Pathology: breast Flashcards
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
How would you investigate pt presenting with breast lump?
Triple assessment
Core biopsy
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`
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
How are fibroadenomas managed?
Triple assessment
If <2cm + solitary: conservative
If >4cm: pt choice whether to excise
2-4cm: follow up
What would be presenting features of patients with periductal mastitis?
Smokers
Unilateral
Pain, swelling, redness, nipple discharge
Localised to nipple areolar complex
What organisms commonly cause periductal mastitis?
Staphylococcus most common
enterococcus
How would you manage periductal mastitis?
Co-amoxiclav
Or Fluclox and metro
Erythromycin if pen allergic
Follow up to r/o inflammatory breast ca
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
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
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
What are the main clinical features of poland syndrome?
Hypoplasia pec minor on affected side, hypoplasia shoulder girdle
No breast development
What are the causes for gynaecomastia?
Steroid abuse
Obesity
Drugs (spironolactone, digoxin, 5 alpha reductase inhibitors)
testicular ca
Liver cirrhosis
What is the current breast screening programme?
3 yearly mammogramm 50-70: 2 view mammogram interpreted by 2 radiologists
What are the risk factors for developing breast ca?
Early menarche
Late menopause
Exogenous hormones (HRT)
Previous breast ca
+ve fhx–> BRCA gene
What factors reduce risk of developing breast ca?
High parity
Breastfeeding
Late menarche
Early menopause
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)
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
