Part two - breast Flashcards
Differential diagnosis for nipple discharge
- Physiological/lactational
- Infection
- Fibrocystic disease
- Duct ectasia
- Intraduct papilloma
- Intraduct carcinoma
- Rare - hypothyroidism and pituitary tumours
Assessment and treatment for nipple discharge
Reassure if multiduct and sebaceous or bilateral and mammogram up-to-date
Triple assess otherwise and treat findings.
If triple assessment negative review in 3 months and reassess. If persistent offer microdochectomy or total duct excision
Pathological breast lesions associated with the terminal duct lobular unit
Cyst Sclerosing adenosis Hyperplasia Atypical hyperplasia Small duct papilloma Carcinoma
Pathological breast lesions associated with the lobular stroma
Phylloides tumour
Fibroadenoma
Pathological breast lesions associated with the large ducts and lactiferous sinuses
Duct ectasia
Recurrent subareolar abscess
Single duct papilloma
Paget’s disease
Pathological breast lesions associated with the interlobular stroma
Fat necrosis Lipoma Fibrous tumour Fibromatosis Sarcoma
Describe the breast
A glandular appendage of the skin lying within the subcutaneous tissue and superficial fascia overlying ribs 2-6 from the midline to the MAL.
What is the blood supply to the breast?
- Branches from the 2nd part of the axillary artery
- Pectoral branches of the thoracoacromial trunk
- Lateral thoracic artery
- Internal thoracic artery (ITA / IMA)
- Gives off prorating branches
Largest perforators are the 2nd to 4th
- Gives off prorating branches
- Intercostal arteries from ITA
What is the anatomical basis of bony vertebral metastases in breast cancer?
Venous drainage via the posterior intercostal veins which join the vertebral veins
Describe the lymphatic drainage of the breast
Subareolar lymph plexus
80% to axilla
Remainder supraclavicular, parasternal (ITA) and posterior intercostal nodes
When there is lymph obstruction, drainage to opposite breast, cervical nodes, peritoneal cavity or inguinal nodes more common
What are the attachments of pectorals major?
3 heads: - Lateral sternum - Medial clavicle - 2nd - 6th costal cartilages Inserts into bicipital groove of humerus
Nerve supply of pectorals major
Medial pectoral nerve C8 supplies lateral fibres
Lateral pectoral nerves (C6-7) supplies medial fibres
Describe the breast
A glandular appendage of the skin lying within the subcutaneous tissue and superficial fascia overlying ribs 2-6 from the midline to the MAL.
What is the blood supply to the breast?
- Branches from the 2nd part of the axillary artery
- Pectoral branches of the thoracoacromial trunk
- Lateral thoracic artery
- Internal thoracic artery (ITA / IMA)
- Gives off prorating branches
Largest perforators are the 2nd to 4th
- Gives off prorating branches
- Intercostal arteries from ITA
Levels of axillary lymph nodes
I - lateral to pec minor
II - behind pec minor
III - beyond medial border pec minor
Describe the lymphatic drainage of the breast
Subareolar lymph plexus
80% to axilla
Remainder supraclavicular, parasternal (ITA) and posterior intercostal nodes
When there is lymph obstruction, drainage to opposite breast, cervical nodes, peritoneal cavity or inguinal nodes more common
Insertions of pectorals minor
Variable origin form the ribs on the chest but usually 3rd to 5th
Inserts into coracoid process
Divides axillary artery into three parts
- 1st part - proximal to muscle
- 2nd part - behind
- 3rd part - distal to muscle
Insertions serratus anterior
- Digitations from the outer surface of the first 8 ribs near the costal cartilages
- Inserts into medial border of scapula
- Holds scapular to chest wall
- Innervated by long thoracic nerve
Spinal roots of the brachial plexus
Ventral rami of C5-8 and T1
Contents of the axilla
Muscles - Long & short heads biceps, lat dirsi, trees major, pec minor, coracobrachialis
Vessels - axillary vein and artery
Nerves - cords of brachial plexus, long thoracic nerve
Lymph nodes - APICAL = anterior, posterior, infraclavicular, central, apical, lateral
Levels of axillary lymph nodes
I - lateral to pec minor
II - behind pec minor
III - beyond medial border pec minor
Structures piercing clavipectoral fascia
C - cephalic vein
A - acromiothoracic trunk
L - lateral pectoral nerve
L - lymphatics
Insertions of pectorals minor
Variable origin form the ribs on the chest but usually 3rd to 5th
Inserts into coracoid process
Divides axillary artery into three parts
- 1st part - proximal to muscle
- 2nd part - behind
- 3rd part - distal to muscle
Insertions serratus anterior
- Digitations from the outer surface of the first 8 ribs near the costal cartilages
- Inserts into medial border of scapula
- Holds scapular to chest wall
- Innervated by long thoracic nerve
Spinal roots of the brachial plexus
Ventral rami of C5-8 and T1
Axillary artery
Continuation from SCA at lateral border 1st rib
1st part medial to upper border pec mini
- Superior thoracic
2nd part behind pec minor
- Thoraco-acromial trunk
- clavicular
- humeral
- acromial
- pectoral
- Lateral thoracic
3rd part lower pec minor to lower teres major
- Subscapular
- thoracodorsal artery
- circumflex scapular artery
- Anterior circumflex humeral
- Posterior circumflex humeral
Some Times Life Seems A Pain
What is Paget’s disease of the breast?
