DSA - Benign and Malignant Breast Cancer (Tieman) - SRS Flashcards
What is the most common breast mass in young women (under 30 y/o)?
Fibroadenoma (rare in women over 45)
Fibroadenomas are benign solid tumors consisting of fibrous and epithelial elements. What will these feel like on PE?
How can you differentiate these from cysts?
- Usually firm, moveable, non-tender smooth or lobulated masses
- Can be distinguished from cysts by ultrasound
An FNA may be done to aid in making the diagnosis of a fibroadenoma, but this cannot distinguish between a fibroadenoma and what?
Phyllodes tumor
What are the two subtypes of fibroadenomas?
What are some defining features of each?
- Giant fibroadenomas: > 5 cm
- Juvenile fibroadenomas: Hypercellular adenoma that develops in adolescents and young adults
Fibroadenomas are benign tumors that rarely develop malignancy in the epithelial elements of the tumor. What are the three treatment possibilities?
- Observation
- Cryoablation
- Excision (open or via US guidance)
When should a fibroadenoma definitely be excised? 2
- When the patient wants it.
- If mass enlarges rapidly/significantly
A phyllodes tumor is similar to a fibroadenoma but does have some differences. What are they?
- Cellular stroma grows rapidly
- Tumors typically become quite large
- May be malignant or benign
A phyllodes tumor may be benign or malignant depending on mitotic rate and histologic characteristics. What is the treatment for both benign and malignant lesions?
- Benign lesions treated by local excision with margin of normal breast tissue to avoid recurrence
- Malignant lesions treated by wide local excision or mastectomy, w/o node dissection or sentinel node biopsy
What shape does the stroma of a phyllodes tumor end up forming?
Forms epithelial-lined clefts resembling leaves (phyllodes = leaves in greek)
Fibrocystic breast disease is most common in women ages 35 - 55 and fluctuates with the menstrual cycle. How do these cysts present?
- An individual cyst may be painless, but multiple painful cysts are common.
- Cysts may present as breast masses
What happens to the duct system in fibrocystic breast disease?
- Areas of fibrosis in the ducts with destruction and dilatation of terminal ductules and lobules, which fill with cystic fluid
Cysts may present as breast masses and are usually easily identified by U/S and amenable to aspiration. Cyst fluid may be clear, yellow or green. If cyst disappears with aspiration and fluid is not bloody, cytology is not needed. If the cyst recurs, you can reaspirate it.
- What is the risk of malignancy?
- What should be done if it recurs multiple times?
- Risk of malignancy is very low.
- Multiple recurrances should be biopsied or excised
Fibrocystic disease of the breast often presents as breast pain, which is bilateral, diffuse and cyclical. The breasts are usually tender and nodular w/o a dominant mass, with pain increasing prior to menses. U/S may reveal multiple small cysts and mammography reveals dense fibrous breasts, usually w/o a mass.
Overall this condition is difficult to treat, despite the cysts being amenable to aspiration.
- What is the treatment directed towards?
- What are the ways we try to effect this treatment?
Treatment is directed towards the pain symptoms
- Support bra, analgesics, avoid trauma
- Danazol and tamoxifen can be used in severe cases
- Oil of evening primrose (gamolenic acid)
- Low-fat diet
- ? Avoiding caffeine and chocolate, alcohol
- ? Vitamin E
Sclerosing adenosis is a common finding in fibrocystic conditions. What will you see happening in the afflicted tissues?
What mammographic finding can make this a confusing diagnosis?
- Proliferation of fibrous stroma and terminal ductules with deposition of calcium.
- On mammogram, it appears similar to the microcalcifications seen in breast cancer
What is a common situation in which sclerosing adenosis is identified?
What is the malignant potential?
- Common histological finding in needle-directed biopsies for microcalcifications
- No known malignant potential
A radial scar is a complex sclerosing lesion that can be characterised by what four features?
- Microcysts
- epithelial hyperplasia
- adenosis
- central sclerosis
Prior to biopsy radial scars can be difficult to distinguish from breast cancer d/t to the presence of what similar findings?
Are radial scar lesions associated with increased risk of breast cancer?
- Mass on exam or mammogram
- Spiculation
- May have calcifications
- May cause skin dimpling
Usually require biopsy, and is associated with slight increase in subsequent development of breast CA
Nipple discharge may be either expressed or spontaneous where…
- Expressed nipple discharge usually goes away when the manipulation of the nipple is stopped
- Spontaneous nipple discharge may require evaluation, if the discharge is serous or bloody
How is evaluation of this condition usually done?
- Cytology
- Mammogram
- Ultrasound
If a patient comes to you with spontaneous, unilateral bloody (or serous for that matter) nipple discharge coming from a single duct, what must be done?
