Breast Malignancy Flashcards
When assessing a breast lump what are the key features to assess and describe?
Location, size, shape, consistency, tenderness, mobile/fixed, margins (smooth/irregular)
What makes up the triple assessment to exclude or diagnose breast cancer?
Clinical assessment (history and examination)
Imaging (mammogram or ultrasound)
Histology (fine needle aspiration or core biopsy)
What are clinical features which may suggest cancer as a cause of a breast lump?
Hard, irregular, painless, fixed, nipple retraction, skin dimpling or oedema, lumps tethered to skin or chest wall
Why does skin dimpling occur with breast cancer?
Coopers ligaments, which create and support normal breast morphology, retract in response to tumour infiltration which pulls the skin of the breast inwards
Why does nipple inversion or retraction occur with breast cancer?
Tumour invasion of the lactiferous ducts behind the nipple shortens them, pulling the nipple into the areola
Why can nipple discharge occur wit breast cancer?
Tumour invasion of the lactiferous ducts can enhance ductal secretions
What features of nipple discharge may indicate breast cancer as the cause?
If its unilateral, uni-ductal and spontaneous
Why can diffuse breast erythema occur with breast cancer?
Tumour cells in dermal layer produce cytokines causing local vasodilation of blood vessels under the skin
Why can we get the clinical sign of peau d’orange with breast cancer?
Tumour cells infiltrate and block lymphatic ducts preventing drainage of interstitial fluid
Which patients would be put through a 2 week wait referral for breast cancer?
> 30 with an unexplained breast lump, >50 with unilateral nipple changes, >30 with unexplained lump in axilla, skin changes suggestive of breast cancer
What are fibroadenomas?
Common benign tumours of the stroma/epithelial breast duct tissue
In what ages are fibroadenomas most common?
20-40
What are fibroadenomas like on examination?
Painless, firm, smooth, well circumscribed, mobile and up to around 3 cm in diameter
When are fibrocystic breast changes mos likely to occur around menstruation?
Within 10 days before menstruation then resolve once menstruation begins
What are fibrocystic breast changes?
When the connective tissue of the breast becomes fibrous and cystic in response to oestrogen and progesterone
hat are symptoms of fibrocystic breast changes?
Lumpiness of the breast(s), breast pain or tenderness, fluctuation of breast size
How can fibrocystic breast change symptoms be managed?
Wearing a supportive bra, NSAIDs, avoiding caffeine, applying heat to the area. Hormonal treatments can be started under specialist guidance (e.g danazol and tamoxifen)
What are breast cysts?
benign, fluid filled lumps in the breast. They can be painful and may fluctuate in size over the menstrual cycle
When are breast cysts most common?
Between the ages of 20 and 50, more so in the perimenopausal period
What are breast cysts like on examination?
Smooth, mobile, well circumscribed and possibly fluctuant
What investigations and management is required for breast cysts?
Imaging with potential fine needle aspiration or excision to rule out cancer. Aspiration may resolve symptoms
Do fibroadenomas, fat necrosis or breast cysts increase the risk of breast cancer?
Fibroadenomas= no
Fat necrosis= no
Cysts= may slightly increase the risk
What causes fat necrosis?
Localised degeneration and scarring of fat tissue of the breast often triggered by an inflammatory reaction because of localised trauma, radiotherapy or surgery
How may fat necrosis appear on examination?
Painless, firm, irregular, can be fixed in local structures,there may be skin dimpling or nipple inversion
What investigations are carried out for suspected fat necrosis?
Imaging will often give similar appearance to breast cancer so histology may be required to confirm the diagnosis
What are lipomas?
Benign tumours of adipose tissue
On examination, what are lipomas like?
Soft, mobile, painless and do not cause skin changes
How are lipomas treated?
Typically conservatively with reassurance but occasionally can be removed surgically
What are galactocoeles?
Breast milk filled cysts occuring when there is blockage of the lactiferous ducts in lactating women
What is a phyllodes tumour?
Rare tumour of the connective tissue of the breast, which are large and fast growing. Most commonly occuring between ages 40-50
Are phyllodes tumours malignant?
25% can be malignant, with another 25% being borderline and 50% being benign
What is a carcinoma in situ?
Pre-malignant within the basement membrane
How are carcinomas in situ usually diagnosed?
Through imaging as usually are asymptomatic
What is the most common type of non-invasive breast cancer?
DCIS
What is the management of DCIS?
Surgical excision with wide local excision but mastectomy may be needed if widespread or multi focal DCIS
How does DCIS appear on imaging?
Microcalcifications on mammogram which can be localised or widespread
Which of DCIS or LCIS is more likely to become invasive and be diagnosed pre-menopause?
LCIS
Why are LCIS harder to detect?
They dont appear as microcalcification on X-ray like DCIS often diagnosed as incidental finding on biopsy
How do we manage LCIS?
If low grade, LCIS is monitored. Prophylactic bilateral mastectomy potentially in BRCA1/2 patients
What are the different types of invasive breast cancer?
Ductal carcinoma (85%)
Lobular carcinoma (10%)
Other
What are some risk factors for breast cancer?
Female, increasing age, BRCA mutations, obesity, prolonged oestrogen exposure, family history
What are factors influencing oestrogen exposure?
Early menarche, late menopause, nulliparity, >5 years of HRT
What is current screening program for breast cancer?
Mammogram every 3 years for women 50-70
How does Paget’s disease present?
Roughened, thick, itchy, flaky, red, ulceration of the nipple
What is one way to differentiate eczema and Paget’s disease?
Eczema does not affect the nipple just the areola, Paget’s disease also affects nipple
What is wide local excision and when is it done?
Breast conserving surgery to remove localised disease with 1 cm microscopically clear margin.
How are axillary surgeries done for breast cancer?
Injection of blue dye and radioisotope to identify sentinel node- remove and send for histology. If malignant change seen then may do axillary node clearance
Which medication blocks oestrogen receptor and is given to pre-menopausal women with ER+ Breast Ca?
Tamoxifen
What are two main side effects of tamoxifen?
Incresed risk of Thromboembolic events and may cause endometrial thickening increasing risk of endometrial cancer
How does anastrozole work? Who is it given to?
Block oestrogen receptors and reduces production of oestrogen
Given to post-menopausal women with breast Ca
What is herceptin?
Drug used in breast cancer than internalises HER-2 receptor to reduce this triggering growth
What is a therapeutic mammoplasty?
WLE and breast reduction followed by reconstruction. Gives smaller, uplifted breasts and areola moved to better suited position
What is a flap formation in breast surgery?
Uses a piece of muscle and its skin to reconstruct breast that has been removed
