Breast Surgery JC076: Breast Mass: Breast Cancer, Benign Breast Diseases, Mammography, Breast Cancer Screening Flashcards

Question

***Fibrocystic disease: Physiological cyclical swelling + tenderness

Answer 1

***Fibrocystic disease (aka ***Fibroadenosis) - ***NOT a disease but general term that refers to a group of anomalies / symptoms - main benign diagnosis in 30-40 yo S/S: 1. ***Cyclical mastalgia, ***Lumpiness, ***Nodularity - areas of pronounced nodularity can mimic a lump - ***premenstrual breast tenderness with mild swelling (engorgement of breast during menstrual period) —> result from variation in plasma concentration of gonadotrophic + ovarian hormones 2. Breast can be nodular with ***no definitive mass —> Not considered abnormal breast

Answer 2

- A disease entity - most common benign breast tumour Onset: - any time after puberty - most frequently 20-30 yo S/S: - ***Painless (記住!) - ***Well-circumscribed - ***Freely movable tumours with rounded lobulated / discoid configuration —> “Breast mouse” - Multiple in 10-15% - Can become quite large Prognosis: - ***NOT regress with time but tends to grow slowly - Estimated incidence of malignancy: 0.12-0.3% - ***Giant Fibroadenoma (>5 cm): may rapid growth —> require excision (usually in young girls) —> ∵ triple assessment not 100% accurate —> have to rule out ***Phyllodes tumour Treatment options: 1. Surveillance (USG) 2. Surgery (Excision) 3. HIFU - can be used to treat various solid tumours (e.g. Fibroadenoma, Thyroid adenoma)

Answer 3

- A disease entity - Commonest breast lump in 30-50 yo Types: 1. ***Simple cysts: Accumulation of fluid 2. ***Complex cysts: contain debris (solid components) —> need to rule out ***cystic tumour by Triple assessment Treatment: 1. Aspiration to confirm nature (to rule out cystic tumour), also therapeutic to relieve symptom 2. ***Fluid for cytology 3. ***Excision for suspicious lesions (e.g. complex cysts with solid components)

Answer 4

1. ***Cyclical 2. ***Non-cyclical - Muscular pain - Costochondritis - Non-specific

Answer 5

1. Unilateral vs Bilateral - ***Unilateral: pathological likely (involving single site) - Bilateral: physiological likely (e.g. lactation (but can be prolactinoma)) 2. Single ductal vs Multiductal - ***Single duct: pathological likely (involving single site) - Multiductal: physiological likely 3. Nature of discharge - Milk (Galactorrhoea): Lactation, Prolactinoma - ***Blood / Brown (Suspicious): Intraduct papilloma, Malignancy - Yellowish / Green: Infection, Ductal ectasia - Serous / Colourless: Physiological, Ductal ectasia Investigations: Triple assessment - +/- ***Ductogram (inject contrast into diseased duct to look for filling defect —> identify cause of nipple discharge + location of lesion) - +/- ***Ductoscopy (allow direct visualisation of lining of lactiferous ducts via a small fibreoptic scope)

Answer 6

1. ***Sclerosing adenosis 2. Radial scars and complex sclerosing lesions 3. ***Papillomas - Intraductal papilloma (usually only involves single duct) 4. ***Atypical lesions - ***Atypical ductal hyperplasia - Atypical lobular hyperplasia - Atypical columnar cell hyperplasia - etc. —> ***Atypia ↑ risk of breast cancer —> whenever see this in biopsy —> ***excise (***surveillance NOT an option)

Answer 7

1. Mammography - used for screening - for older female 2. USG - for younger female (denser breast: USG better penetration) 3. MRI breast

Answer 8

Malignant features on mammogram 1. ***Clustered + ***Pleomorphic microcalcifications - apoptosis of dead cells (a normal phenomenon, but if ↑ cell turnover —> clustered instead of scattered) - different size and shape (∵ some cells die quickly / slowly) - Coarse calcifications: likely ***benign 2. ***Spiculated border, High density mass 3. Architectural distortion - ***tethering of skin - involvement of muscles etc. 4. ***Asymmetrical density - compare both breasts + both views