What percentage of the time will the finding be a…
- Benign papilloma
- Papillary carcinoma
Duct excision
- Benign papilloma - 95%
- Papillary Cancer - 5%
Nipple discharge that is unilateral and from a single duct is more concerning for intraductal pathology. What are some things to consider when you see either bilateral discharge or, unilateral with multiple duct? 4
- Fibrocystic disease with duct ectasia
- hyperprolactinemia
- hypothyroidism
- drug-induced
What are three drug types (generally speaking) that are known to induce nipple discharge?
- Oral contraceptives
- Estrogen
- Anti-psychotics
What are the two forms of mastitis and breast abscess?
- Lactational
- Chronic sub-areolar with duct ectasia
Lactational mastitis occurs in younger, breast-feeding women with fever, breast erythema and tenderness.
- What is the common cause of this condition?
- How should it be treated?
- What are the likely outcomes?
- S. Aureus
- Tx with antibiotics and emptying of the breast
- Usually clears with this treatment, but can form abcess
If a patient, despite your best management efforts ends up with their lactation mastitis progressing to an abscess. What should be done?
- Drain surgically
What patient group tends to get chronic sub-areolar mastitis with duct ectasia?
Older women, especially diabetics who smoke
What causes chronic sub-areolar mastitis with duct ectasia?
How do you treat? 4
- Mixed aerobic/anaerobic flora
- Treated with antibiotics, if caught early
- Often require incision and drainage
- Recurrent infections/abscesses may require excision of the entire duct
What is required in any non-resolving mastitis?
Why?
Biopsy, as mastitis and inflammatory breast cancer look alike!
Fat necrosis is a mass created by scarring following trauma, surgery or radiation. What does this lesion consist of?
What is the malignant potential?
- Consists of scar tissue, chronic inflammatory cells and macrophages
- Often contains calcifications, but usually macrocalcifications
- No known malignant potential
There are two major forms of diffuse male breast hypertrophy, which may be unilateral or bilateral, firm, and tender. What are these two types?
Pubertal
Senescent
As you might expect, pubertal male gynecomastia affects adolescent boys. Describe the typical course of this condition?
Transient and rarely requires treatment
Senescent male gynecomastia tends to hit over the age of 50, and is usually associated with medication. What are some examples that Tieman listed for us to know?
- Digoxin
- Thiazides
- Estrogens
- phenothiazines
- theophylline
When working up a man with likely senescent gynecomastia what must you rule out?
Underlying causative medical conditions such as:
- hepatic cirrhosis
- renal failure
- malnutrition
How is male breast cancer distinguishable from gynecomastia?
Cancer will be hard, non-tender and is often fixed to surrounding structures
In what age range is a breast fibroadenoma most common?
Under 30
What age group is a fibrocystic mass most common in?
30 - 50 y/o
What age are the majority of breast cancers found in patients?
but?
Over age 60
but cancers can occur at any age
What are some important history items to flesh out when dealing with a breast mass?
- Length of time mass has been present
- Growth or change in mass
- Pain
- Associated symptoms (eg. Areolar rash)
What defines the “estrogen window”?
Menstual status: Menarche to menopause
What impact does pregnancy/nonpregnancy have on breast cancer?
Age of 1st full-term pregnancy
- 1.5-3 x increased risk if >35 or nulliparous
What other cancer is heritable, and arises from the same mutation(s) as many breast cancers?
Ovarian CA (BRCA gene)
- BRCA1—up to 80% lifetime risk
- BRCA2—up to 80% lifetime risk
How does family history play into the risk of breast cancer?
Breast CA in first degree relative(s) = 2-3 x increased risk, especially if pre-menopausal
What are some important social history factors that should be considered in a breast mass?
- Smoking
- ETOH
- Occupation
When formulating your ROS questions for a patient with a breast mass, what should you be looking for?
Looking for symptoms suggestive of metastatic disease
- Bone
- Brain
- Lungs
- Liver
- Adrenal
What is the primary lymph drainage path of the breast?
Axillary chain
Breast exam observation can be done sitting and lying down, with arms at rest and then extended.
What are somethings to look for on inspection?
- Visible Mass
- Skin retraction
- Nipple/Areolar eczema
- Nipple Discharge
- Erythema/Induration
What should you be palpating for during PE of the breast?
- Size of mass
- Consistency
- Tenderness
- Fixation
- Regional Lymph Nodes
When assessing the risk of a breast mass, you should be determining the probability of malignancy. What model does Tieman recommend?
Gail Model
What follow up steps should you take with a patient who has an identified breast mass?
- close follow-up
- radiology/ultrasound
- biopsy
What is the Gail Model for breast cancer risk assessment?
Algorithm where risk factors are aggregated and a risk score is spat out.
http://www.cancer.gov/bcrisktool/
What are the diagnostic studies that should be done in the case of a breast mass? 4
- Ultrasound
- Mammogram
- MRI
- Biopsy
describe the sensitivity and specificity of MRI in determining breast masses?
High sensitivity
Low specificity
results in more false positives and biopsies, is costly
What are four uses for breast MRI?
