Breast Disease - teaching Flashcards by Ella Harris

Breast surface anatomy

Axillary tail (inferolateral edge of pec major)
Montgomery glands (around areola, modified sebaceous gland)
Areola
Nipple - tends to be 4th ICS in men
Infra-mammary fold (below breasts)

Attached from ribs 2-6 and lateral border of sternum to mid-axillary line

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Breast anatomy - inside

15-20 lobules of glandular tissue within fat
Lobules converge and drain via lactiferous duct to nipple
Lobules seperated by fibrous septa from subcut fascia to chest wall fascia - suspensory ligaments

Lobules same amount, size difference due to fat

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What causes dimpling in breast cancer?

If cancer has invaded suspensory ligaments

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Arterial supply to breast

Axillary artery
Internal thoracic (mammary)
Intercostal artery - branches of 2nd, 3rd and 4th)

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Lymphatic drainage of breasts

Axillary nodes - 75%, 3 levels
Parasternal lymph nodes - <25%

Parasternal never removed with surgery - always chemo

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3 levels of axillary lymph node drainage of breast

Level 1 - lateralto pec minor
Level 2 - behind/deep to pec minor
Level 3 - medial to pec minor

Level 3 most difficult to remove due to it being near neck at apex

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Reasons for pts being reffered to breast clinic

Self examination and then GP
NHS breast screening program
FH or high risk screening
Incidental finding on imaging

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Common signs patients may find which can suggest breast cancer

Lump
Change to skin - puckering/dimpling
Change colour - red/inflamed
Nipple change - inverted
Rash/crusting around nipple
Discharge from nipple
Changes in size/shape of breast
Pain - not usually a sign of cancer esp if cyclical can just be hormonal

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NHS breast screening program

Women aged 50-70
Mammogram
Every 3 years
After 71, can request to continue
Can be done with implants
If abnormal, recalled for another screen or sent for breast clinic appt

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Screening program for moderate/high risk patients

Start at 40 and have annual mammograms
If younger can have annual MRI from 30-40 eg gene mutations p53 have MRI from 20 and BRCA1/2 have from 30

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What is the triple assessment patients undergo at breast clinic?

Clinical assessment - history, examine breast and axilla
Radiological assessment - mammography/USS breast + USS axilla
Pathological assessment - core biopsy, FNAC or VAB

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What to ask about in HPC for breast symptom?

Duration
Cyclical?
Trauma –> can cause fat necrosis of breast
Weight loss/night sweats

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What imaging is used for men?

USS

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PMH, DH, SH and FH for breast symptoms

DH - HRT/COCP?
PMH - Late menopause/early menarche?, Breast disease/surgery/bra size
SH - Smoking/alcohol
FH - First/second degree relative with breast cancer, ovarian, prostate, pancreatic or sarcoma
Jewish?

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Imaging for triple assessment - over 35

Mammogram
Medial-lateral oblique and cranio-caudal views
Check for irregular opacity or microcalcification

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Imaging for women under 35

USS

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Mammogram views

Biopsy options for triple assessment

Core biopsy of breast lesion +/- axilla node - if US showed abnormal/palpable - GOLD STANDARD
Nipple discharge –> smear
FNA for cytology
Vaccum assisted biopsy - VAB
Vaccum assisted excision - VAE

When is VAB and VAE used?

VAB if core biopsy was not adequate/unsure
VAE for pre malignant lesions, remove whole thing at once, no need for surgery

Usually done if B3 on histology score

Histology score for breast tissue

B1 - normal
B2 - benign
B3 - uncertain, probably benign
B4 - suspicious of malignancy
B5 - malignant

Also used for M1-5, U1-5 and P1-5 for mammogram, US and exam findings

Why are fibroadenomas >5cm often excised?

Could be phyllodes tumour
These often benign too but can be very aggressive malignant cancer that behave like sarcomas

RF for breast cancer

MORE EXPOSURE TO OESTROGEN - just think this in an exam eg:
* Female
* Early menarche, late menopause
* HRT, COCP
* Few/no children

Also BRCA1/BRCA2 gene mutation, previous radiotherapy to chest, higj alcohol

Problem with radiotherapy to the chest

Used as treatment for BC but can then increase risk of angiosarcoma - aggressive cancer

Types of breast cancer

DCIS
Ductal carcinoma - “No special type” is majority
Lobular carcinoma
Mixed ductal/lobular
Pagets disease
Inflammatory - LOOKS LIKE MASTITIS, be aware if resistant/chronic mastitis
Rarer - mucinous, tubular, medullary, papillary

DCIS vs ductal carcinoma

* DCIS has not invaded the BM

Lobular CIS vs ductal CIS

* Lobular not typically treated like cancer * BUT DCIS is as high likelihood of progression

Receptors for breast cancer

* Oestrogen * Progesterone * HER2 - human epidermal growth factor * NONE = TRIPLE -ve

Differentiation breast cancer

* 1 - well differentiated, like normal tissue * 2 - moderate * 3 - poor, very abnormal cells

Surgical treatment for breast cancer (breasts)

* Mastectomy - simple, skin sparing or nipple sparing * Breast conserving surgery - wide local excision

What can all breast surgery have with it?

* Partial/reconstruction * Contralateral surgery if need to match breasts

Options for axillary surgery (can have any combo with any breast surgery)

* **Sentinal node biopsy** - done if no US findings in axilla * **Axillary node sampling** - done if cannot have dye for sentinal node * **Axillary node clearance** - done if abnormality found already and tested

Breast reconstruction options

* Implants * Lipofilling - liposuction elsewhere and then fill gap with this * Pedicled flap - using skin under breast and around back to flip around on pedicle under skin, keep original blood supply * Free flap - flap from elsewhere on body, replumb in new blood supply

How is sentinal node biopsy done?

* Dual technique * Patent blue dye and radio-isotope * So looking for bright blue node and high gamma count when removed * Then send for histology

Which is only cancer which doesnt have axillary surgery?

* DCIS * Technically should not be invasive so should not have spread * BUT if when remove cancer and test it has spread beyond BM may need to go back in and do again

Deciding mastectomy vs wide local excision

* Patient preference * Tumout:breast ratio * Location of tumout * MDT * Multi-focal - mastectomy * Risk of local recurrence

Complications of breast surgery

All of the typical surgical ones +: * Fat necrosis * Nipple necrosis

Complications of axillary surgery

* Seroma * Shoulder stiffness * Cording - thick scar tissue * Lymphoedema * Damage to vessels/nerves

Medical treatment options for BC

* Hormone therapy * HER2 inhibtors * CDK4 and 6 inhibitors (cyclin dependent kinase) * Bisphosphonates * Chemotherapy * Radiotherapy - used ALWAYS if wide local excision

Hormone therapy for BC

* ER +ve and pre menopausal - Tamoxifen * ER +ve and post menopausal - aromatase inhibitors eg anastrozole * Can be neoadjuvant or adjuvant for 5+ years

When is chemotherapy used?

* Triple -ve breast cancer * Her2+ve * Can be neoadjuvant or adjuvant

Prognostic calculators for breast cancer

* Predict - website * Nottingham prognostic index - (sizex0.2) + nodal status + grade * Oncotype - for ER+ve, HER2-ve, send off sample to America and it sees how it behaves with chemo

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Breast Disease - teaching Flashcards

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