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Clinical Application > Breast Disease > Flashcards

Breast Disease Flashcards

1
Q

What physiological changes are seen in breast tissue?

A

Prepubertal breast - few lobules
Menarche - increase in no. lobules, increased vol. of interlobular stroma
Menstual cycle - follicular phase lobules quiescent (dormant), after ovulation cell proliferation + stromal oedema, with menstruation see decrease in size of lobules
Pregnancy - increase in size + no. of lobules, decrease in stroma, secretory changes
Cessation of lactation - atrophy of lobules but not to former levels
Increasing age - terminal duct lobular units decrease in no. + size, interlobular stroma replaces by adipose tissue

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2
Q

How can breast conditions present?

A
  • Physiological swelling + tenderness
  • Pain
  • Palpable mass
  • Nipples discharge inc. galactorrhoea
  • Skin changes
  • Nodularity
  • Mammographic abnormalities
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3
Q

What breast conditions cause a pain?

A
  • Physiological changes - cyclical and diffuse pain
  • Ruptured cysts, injury, inflammation - Non-cyclical + focal pain
  • Breast cancer
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4
Q

Which breast conditions cause a palpable mass?

A

Normal nodularity
Invasive carcinomas
Fibroadenomas
Cysts

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5
Q

What is the most worrying type of mass?

A

Hard, craggy and fixed

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6
Q

Which breast conditions cause mammographic abnormalities?

A

Densities - Invasive carcinomas, fibroadenomas, cysts

Calcifications - ductal carcinoma in situ (DCIS), benign changes

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7
Q

What age are women invited for a mammographic screening and how often?

A

Between 47-73 years every 3 years

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8
Q

Is it easier to detect lesions in younger or older women?

A

Older women

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9
Q

Are breast conditions common?

A

Breast symptoms and signs are common. Most will be benign, however Breast cancer is rare before 25 yrs (except in familial cases).

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10
Q

What is the most common benign tumour?

A

Fibroadenoma

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11
Q

At what age do fibroadenomas occur?

A

At any age during reproductive period, often <30yrs

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12
Q

What is a phyllodes tumour?

A

Growth of tumour (stromal proliferation) that causes a hard lump in the breast, can be benign, malignant or borderline

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13
Q

When do Phyllodes tumours mainly present?

A

Most present in the 6th decade, usually at older ages

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14
Q

What is the average age of diagnosis of breast cancer?

A

64 yrs

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15
Q

What are the different classifications of pathological breast conditions?

A 
Disorders of development
Inflammatory conditions
Benign epithelial lesions
Stromal tumours 
Gynaecomastia
Breast Carcinoma
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16
Q

Give examples of inflammatory breast conditions

A

Acute mastitis

Fat necrosis

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17
Q

What is acute mastitis?

A

Bacterial infection of the breast tissue that almost always occurs during lactation. Usually Staphylococcus aureus infection from nipple cracks and fissures.

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18
Q

How does Acute mastitis commonly present?

A

Erythematous painful breast, often pyrexia. May produce breast abscesses.

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19
Q

How is Acute mastitis treated?

A

Usually treated by expressing milk and antibiotics. Stop breastfeeding

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20
Q

How does fat necrosis present?

A

A mass, skin changes or mammographic abnormalities. Often a history of trauma or surgery. Can mimic carcinoma clinically and mammographically

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21
Q

Give an example of a benign epithelial lesion

A

Fibrocystic change

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22
Q

How do people present with a fibrocystic change?

A

A mass of mammographic abnormality with pain and nodularity, usually women aged 20-50yrs. Mass often disappears after fine needle aspiration. Can mimic carcinoma clinically and mammographically

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23
Q

Give some examples of stromal tumours

A 
Fibroadenoma (benign tumour)
Phyllodes tumour
Lipoma
Leiomyoma
Hamartoma
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24
Q

How do people present with fibroadenomas?

A

Peak age = 20-24yrs
Present with a firm, non-tender mass, or mammographic abnormality
The mass is mobile and elusive
Can be multiple and bilateral
Can grow very large and replace most of the breast tissue
Can mimic carcinoma clinically and mammographically

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25
Q

What are the macroscopic features of a fibroadenoma?

A

Well circumscribed, rubbery, greyish/white

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26
Q

What is gynaecomastia?

