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Met 3b > Breast Disease > Flashcards

Breast Disease Flashcards

1
Q

Normal findings in breast exam

A

ANDI- aberrations of normal development and involution

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2
Q

ANDI

A

Group of conditions that are so common they should be considered as normal variations of these physiological processes
Changes seen throughout life from menarche –> after menopause

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3
Q

Breast development

A

Occurs in both sexes from age 10

May be asymmetrical initially

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4
Q

Surgery on developing breast

A

May significantly damage breast bud with consequent long term deformity:
Juvenile hypertrophy
Accessory breast tissue
Fibroadenoma

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5
Q

Menstruation

A

Breast undergoes regular changes associated with menstrual cycle
Fibroadenoma
Cyclical nodularity
Localized benign nodularity

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6
Q

Involution

A

Process begins from 30 in nulliparous women
Fat replaces breast tissue, and lobular stroma replaced by fibrous tissue
Breast cyst
Fibrocystic change
Sclerosing lesions
Duct ectasia

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7
Q

Fibroadenoma

A

Mainly women early 20s
Arise from lobular units
Consists of stromal tissue + proliferatory epithelium
Well defined, mobile, rubbery mass
Most commonly found upper outer quadrant
Management depends on age, size and anxiety about it

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8
Q

Fibroadenoma management

A

Young patient, painless, small –> conservative

Older patient, large mass, anxiety –> surgical excision

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9
Q

Phyllodes tumour

A

Rare fibroepithelial tumour commonly confused with fibroadenoma
Must be excluded in older women by core biopsy

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10
Q

Cysts

A

Usually found in pre and postmenopausal women due to falling hormones
Fluid filled sac found within the breast that are formed when breast ducts become dilated + filled with fluid
May have one or multiple in both breasts
Round or oval lumps with distinct edges + feel like soft grape
Can increase in size + become tender before menstruation, + decrease in size + become o=painless after menstruation

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11
Q

Cysts management

A

Usually conservative with reassurance OR aspiration if cyst causing symptoms
Complex radiologically indeterminate cysts should be core biopsied
No malignant potential so surgical excision rare

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12
Q

Multi-duct nipple discharge

A

Occurs when woman squeezes breast + notes discharge from multiple spots on nipple
If non-spontaneous + from multiple ducts on nipple surface –> normal

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13
Q

Not normal discharge

A

Blood stained, spontaneous, unilateral + uniductal

–> further investigation

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14
Q

Cyclical mastalgia

A

Cyclical breast pain is related to menstrual cycle + not associated with specific underlying breast disease
Affects 2/3 of women- 1 in to have moderate/severe pain

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15
Q

Cyclical breast pain clinical features

A

Starts during luteal phase (2 weeks before period), increases until menstruation begins, improves after period
Dull, heavy, aching
Usually bilateral
May be poorly localised + extend into axilla

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16
Q

Cyclical breast pain reassurance + advise

A 
Reassure no underlying pathology
Wear soft-fitting bra
Take pain relief
Keep pain diary
Severe pain- primrose oil, progesterone only contraceptive, low fat diet
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17
Q

Radial scar + complex sclerosing lesion

A

Areas of benign myoepithelial proliferation
Complex sclerosing lesion>1cm
Radial scar<1cm
Asymptomatic- detected on mammography screening
Require careful investigation (core biopsy) as can radiologically appear similar to carcinoma
Mammographic surveillance continued after diagnosis

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18
Q

Mammography

A

Highly sensitive for all breast lesions in women over 40 where breast tissue less dense
Used as screening method for BC for women >50 every 3 years
Plain X Ray of breast done with 2 views- craniocaudal and medial-lateral-oblique)

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19
Q

Mammogram- advantages

A

Gold standard due to high sensitivity for symptomatic BCs (around 95%)
Good for localisation of breast lesions, especially those that are impalpable
Can visualise micro-calcifications
Can exclude multiple lesions before surgery on one lesion
Valuable to compare to old images as they are standardised

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20
Q

Mammogram- disadvantages

A

Breast compressed between two plates –> uncomfortable

Less sensitive in <40 as tissue more dense + lesions harder to identify

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21
Q

Ultrasound

A

High frequency sound waves directed through breast, and reflections from different tissue components are detected + turned into images

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22
Q

Ultrasound- advantages

A

Specificity of distinguishing a cyst from solid lesion almost 100%
Best imaging <40 with dense breast tissue
Allows guidance for FNA or core biopsy
No radiation
Not uncomfortable
Can distinguish discrete lumps from areas of nodularity in young women
Can also visualise axilla for nodes

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23
Q

Ultrasound- disadvantages

A

Operator dependent
Poor visualisations of micro-calcifications
Poor screening tool as less sensitive than mammography
Less valuable to compare to old images as user dependent + live images

