Breast Disease Flashcards
What is the most common cancer of all women?
Breast
What is the second most common cancer of women?
Ovarian
80% of breast cancers are the _______ type
Ductal
Outline the 5 year survival rates by extent of breast cancer at time of diagnosis.
- All stages – 86%.
- Localized cancer – 97%.
- Cancer with regional involvement – 78%.
- Metastatic cancer – 23%.
List risk factors for breast cancer.
- Female.
- Old age.
- Gene mutations e.g BRCA
- Atypical ductal or lobular hyperplasia.
- Lobular carcinoma in situ.
- Atypical epithelial hyperplasia.
List some epidemiological risk factors for breast cancer.
- First child born after 30y/o.
- Alcohol consumption one or more times per day.
- Early menarche.
- FHx of breast cancer.
- Past history of breast cancer.
- Nulliparity.
- Postmenopausal obesity.
Having never had children is a risk factor for breast cancer
T
Having your first baby >30 years is a risk factor for breast cancer
T
Early menarche is a risk factor for breast cancer
T
Postmenopausal obesity is a risk factor for breast cancer.
T
List the common symptoms of breast cancer.
- Dimpled or depressed skin
- Visible lump
- Nipple change - inversion
- Bloody discharge
- Textured change
- Colour change
What is the most common histologic type of breast cancer, accounting for as many as 80% of breast malignancies?
Ductal carcinoma
What are the typical findings of a ductal carcinoma?
Stellate solid mass or pleomorphic casting microcalcifications
BUT, a malignant solid mass may be circular and the calcifications may be non-casting
Ultrasound can be helpful in defining a malignant solid mass
T
Who is US easier to detect breast cancer in?
- Mammographically dense breasts
* Young women
The DEFINITIVE DIAGNOSIS is established by IMAGE-GUIDED TISSUE CORE-NEEDLE BIOPSY
T
How do we get a DEFINITE diagnosis of breast cancer in situ?
Image guided tissue core needle biopsy
Ductal carcinoma in-situ is commonly ____ __________
Non-palpable
How is a ductal carcinoma in situ easily seen?
On screening mammography as malignant calcifications, usually pleomorphic and of the casting type
How do we get a DEFINITE diagnosis of ductal carcinoma in situ?
By stereotactic vacuum-assisted core biopsy
How does an invasive lobular carcinoma spread?
Spreads diffusely, with a typical histologic Indian file pattern
How does an invasive lobular carcinoma usually present?
Invasive lobular carcinoma not being apparent, either by palpation or imaging, until the cancer is at an advanced stage
What is a tumour marker for invasive lobular carcinoma?
Lobular carcinoma in situ (LCIS).
What is LCIS associated with?
Associated with increased risk of eventual invasive carcinoma that usually is of the ductal type
Equivalent long-term breast cancer survival can be achieved by either breast-conserving therapy or mastectomy
T
What is the best tx for breast cancer?
Masectomy
Although mastectomy is the best treatment for breast cancer, what is the PREFERRED treatment?
Breast conserving therapy
What is breast conserving therapy?
A wide local excision, with or without an oncoplastic procedure to shape the breast
What is the other essential component of breast conserving surgery?
Radiation therapy (irradiation).
Describe the radiotherapy used in breast cancer.
Total dose of 4500-5000 centigrays is administered in fractions, using opposed tangential fields.
Course is usually administered in daily fractions, 5 days per week for 3-6weeks.
A boost dose of irradiation to the tumour bed increases the target dosage to 6000-6500 centigrays.
What does a modified radical/total mastectomy do?
Removes the entire breast, including the overlying skin and the axillary lymph nodes
Entire breast, skin, nipple, and axilla are removed
In radical/total mastectomy, everything is removed except what?
Pectoralis major muscle …
- Facilitates improved wound healing and, potentially, allows reconstruction
Breast reconstruction should be offered to all women
T
What are the 2 options for breast reconstruction, in terms of timing?