Eczema-like eruption on the nipple and areola due to Paget’s cells in the nipple epidermis
Paget’s cells are large cells with pale cytoplasm and prominent nucleoli
What are the two theories for the pathogenesis of Paget’s disease of the breast?
EPIDERMOTROPHIC THEORY
Paget cell arises from underlying mammary adenocarcinoma with neoplastic ductal epithelial cells migrating through the ductal system of the breast into the epidermis of the nipple
IN SITU TRANSFORMATION THEORY
Epidermal keratinocytes within the nipple transform into malignant Paget cells
PDB is an epidermal carcinoma in situ that is independent of any underlying ductal carcinoma
Define fibroadenoma
Benign breast tumour, containing both glandular (epithelial) and stromal (connective tissue) components
What is Li-Fraumeni syndrome
Rare autosomal dominantly inherited abnormality of p53 resulting in increased rate of sarcoma, breast, leukaemia and adrenal cancers
Risk factors for male breast cancer
Hyperoestrogenic states - Klinefelter's syndrome (47XXY) - Testicular dysgenesis/cryptorchidism - Obesity - Alcoholism and liver disease Chest irradiation Occupational exposures - Electromagnetic fields - High temperature Genetic causes - Up to 20% have a first degree relative with breast cancer - BRCA2 mutation most common in males - Cowden syndrome is rare - CHEK2 rare
Treatment of male breast cancer
Usually total mastectomy with SLNB +/- ALND
Post-mastectomy radiotherapy if:
- Large tumour
- > 3 axillary nodes involved
- High grade disease
Tamoxifen for 5 years if ER/PR positive (improves survival)
Adjuvant chemotherapy if lymph node positive
Prognosis of male breast cancer
Same stage for stage but is usually more advanced at presentation
Breast Birads Classification
0 - needs additional imaging evaluation and/or prior mammograms for evaluation 1 - negative 2 - benign 3 - probably benign 4 - suspicious 5 - highly suspicious of malignancy 6 - known malignancy
Indications for breast MRI
- All woman less than 40 even if having mastectomy to check for contralateral disease
- Lobular cancer (multifocality and bilaterally)
- Suspicion of multifocal disease
- Tumour size uncertain and planning WLE
- Suspicion of chest wall invasion
- High grade DCIS 20mm or more for WLE
- Dense breasts in those less than 50 years
- History of breast cancer < 40 years
- Node positive with occult primary
- Assessing loco-regional recurrence and differentiating from scar, particularly in reconstructed breasts
- Assess silicone implant integrity when suspicion of rupture and USS negative
Nottingham Prognostic Index (NPI)
Size - 0.2 x size in cm
Grade - I=1, II=2, III=3
Nodes - nil=1, 1-4=2, >4 =3
5.4 = 30% annual mortality
Contraindications to breast conserving surgery with radiotherapy
Large tumour (>4 cm) Small breast vs tumour ratio Multi-focal /-centric disease/ Extensive co-existent DCIS (>1 quadrant) Skin involvement / Fixation Inflammatory Contraindications to radiotherapy - Previous radiotherapy at the site - Connective tissue disease - Severe heart and/or lung disease - Pregnancy - +/- subareaolar tumour - cosmesis may be greatly compromised but can be done Patient preference for mastectomy - May not want the risk of having to undergo further surgery if margins not adequate - Strong family history of breast cancer
Margin for WLE for BCS
2mm
If margin less than this, consider the following before re-excision:
* Patient age * Tumour histology - LVI, grade, extensive in situ component, type - eg lobular) * Which margin - smaller margins may be accepted for superficial and deep margins
Bloom-Richardson histologic grading system for breast cancer
Tubule formation 1-3
Mitotic count 1-3
Nuclear pleomorphism 1-3
Low grade (I) = 3-5 Intermediate grade (II) = 6-7 High grade (III) = 8-9
Indications for SLNB in DCIS
Large volume (palpable mass, mammographic mass, >3cm - definitely if >5cm) High grade Suspicion for invasive disease Mastectomy (further SLNB impossible) Reconstruction involving axilla
What is DCIS
Abnormal proliferation of ductal epithelial cells with morphological features of malignancy but no basement membrane or stromal invasion and involving at least two ducts
What is inflammatory breast cancer
A form of locally advanced breast cancer characterised by erythema, oedema, induration, warmth and tenderness of the skin resulting in peau d’orange - attributed to tumour emboli in derma lymphovascular spaces.