- Screening in very high-risk patients (BRCA)
- Dense Breasts
- Small multicentric lesions
- Implants
Breast biopsy can be done in what three ways?
- FNA
- Core needle biopsy
- Open Biopsy
FNA is minimally invasive, can be done in the office, but requires what things?
- Requires good and experienced cytopathologist
- Usually requires confirmatory tissue biopsy
Core needle biopsies obtain breast tissue for diagnosis, ER/PR analysis. The require only local anesthesia, does not interrupt lymphatic flow, and the findings can direct the treatment plan.
What are the three ways this can be done?
- Palpation
- Ultrasound
- Stereotactic (mammotome)
Open biopsy of a breast mass may be incisional or excisional. What is one example of a scenario where this must be an excisional biopsy?
Atypia on FNA or core needle biopsy always requires excision of the entire lesion to R/O malignancy
If a breast mass biopsy yields atypical hyperplasia, what is the increased risk of later invasive carcinoma?
3 - 6 times
If a biopsy of a breast mass reveals a lubular carcinoma in situ, how is it treated?
What is the risk of invasive ductal carcinoma bilaterally as a result of this finding?
- Treated as a risk factor, not invasive CA, Requires close follow-up and usually chemoprophyllaxis.
- 15-20% risk of invasive ductal CA bilaterally
How would a ductal carcinoma in situ be treated?
Usually treated the same as small invasive CA with lumpectomy and irradiation
Which type of invasive breast cancer is more common, lobular or ductal?
Ductal is more common 80 - 90%
Lobular only 6 - 8%
What are the favorable subtypes of ductal carcinoma?
- Medullary
- Tubular
- Mucinous
- Papillary
Lobular breast carcinoma is often bilateral and has what prognosis relative to ductal?
Slightly better prognosis
What is Paget’s disease?
Eczematous dermatitis of nipple/areola with underlying invasive ductal CA or DCIS
Inflammatory breast cancer comprises only ~3% of invasive breast cancers, what is a feature that Tieman specified for this type of cancer?
“peau d’orange” changes
In the TNM staging, what are the T stages?
- T1–< 2 cm
- T2– 2-5 cm
- T3– >5 cm
- T4– wall fixation or skin involvement
In the TNM staging, what are the N stages?
- N0—no nodal metastasis
- N1—mets to movable ipsilateral axillary nodes
- N2—mets to fixed or matted axillary nodes
In the TNM staging what are the M stages?
- M0—no distant mets
- M1—distant mets
What are the prognoses for stage 0 - IV invasive breast cancer?
- Stage O—95 % 5 year survival
- Stage I—85% 5 year survival
- Stage II—60-70% 5 year survival
- Stage III—30-55% 5 year survival
- Stage IV—5-15% 5 year survival
Screening mammograms classify the results as BI-RADS 0 - 5. Describe what each level of the scale indicates.
- BI-RADS 0—requires additional studies
- BI-RADS 1—No abnormal findings
- BI-RADS 2—benign findings
- BI-RADS 3—probably benign finding
- BI-RADS 4—suspicious abnormality
- BI-RADS 5—highly suggestive of malignancy
What are the 4 breast surgery options?
- Partial Mastectomy
- Total Mastectomy
- Modified Radical Mastectomy
- Radical Mastectomy
Partial mastectomy involves removal of part of the breast. What stages of cancer is this appropriate for?
Appropriate treatment for T1 and T2 breast CA, if combined with post-op breast irradiation
Total mastectomy involves removal of the breast alone. What is this an appropriate treatment for?
Appropriate treatment alone for breast CA with negative axillary lymph nodes
What does a modified radical mastectomy involve?
Removal of breast and axillary lymph nodes en block
What does a radical mastectomy involve?
When is this used?
- Removal of breast, pectoralis muscles and axillary lymph nodes
- Rarely used; only used if cancer is invading pectoralis muscles
What are the interventional options for regional lymph nodes in breast cancer treatment?
- Axillary Lymph Node Dissection (ALND)
- Sentinel Lymph Node Biopsy
ALND can be complicated by arm numbness and lymphedema, when is this the preferred treatment?
Preferred treatment if lymph nodes + for cancer or patient doesn’t want to risk having two procedures.
What is the initial step in treating inflammatory breast cancer?
Also used to down-size or down-stage tumors.
Neoadjuvant Therapy
- Treatment with Chemotherapy and/or Radiation before surgery
Adjuvant therapies include chemotherapy and/or radiation after the surgery. What are the chemotherapeutic options?
- Cytotoxic
- Monoclonal antibodies
- Hormonal
- Tamoxifen, raloxifene(anti-estrogens)
- Anastrozole (aromatase inhibitor)
Recommend reviewing Michaels anticancer drugs map.
Describe the post surgical breast cancer follow up schedule.
Physical Exam: 6 - 12 month interval
- Look for recurrence/metastases
Mammograms: Yearly, bilateral
Laboratory: not specified, yearly probably to look for metastases
