Breast Pathology Flashcards
How common is breast cancer?
Affects 1/8 women
Give risk factors for breast cancer
>Age
Early menarche/late menopause
Ionising radiation
FH
Previous breast cancer
COCP/combined hormonal replacement therapy
Genetics
Obesity
Nulliparity
Previous surgery for breast disease
What genes are associated with breast cancer?
BRCA 1
BRCA 2
TP53
PTEN
p53 gene mutations
What are the types of non-invasive breast cancer?
Ductal carcinoma in situ (DCIS)
Lobular carcinoma in situ (LCIS/LISM)
What are the types of invasive breast cancer
Invasive ductal carcinoma
Invasive lobular carcinoma
Special types
What is the most common type of breast cancer?
Invasive ductal carcinoma (no special type)
What are the ‘special types’ of breast cancer?
Medullary breast cancer
Tubular carcinoma
Mucinous carcinoma
Carcinoma with medullary features
Metaplastic carcinoma
Which type of breast cancer is associated with spread to opposite breast?
Invasive lobular carcinoma
Where can breast cancer spread?
Local
- Skin
- Pectoral muscles
Lymphatic
- Axillary
- Internal mammary
Blood
- Bone
- Lungs
- Liver
- Brain
What investigations are used in breast cancer diagnosis?
Mammogram X-ray of the breast, soft tissue opacity, microcalcification
Fine Needle Aspiration Cytology
Biopsy
Staging
- Hb
- FBC
- U&Es
- LFTs
What tumour marker is most associated with breast cancer?
CA 15-3
Describe the screening programme for breast cancer
Mammogram every 3 years for women 50-70
After the age of 70 years women may still have mammograms but are ‘encouraged to make their own appointments
Women who are at an increased risk of breast cancer due to their family history may be offered screening from a younger age
How does breast cancer present?
Lump of thickening in breast, often painless
Discharge or bleeding
Change in size or contours of breast
Change in colour of appearance of areola
Redness or pitting of skin over the breast, like the skin of an orange
Fixed to deep tissue, invasive
How is breast cancer managed?
Surgery
- Wide local excision/breast conserving surgery, <4cm wide
- Mastectomy
Radiotherapy
Adjuvant Hormonal therapy
Biological therapy
Chemotherapy
What are the two main groups of anti oestrogen drugs?
Selective oestrogen receptor modulators (SERM)
- Tamoxifen
Aromatase inhibitors
- Anastrozole
Give adverse effects of SERMS
Endometrial cancer
VTE
Menstrual disturbance
- Vaginal bleeding
- Amenorrhoea
Menopausal symptoms
Give adverse effects of aromatase inhibitors
Osteoporosis
Hot flushes
Arthalgia
Insomnia
What hormonal therapy is used in women with ER+ breast cancer?
Anastrozole, post menopausal
Tamoxifen, pre menopausal
What hormonal therapy is used in women with HER2+ breast cancer?
Herceptin/Trastuzumab
When is Trastuzumab contraindicated?
History of heart disorders
When is radiotherapy used in breast cancer management?
After a woman has had a wide-local excision as this may reduce the risk of recurrence by around two-thirds
For women who’ve had a mastectomy radiotherapy is offered for T3-T4 tumours and for those with four or more positive axillary nodes
When is chemotherapy used in brest cancer management?
Prior to surgery to downstage a primary lesion, allowing breast conserving surgery rather than masectomy
After surgery if axillary node disease
Give adverse effects of neo-adjuvant chemotherapy
Nausea
Hair loss
Which breast cancer cases are offered a masectomy?
Multifocal tumour
Central tumour
Large lesion in small breast
DCIS >4cm
Which breast cancer cases are offered wide local excision?
Solitary lesion
Peripheral tumour
Small lesion in large breast
DCIS <4cm
How is palpable axillary lymphadenopathy at presentation managed?
Axillary node clearance at primary surgery or radiotherapy
How is no palpable axillary lymphadenopathy at presentation managed?
Pre-operative axillary US
If positive, sentinel node biopsy to assess nodal burden
Give a complication of axillary node clearance
Arm lymphedema and functional arm impairment
What is inflammatory breast cancer?
Rare but rapidly progressive form of breast cancer caused by obstruction of lymph drainage causing erythema and oedema
What are the causes of nipple discharge?
Galactorrhoea
Hyperprolactinaemia
Mammary duct ectasia
Carcinoma
Intraductal papilloma
Give features of fibroadenoma
Young women
Mobile
Smooth
Well defined
Non-tender
Not tethered to underlying structures
How are breast fibroadenomas managed?
Surgical excision if >3cm
Give features of breast cysts
Perimenopausal women
Soft, fluctuant swelling
What mammography sign is seen in breast cyst?
Halo appearance
How are breast cycts managed?
Aspiration, followed by re-examination to ensure the lump has gone
Those which are blood stained or persistently refill should be biopsied or excised
What is paget’s disease of the nipple?
Eczematoid change of the nipple associated with an underlying breast malignancy, differs from eczema of the nipple in that it involves the nipple primarily and only latterly spreads to the areolar, while the opposite occurs in eczema
Give features of pagets disease of the nipple
Nipple itching
Crusty lesion
Erythema
Thickened skin
Bloody nipple discharge
Underlying breast lump
Palpable axillary node
Give features of mammary duct ectasia
Peri/postmenopausal women
Nipple discharge, often cheese like, can be brown-green
Nipple retraction
Tender lump
How is mammary duct ectasia managed?
Reassurance, as no specific management
Total duct excision can be used in older women if condition is troublesome
Microdochectomy can be used in younger women
How is periductal masitis managed?
Co-amoxiclav
How does periductal massitis present?
Present at younger age than duct ectasia
Features of inflammation, abscess or mammary duct fistula
Recurrent infection
What is periductal massitis strongly associated with?
Smoking
How does masitis present?
Breast feeding women
Breast pain
Tender area that feels firm, warm, swollen
Erythema
Reduced milk output
Fever
Raised WCC and CRP
How is masitis managed?
Continue breast feeding
flucloxacillin for 10-14 days
- If systemically unwell, nipple fissure, no improvement 12-24 hours after milk removal, if culture indicates infection
- Breastfeeding can continue
What organism most commonly causes masitis?
Staph aureus
Give a complication of untreated masitis
Breast abscess
What is cyclical mastalgia?
Common cause of breast pain due to menstruation
How is cyclical mastalgia managed?
Supportive bra
Oral and topical analgesia
Flaxseed oil and evening primrose oil
Referral and hormonal agent consideration
- If pain has not responsed with conservative measures after 3 months
- Bromocriptine and danazol
Give features of intraductal papilloma
Younger patients
Blood stained discharge
Usually no palpable lump
Give features of fibroadenosis
Middle aged women
Bilateral ‘Lumpy’ breasts
May be painful
Symptoms worsen prior to menstruation
Give features of fat necrosis
Trauma
Tender
When should women with an unexplained breast lump be referred to specialist services?
Refer women aged >30 with an unexplained breast lump using a suspected cancer pathway referral