What is HER2?
Human Epidermal Growth Factor Receptor 2
Transmembrane glycoprotein receptor
Critical regulator of cell cycle signalling
Over-expressed due to a gene mutation in up to 20% of breast cancers
Independent poor risk factor
What is Herceptin
Trastuzumab (Herceptin) is a monoclonal antibody that binds to the extracellular domain of the human epidermal growth factor receptor 2 protein (HER-2).
It mediates antibody-dependent cellular cytotoxicity by inhibiting proliferation of cells which overexpress HER-2 protein.
Define accessory breast and nipples
Residuals of mammary gland tissue due to incomplete regression of the mammary ridges.
Most commonly in the axilla but may occur anywhere along the milk lines
Risk factors for male breast cancer
AGREE
Age
Genetics - BRCA 2, Cowden syndrome, CHEK2
Radiation
Estrogen exposure - Klinefelter’s, testicular dysgenesis, cryptorchidism, obesity, alcoholism, liver impairment
Exposure occupational - Electromagnetic fields, high temperature
What is the association between Paget’s disease of the nipple and malignancy?
> 95% have an underlying malignancy of which half are clinically and mammographically occult.
- 90% invasive
- 10% DCIS
- 90% HER2 positive
- 50% hormone receptor positive
Life time risk of breast cancer
3%
15% with ADH/ALH (5x)
30% with DCIS/LSIS (10x)
How do you identify the axillary vie during axillary dissection?
Follow the anterior branches of the axillary vein
Follow the medial pectoral leash
Groove between biceps and triceps at 90 degrees
1cm above latissimus dorsi tendon
Immediately below axillary artery pulsation
Risk factors for lymphoedema
Extent of dissection Number of nodes removed Post-operative radiotherapy Obesity Arm infection Trauma
Hereditary breast cancer syndromes
5% of all breast cancers BRCA1 and BRCA2 Li-Fraumeni syndrome Cowden's syndrome Muir-Torre syndrome Ataxia telangectasia Hereditary diffuse gastric cancer Peutz-Jegher's syndrome
Five things to assess on a mammogram
Symmetry Architectural distortion Masses Calcifications Densities
Classify calcifications on mammogram
Typically benign
- skin
- vascular
- popcorn-like
- rod-like
- round
- punctate
- milk of calcium
- eggshell
- dystrophic
- suture
Intermediate concern
- amorphous
- indistinct
Concern for malignancy
- pleomorphic microcalcifications
- heterogeneous microcalcifications
- fine linear calcifications
- linear/branching calcifications
Indications for mastectomy in DCIS
Multifocal or multicentric
DCIS > 4cm
Contra-indication to radiotherapy
- previous radiotherapy
- CTD
- severe cardiorespiratory disease
- radiotherapy
Residual diseae / positive margins
Poor cosmesis
- large tumour in small breast
- location of disease
Patient preferenceVan Nuys Prognostic Index
Pronounced Van Nye
TRAP
Tumour size - 40
Resection margin - >10, 1-9, 60, <5 - no benefit from radiotherapy
Role of tamoxifen in DCIS
Lowers disease recurrence or prevent development of invasive cancer in hormone receptor positive DCIS especially in those <50 years
Granulomatous mastitis
Rare benign chronic non-caseating granulomas and microabscess confined to a breast lobule
Management of granulomatous mastitis
Drain sepsis
Exclude malignancy
Exclude secondary causes
- Infection
-Tb
-Histoplasmosis
- Systemic granulomatous disease
-Sarcoidosis
-Wegeners granulomatosis
High dose tetracycline and penicillin
Avoid excision due to persistent wound & discharge
Try steroids
MastectomyClassify granulomatous mastitis
Primary - Aetiology unknown - ? Corynebacterium Secondary - Granulomatous disease - sarcoid, Wegeners - Granulomatous infection - Tb, histo
Sub-types of DCIS
Comedo = central necrosis
Non-comedo
* Cribriform = sieve-like appearance
* Solid = ducts filled with malignant cells
* Papillary = papillary projections
* Micro-papillary
Required information from breast cancer pathology report
Size Grade Lymph nodes Margins Receptors
