Breast Diseases Flashcards
is breast cancer the most common cancer in women
yes
what is the most common type of invasive and in situ carcinoma
80% ductal type
what is the prognosis of breast cancer
5 year: 86% for all stages 97% localised 78% regional involvement 23% metastatic
what are the risk factors for breast cancer
being female increasing age genetic mutations atypical ductal or lobular hyperplasia lobular carcinoma in situ atypical epithlial hyperplasia first child after 30 alcohol early menarche FMHx previous breast cancer nulliparity postmenopausal obesity alcohol hormone replacement radiation exposure
what lifestyle changes reduce rsk of breast cancer
routine vigorous physical activity
maintenance of health body weight
what are the common breast cancer presentation symptoms
50% asymptomatic - screening
50% symptomatic- half of these have a lump
dimple of depressed skin visible lump nipple change or external inversion bloody discharge texture change colour change
what is the triple assessment for breast disease (for symptomatic patients)
Hx
exam +/- mammogram (standard, do 4 views) +/- USS (can see if solid or cystic)
biopsy (histology to see if invasive, ductal or lobular, degree of differentiation, receptor status)
what is the staging for breast cancer
T0 no tumour T1 <2cm T2 2-5cm T3 >5cm T4 extension to skin or chest wall/ both
N1 mobile nodes
N2 fixed nodes
N3 ipsiplateral internal mammary nodes involves
M0 no distant mets
M1 mets demonstrable
Mx mets suspected but not confirmed
is disseminated breast cancer curable
no
are the majority of breast Cxs early or late stage
early
what is the treatment overview for early breast cancer
local- surgery, radio
systemic- chemo, hormonal, targeted therapies
what is oncoplastic surgery
uses plastic surgery techniques for wider excisions to conserve more of the breast, leaves symmetrical breasts
oncoplastic prodedures shape the breasts
is radio therapy local or systemic treatment
local
what is a modified radical mastectomy
total mastectomy
removes entire breast inc overlying skin and axillary lymph nodes
preserves pec major which facilitates wound healing and allows reconstruction
what are the options available for breast reconstruction
most women who get mastectomy are eligible
can be prosthetic or autologous tissue
both these can be done immediately or delayed
skin sparing mastectomy provides better aesthetic outcome after reconstruction
choice of the reconstruction method depends upon:
-patient’s body habitus
-co-morbidity
-smoking history
-size and shape of her breasts
-her preference
-surgeon’s experience
what are the indications or post mastectomy radiotherapy
involvement of >3 nodes
positive surgical margins
and/ or tumours larger than 5 cm
when can partial breast radiotherapy be given
intra op or post op (breast conserving therapy)
what are the adjuvant systemic therapies for breast cancer
chemo (adjuvant, neoadjuvant)
hormonal therapy
targeted therapy
what drug is most commonly used for hormonal therapy for breast cx
tamoxifen
why do lose your hair while getting chemo
kills everything in end phase- hair follicles, lining of gut
what are the forms of hormonal therapy for breast cancer
non invasive- -SERM= selective estrogenic receptor modulators,
- aromatase inhibitors (stop production of oestrogen)
- GnRH (blocks hypothalamic pathway for ovarian stimulation)
invasive:
-oophrectomy (rarely done now for breast Cx)
what receptor is implicated int he pathogenesis of breast cancer as is acted upon by the targeted therapies
HER-2
human epidermal receptor
what is herceptin
human epidermal growth factor receptor 2 monoclonal antibody
= trastuzumad
targets HER2
what are bevacizumab and lapatinib
other biological therapies for breast cx
bevaciumab is a monoclonal antibody that targets vascular endothelial growth factor, first line for metastatic breast cancer
lapatinib- dual inhibitor of epidermal growth factor receptor and human epidermal growth factor 2 tyrosine kinases. used in advanced disease when other biological treatments have already been used
where does breast cancer spread to
bone
liver
brain
lung
what can be done for late or advanced breast cancer
palliative chemo or radio therapy to relieve symptoms
are 80% of symptomatic breast cases benign or malignant
benign
what are the causes of benign breast disease
hormonal changes
infective/ inflammatory changes
aberrations in the normal development and involution of the breast (ANDI)
what conditions can be caused by ANDI
cysts
fibroadenoma
papilloma
what is a fibroadenoma
most common benign neoplasm of the breast
what is the presentation of a fibroadenoma
palpable mass 1-3 cm early reproductive years (15-25) on exam: -rubbery to firm -mobile -smooth -distinct borders -usually non tender
how do you diagnose a fibroadenoma
USS core biopsy
what is the management of fibroadenoma
dont need to be removed, most reabsorb and usually become nonpalpable after the menopause
some women prefer to have them removed- lumpectomy/ percutaneous vacuum assisted core biopsy under LA
what tumour can a fibroadenoma mimic- how do you tell them apart