Answer 9

Benign features: 1. ***Regular border 2. ***Oval in shape (grow along anatomical plane) (Width > Height) 3. Lobulated (sometimes) 4. ***Posterior enhancement (indicate fluid in lesion) (Solid tumour: posterior shadowing) 5. ***Homogeneous Malignant features: 1. ***Irregular outline 2. ***Height > Width (i.e. grow across anatomical planes: invading up / down) 3. ***Posterior shadowing (Acoustic shadowing) 4. Echogenic halo

Answer 10

Not routinely done - very sensitive but not specific Indications: 1. Screening women at ***high risk of breast cancer (e.g. BRCA carriers) 2. Patients with ***breast implants / augmentation (obscure view on USG) 3. Evaluate questionable suspicious lesions seen on mammography / USG (***conflicting between imaging and histology) 4. Identify patients with clinical ***occult tumour presenting with positive axillary LN 5. Monitor result of neoadjuvant therapy 6. Identify extent of residual disease after excision which show positive margins

Answer 11

Indication: 1. Evaluation of a palpable breast mass 2. Evaluation of a non-palpable breast mass 3. Evaluation of nipple discharge 4 techniques: 1. FNAC 2. Core biopsy 3. Incisional biopsy 4. Excisional biopsy

Answer 12

FNAC: Advantages: - safe, simple, inexpensive - immediately distinguishes ***cysts from solid masses (tumour) Disadvantages: - cannot reliably distinguish ***DCIS from invasive cancer - cannot perform ***immunohistochemical staining Core biopsy: Advantages: - distinguishes DCIS from invasive cancer - allow ***immunohistochemical staining for ***ER / PR / C-erbB2 (HER2) status Disadvantages: - relatively ***more invasive, require local anaesthesia - small stab incision

Answer 13

1. Imaging - USG - Mammogram - MRI 2. Biopsy (depends on which imaging picked up the lesion) - USG picked up —> USG guided FNAC / Core biopsy - Mammogram picked up —> Mammogram-guided biopsy (aka ***Stereotactic guided biopsy —> for ***microcalcifications) - MRI picked up —> MRI guided biopsy Biopsy techniques: 1. FNAC / Core biopsy (when clinical suspicion) 2. Vacuum assisted core biopsy (***larger bore, more traumatic, vacuum to suck lesion, can achieve complete removal of small lesion) 3. Hookwire guided excisional biopsy (can do specimen mammogram / radiology / USG) 4. Radio-guided occult lesion localisation (ROLL) Excisional vs Incisional biopsy: Incisional: - ***Fungating / ***Ulcerative tumour - take out a strip of tissue directly from skin surface from ***fungating edge (because ***rapidly-growing area) - cannot be done on a breast lump ***without ulceration Excisional: - when conflict between radiological vs core biopsy —> to be ***100% sure - cannot be done on a breast lump ***without ulceration

Answer 14

- Aim to detect cancer as an asymptomatic + curable stage - Already proven decrease mortality rate in international studies - Problems: Psychological impact / over-diagnosis, Cost effectiveness Why suitable for screening? - Common disease / high prevalence - Significant impact to population - Detectable in early phase - Low cost - Accurate - Specific - Critical point before clinical diagnosis - Short lag phase - Tool is acceptable / tolerable to population - Treatment available after diagnosis - Treatment acceptable to population “Standard” screening guidelines: 30s: - ***Yearly breast examination - Monthly self-breast examination 40s: - Mammogram every ***2 years - Yearly breast examination - Monthly self-breast examination 50s: - Mammogram every ***1 year - Yearly breast examination - Monthly self-breast examination

Answer 15

Pros: - Decreased breast cancer mortality + total mortality - Decreased morbidity from breast cancer (Reduction of late-stage breast cancer) Cons: - Radiation exposure - False-positive and false-negative mammography results, additional imaging + biopsies - Anxiety, distress, psychological responses World: - Variation in different countries depending on resources - Voluntary: Not population screening - Privately / Charity funded - Means of screening: Mammography - USG as part of screening (but lack evidence) - Age 40: every 1-2 years - Age 50: every 2 years - Can consider screening earlier if family history HK: Past: Voluntary breast screening Last year (2021): ***Risk based breast screening: - Starting at age 44 based on risk calculation model - Screening every 2 years