A

Enlargement of male breast tissue. Can be unilateral of bilateral, can mimic breast cancer if unilateral

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27
Q

When do people usually present with gynaecomastia?

A

Often seen at puberty and in the elderly

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28
Q

What is the general cause of gynaecomastia?

A

-caused by relative decrease in androgen (testosterone) effect or increase in oestrogen effect

29
Q

Give examples of specific conditions that cause the hormonal imbalance leading to gynaecomastia

A
  • neonates=secondary to circulating maternal and placental oestrogens and progesterone
  • transient gynaecomastia common in pubertal boys as oestrogen peaks earlier than that of testosterone
  • Klinefelter’s syndrome
  • Oestrogen excess (cirrhosis of the liver-oestrogen not metabolised properly)
  • Gonadotrophin excess - functional testicular tumour (leydig + sertoli tumours), testicular germ cell tumours
  • Drug related - spironolactone, chlorpromazine, digitalis, cimetidine, alcohol, marijuana, heroin, anabolic steroids
30
Q

What is the most common site of breast cancer?

A

Upper outer quadrant

31
Q

What are the risk factors for breast cancer

A
  • Gender + age ( Older female = increased risk)
  • Uninterrupted menses
  • Early menarche (<11yrs)
  • Late menopause
  • Reproductive history - parity + age
  • Breastfeeding (no breastfeeding = increased risk)
  • Obesity + high fat diet
  • Exogenous oestrogens - HRT slightly increases risk, long-term use of ODP increases risk
  • Breast density (increased density=increased fatty tissue)
  • Geographic influence (US + Europe=increased risk)
  • Atypical changes on previous biopsy (4-5 times)
  • Previous breast cancer
  • Radiation
  • Hereditary breast cancer
32
Q

How do we classify breast carcinoma?

A
  • In situ + Invasive

- Ductal or Lobular

33
Q

What is in situ carcinoma?

A

Neoplastic populations of cells limited to ducts and lobules by basement membrane, myoepithelial cells are preserved
Doesn’t invade into vessels and therefore cannot metastasise or kill the patient

34
Q

Why is ductal carcinoma in situ a problem?

A

Non-obligate precursor of invasive carcinoma. Can spread through ducts and lobules and be very extensive

35
Q

How does a ductal carcinoma in situ (DCIS) often present?

A

Often presents as mammographic calcifications (clusters or linear and branching) but can present as a mass. Histologically often shows central necrosis with calcification.

36
Q

What is Paget’s disease?

A

Eczema- like changes to the skin of the nipple and the area of darker skin surrounding the nipple. It’s usually a sign of breast cancer in the tissue behind the nipple.

Cells can extend to the nipple skin without crossing the basement membrane

37
Q

What’s the difference between invasive carcinoma and DCIS?

A

In IC the neoplastic cells have invaded beyond the basement membrane into the stroma. It can invade into vessels and can therefore metastasise to lymph nodes and other sites.

38
Q

How does invasive carcinoma usually present?

A

A mass or mammographic abnormality. By the time a cancer is palpable, more than half of the patients will have axillary lymph node metastases

39
Q

Define Peau d’orange

A

Involvement of lymphatic drainage of skin

40
Q

How is invasive breast carcinoma classified?

A

Invasive ductal carcinoma, no special type (70-80%)
Invasive lobular carcinoma (5-15%)
Other types - tubular, mucinous

41
Q

Describe well-differentiated type of IDC

A

Tubules are lined by atypical cells

42
Q

Describe poorly-differentiated type of IDC

A

Sheets of pleomorphic cells

43
Q

What is the 10 year survival prognosis of IDC?

A

35-40%

44
Q

What is invasive lobular carcinoma?

A

Infiltrating cells in a single file, cells lack cohesion

45
Q

How does breast cancer spread?

A
  • Lymph nodes via lymphatics - usually in the ipsilateral axilla
  • Distant metastases via blood vessels - bones, lungs, liver, brain
  • Invasive lobular carcinoma can spread to odd sites - peritoneum, retroperitoneum, leptomeninges, gastrointestinal tract, ovaries, uterus
46
Q

What factors determine prognosis in breast cancer?

A
  • In situ or invasive carcinoma
  • Tumour stage - TNM
  • Tumour grade
  • Histological subtype - IDC NST has poor prognosis
  • Molecular classification and gene expression profile
47
Q

Which is worse Grade 1 or Grade 3 and why?