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24
Q

Fine needle aspiration (FNA)

A

Sample of cells taken from lesion + examined under microscope

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25
Q

FNA Advantages

A

Quick and easy
Results available fast (30mins)
Samples large area

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26
Q

FNA Disadvantages

A

Information limited to malignant or benign –> no differentiation between malignant lesions)
Results dependent on person performing the FNA + cytologist interpreting it
Cannot assess micro-calcifications

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27
Q

Core biopsy

A

Sample of cells within the breast architecture using a wide bore needle which can then be examined under microscopy

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28
Q

Core biopsy advantages

A

Larger sample so more of the lesion is samples

Cells are within the breast architecture so more information on morphology, grading, receptor status is available

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29
Q

Core biopsy disadvantages

A

More bruising and pain

Results take longer (24-48hrs)

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30
Q

Distant disease

A

Cause of 90% of deaths from breast cancer

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31
Q

Most common site of metastasis

A

Bone
Severe and progressive pain
Pathological features
Erythema over affected bone

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32
Q

Metastasis Lungs

A

Chronic cough
Dyspnoea
Abnormal CXray
Chest pain

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33
Q

Metastasis Brain

A 
Persistent, progressively worsening headache
Visual changes
Seizures
Nausea or vomiting
Vertigo
Behavioural + personality changes
Increased intracranial pressure
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34
Q

Metastsis liver

A 
Jaundice
Elevated liver enzymes
Abdo pain
Loss of appetite
Nausea + vomiting
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35
Q

Systemic symptoms of metastatic disease

A

Fatigue
Malaise
Weight loss
Poor appetite

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36
Q

Scoring system using 3x assessment- modalities

A 
Clinical assessment (palpation)- P
Mammography- M
Ultrasound- U
Biopsy- B
Cytology- C
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37
Q

Modality scoring 1

A

Normal appearance (or inadequate assessment e.g. needle doesn’t hit its target in FNA)

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38
Q

Modality scoring 2

A

Consistent with a benign lesion

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39
Q

Modality scoring 3

A

Atypical or indeterminate but probably benign

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40
Q

Modality scoring 4

A

Suspicious of malignancy

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41
Q

Modality scoring 5

A

Consistent with a malignant lesion

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42
Q

Evidence of role of breast screening programmes

A

Mammograms every 3 years women 50-70
Mammograms sensitive enough to pick up breast lesions that may be asymptomatic and impalpable
Prolongs life of 1 person for every 2000 ppl screened

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43
Q

Incidence BC

A

Most common cancer in UK (men and women combined)
1 in 8 women diagnosed in life
Incidence increases with age with half being diagnosed 65+

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44
Q

BC mortality

A

3rd most common cause of cancer death
5 year survival 77%
65% ppl with breast cancer will survive 20 years or more

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45
Q

BC RFs

A 
Female
Increasing age
PH of breast cancer
FH of breast cancer
Increased oestrogen exposure
Diet and lifestyle
Radiation exposure before 40
Prior benign or premalignant breast disease
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46
Q

Risk reduction strategies

A

CHildbirth before 30
Exercise 3-5 hours per week
Normal weight
Limit alcohol
No smoke
Avoid prolonged hormone therapy
Preventative mastectomy for those with genes
Tamoxifen can be used as primary prevention
Aromatase inhibitors (postmenopausal)–> anastrozole, exemestane, letrozole

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47
Q

Anastrozole, exemestane, letrozole

A

Aromatase inhibitors

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48
Q

Aromatase inhibitors

A

Anastrozole, exemestane, letrozole

49
Q

Non invasive carcinoma in situ

A

Has not progressed beyond basement membrane

50
Q

Non invasive carcinoma in situ examples

A

Ductal carcinoma in situ (DCIS)

Lobular carcinoma in situ (LCIS)

51
Q

Ductal carcinoma in situ

A

Non invasive

Cancer of epithelial cells of breast ducts

52
Q

Lobular carcinoma in situ

A

Non invasive

Cancer of epithelial cells of breast ducts

53
Q

Invasive carcinoma

A

Has spread beyond the basement membrane
Infiltrating ductal carcinoma
Infiltrating lobular carcinoma

54
Q

Infiltrating ductal carcinoma

A

Most common type- 80% of invasive
Arise from epithelial layer of ducts within the breast + has shown invasion through the basement membrane
Hard, irregular, well defined lump

55
Q

Infiltrating lobular carcinoma

A

15-20% invasive carcinomas
Arises from epithelial tissue within lobules
Presents as diffuse thickening (rather than distinct lump)
Hard to see on mammogram and not as distinct on clinical exam, so delay in diagnosis compared to ductal

56
Q

Paget’s disease of breast

A

Adenocarcinoma that mainly affects nipple

Associated with underlying parenchymal cancer (usually IDC or more uncommonly DCIS)

