Breast & endocrine Flashcards
High risk family history of breast cancer
3+ family members with breast cancer
OR
2+ members with breast cancer (one with bilateral disease)
OR
1+ immediate family member with breast cancer younger than 40y/o at diagnosis
Percentage of breast cancers confirmed by triple assessment
Over 90%
Why is mammogram more efficient in older women than younger
Depends on fat replacement to tell dense changes compared to loose surrounding fat
Dense breasts make mammography less sensitive to small change
Benefits of breast ultrasound
- Determines if lesion is solid OR fluid-filled OR both
- Used in younger patients, and as a supplemental imaging with mammography
- Can also be used to guide biopsy
Findings of breast fibroadenoma on imaging
Elliptical shape
Regular
Findings of breast carcinoma on imaging
Invasive, irregular, shadowing
What does the triple test for breast cancer entail
Clinical examination
Imaging (mammogram or USS)
Fine needle biopsy
What to do if triple assessment is discordant in work up of breast lesion
Perform core or open biopsy to confirm diagnosis
What to do with results for breast lesion FNA
Cellular and benign - accept unless inconsistent with imaging (repeat with core biopsy)
Cellular atypia - core or open biopsy
Suspicious - repeat with core or open biopsy
malignant - progress to treatment
Management of breast cancer
Wide excision of primary tumour + mastectomy OR radiotherapy to remaining tissue
Surgical removal of sentinel nodes for assessment of local spread and need for adjuvant tx
Metastasis: chemotherapy, hormonal therapy (tamoxifen), herceptin
Indications for breast conserving surgery
Early breast cancer
Small cancers (less than 3cm or less than 4cm in large breasts)
Need for small excision without cosmetic detriment
Single tumours
T1-2 minimal nodal involvment, MO
Contraindications for breast conserving surgery in breast cancer
T4, N2 or M1 Patient choice Strong family history (e.g. BRCA) Incomplete excision Multi-centric cancers
Indications for total mastectomy
Large cancer, small breasts Extensive nodal disease Multiple cancers Patient Choice Following attempted, failed breast conserving surgery
Complications of axillary clearance
Seroma Infection Injury to motor and/or sensory nurves Lymphoedema reduced shoudler mobility
Indications for radiotherapy in breast cancer
Inoperable cancer
- after conservative surgery
- post-mastectomy (involved nodes, extensive primary, vascular invasion)
Advanced local disease
Metastatic disease (palliation of bone disease and local recurrence)
Types of systemic therapy in breast cancer
Chemotherapy Hormone therapy (e.g. tamoxifen) Biological therapy (e.g. herceptin)
Clinical features of breast fibroadenoma
Detection of mobile lump on self-examination
May grow during pregnancy
Well-defined mobile mass (breast mouse)
Usually in upper outer quadrant
Ultrasound of breast fibroadenoma
Well-circumscribed, round-ovoid mass, generally uniform hypoechogenicity
Management of breast fibroadenoma
Core biopsy or follow-up in 6 months
Surgical excision if symptomatic or patient choice
- cryoablation also an option
If increase in size, excise to exclude malignant change
Clinical features of intraductal papilloma of breast
Nipple discharge (bloody or clear) for less than 6 months (spontaneous and intermittent), sense of fullness below the nipple relieved by passage of discharge
Imaging findings in intraductal papilloma of breast
Often normal
May have dilated duct(s), circumscribed benign appearing mass or cluster of suspicious calcifications
Solid hypoechoic mass on ultrasound
Galactography - filling defect or other ductal abnormality e.g. ectasia, obstruction or irregularity
Causes of breast abscesses
RARE
most common in breast-feeding women as a complication of mastitis (primiparous women especially)
higher incidence in diabetes
Common bacterial causes for breast abscess
Staph aureus
Staph epidermidis
Proteus mirbilis
Classifications of breast abscess
Puerperal abscess (breastfeeding) Non-puerperal central abscess (mostly young women, smokers) Non-puerperal peripheral abscess (less common, older women with underlying medical conditions e.g. DM, RA, steroids or post-breast intervention)
Management of breast abscess
Continue feeding or expression of milk
Antibiotics and drainage
