Breast Disease Flashcards
Clinical presenting features for breast cancer
Physiological swelling & tenderness (thelarche, one breast can delvelop more than the other)
Nodularity
Breast pain/ mastalgia - non-cyclical, unilateral, persistent
Palpable breast lumps
Nipple discharge including galactorrhoea (especially unilateral, blood stained)
Breast infection & inflammation usually associated with lactation
What is benign breast disease?
Fibrocystic change most common benign breast disorder ✅fine needle aspiration, can get apocrine metaplasia
20-50yrs usually, hormonal aetiology (more painful before/ during period)
Smooth, mobile, regular borders, not tethered
Solid - fibroadenomas
Cystic - cysts (35-50yrs)
Both present as density on mammogram, along with invasive carcinomas
Calcification on mammogram - could be benign changes or ductal carcinoma in situ
What are fibroadenomas?
Benign tumours
20-24yrs peak
Most common breast lesion
Arise in breast lobules, fibrous & epithelial tissue
Firm, non tender, highly mobile palpable lumps, smooth
Hormones involved & HRT increases incidence
What is mammary duct ectasia ?
Unknown aieteiology
Dilation of major ducts filled creamy secretion with periodical inflammation
May Asymptomatic or nipple discharge (bloody, serous, creamy white or yellow), retracted nipple, acute inflammation, recurrent chronic inflammation with abscess formation
✅surgical excision of major duct, correction nipple retraction
What is intraductal papilloma?
Benign growth single milk duct
Spontaneous discharge unilateral
Infections of breast
Periductal Mastitis- generalised cellulitis ✅ antibiotics
Breast abscess - point tendencies, erythema, fever, related to lactation, non-lactation always abscess more frequent smokers, caused staph ✅I&D or strep (more diffuse, superficial) ✅local wound care & abx
When to refer?
_>30yrs unexplained breast lump
_>50yrs any following unilateral: discharge, retraction, other changes of concern (e.g. swollen LNs)
New nipple retraction
Peak d’orange - involvement lymphatic drainage of skin (looks like orange peel)
Consider:
Skin changes suggests breast cancer
_>30yrs unexplained lump axilla
Consider Non-urgent referral:
<30yrs unexplained breast lump
Stages of grief
Stability Immobilisation Denial Anger Bargaining Depression Testing Acceptance
Move between stages
What does normal breast tissue look like histologically?
See slide 4
What physiological changes are seen in breast tissue?
Prepubertal breast - few lobules
Menarche - increase number lobules, increased volume interlobular stroma
Menstrual cycle - follicular phase lobules quiescent, after ovulation cell proliferation & stromal oedema with menstruation decrease size lobules
Pregnancy - increase size/ number lobules, decrease stroma, secretory changes - cessation of lactation (atrophy lobules)
Increasing age - terminal duct lobular units decrease number/ size, interlobular stroma replaced adipose tissue
What is the phyllodes tumour?
Similar stromal presentation as fibroadenomas
Usually 6th decade presentation
What is acute mastitis?
Almost always during lactation
Usually staphylococcus aureus from nipple cracks & fissures
Erythematous painful breast, often Pyrexia
May produce breast abscess
✅expressing milk, antibiotics
What is fat necrosis?
Inflammatory condition
Mass, skin changes or mammographic abnormality
History trauma/ surgery
Mimic carcinoma clinically and mammographically
What stromal tumours can present in breast?
Fibroadenomas, phyllodes tumours, lipoma, leiomyoma, hamartoma
Mass, usually mobile, mammographic abnormality, multiple, bilateral, rubbery,
can mimic carcinoma
Localised hyperplasia
What is gynaecomastia?
Enlargement makes ebreast
Often at Puberty (transient, more half boys, oestrogen peaks) and elderly (reduced testosterone)
Caused: relative decrease androgen effect or increase in oestrogen effect, klinefelter’s syndrome, cirrhosis of liver (oestrogen XS), gonadotrophin XS (functioning testicular tumour), drug related (spironolactone, chlorpromazine, marijuana, heroin, anabolic steroids)
Can mimic Male breast cancer especially unilateral
What makes up 95% of breast cancers?
Adenocarcinomas
Risk factors for breast cancer
Female Uninterrupted menses Early menarche Late menopause Reproductive history - never pregnant Not Breast feeding Obesity/ high fat diet Western countries Atypical changes previous biopsy Previous breast cancer Radiation Hereditary (10% e.g. BRCA1/2, ovarian cancer, p53)
exogenous oestrogens - HRT, long term OCP
Breast density higher - more ducts, harder to detect
Men:
Transgender male to female, klinefelter’s syndrome, men treated oestrogen for prostate cancer
How do we classify breast carcinoma?
In situ -neoplastic population limited to ducts & lobules by basement membrane, myoepithelial cells are preserved (ductal carcinoma IS pre-cursor of invasive carcinoma, can spread, often central necrosis with calcification)
Invasive - neoplastic cells invaded beyond BM into stroma, can invade vessels & metastasize to LNs/ other sites
Ductal -
Lobule -
What is Paget’s disease?
Cells can extend to nipple skin without crossing BM
Unilateral red and crusting nipple
Eczematous/ inflammatory conditions regarded suspicious & need biopsy
How is invasive breast carcinoma a classified?
I Ductal c (IDC, NST), 75%, tubule slimed atypical cells, poorly differentiated, sheets pleomorphic cells, 35-50% 10yr survival
See slide 39/ 40
Invasive lobular carcinoma - 5-15%, infiltrating cells in single file, cells lack cohesion, 35-50% 10yr survival
See slide 41
Others: tubular, mucinous (older) both good prognosis
How does breast cancer spread?
LNS - ipsilateral axilla normally
Distant metastases - blood vessels, often bones, lungs, liver, Brian
Invasive lobular carcinoma - spread odd sites e.g. peritoneum, GiT, ovaries, uterus
Molecular classification of breast cancer?
Oestrogen positive/ negative (worse)
Her2 positive/ negative (worse)
How does mammographic screening work?
47-73yrs
2view mammogram every 3yrs
Detect small impalpable Cancer & pre-invasive cancer
Asymmetric densities, parenchyma, deformities, claicfications
Further imaging, core biopsy, FnAC
Therapeutic approaches to breast cancer
- mastectomy/ breast conserving surgery
- axillary surgery - depending whether there are involved nodes (sentinel node sampling or axillary dissection. Lymphatic mapping dye)
- post-op radiotherapy to chest and axilla
- chemotherapy
- hormonal treatment e.g. tamoxifen (increased risk thromboembolism/ endometrial cancer) depending on oestrogen receptor status
- herceptin depending on Her2 receptor status positive