57
Q

Lymphoma

A

Large number of lymph nodes within breast so lymphoma can occur

58
Q

Inflammatory carcinoma

A

Uncommon

59
Q

Malignant Breast cancer presentation- Mass

A

Often non-tender
Often hard, fixed to skin/muscle, irregular texture, poorly defined margins
Doesn’t change with menstrual cycle

60
Q

Malignant Breast cancer presentation- Skin changes

A

Thickening of skin
Oedema–> peau d’orange
Erythema + other discolouration

61
Q

Malignant Breast cancer presentation- lymph nodes

A

Enlarged in axilla

62
Q

Malignant Breast cancer presentation- Nipple changes

A 
Inversion
Discharge (often bloody, spontaneous and one duct only)
63
Q

Malignant BC imaging

A

First line if above 40- mammogram (can localise lesion + show micro-calcification)
Second line- ultrasound (good for differentiating cysts from solid masses)
MRI may be indicated in high risk patient due to increased sensitivity

64
Q

Malignant BC Biopsy

A

FNA- can obtain rapid diagnosis of cancerous cells but can’t differentiate between malignancies
Core biopsy- preferred modality of diagnosis as enable differentiation between pre-invasive and invasive, less likely to be associated with inadequate sampling + also enables assessment of receptor status

65
Q

Grading BC

A 
1= well differentiated
2= moderately differentiated
3= poorly differentiated
66
Q

Staging BC

A 
T= tumour (X-4d)
N= nodal involvement (X-3)
M= metastasis (X-1)
67
Q

Staging BC- T

A 
Tis= carcinoma in situ
T1= tumour <2cm in greatest dimension
T2= 2-5cm
T3= >5cm
T4= any size with extension to chest wall (4a), oedema (4b), both (4c), or inflammation (4d)
68
Q

Staging BC- N

A

N0- no nodal involvement

N1-3= metastasis to increasing number of nodes

69
Q

Staging BC- M

A

M0- no evidence

M1= distant metastasis >0.2m

70
Q

Oestrogen + progesterone receptors in BC

A

Determined using immunohistochemistry on samples obtained from core biopsy
Scoring system 0-5 used to show proportion of cells that stain positive
Scoring system 0-3 used to show staining intensity
Combined score 0-2 negative, score 3-8 positive

71
Q

HER2 in BC

A

Initial test performed using immunohistochemistry
If IHC score 2+ –> fluorescent in situ hybridisation (FISH) can be used to see if HER2 being overexpressed and therefore poses as potential treatment target 9e.g. Herceptin)

72
Q

Tumour size- stage

A

Larger size increases risk of nodal involvement + recurrent risk

73
Q

Lymphatic + vascular invasion- stage

A

Increases risk of local + distant invasion –> worse prognosis

74
Q

Nodal involvement- stage

A

Any nodal involvement suggests local advancement of disease–> worse prognosis

75
Q

Distant metastasis- stage

A

Decreases change of recovery and remission

76
Q

Grade

A

Higher grade tumours have worse prognosis compared to lower grade as tend to grow slower + less likely to spread

77
Q

Receptor status- HER2

A

HER2+ is a negative prognostic factor –> increased tumour aggressiveness and rate of recurrence

78
Q

Receptor status- ER and PR

A

ER- and PR- is a negative prognostic factor (HR+ status usually means tumour is of a lower grade and less aggressive

79
Q

Receptor status- triple negative

A

Poor prognosis

80
Q

Proliferation markers

A

Can be used to asses speed of growth

81
Q

Age of diagnosis

A

Women diagnosed under 35 tend to have more aggressive, high-grade tumours

82
Q

Wide local excision

A

Tumours <2-4cm in diameter or a low tumour to breast volume ratio
Therapeutic mammoplasty can be used to reshape the breast using woman’s own tissue to prevent large defects
All cases of WLE for invasive cancer require post-op radiotherapy
May need repeat surgery if surgical margins not clear

83
Q

Mastectomy

A

For larger tumours or a large tumour to breast vol. ratio
Also used commonly for tumours involving nipple
Indicated for locally advanced tumours including inflammatory cancers
Breast reconstruction

84
Q

Sentinel node biopsy

A

Done if preoperative ultrasound + biopsy of axillary lymph nodes show no abnormality–> only done in DCIS if imaging suggests invasive disease
Blue dye and technetium 99 injected in breast to identify sentinel node which can then be removed and sent for biopsy –> if comes back with cancer cells, clearance or radio

85
Q

Axillary node clearance

A

Done if preoperative ultrasound + biopsy of axillary lymph nodes show suggestion of migration of cancer to axillar nodes
If even one suspected, all nodes removed