phyllodes (these are uncommon) phyllodes are: larger 3-6cm occur in older women (35-45) increase in size
what is the management for a phyllodes tumour
as can be benign, intermediate or malignant need histology
tumour should be excised with wide 1cm clear surgical margins
follow up
mets rare
what is the presentation of a breast cyst
common in late reproductive years
palpable, clearly defined, soft, smooth, mobile with distinct borders
often tender, especially before menstruation
may be mulitpl and/ or bilateral
what is the management of a breast cyst
USS
can leave or
FNA aspiration (for diagnosis and Tx)
if fluid grossly bloody then cytology needed
palpate after aspiration to ensure no residual mass
what are breast cysts
milk duct that rapidly fill with fluid then cant drain
what condition can occur within breast cysts
papillomas, esp associated with a bloddy filled cyst
what is a papilloma
benign intracystic papillary proliferation
what is a intracystic carcinoma (malignant papilloma suspected)
when fluid in cyst is grossly bloody/ residual mass after aspiration
what histological diagnosis for any intracystic solid lesion
ultrasound guided core biopsy
what is mastalgia
breast pain
dull, heavy, achy
begins up to 2 weeks before a period, gets worse immediately premenstrual then improves usually as it ends
cyclic mastalgia is usually bilateral
can be noncyclic: tends to be localised, persistent, less resposive to Tx than cyclical
is mastalgia associated with malignancy
no
what are the non breast causes of anterior chest wall pain
Achalasia Angina Cervical radiculitis Cholecystitis Cholelithiasis Coronary artery disease Costochondritis (Tietze syndrome) Fibromyositis Hiatal hernia Myalgia Neuralgia Osteomalacia Phantom pain Pleurisy Psychological pain Pulmonary embolus Pulmonary infarct Rib fracture Sickle cell disease Trauma Tuberculosis
what causes cyclic mastalgia
intense variant of physiological changes that occur to breast during menstrual cycle
what Ix for cyclical mastalgia
complete evaluation and mammogram well fitting bra, regular exercise primrose oil topical NSAID dialy pain chart
when is nipple discharge pathological
(most women of repro age can elicit clear, watery yellow discharge)
if it is bloody and particularly from a single duct
what is the most common cause of nipple discharge
intraductal papilloma/ papillomas (benign lesions)
excise all so dont miss intraductal carcinoma
when is nipple discharge associated with malignancy
when there is a palpable mass
however all intraductal lesions should be excised and histologically evaluated
what Ix for pathological nipple discharge
mammography
USS
surgical excision of discharging ducts
what is pagets disease of the nipple
variant of ductal carcinoma
how does pagets disease of the nipple present
erythematous weeping lesion on surface of nipple and areola
dry, scaly
patient may perceive this as nipple discharge
how do you diagnose pagets disease of the nipple
biopsy (incisional or punch)
often underlying palpable mass/ radiological abnormality
what management for mastitis
Abx for staph aureus e,g, flucloxacillin
examined every three days to see response and ensure no abscess formation
lack of response -> change abx
what are the symptoms of mastitis
fever erythema induration tenderness swelling
can you breast feed when you have mastitis
yes continue if already begun or breast can be pumped until infection clears
how does a breast abscess present
bulging mass in the central area of mastitis
fluid filled centre on USS
management for a breast abscess
aspiration under LA for diagnosis (pus filled) and Tx
aspirate sent for microbial analysis
may need repeated aspiration/ surgical drainage
antibiotics continued until cellulitis has cleared
what organisms cause nonpuerperal mastitis
S aureus
peptostreptococcus magnis
bacteriodes fragilis
is nonpuerperal mastitis common
no esp in postmenopausal women
management for nonpuerperal mastitis
re-examined every 3 days until the infection clears. Augmentin 625 mg orally every 8 hours for 7 days as initial therapy is usually effective. Alternately, cephalexin 500 mg orally every 6 hours for 7 days can be prescribed.
what is chronic mastitis associated with
(uncommon)
subareolar abscess
what is a complication of chronic mastitis
periareolar fistulae
when should you suspect malignancy in mastitis
if inresponsive to Abx and spread over entire breast
inflammatory carcinoma
what makes mastitis more likely to develop into an abscess
poor immune system- diabetes, smoking
what is an adenolipoma
aka hamartoma- benign breast lesion, Circumscribed lesion composed of cell types normal to the breast but present in an abnormal proportion or distribution
what is a galactocele
a palpable milk-filled cyst most commonly associated with pregnancy or lactation. FNA can diagnose and drain a galactocele
what is mondors disease
phlebitis (vein inflammation) and subsequent clot formation in the superficial (skin) veins of the breast
usually resolves spontaneously in 8–12 weeks
how does mondors disease present
firm, vertical, cord-like structure usually associated with a history of trauma to the breast
