Breast disease Flashcards
What is concluded in the triple assessment?
Clinical assessment
Imaging
Needle biopsy
In the triple assessment each compenent is scored from 1-5. What do each of the numbers indicate?
1 - normal 2 - benign 3 - uncertain/ likely benign 4 - suspicious 5 - malignant
What are the risk factors for s for developing breast cancer?
Oestrogen exposer Family history Obesity Smoking Alcohol Dense (Fibroglandular) breasts
What are examples of oestrogen exposure which increase the risk of breast cancer in women?
Early monarchy Late menopause HRT OCP No breast feeding No children
When ultra sounding the breast what are the two views of the breast?
Mediolateral oblique
Cranial-cuadal
What aspect of the breast does the mediolateral oblique capture?
The tail of the breast and therefore capturing lymph nodes
Why is a breast compressed during the mamogram
Spread out tissue
Uniform thickness of the breast
Stabilise the tissue
When is mammography used on top of ultrasound?
When a patient is over the age of 40 years
Why are ultrasound used in women under the age of 40 years?
Reduce radiation exposer
Less likely to have cancer
More dense (fibroglandular) breasts
What is the tail of Spence?
Projection of the breast along to the axilla
Where does majority of the lymph from the breast drain to?
The axilla
What lymph node regions are assessed during the breast examination?
Axillary
Supra/Infra-clavicular nodes
What is involved in the histological terminal duct unit?
Extralobular terminal duct
Intralobular terminal duct
What causes breast development in females after puberty?
Oestrogen (and some progesterone)
After pregnancy what stimulates lactation.
Prolactin and oxytocin (released from suckling)
What is the meaning of the word mystalgia?
Breast pain
What is skin tethering?
Lump is attached to skin but doesn’t move with skin
Where do most breast cancers occur?
50% occur in the upper inner quadrant
What growth factors are assessed when evaluating treatment of breast cancer?
Oestrogen
Progesterone
Human epithelial growth factor 2
What is protective for breast cancer?
Early age at first birth increased parity (duration of breast feeding)
What is used for ER positive breast cancers?
Tamoxifen
What is used for HER2 breast cancers?
Transtuzumab (herceptin)
What is better a mastectomy or a wide local excision (with radiotherapy) ?
They have an equivalent prognosis
How does adjuvant chemotherapy (tamoxifen etc) reduce spread of disease?
Stops micrometastesis
When would a mastectomy be chosen over a local excision?
Tumour > 4cm
Multifocal
Poor cosmetic result with local excision
What features of breast pain are less concerning?
Bilateral
Self resolves
Associated with menstrual cycle
However recommend a mammogram anyway
How is breast pain treated?
NSIADs and Danzol
What is Colostrum?
First milk production after delivery, rich in antibodies
What factors are associated with breast abscess?
Smokers
Diabetics
Immunocompromised
What distinguishes a ductal carcinoma in situ to a invasive ductal carcinoma?
Histological the cancer has not broken the epithelial basement membrane
A young female patient notices a unilateral lump which movable and has no pain. NO breast or family history of significance. What is the likely diagnosis?
Fibroadenoma, stile for triple assessment
How can a cyst vs a mass be distinguished when detected via mammography?
Ultrasound, black hola on ultrasound
When is a cyst treated?
if symptomatic, fine needle aspiration
How do cysts look on mamography?
Multiple cysts with varying size, bilateral
When are core biopsies used?
solid tumour masses
When are fine needle aspirations used?
axillary nodes
cysts
What criteria in a family history would lead to a specialist referral (NICE guidelines).
1 first degree relative less than 40 years old
2 first or second degree relatives of any age
+ jewish, male BC, ovarian, bilateral history etc.
What ages do screening take place?
From 47-73 years, every 3 years
When there is a genetic predisposition like BRCA how often does breast cancer screening take place?
Annual MRI and mammograms
What factors are involved in an increased risk of breast cancer?
TP53 mutation
BRCA mutation
supradiaphrmatic irradiation for hodgkins lymphoma
What are the common sites of metastasis?
2 Ls and 2 Bs
Bone
Brain
Lung
Liver
Why is Anastrozole used over tamoxifen in postmenopausal women?
Aromatase is the main enzyme for oestrogen in peripherally, this is the main source of oestrogen in postmenopausal women
What is a sentinel node biopsy?
Where the lymphatic drainage of the breast using a dye or radioactive marker indicates the first lymphatic node(s), and therefore which may have malignant cell.
If a sentinel biopsy shows malignant cells what is the next course of action for a person with an excised breast cancer?
Total node clearence
What are the side effects of tamoxifen
DVT
Endometrial thickening
Hot flushes and headaches
What to ask in a history of breast cancer?
Ask about related breast symptoms (inc. red flags)
Risk factors
FH
Life style (smoking, alcohol, children things)
medication
What to describe when describing a lump?