Definition of fat necrosis
An ill-defined breast lump produced by a benign inflammatory process caused by necrosis and saponification of fatty tissues secondary to trauma
Causative factors of fat necrosis of breast
Direct trauma
- Seatbelt
- breast biopsy
- breast surgery
- injury
Clinical features of fat necrosis
history of trauma to breast
Tender mass
Solitary irregular ill-defined mass
Skin retraction
imaging of fat necrosis of breast
MG: Ill-defined, irregular, spiculated mass +/- peripheral calcification
USS: hypoechoic mass +/- mural nodules
Management of fat necrosis of the breast
Excisional biopsy to exclude malignancy
Follow up evaluation
minimise risk of trauma
epidemiology of galactoceles
most common benign breast lesion
typically occurs in young lactating women, on cessation of lactation
RF: breast feeding, mastitis, galactorrhoea, abrupt weanint
Clinical features of galactocele
Painless mass in central portion of breast occurring over weeks to months
Non-tender
Thick, creamy material on aspiration
management of galactocele
No specific therapy required
Will subside in a few weeks
Needle aspiration or drainage with gentle pressure if complicated by infection
Mammary duct ectasia definition
Dilation of ducts of breast with inspissation of normal secretions, arising from chronic intraductal and periductal inflammation causing fibrosis
Clinical features of mammary duct ectasia
thick grey-black nipple discharge
Pain and nipple tenderness
Palpable mass with skin retraction
Firm, rounded, fixed mass
Imaging of duct ectasia
MG: dilated linear branching densities in subareolar region, rod-like calcifications pointing towards nipple
US: dilated, fluid filled subareolar ducts with moving echogenic debris (often mimics intraductal papilloma)
Management of mammary duct ectasia
Surgical excision with a cone of surrounding tissue if warranted by patients symptoms
Lifetime risk of breast cancer if BRCA1 or 2 positive
50-85%
gene mutation present in 5-10% of all breast cancers
Risk factors for breast cancer
70% OF BREAST CANCER IS IN WOMEN WITH NO KNOWN RISK FACTORS
- older age
- family history
- BRCA1 or BRCA2
- hormonal factors (early menarche, late menopause, late parity, multiparity, HRT)
- radiation exposure
- benign breast disease
Protective factors for breast cancer
Prolonged breast feeding
Avoidance of alcohol and reducing dietary fat
Maintaining a slim body and exercise
Biological markers in breast cancer
Oestrogen and progesterone (if +ve more likely to respond to hormone therapy)
HER2 gene amplified - more likely to respond to herceptin therapy
What are the most common malignancies of the breast
- Infiltrating ductal carcinoma
2. Infiltrating lobular carcionma
Most common location of malignant breast lesions
Upper outer quadrant
Differences between clinical features of lobular and ductal infiltrating carcinomas of the breast
Lobular more likely to be bilateral/contralateral
Lobular more likely to be larger (due to histology, difficult to palpate smaller mass)
Slightly overall higher survival rates for lobular than for ductal
Most common types of thyroid cancers
Papillary carcinomas (80%) Follicular carcinomas (10%) Medullary thyroid carcinomas (5-10%) Anaplastic carcinomas Primary thyroid lymphomas Primary thyroid sarcomas
Risk factors for papillary carcinoma of the thyroid
OCP use
Benign thyroid nodules
Late menarche
Nulliparity/late age at first birth
May be associated with uncommon familial syndromes
Most common thyroid cancer associated with radiation to head and neck
Most common thyroid cancer in children
NOT ASSOCIATED WITH MEN SYNDROMES
Histological features of papillary carcinoma of the thyroid
Large thyrocytes with abnormal nucleus and cytoplasm
- “orphan annie” eyes = large round cells with dense nucleus and cytoplasm
Psammoma bodies
Thyroglobuln +ve, keratin +ve, calcitonin -ve, CEA -ve
Features of follicular carcinoma of the thyroid
Macroscopic:
Encapsulated, solitary, often necrotic/haemorrhagic areas
Microscopic:
Well-defined follicles containing colloid (similar to normal thyroid)
Thyroid cancers associated with MEN syndromes
Medullary thyroid carcinoma associated with MEN2a and MEN2b
Radioisotope uptake in thyroid cancers
Thyroid cancers are non-secretory therefore they do not take up radioactive iodine (Cold nodules)
