Malignant and Benign Diseases of the Breast Flashcards
What is the 5 year survival rate for breast ca?
All stages; 86%
97% localized cancer
75% cancer with regional involvement
23% for metastatic cancer
What are the clinically relevant risk factors for breast cancer?
Gender; female Age Gene mutations Atypical ductal or lobular hyperplasia Lobular carcinoma in situ Atypical epithelial hyperplasia Birth of first child after 30 Consumption of alcoholic beverage once or more a day Early menarche FMHx of breast ca Previous history of breast ca Nulliparity Postmenopausal obesity
What are the most common breast cancer presentations?
Dimpled or depressed skin Visible lump Nipple change including inversion Bloody discharge Texture change Colour change
What will the lump feel like in a ductal carcinoma?
Stellate solid mass
Pleomorphic casting microcalcifications
How is the definitive diagnosis of breast cancer made?
Image guided core-needle biopsy
How is DCIS caught on MMG?
Not palpable
Perceived on MMG as malignant calcifications
Usually pleomorphic
Casting type
How is the definitive diagnosis of DCIS made?
Stereotactic vacuum assisted core biopsy
How will invasive lobular carcinoma tend to spread?
Typical histological indian file pattern
What is breast conserving surgery (BCS)?
Wide local excision with or without oncoplastic procedure to shape breast
What is an essential component of breast conserving therapy?
Radiation therapy
Total dose of whole breast irradiation of 4500-5000 centigrays using opposed tangential fields
5 days a week for 3-6 weeks
Boost dose of irradiation to tumour bed increases dose
What is a modified (total) mastectomy?
Removes entire breast; incl overlying skin and axillary lymph nodes
Modification is perseverance of pectoralis major muscle
When can breast reconstruction occur?
Immediate (during same operation as modified radical mastectomy)
Or delayed
What are the different forms of breast reconstruction?
Prosthetic
Autologous tissue reconstruction; latissimus dorsi myocutaneous flap, deep inferior epigastric perforator free flap, transverse rectus abdominis myocutaneous flap or superior/ inferior gluteal artery perforator free flap
What is the downside to a non-skin sparing mastectomy?
Prominent scars on new breast
Paddle of skin that is of a different colour and texture
Why is a skin sparing mastectomy preferred?
Preserves most of overlying skin during an immediate breast reconstruction thus leading to a superior aesthetic outcome
What does the choice of breast reconstruction depend on?
Patient's body habitus Co-morbs Smoking history Size and shape of breasts s Her preference Surgeon's experience
What are the indications for post mastectomy radiotherapy (RT)?
More than 3 nodes involved
Positive surgical margins
Tumour’s >5cm
What is the most commonly used hormonal therapy?
Tamoxifen
What is a fibroadenoma?
Most common benign neoplasm of breast
What will a fibroadenoma feel like by examination?
Rubbery Firm Mobile Smooth Circumscribed Non-tender
At what age are fibroadenomas usually diagnosed?
20-40
Do fibroadenomas require removal?
No; they tend to remain unchanged or decrease in size approaching menopause and usually become non palpable after menopause
If required, how are fibroadenomas removed?
Open lumpectomy
Percutaneous vacuum assisted core biopsy under LA
What is the difference in the management of a fibroadenoma and a phyllodes tumour?
Phyllodes tumours should be excised with wide (1cm), clear surgical margins
Carefully followed up
What is mastalgia?
Pain in the breast; most common breast symptom for women during reproductive years
Describe cyclical mastalgia?
Diffuse pain
Most intense during immediate premenstrual phase of cycle
Usually bilateral
Describe non cyclical mastalgia?
Usually localized
Persistent
Less responsive to tx than cyclical
What are non breast aetiologies of anterior chest wall pain?
Achalasia Angina Cervical radiculitis Cholecystitis Cholelithiasis Coronary artery disease Costochondritis (Tietze syndrome) Fibromyositis Hiatal hernia Myalgia Neuralgia Osteomalacia Phantom pain Pleurisy Psychological PE Pulmonary infarct Rib # Sickle cell Trauma TB
What are effective therapies for mastalgia?
Well-fitting firm bra Regular exercise Evening primrose oil Tamoxifen Topical NSAIDs
Can you do a MMG in women <35?
No; can’t see anything as breast tissue is too dense
When will palpable breast cysts tend to occur?
Late reproductive years
On examination, what will a breast cyst feel like?
Typically palpable Clearly defined Soft Mobile Smooth Distinct borders Can be tender; esp before menstruation Can be multiple and/or bilateral
What is the method for diagnosing and treating a cyst?
FNA
Does the fluid extracted from a breast cyst FNA need to be sent for cytological eval?
No; only if grossly bloody
What is a papilloma of a cyst?
Benign intracystic papillary proliferation that occurs within a cyst
What will occur if there is a papilloma within a cyst?
Creates bloody cyst fluid
When is an intracystic carcinoma suspected?
Fluid is grossly bloody
Residual mass after aspiration
What is recommended for any intracystic solid lesion of irregular cystic wall?
USS guided core biopsy for histological diagnosis
Is nipple discharge normal?
Yes; clear, yellow and watery discharge is physiological for women of reproductive age
When does nipple discharge become pathological?
Bloody discharge from a single duct
What is the most common etiology of spontaneous nipple discharge?
Intraductal papilloma
Is nipple discharge commonly a sign of malignancy?
No; unless assoc with a palpable mass
What investigations are recommended for pathological nipple discharge?
MMG
USS
Surgical excision of discharging ducts
How can paget’s disease of the nipple present?
Erythematous weeping lesion on the surface of nipple and areola
More commonly presents as a dry, scaly, eczematous lesion
How is paget’s disease of the nipple be diagnosed?
Histologic tissue biopsy (incisional or punch)
Often underlying palpable mass or a radiological abnormality
What are signs of mastitis?
Fever Erythema Induration Tenderness Swelling
How will a breast abscess present?
Flocculent sometimes bulging mass usually located in central area of mastitis
How can a breast abscess be diagnosed?
Focused USS; determines a fluid filled (pus) center
Aspiration with 18-gauge needle using LA is diagnostic and therapeutic
When is excision and drainage required in breast abscesses?
If repeated aspirations are not effective
What is chronic mastitis assoc with?
Subareolar abscess
Periareolar fistula can occur
What should be suspected in a case of mastitis that is unresponsive to antibiotic therapy that has spread over entre breast?
Inflammatory carcinoma
Describe an adenolipoma?
Smooth palpable mass
Characteristic MMG pattern
What is ductal hyperplasia?
Benign histologic process
BUT
When hyperplasia is atypical, it is assoc with an increased risk of carcinoma
What is a galactocele?
Palpable milk-filled cyst most commonly associated with pregnancy or lactation
FNA can diagnose and drain
What is mondor’s disease?
Phlebitis (inflammation of vein) and subsequent clot formation in superficial veins of breast
How will mondor’s disease present?
Firm
Vertical
Cord like structure usually assoc with hx of trauma to breast
Describe the triple assessment in breast pathology?
Clinical breast examination and history
MMG
USS
Core-needle biopsy
What will histology tell you in breast ca?
Invasive or not
Ductal or lobular
Degree of differentiation
Receptor status
What does chemotherapy target?
Any cells in the M phase of cell replication
Non-invasive forms of hormonal therapy?
SERMs (tamoxifen)
AIs
GnRH