- Immediate - at the same time as the masectomy
* Delayed - after mastectomy during another surgery
Skin sparing masectomy leads to a more aesthetically pleasing outcome
T
Outline the different options of breast reconstruction.
- A breast prosthesis
- The latissimus dorsi (LD) myocutaneous flap (usually plus a breast prosthesis)
- Deep inferior epigastric perforator (DIEP) free flap
- Transverse rectus abdominis myocutaneous (TRAM) flap
- Superior/inferior gluteal artery perforator (S-GAP or I-GAP) free flaps
What is radiation an important feature of?
Breast conserving surgery
What are the 3 indications for post-masectomy radiotherapy?
- Involvement of >3 nodes.
- Positive surgical margins.
- Tumours >5cm.
What new technique is a promising alternative to whole-breast RT?
Partial breast irradiation, given either intra- or post-operatively through special catheters.
What is the most commonly used hormonal therapy?
Tamoxifen
What is tamoxifen?
An anti-oestrogen
Overexpression of ____ _ is implicated in the pathogenesis of breast cancer
HER 2
What is a key marker for determining a pt’s outcome?
HER 2
What drug targets HER 2?
Herceptin (Trastuzumab) – a recombinant humanized monoclonal antibody
What is Bevacizumab?
A recombinant humanized monoclonal antibody against vascular endothelial growth factor
What is Bevacizumab 1st line in the treatment of?
Metastatic breast cancer
What is the 1st line treatment of metastatic breast cancer?
Bevacizumab
‘A dual inhibitor of epidermal growth factor receptor (EGFR) and human epidermal growth factor receptor 2 (HER2) tyrosine kinases’ is referring to what drug?
Lapatinib
What is the indication for Lapatinib?
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 a fibroadenoma?
The most common benign neoplasm of the breast
What is the most common benign disease of the breast/
Fibroadenoma
How does a fibroadenoma present?
A palpable mass (e.g. 1-3mm) in the early reproductive years of a woman’s life
What women get fibroadenomas?
Women in early years of reproductive life
When do fibroadenomas usually occur?
In the early reproductive years, but can be diagnosed at any age
How is a fibroadenoma diagnosed?
With ultrasound core biopsy
Describe how a fibroadenoma feels on examination.
- Rubbery to firm.
- Mobile.
- Smooth, with distinct border.
- Usually NON-TENDER.
Fibroadenomas are pre-malignant
F
Is a fibroadenoma pre-malignant?
NO
Do fibroadenomas need to be removed?
No – because they tend to remain unchanged or decrease in size approaching the menopause, and usually become non-palpable after the menopause
When do fibroadenomas become non-palpable?
After menopause
Some women would rather have their fibroadenomas removed even although this is not necessary. How is this done?
Electively, in the form of open lumpectomy, or percutaneous vacuum-assisted core biopsy as an outpatient procedure, under local anaesthesia.
What resembles fibroadenomas in clinical presentation and cytology?
The uncommon phyllodes tumour
How care phyllodes tumours different from fibroadenomas?
- Larger – 3-6cm.
- Tend to occur in older women – 35-45y/o.
- Tend to increase in size.
What does diagnosis of a phyllodes tumour need?
Histologic verification
Phyllodes tumours can be …
- Benign.
- Intermediate.
- Malignant.
How is a phyllodes tumour managed?
- With wide (1cm), clear surgical margins, and followed up carefully.
- Metastasis, although rare, is possible.
What is mastalgia?
Breast pain
Mastalgia is usually _________
Cyclical (but can be non-cyclical)
When is the pain of mastalgia more intense?
During the immediate premenstrual phase of the cycle
The pain in mastalgia is diffuse
T
Mastalgia is unilateral/bilateral
Usually bilateral, but can be unilateral
In non-cyclical mastalgia, the pain is …
Localized, and often persistent
Non-Cyclical mastalgia is LESS responsive to treatment than cyclical mastalgia
T
Is mastalgia associated with malignancy?