Shape Size Consistency Hardness Tethering
What are the red flags for breast cancer?
Eczema
Nipple changes and discharge
Dimpling and redness
Discharge
What is fat necrosis?
Caused by trauma and neurosis. Can also cause oil cysts
Describe what a lump in the breast feels like?
Stony hard Irregular Fixed Nipple retraction Skin changes
What is the pathophysiology of Peau d’orange?
lymphedema caused by cancer blocking lymph drainage, axillary clearance and radiotherapy
What differentials for redness on the breast?
Immunocompromised
Diabetic
Smokers
Inflammatory breast cancer
What does fungating in relation to breast cancer?
The cancer breaking through the epidermis out of the skin. Can smell. Can cause discharge.
If metastatic breast cancer is suspected, what can be done in addition to the standard breast exam?
Auscultation of the lungs
Palpate liver
Consider bone mets
When would an MRI of the breast be used?
BRCA women Lobular carcinoma (breast cancer)
What are the feature of lobular carcinoma which make is different from ductal carcinoma?
Multifocal
Bilateral
Not seen on a mammogram!
Why can a patient only be given radiotherapy once?
Greater risk of angiosarcoma with subsequent radiotherapy
Breast reconstruction may be indicated in patients with…
Increased BMI
PVD
Smoking
Diabetic
What effect does tamoxifen have on fertility?
Not allowed OCP but increases fertility. Is teratogenic
How can nipple eczema and Pagets disease be differentiated?
Bilateral
Normally active at another site on the skin
How is lactational mastoiditis treated?
Carry on breast feeding
Ultrasound for abscess
antibiotics - flucloxacillin
What complete pathological remission
When chemotherapy has completely eradicated all viable cancer from the breast and axilla
What are the three components of a triple assessment?
clinical assessmentimaging assessmentneedle biopsy
Lifetime risk of developing breast cancer
1 in 8
Lower risk of developing breast cancer
longer duration of breastfeedingincreasing parityearlier age at first birth
Higher risk of breast cancer
FHHRT useearlier menarche
things marked 1-5 in triple assessment
Palpationultrasound/Mammographycytology
Paget’s disease
looks like eczema or psoriasis but on one breast
Swelling of arm after breast cancer
Axillary node clearance
two angles of mammography
mediolateral obliquecraniocaudal
Grade of breast cancer shows how…
aggressive the cancer is
HER2 positive spread faster or slower?
faster
invasive lobular carcinoma- what scan is nneded
MRI- identifies extent of cancer
IF P4 but M0 and U0- what next
clinical (freehand) core biopsy
if positive for cancer, where scan next?
axilla
ER pos, HER2 neg. What treatment?
Tamoxifen
HER2 pos- what treatment?
trastuzumab
what is the aim of chemo?
to eradicate micrometastatic disease
what three characteristics are used to determine stage?
tumour size, number of lymph nodes involved, presence of mets
triple neg breast cancer means
no HER2, ER or PR receptors
What tool can be used to estimate breast cancer survival
PREDICT
Side effects of tamoxifen
endometrial thickening, DVT, menopausal symptoms, cataracts
Small lumps on nipple.
Montgomery tubercles- can be normal but become more pronounced in pregnancy
Cyclical breast pain
usually more in menstrual cyclesettles down by itself stops after menopause
non cyclical breast pain
could be costochondritis, causes are often unclear and resolves itself
patient report cyclical type breast pain. Next step
reassure, offer bilateral mammogram
painful area in breast. red and tender. Beginning to feel tired and unwell. had baby 5 weeks ago
lactational mastitis- can be infectious or non infectious
Lump in context of lactational mastitis
could be an abscess- ultrasound it.
abscess present- what next
ultrasound guided drainage. send fluid to microbio. start fluclox
red, swollen, hot breast. Not lactating
consider inflammatory breast cancer- can mimic mastitis and breast abscesses
treatments to consider in pts with breast pain
NSAIDS, danazol
do you stop breastfeeding in mastitis
no- feed on demand from both breasts unless too painful
predisposing factors for breast abscess
immunocompromised, diabetes, nipple piercing, smoking
Breast implant problems
could be PIP implants (wrong grade silicone)leaking implant
Investigation with implant problems
UltrasoundMRI
Young female with breast lump
fibroadenoma
even if thinking fibroadenoma- what next
triple assess- palpate, image, biopsy (if over 25)
imaging in woman over 40
mammogram and ultrasound
blood stained cyst fluid- what next?
send for cytology
what type of gene is BRCA
tumour suppressor protein
inheritance of BRCA
autosomal dominant
chromosomes with BRCA
13 and 17
prophylactic mastectomy reduces risk of cancer by what percent
90
herceptin
HER2 cancers
