Repro: Breast Disease

Question 1

How do the breasts change at menarche?

Answer 1

There is increase is the number of lobules and increased volume of stroma.

Question 2

How do the breasts change during the menstrual cycle?

Answer 2

After ovulation there is stromal oedema which is why some women experience breast tenderness before menstruation

Question 3

How do the breast change during pregnancy?

Answer 3

Increase in size and number of lobules, decrease in stroma, secretory changes

Question 4

Why are mammographs easier to interpret in older women?

Answer 4

With age the lobules and stroma are replaced by adipose tissue which appears black on mammographs
In younger women the breasts are dense and hard to see

Question 5

What are some good questions to ask about breast pain?

Answer 5

Is the pain cyclical?
Is the pain in both breasts? (Most often physiological)
Is the pain focal? May be a ruptured cyst, trauma, inflammation.

Pain is occasionally the presenting complaint in breast cancer

Question 6

What are some causes of a palpable mass in the breast?

Answer 6

• invasive carcinomas (usually present as a mass)
• fibroadenomas (benign)
• cysts

NB All women should have breast lumps diagnosed, even cancers may feel benign

Question 7

What features of nipple discharge are important to ascertain and why?

Answer 7

• if the discharge is unilateral and spontaneous, more likely to be malignant
• if the discharge is milky, most likely to be endocrine disorder or side effect of oral contraceptives
• if the discharge is bloody or serous, most likely benign but occasionally malignant

Question 8

What is a common cause of breast lumps in women under 30?

Answer 8

Fibroadenomas - benign.

Present usually as a mobile mass that can grow up to take over most of the breast.
Appear white, smooth and rubbery. Due to a local hyperplasia rather than a neoplasia

Question 9

What is a phyllodes tumour?

Answer 9

A tumour that usually presents in 60s, looks very similar to fibroadenoma but can be malignant (very aggressive and metastasise by blood stream).

Need to be excised with a wide margin

Question 10

What age does breast cancer present in?

Answer 10

3/4 are over 50

Question 11

What is acute mastitis?

Answer 11

An infection almost always related to lactation. Usually caused by a staphylococcus aureus infection from nipple cracks.
The breast is swollen and very painful - best treatment is expressing milk and antibiotics

Question 12

What is fat necrosis?

Answer 12

Fat necrosis after a history of trauma or surgery. Present as a fixed craggy mass which can mimic carcinoma clinically and mammographically

Question 13

What is fibrocystic change?

Answer 13

The most common breast lesion which presents as a mass or mammograph abnormality.
The ducts are dilated and muck pinker. Get metaplasia
Usually disappears after fine needle aspiration - contents leak out

Question 14

What is gynaecomastia?

Answer 14

‘Man boobs’!

Unilateral or bilateral - can mimic breast cancer esp if unilateral.

Question 15

What are the causes of gynaecomastia?

Answer 15

• neonatal secondary to maternal and placental oestrogen and progesterone
• can occur at puberty because oestrogen peaks slightly before testosterone
• liver cirrhosis when oestrogen is not metabolised correctly
• gonatrphin excess eg testicular tumours
• drugs related eg spironllactone, alcohol, heroin, marijuana

Question 16

What is the most common type of breast cancer?

Answer 16

95% are adenocarcinomas

Question 17

Where in the breast does breast cancer occur?

Answer 17

50% in the upper outer quadrant

Question 18

Which males are at increased risk of breast cancer?

Answer 18

• male to female transsexuals

- men treated with oestrogen for prostate cancer

Question 19

What are the major risk factors for breast cancer and why?

Answer 19

• Uninterrupted menses, eg no pregnancies and breast feeding, turnover of cells in cycle so more mitoses
• early menarche and late menopause due to long term oestrogen exposure
• obesity, more oestrogen produced
• exogenous oestrogen eg HRT, decades of oral contraceptives
• gender (males only 1% of cases)
• previous breast cancer (10x increased risk)
• radiation, eg Mantle radiation in Hodgkins lymphoma
• family history

Question 20

What is the risk of getting breast cancer for a BRCA carrier?

Answer 20

Lifetime risk is 60-85% therefore most women undergo a prophylactic mastectomy

Question 21

How can breast cancers be classified?

Answer 21

• can be in-situ or invasive

- can be ductal or lobular

Question 22

Outline what an in-situ carcinoma is

Answer 22

A neoplastic population of cells which are limited to the ducts and lobules by the basement membrane. The myoepithelial cells are preserved

Does not invade into vessels therefore cannot metastasise. Will not kill pt

Question 23

Give examples of an in-situ breast carcinoma

Answer 23

• Ductal carcinoma in situ

- Pagets disease

Question 24

How does ductal carcinoma in situ present?

What is the histological appearance?

Answer 24

Presents as mammographic calcifications or a mass. Can be very extensive

Histologically the ducts are dilated with necrosis and calcification in the centre

Question 25

How does pagets disease of the breast present?

Answer 25

Cells can extend all the way to the nipple without crossing the basement membrane.
Presents as unilateral red, crusty nipple . (Therefore any eczema or inflammation of the nipple should be regarded as suspicious)

Question 26

What is an invasive carcinoma?

Answer 26

A cancer that has invaded beyond the basement membrane and into the stroma. Can invade into vessels and metastasise to lymph nodes. (By the time the mass is palpable >50% will have metastasised to axillary nodes)

Question 27

How can the breast appear microscopically with an invasive carcinoma?

Answer 27

The nipple can be inverted - the growth of the tumour pulls the nipple inwards.

Peau d’orange, the cancer has got into the lymphatics and the breast is oedematous. The hair follicles are well attache but the skin is swollen so gives an orange peel appearance.

Question 28

Give examples of invasive carcinomas

Answer 28

• invasive ductal carcinoma, no specific type (IDC NST)
  3/4 of invasive cancers, 50% 10 year survival
• invasive lobular carcinoma
  10% of invasive
  Cells lack cohesion and line up
  Similar prognosis to IDC NST
• others such as tubular or mucinous. Have excellent prognosis

Question 29

How does breast cancer metastasise?

Answer 29

Lymph nodes - usually the ipsilateral axilla

Distant metastasis via blood, eg bones, lung, liver, brain

Question 30

What factors determine the prognosis of breast cancer?

Answer 30

• in situ or invasive (NB in situ can progress to invasive)
• tumour stage is most important eg has it metastasised
• tumour grade eg how well differentiated
• which genes are expressed (can be used to determine the marker genes that have potential to metastasise)

Question 31

What is the triple approach to diagnosing breast cancer?

Answer 31

1. Clinical - history, family history, examination
2. Radiographic imaging - mammograph and USS
3. Pathology - fine needle aspiration and core biopsy

Question 32

What is mammographic screening?

Answer 32

All women aged 47-73 are offered a mammograph every 3 years.
Aims to detect small impalpable cancers and pre-invasive cancers so they can be treated early.

Abnormalities are offered further testing

Question 33

What is sentinel lymph node biopsy?

Answer 33

Reduces risk of postoperative morbidity.
The draining nodes are dyed and the one most likely to contain metastasis is tested.
If it is negative axillary dissection can be avoided.

Question 34

What types of cancer are tamoxifen and herceptin used for?

Answer 34

Tamoxifen - given in cancers that are oestrogen receptor positive (ER positive)

Herceptin - given in cancers that are HER2 positive