86
Q

Breast surgery complications- Musculoskeletal

A

Anaesthesia of armpit
Winged scapula
Frozen shoulder
Stiffness

87
Q

Breast surgery complications- Lymphoedema

A

5-50% women following axillary surgery

–> manual lymphatic drainage, massage, arm elevation, compression garments

88
Q

Breast surgery complications- wound problems

A

Skin flap necrosis
Breakdown wound edges
RFs- smoking, diabetes, obesity, CT disorders

89
Q

Adjuvant therapy

A

Therapy given after surgery to reduce recurrence risk

90
Q

Adjuvant therapy- Low Risk

A

Hormonal therapy only

Node negative, tumour <2cm, grade 1, no lymphovascular invasion, HER2 not overexpressed, age >35

91
Q

Adjuvant therapy- Medium Risk

A

Hormonal therapy if responds, or chemo
Node negative
1 of: tumour >2cm, lymphovascular invation, HER2 overexpressed, age<35

92
Q

Adjuvant therapy- High Risk

A

Hormonal therapy + chemo

Node positive + HER2 overexpressed

93
Q

Neoadjuvant therapy

A

Given before surgery to make surgery possible or easier

Often done for tumours >2cm or nodal involvement

94
Q

Common combination neoadjuvant therapy for aggressive HER2 positive breast cancer

A

trastuzumab
peruzumab
docetaxel

95
Q

Radiotherapy

A

High energy x ray beams directed at cancer cells to kill them
Used to treat residual disease in breast + reduce chance local recurrence

96
Q

Radiotherapy SEs

A 
Erythema
Skin desquamation
Aches and pains
Breast fibrosis
Breast lymphoedema
Rib fractures and pain
Pneumonitis
Brachial plexus discharge
97
Q

High risk cases for Radio

A

Large tumours >5cm
Margins <1cm from pec major or skin
Positive lymph nodes 4+
Lymphovascular invasion

98
Q

ER+ BC

A

Selective oestrogen receptor modulators
Aromatase inhibitors
GnRH agonists
Surgical oophorectomy

99
Q

Tamoxifen

A 
Selective oestrogen receptor modulator
Act as oestrogen antagonists in breast + therefore reduce rate of proliferation of tumours that express oestrogen receptors
Only in ER+ BCs
Act as oestrogen agonists in bone
First line in pre-menopausal
Second line in postmenopausal after AIs
100
Q

Tamoxifen SEs

A

Increased risk endometrial cancer
Increased thrombotic tendency
Hot flushes

101
Q

Aromatase inhibitors examples

A

Anastrozole
Exemestane
Letrozole

102
Q

Anastrozole

A

Aromatase inhibitor

103
Q

Aromatase inhibitors MOA

A

In post-menopausal women, most of circulating oestrogen produced by peripheral aromatisation of testosterone produced by adrenal cortex
Drugs that can inhibit this can therefore reduce circulating oestrogen –> reduced proliferation of ER+ breast cancers
Can’t be used in pre-menopausal as has no activity with ovarian pathway of oestrogen synthesis

104
Q

Aromatase inhibitors SEs

A

GI upset
High cholesterol
Bone pain
Decreased bone mineral density

105
Q

GnRH agonists examples

A

Goserelin

Leuproprelin

106
Q

GnRH agonists

A

Inhibit testosterone + oestrogen production

107
Q

GnRH agonists SEs

A

Infertility

Decreased bone mineral density

108
Q

Surgical oophorectomy

A

Ablation of ovaries

Infertility, decreased bone mineral density

109
Q

Anti-HER2 monoclonal antibodies

A

Trastuzumab (Herceptin) - HF, fever, infection, headache, rash
Pertuzumab- diarrhoea, hair loss, neutropaenia

110
Q

Lapatinib

A

Dual tyrosine kinase inhibitor against HER2 and EGFR- diarrhoea, nausea, fatigue, rash

111
Q

Chemo duration

A

3 weekly for 4-6 months

112
Q

Chemo anti-metabolite

A

Methotrexate

Inhibits folate synthesis

113
Q

Chemo Alkylator

A

Cyclophosphamide

Direct DNA damage

114
Q

Chemo Anthracycline

A

Doxorubicin

Topimerase 2 inhibitor

115
Q

Chemo Taxane

A

Docetaxel

Prevents microtubule disassembly

116
Q

Chemo SEs

A 
Nausea + vom
Sore mouth
Fatigue
Hair loss
Bleeding
Diarrhoea
Oedema
Nail disorders
Weight loss
117
Q

Radio main use

A

Bone metastasis

Can also be used for brain

118
Q

Pain

A

Use opioids

Give laxatives as opioids can cause constipation

119
Q

Bone metastasis + calcium

A

Can cause hypercalcaemia

Give biphosphonates

Met 3b (21 decks)

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