Pathology: breast Flashcards by Eliot Carrington-windo

What are the main differentials for patients presenting with breast lumps? What are their predominant risk factors?

Benign:
-Fibroadenoma
-Cyst
-Periductal mastitis (smoker)
-Fat necrosis (trauma)
-Breast abscess (lactating)
-Phyllodes (menopause)

Cancer

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How would you investigate pt presenting with breast lump?

Triple assessment
Core biopsy

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What are features of fibroadenoma of the breast?

-16-24 years
-Well defined mobile lesions
-Usually located in upper outer quadrant
-Usually <2cm in size`

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What is triple assessment?

Physical examination
Imaging: US and/or mammography. <40 and men –> US only as tissue is dense. >40: mammography and US
Histology: Core biopsy

Each stage is graded 1-5, 5 being malignant
P1-5
M/U 1-5
B1-5

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How are fibroadenomas managed?

Triple assessment
If <2cm + solitary: conservative
If >4cm: pt choice whether to excise
2-4cm: follow up

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What would be presenting features of patients with periductal mastitis?

Smokers
Unilateral
Pain, swelling, redness, nipple discharge
Localised to nipple areolar complex

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What organisms commonly cause periductal mastitis?

Staphylococcus most common
enterococcus

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How would you manage periductal mastitis?

Co-amoxiclav
Or Fluclox and metro

Erythromycin if pen allergic

Follow up to r/o inflammatory breast ca

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What is duct ectasia? How is it managed?

Involutional change most common in perimenopausal women
Shortening and dilatation of subareolar ducts
Presents with discharge or subareolar mass
-Discharge can be creamy or blood stained
-Duct excision performed to exclude malignancy, especially if discharge is bloodstained

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What are the causes for nipple discharge? Which are the most common?

Duct ectasia
-Involutional change most common in perimenopausal women
Intraductal papilloma
–> above 2 most common

Physiological discharge
Galactorrhea
DCIS less common

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How would you manage nipple discharge?

Suspcicious features:
-clear, bloody, single duct

If associated with a lump will always require triple assessment

If suspicious:
-Cytology
-Mammogram
-Duct excision

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What are the main clinical features of poland syndrome?

Hypoplasia pec minor on affected side, hypoplasia shoulder girdle
No breast development

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What are the causes for gynaecomastia?

Steroid abuse
Obesity
Drugs (spironolactone, digoxin, 5 alpha reductase inhibitors)
testicular ca
Liver cirrhosis

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What is the current breast screening programme?

3 yearly mammogramm 50-70: 2 view mammogram interpreted by 2 radiologists

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What are the risk factors for developing breast ca?

Early menarche
Late menopause
Exogenous hormones (HRT)
Previous breast ca
+ve fhx–> BRCA gene

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What factors reduce risk of developing breast ca?

High parity
Breastfeeding
Late menarche
Early menopause

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What genes are associated with increased risk of developing beast ca and what are their key characteristics?

BRCA 1+2–> autosomal dominant
TP53 (li fraumeni)

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What is the role of MRI in imaging breast lumps

-Breast implants
-<30, fhx BRCA
-Invasive lobular carcinoma (can be multifocal: especially if offered breast conserving surgery for unifocal ILC)
-Discrepancy between clinical and radiological size lump
-Dense breast

What are features of phyllodes tumour of breast?

Rapidly growing
Stromal tissue rather than ducts/glands
Haematogenous spread if malignant
40-60
Most benign, can be malignant

How would you manage phyllodes tumour of breast?

Triple assessment
WLE/mastectomy, no need for margins

What are key features of breast cysts?

Fluid filled smooth painful lumps
Develop in perimenopausal women
Rare after menopause unless on HRT

How would you manage breast cyst?

US or mammogram to confirm dx
Aspirate: should resolve`
If persists or aspirate is blood stained, will need triple assessment

What is an abscess? How would you classify breast abscesses?

Abscess: collection of pus surrounded by fibrous or granulation tissue

Breast abscess: can be lactational or non lactational

Lactational: occurs in 5% perperal females, babies teeth cause trauma to nipple

Management of lactational abscess

US to confirm diagnosis
Us guided/surgical drainage
Culture for MC and S for abx
Advise to continue breastfeeding/express milk

Key features of paget's disease

Erythema and scaly rash Starts from nipple and spreads outwards, unlike eczema which starts outside and spreads inwards Nipple discharge

How would you manage DCIS of the breast?

Pre-invasive 90% impalpable If high risk: WLE/mastectomy If mastectomy: must stage axilla as can then not do SLNB

What is TNM staging of breast ca?

T1 <2cm T2 2-5cm T3 >5cm, (out of capsule) T4: fixed to underlying skin (peau d'orange) N: nodes M: metastases

What is role of IHC and FISH in management of breast ca?

Tests on biopsied tissue to determine if HER2 +ve (FISH more accurate)

What are the indications for neoadjuvant chemotherapy in breast ca?

If large tumour (>5cm) in young pt for downstaging--> convert mastectomy to WLE Locally advanced tumour Axillary node +ve If triple -ve, HER 2 +ve Inflammatory breast ca

What are the indications for adjuvant chemo in breast ca?

To treat +ve axilla Triple -ve/HER 2 +ve Inadequate margins instead of further surgery

What is the indication for radiotherapy in breast cancers?

Offered to all pt's who undergo WLE Other indications: Adjuvant (no such thing as neoadjuvant) -Positive resection margins ->4 positive nodes in axilla -Large tumour size (>5cm) -Palliative

How would you manage positive lymph nodes in the axilla in a pt with breast ca?

If lymph nodes +ve: neoadjuvant/adjuvent chemo/adjuvant radiotherapy Trying to avoid axillary clearance FINAL DECISION IN MDT

What drugs are you aware of in the treatment of breast cancers?

Tamoxifen if pre menopausal (for 10 years Letrozole for post menopausal women herceptin

What is the mechanism of action of tamoxifen in breast ca

Oestrogen receptor antagonist Can be an agonist in other tissues

What is the mechanism of action of letrozole in breast ca

Aromatase inhibitor: prevents conversion of androgens to oestrogen

What are the indications for wide local excision for a breast ca?

T1/T2 (<4-5cm) + no nodes: lumpectomy >5cm with large breast: WLE Single lesion: WLE Peripheral tumour

What are the indications for mastectomy?

High tissue to breast ratio multifocal Recurrence following local excision BRCA prophylactically Central tumour

What do you understand by BRCA 1 and 2?

Tumour suppressor genes BRCA 1 mutation carries 80% lifetime risk breast ca BRCA 2: slightly lower risk. Also associated with melanoma.

What is the role of a sentinel node biopsy in breast cancer?

First node in a lymph chain to receive drainage from a tumour Used in early breast ca where nodes are US/FNA negative Not used if palpable nodes

Describe technique of SNB

Blue dye/radioisotope is injected into subdermal layer around areolar region pre-operatively Hand held geiger counter/blue dye used to identify sentinel node If +ve, that group of nodes is excised

What reconstructive options are there?

Breast mound: -Implant alone -Implant and autologous (LD flap most common) -Autologous alone (local or pedicled flap) Nipple -Graft from contralateral side or local flap -Areolar: tattooing -

What other flaps are available in breast surgery

TRAM flap (transverse rectus abdominis muscle) DIEP (deep inferior epigastric perforators)

What is herceptin?

Monoclonal antibody can be given to all pt's who are her-2 +ve Causes antibody mediated destruction of cells over producing HER 2