A

Grade 3 because grade refers to the differentiation (how much resembles tissue of origin). Grade 3 is poorly differentiated, which means the cancer cells look very different from normal cells and so are more likely to invade and metastasise.

48
Q

Does someone who has oestrogen receptor positive breast carcinoma have a better prognosis than someone with oestrogen receptor negative breast carcinoma?

A

Yes, regardless of whether they are HER2 positive or negative. Oestrogen receptor positive peaks at age 50 (earlier compared to 70) and has a better prognosis.

Oestrogen receptor positive + HER2 positive = best

49
Q

What phenotype do most BRCA1 tumours have and is the prognosis good or bad?

A

Oestrogen receptor negative + HER2 negative + Basal like phenotype. Poor prognosis and is associated with high grade lesions

50
Q

What is a gene expression profile and why is it important in breast cancer?

A

Microarrays that are used to examine expression patterns of some 25,000 genes in tissues from breast cancer patients.

Computer cluster analysis the patterns identified 17 marker genes that can correctly identify about 90% of women who would eventually develop metastases. Women who are identified as having a metastatic potential can be treated with more aggressive therapy, whereas women with no metastatic potential can be treated with conservative therapy.

51
Q

How do we investigate and diagnose breast cancer?

A

Triple approach

  • Clinical (history, family history, examination)
  • Radiographic imaging (mammogram + ultrasound)
  • Pathological (core biopsy + fine needle aspiration cytology)
52
Q

What is the aim of mammographic screening?

A

To detect small impalpable cancers and pre-invasive cancer. They look for asymmetric densities, parenchymal deformities + calcifications

53
Q

What are the therapeutic approaches in breast cancer?

A

Local and regional control - breast surgery, axillary surgery, post-operative radiotherapy to chest + axilla

Systemic control - chemotherapy, hormonal treatment, herceptin treatment (depends on HER receptor status)

54
Q

What is sentinel lymph node biopsy?

A

Intraoperative lymphatic mapping with dye +/or radioactivity of draining or ‘sentinel’ lymph nodes - the one most likely to contain breast cancer. It reduces the risk of post-operative morbidity

55
Q

What is HER2?

A

HER2 is a member of the human epidermal growth factor receptor family. It encodes a transmembrane tyrosine kinase receptor

56
Q

What drug is used to target HER2 receptors?

A

Herceptin (trastuzumab), which is a humanised monoclonal antibody against the Her2 protein

57
Q

How do we improve survival from breast cancer?

A
  • Early detection - importance of family history, self-examination, mammographic screening
  • Neoadjuvant chemotherapy - early treatment of metastatic disease
  • Use of newer therapies - Herceptin
  • Gene expression profiles
  • Preventionin familial cases - genetic screening, prophylactic mastectomies
58
Q

What is Thelarche?

A

Pubertal breast development due to variance in hormones

59
Q

When are nodularity symptoms greatest?

A

about 1 week before menstruation and decrease when it starts

60
Q

What is cyclical mastalgia?

A

breast pain related to hormonal variations associated with the menstrual cycle. Some degree of tenderness and nodularity in the premenstrual phase is common, it rapidly resolves once menstruation starts.

61
Q

What are certain characteristics of a benign mass?

A

Usually 3D, mobile + smooth, has regular borders and is sold or cystic in consistency.

62
Q

At what ages are cysts common?

A

35-50yrs

63
Q

Can cysts be distinguished from solid tumours in a clinical examination?

A

No, they too are palpable discrete lumps

64
Q

What are fibroadenomas comprised of?

A

Fibrous and epithelial tissue

65
Q

What can increase the incidence of fibroadenomas?

A

Hormone Replacement Therapy (HRT)

66
Q

How do people often present with breast abscesses?

A

Point tenderness, erythema and fever

67
Q

What bacteria causes breast abscesses?

A

Staph or Strep

68
Q

When would you refer someone to a specialist breast clinic?

A

Aged ≥30 and have an unexplained breast lump with or without pain

Aged ≥50 and any of the following symptoms in one nipple only:

  • discharge
  • retraction
  • other changes of concern

Skin changes that suggest breast cancer (urgent)

Aged 30+ with an unexplained lump in the axilla (urgent)

Under 30 with an unexplained breast lump with out without pain (non urgent)

Clinical Application (9 decks)

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