Answer 16

1. ***Microcalcifications - ***Clustered / Segmental - ***Pleomorphic (有大有細) - ***Stellate patterns (星狀) 2. ***Spiculated, high density mass 3. ***Architectural distortion 4. ***Asymmetrical density ***BiRADS score: Mammogram reporting (now for USG + MRI as well) Category 0: Need further investigations (without any clinical examinations) Category 1: Normal Category 2: ***Benign Category 3: Probably benign (<2% malignant) Category 4: Suspicious of malignancy Category 5: Highly suggestive of malignancy >=95% Category 6: Malignancy proven with biopsy

Answer 17

1. Breast implant 2. Dense breast 3. Paraffin calcification

Answer 18

- Mammography still most sensitive test for breast cancer detection - USG used in conjunction with mammography - USG is commonly used in our locality to add diagnosis of breast lesion Cons: - USG not as sensitive for macrocalcification detection - Less useful in fatty breast Pros: - Good at: mass lesions, cysts - Easy to use, fast, cheap - Useful in breasts with dense parenchyma Reading USG: - R93N: Right, 9 o'clock , 3 cm from nipple

Answer 19

- Screening women at ***high risk of breast cancer e.g. strong family history, hereditary cause - Evaluate ***questionable suspicious lesions seen on mammography / USG - Identify patients with ***clinically occult (i.e. ***non-palpable) tumour presenting with positive axillary nodes - Monitor result of ***neoadjuvant therapy - Exclude ***multifocal lesions when planning breast conservation surgery MRI breast kinetic curve: - leaky neovascularisation —> type 3 kinetic curve —> contrast concentration drops rapidly (vs benign disease will hold contrast)

Answer 20

Purpose (ALWAYS answer in exam): 1. Stage to plan treatment 2. Prognostication Methods: 1. PET-CT / PET-MR Alternative ways: 2. Bone scan 3. CT thorax / abdomen 4. USG (AJCC TNM staging: T stage: T0: no evidence of primary tumour Tis: Carcinoma in Situ T1: Tumour ***<2cm - T1a: 0.1-0.5cm - T1b: 0.5-1.0cm - T1c: 1.0-2.0cm T2: Tumour ***>2cm but <5cm T3: Tumour ***>5cm ***T4: Tumour with ***direct extension to - T4a: chest wall (ribs, IC, serratus)* - T4b: skin (Peau d’orange, ulceration, satellite skin nodule) - T4c: T4a + T4b - T4d: inflammatory breast cancer N stage (***Clinical / ***Pathological): N0: no lymph node involvement N1: mets to movable ipsilateral level I, II axillary LN N2: mets to ipsilateral level I,II axillary LN – clinically fixed or matted or mets to ipsilateral mammary LN in absence of axillary LN N3: mets to ipsilateral infraclavicular (level III) lymph nodes, ipsilateral mammary LN, ipsilateral supraclavicular LN (with or w/o level I & II axillary LN) M stage: M0: no distant mets M1: distant detectable metastasis (histologically proven > 0.2mm))

Answer 21

1. FNAC 2. Core biopsy (e.g. Vacuum assisted core biopsy) 3. Excisional biopsy If ***palpable —> ***Direct / Free hand If ***non-palpable —> ***Image-guided - USG guided - Mammogram (Stereotactic) guided - MRI guided (others: Wire guided, Radio-guided occult lesion localisation (ROLL))

Answer 22

C1: Inadequate C2: Benign C3: Atypia, probably benign C4: Suspicious of malignancy C5: Malignant

Answer 23

Hormonal factors: 1. Early menarche <12 2. Late menopause >55 3. Pregnancy after age 30 4. Nulliparity 5. Use of OC pills / HRT 6. Obesity Non-hormonal factors: 7. Family history of breast cancer (BRCA1, 2) 8. History of breast biopsy showing a premalignant condition, atypical ductal hyperplasia, proliferative fibrocystic changes, LCIS, DCIS 9. Smoking, Alcohol 10. Diet 11. Lack of exercise 12. Advanced age

Answer 24

BRCA1: - Breast cancer - Ovarian cancer - Prostate cancer - Colon cancer BRCA2: - Breast cancer - Male breast cancer - Ovarian cancer - Prostate cancer - Laryngeal cancer - Bile duct cancer - Stomach cancer - Colon (minimal) melanoma - Pancreatic cancer

Answer 25

Pre-surgery / Pre-chemotherapy egg harvesting + storage can be offered