No- unless there’s a palpable breast mass
Clinically, it is imperative to be certain that pain in mastalgia is where?
Within the breast, and not of a non-breast aetiology, affecting the anterior chest wall
What is cyclic mastalgia due to in most women?
The woman having an intense variant of physiologic breast changes that occur during the menstrual cycle.
When can a woman with mastalgia be reassured that there is no evidence of cancer and that her sx are physiologic?
After complete evaluation and examination, including a mammogram for a woman aged 35 or older.
When can mammograms start to be given?
> 35 years
Give examples of therapies which have been shown to be effective in treating mastalgia.
- Evening primrose oil.
- Tamoxifen.
- Topical NSAIDs.
When do palpable breast cysts commonly occur?
During the late reproductive years of a woman’s life
Describe how a breast cyst will feel on examination.
- Palpable, clearly defined, soft, mobile and smooth.
* The borders are distinct.
Are breast cysts tender?
YES !!!!
When are breast cysts particularly sore?
Before menstruation
Many cysts are multiple or bilateral
T
What is an effective and efficient way of diagnosing and treating a cyst?
FNA
During FNA in the management of a breast cyst, how much fluid should be removed?
As much as possible
Should all cyst fluid be sent for cytologic evaluation?
No – only grossly bloody fluid should be cytologically evaluated
What should be done after FNA of a ‘cyst’?
The area of the cyst must be palpated to be certain that there’s no residual mass
Cysts are not usually/necessarily premalignant.
T
What can occur within a cyst?
A benign intracystic papillary proliferation i.e PAPILLOMA
What is often seen if a cyst has a benign intracystic papillary proliferation?
Bloody cyst fluid
When should the rare intracystic carcinoma be clinically suspected?
When the fluid is grossly bloody, or there is a residual mass after aspiration
What is needed for diagnosis of a intracystic carcinoma?
US-guided core biopsy of any intra-cystic solid lesion or irregular cystic wall
Describe the physiologic discharge which can be elicited from the nipples of most women of reproductive age.
Clear, yellow, watery
What type of discharge is pathologic, and requires evaluation?
Bloody nipple discharge, particularly from a single duct
What is the most common aetiology of spontaneous nipple discharge?
An intraductal papilloma or papillomas – benign lesions
Most common cause of nipple discharge is a benign intraductal papilloma
T
Is nipple discharge a sign of malignancy?
Rarely – unlikely unless there is an associated palpable mass
What should be done to all intraductal lesions?
They should be excised and histologically evaluated, to ensure that the rare intraductal carcinoma isn’t missed.
What Ix’s are done in cases of pathological nipple discharge i.e bloody from a single duct?
Mammogram
What is Paget’s disease of the nipple a variant of?
Ductal carcinoma, intraductal, +/or invasive.
How CAN Paget’s disease of the nipple present?
How does Paget’s disease of the nipple USUALLY present?
CAN - red, weeping lesion on the surface of the nipple and areola
USUALLY - dry, scaly, eczematous lesion
How is Paget’s disease of the nipple diagnosed?
By histologic tissue biopsy (incisional or punch).
Palpable mass or radiological abnormality is often found underlying in Paget’s disease of the nipple
T
What does puerperal mean?
The period from childbirth to 6 weeks after
What is mastitis related to?
Pregnancy/lactation
Is mastitis common?
YES !!!!
How is mastitis treated?
- Flucloxacillin
2. Clarythromycin/clindamycin if penicillin allergic
When should abx be given for mastitis?
As soon as clinical signs of mastitis …
- Fever
- Erythema
- Induration
- Tenderness
- Swelling
Once abx for mastitis is started, how often should the patient be examined?
Every 3 days – to be certain the infection is responding to therapy, and that there’s no evidence of abscess formation
What non-drug treatment is good for mastitis?
