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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
FNA Advantages
Quick and easy Results available fast (30mins) Samples large area
26
FNA Disadvantages
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
27
Core biopsy
Sample of cells within the breast architecture using a wide bore needle which can then be examined under microscopy
28
Core biopsy advantages
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
29
Core biopsy disadvantages
More bruising and pain | Results take longer (24-48hrs)
30
Distant disease
Cause of 90% of deaths from breast cancer
31
Most common site of metastasis
Bone Severe and progressive pain Pathological features Erythema over affected bone
32
Metastasis Lungs
Chronic cough Dyspnoea Abnormal CXray Chest pain
33
Metastasis Brain
``` Persistent, progressively worsening headache Visual changes Seizures Nausea or vomiting Vertigo Behavioural + personality changes Increased intracranial pressure ```
34
Metastsis liver
``` Jaundice Elevated liver enzymes Abdo pain Loss of appetite Nausea + vomiting ```
35
Systemic symptoms of metastatic disease
Fatigue Malaise Weight loss Poor appetite
36
Scoring system using 3x assessment- modalities
``` Clinical assessment (palpation)- P Mammography- M Ultrasound- U Biopsy- B Cytology- C ```
37
Modality scoring 1
Normal appearance (or inadequate assessment e.g. needle doesn't hit its target in FNA)
38
Modality scoring 2
Consistent with a benign lesion
39
Modality scoring 3
Atypical or indeterminate but probably benign
40
Modality scoring 4
Suspicious of malignancy
41
Modality scoring 5
Consistent with a malignant lesion
42
Evidence of role of breast screening programmes
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
43
Incidence BC
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+
44
BC mortality
3rd most common cause of cancer death 5 year survival 77% 65% ppl with breast cancer will survive 20 years or more
45
BC RFs
``` 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 ```
46
Risk reduction strategies
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
47
Anastrozole, exemestane, letrozole
Aromatase inhibitors
48
Aromatase inhibitors
Anastrozole, exemestane, letrozole
49
Non invasive carcinoma in situ
Has not progressed beyond basement membrane
50
Non invasive carcinoma in situ examples
Ductal carcinoma in situ (DCIS) | Lobular carcinoma in situ (LCIS)
51
Ductal carcinoma in situ
Non invasive | Cancer of epithelial cells of breast ducts
52
Lobular carcinoma in situ
Non invasive | Cancer of epithelial cells of breast ducts
53
Invasive carcinoma
Has spread beyond the basement membrane Infiltrating ductal carcinoma Infiltrating lobular carcinoma
54
Infiltrating ductal carcinoma
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
Infiltrating lobular carcinoma
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
Paget's disease of breast
Adenocarcinoma that mainly affects nipple | Associated with underlying parenchymal cancer (usually IDC or more uncommonly DCIS)
57
Lymphoma
Large number of lymph nodes within breast so lymphoma can occur
58
Inflammatory carcinoma
Uncommon
59
Malignant Breast cancer presentation- Mass
Often non-tender Often hard, fixed to skin/muscle, irregular texture, poorly defined margins Doesn't change with menstrual cycle
60
Malignant Breast cancer presentation- Skin changes
Thickening of skin Oedema--> peau d'orange Erythema + other discolouration
61
Malignant Breast cancer presentation- lymph nodes
Enlarged in axilla
62
Malignant Breast cancer presentation- Nipple changes
``` Inversion Discharge (often bloody, spontaneous and one duct only) ```
63
Malignant BC imaging
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
Malignant BC Biopsy
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
Grading BC
``` 1= well differentiated 2= moderately differentiated 3= poorly differentiated ```
66
Staging BC
``` T= tumour (X-4d) N= nodal involvement (X-3) M= metastasis (X-1) ```
67
Staging BC- T
``` 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
Staging BC- N
N0- no nodal involvement | N1-3= metastasis to increasing number of nodes
69
Staging BC- M
M0- no evidence | M1= distant metastasis >0.2m
70
Oestrogen + progesterone receptors in BC
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
HER2 in BC
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
Tumour size- stage
Larger size increases risk of nodal involvement + recurrent risk
73
