosis:
- clinical: history & examination
- radiography: mammography + ultrasound
- pathology: fine needle aspiration cytology + core biopsy
Treatment:
LOCAL/REGIONAL =
- breast surgery: mastectomy or breast-conserving (lumpectomy/wide excision) - depends on patient choice, size & site of tumour, size of breast
- axillary surgery (if nodes are involved): sentinel node sampling (reduces risk of post-op morbidity, use dye/radioactivity of the draining lymph nodes) —> axillary dissection —> arm lymphoedema
- post-operative radiotherapy to chest & axilla
SYSTEMIC =
- chemotherapy
- hormonal treatment e.g. tamoxifen (ER positive = 80% of cancers)
- herceptin (monoclonal antibodies against HER2 protein - HER2 positive = 20% of cancers)