Hot bath
What should be done if there is a lack of response of pt with mastitis to abx?
Change abx
Should cultures be done for mastitis?
NO
What should be done regarding breast-feeding of someone with mastitis?
Breastfeeding should be continued if already begin +/or the infected breast can be pumped until to give the baby the breastmilk the mastitis clears.
Use a breast pump for the affected breast, you can give the baby this milk
How does a breast abscess present?
- A flocculent, sometimes-bulging mass.
This is usually located in the central area of the mastitis.
If someone with mastitis develops a breast abscess, where will the abscess be seen?
At the centre of the area of mastitis
How can you confirm a breast abscess?
Using focused ultrasound to show a fluid-filled (pus) centre.
What Ix is diagnostic + therapeutic for a breast abscess?
Aspiration with a number 18-gauge needle using local anaesthesia.
What happens to the aspirate from a breast abscess?
It is sent for microbiological analysis
How often should aspiration of a breast abscess be done?
Every 3 days – especially if there is >10ml of pus initially aspirated.
What is required if repeated aspirations are not effective in clearing a breast abscess?
Open surgical drainage under general anaesthesia.
For how long should abx in an abscess be given?
Until all evidence of inflammation (cellulitis) has cleared.
Non- puerperal mastitis is common/uncommon even in post-menopausal women
Uncommon
What bacteria usually cause non-puerperal mastitis?
- S. aureus.
- Peptostreptococcus magnus.
- Bacteroides fragilis.
How should patients with non-puerperal mastitis be managed?
- Re-examine every 3 days until infection clears.
- Augmentin 625mg orally every 8 hours for 7 days as initial therapy.
- Alternatively, cephalexin 500mg can be given orally every 6 hours for 7 days.
Chronic mastitis is common/uncommon
Uncommon
What is chronic mastitis associated with?
A subareolar abscess
What can occur with a subareolar abscess from someone with chronic mastitis?
Periareolar fistulae
How is a periareloar fistulae managed?
Surgically excise when the inflammation is quiescent.
What should be suspected with a case of mastitis that is unresponsive to antibiotic therapy, particularly if it seems to spread over the entire breast?
Inflammatory carcinoma
What does an adenolipoma usually present as?
A smooth palpable mass, with a characteristic mammographic pattern.
An adenolipoma is a rare benign breast condition
T
What are histologically noted in the lining of a cyst?
Apocrine metaplasia of the epithelial cells, which enlarge and are eosinophilic
Ductal hyperplasia is a ______ histological process
Benign
When can ductal hyperplasia be associated with an increased risk of malignancy?
When the hyperplasia is atypical
What is ductal hyperplasia often the beginning of?
Transformation to ductal carcinoma in situ, and eventually invasive ductal carcinoma
When can fat necrosis mimic carcinoma?
On examination
How do we distinguish fat necrosis from carcinoma?
MAMMOGRAM - and the fact that it is often secondary to breast trauma.
Give an example of a typical situation that results in fat necrosis.
Seat belt injury from a car crash
What happens to fat necrosis as it progresses?
It usually subsides spontaneously, but may leave a residual mammographic lesion.
What is a galactocele?
A palpable milk-filled cyst
What are galactoceles associated with?
Pregnancy or lactation
How is a galactocele diagnosed + managed?
FNA - also drains it
Describe the appearance of the border of a lipoma on mammography.
Thin smooth border - can also be palpable
What does a biopsy of a lipoma reveal?
ONLY adipose cells
What is the ONLY cell type of a lipoma?
Fat cells
What is Mondor’s disease?
Phlebitis and subsequent clot formation in the superficial (skin) veins of the breast.
How does Mondor’s disease present?
As a firm, vertical, cord-like structure, usually associated with a history of trauma to the breast e.g. surgery
What happens in Mondor’s disease
It usually resolves spontaneously in 8-12weeks