Lymphatic + vascular invasion- stage
Increases risk of local + distant invasion --> worse prognosis
74
Nodal involvement- stage
Any nodal involvement suggests local advancement of disease--> worse prognosis
75
Distant metastasis- stage
Decreases change of recovery and remission
76
Grade
Higher grade tumours have worse prognosis compared to lower grade as tend to grow slower + less likely to spread
77
Receptor status- HER2
HER2+ is a negative prognostic factor --> increased tumour aggressiveness and rate of recurrence
78
Receptor status- ER and PR
ER- and PR- is a negative prognostic factor (HR+ status usually means tumour is of a lower grade and less aggressive
79
Receptor status- triple negative
Poor prognosis
80
Proliferation markers
Can be used to asses speed of growth
81
Age of diagnosis
Women diagnosed under 35 tend to have more aggressive, high-grade tumours
82
Wide local excision
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
Mastectomy
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
Sentinel node biopsy
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
Axillary node clearance
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
Breast surgery complications- Musculoskeletal
Anaesthesia of armpit Winged scapula Frozen shoulder Stiffness
87
Breast surgery complications- Lymphoedema
5-50% women following axillary surgery | --> manual lymphatic drainage, massage, arm elevation, compression garments
88
Breast surgery complications- wound problems
Skin flap necrosis Breakdown wound edges RFs- smoking, diabetes, obesity, CT disorders
89
Adjuvant therapy
Therapy given after surgery to reduce recurrence risk
90
Adjuvant therapy- Low Risk
Hormonal therapy only | Node negative, tumour <2cm, grade 1, no lymphovascular invasion, HER2 not overexpressed, age >35
91
Adjuvant therapy- Medium Risk
Hormonal therapy if responds, or chemo Node negative 1 of: tumour >2cm, lymphovascular invation, HER2 overexpressed, age<35
92
Adjuvant therapy- High Risk
Hormonal therapy + chemo | Node positive + HER2 overexpressed
93
Neoadjuvant therapy
Given before surgery to make surgery possible or easier | Often done for tumours >2cm or nodal involvement
94
Common combination neoadjuvant therapy for aggressive HER2 positive breast cancer
trastuzumab peruzumab docetaxel
95
Radiotherapy
High energy x ray beams directed at cancer cells to kill them Used to treat residual disease in breast + reduce chance local recurrence
96
Radiotherapy SEs
``` Erythema Skin desquamation Aches and pains Breast fibrosis Breast lymphoedema Rib fractures and pain Pneumonitis Brachial plexus discharge ```
97
High risk cases for Radio
Large tumours >5cm Margins <1cm from pec major or skin Positive lymph nodes 4+ Lymphovascular invasion
98
ER+ BC
Selective oestrogen receptor modulators Aromatase inhibitors GnRH agonists Surgical oophorectomy
99
Tamoxifen
``` 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
Tamoxifen SEs
Increased risk endometrial cancer Increased thrombotic tendency Hot flushes
101
Aromatase inhibitors examples
Anastrozole Exemestane Letrozole
102
Anastrozole
Aromatase inhibitor
103
Aromatase inhibitors MOA
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
Aromatase inhibitors SEs
GI upset High cholesterol Bone pain Decreased bone mineral density
105
GnRH agonists examples
Goserelin | Leuproprelin
106
GnRH agonists
Inhibit testosterone + oestrogen production
107
GnRH agonists SEs
Infertility | Decreased bone mineral density
108
Surgical oophorectomy
Ablation of ovaries | Infertility, decreased bone mineral density
109
Anti-HER2 monoclonal antibodies
Trastuzumab (Herceptin) - HF, fever, infection, headache, rash Pertuzumab- diarrhoea, hair loss, neutropaenia
110
Lapatinib
Dual tyrosine kinase inhibitor against HER2 and EGFR- diarrhoea, nausea, fatigue, rash
111
Chemo duration
3 weekly for 4-6 months
112
Chemo anti-metabolite
Methotrexate | Inhibits folate synthesis
113
Chemo Alkylator
Cyclophosphamide | Direct DNA damage
114
Chemo Anthracycline
Doxorubicin | Topimerase 2 inhibitor
115
Chemo Taxane
Docetaxel | Prevents microtubule disassembly
116
Chemo SEs
``` Nausea + vom Sore mouth Fatigue Hair loss Bleeding Diarrhoea Oedema Nail disorders Weight loss ```
117
Radio main use
Bone metastasis | Can also be used for brain
118
Pain
Use opioids | Give laxatives as opioids can cause constipation
119
Bone metastasis + calcium
Can cause hypercalcaemia | Give biphosphonates

Met 3b (21 decks)

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