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MRCS B pathology > Pathology: breast > Flashcards

Pathology: breast Flashcards

1
Q

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

A

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

Cancer

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2
Q

How would you investigate pt presenting with breast lump?

A

Triple assessment
Core biopsy

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3
Q

What are features of fibroadenoma of the breast?

A

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

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4
Q

What is triple assessment?

A

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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5
Q

How are fibroadenomas managed?

A

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

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6
Q

What would be presenting features of patients with periductal mastitis?

A

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

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7
Q

What organisms commonly cause periductal mastitis?

A

Staphylococcus most common
enterococcus

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8
Q

How would you manage periductal mastitis?

A

Co-amoxiclav
Or Fluclox and metro

Erythromycin if pen allergic

Follow up to r/o inflammatory breast ca

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9
Q

What is duct ectasia? How is it managed?

A

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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10
Q

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

A

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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11
Q

How would you manage nipple discharge?

A

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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12
Q

What are the main clinical features of poland syndrome?

A

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

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13
Q

What are the causes for gynaecomastia?

A

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

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14
Q

What is the current breast screening programme?

A

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

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15
Q

What are the risk factors for developing breast ca?

A

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

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16
Q

What factors reduce risk of developing breast ca?

A

High parity
Breastfeeding
Late menarche
Early menopause

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17
Q

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

A

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

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18
Q

What is the role of MRI in imaging breast lumps

A

-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

19
Q

What are features of phyllodes tumour of breast?

A

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

20
Q

How would you manage phyllodes tumour of breast?

A

Triple assessment
WLE/mastectomy, no need for margins

21
Q

What are key features of breast cysts?

A

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

22
Q

How would you manage breast cyst?

A

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

23
Q

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

A

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

24
Q

Management of lactational abscess

A

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

25
Q

Key features of paget’s disease

A

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

26
Q

How would you manage DCIS of the breast?

A

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

27
Q

What is TNM staging of breast ca?

A

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

N: nodes

M: metastases

28
Q

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

A

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

29
Q

What are the indications for neoadjuvant chemotherapy in breast ca?

A

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

30
Q

What are the indications for adjuvant chemo in breast ca?

A

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

31
Q

What is the indication for radiotherapy in breast cancers?

A

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

32
Q

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

A

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

33
Q

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

A

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

34
Q

What is the mechanism of action of tamoxifen in breast ca

A

Oestrogen receptor antagonist
Can be an agonist in other tissues

35
Q

What is the mechanism of action of letrozole in breast ca

A

Aromatase inhibitor: prevents conversion of androgens to oestrogen

36
Q

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

A

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

37
Q

What are the indications for mastectomy?

A

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

38
Q

What do you understand by BRCA 1 and 2?

A

Tumour suppressor genes

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

39
Q

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

A

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

40
Q

Describe technique of SNB

A

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

41
Q

What reconstructive options are there?

A

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
-

42
Q

What other flaps are available in breast surgery

A

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

43
Q

What is herceptin?

A

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

MRCS B pathology (14 decks)

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