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Integration To Clinical Anatomy > Session 7 > Flashcards

Session 7 Flashcards

1
Q

State the most common cancers in men and women and write from highest incidence to lower

A

Men: prostate, lung & bowel joint

Women: breast, lung then bowel

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2
Q

What does normal breast tissue look like histologically?

A
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3
Q

How can breast cancer present?

  1. Location?
  2. Presenting features?
A
  1. Most common in the upper outer quadrant (approximately 50% occur here)
  2. Palpable mass
    – Most worrying if hard, craggy or fixed

– No women should have a lump in the breast without a diagnosis

• Mammographic abnormalities

• Nipple discharge
– Bloody or serous (not milky)
– Spontaneous and unilateral

• Rarely Pain

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4
Q

Is breast cancer common?

Incidence in women

Common age of diagnosis

A
  • Most common non-skin malignancy in women
  • Accounts for 20% of all malignancies in women
  • 1 in 8 women will develop breast cancer at some time in their life
  • Incidence rises with age
  • 77% occurs in women >50 years
  • Average age at diagnosis is 64 years
  • Rare before 25 years (except for some familial cases)
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5
Q

Is breast cancer common?

Incidence

Deaths

What increases the risk of breast cancer in men?

A
  • 54,751 new female cases and 371 new male cases a year (UK, 2015)
  • 11,433 deaths per year (7% of total cancer deaths) (UK, 2014)
  • Male breast cancer

– 1% of all cases of breast cancer

– Increased risk with Klinefelter’s syndrome, male to female transsexuals, men treated
with oestrogen for prostate cancer

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6
Q

What are the risk factors for breast cancer? (6)

A

Major risk factors are related to hormone exposure
– Gender

– Uninterrupted menses

– Early menarche (< 11 years)

– Late menopause

– Reproductive history - parity and age at first full term pregnancy

– Breast-feeding

– Obesity and high fat diet

– Exogenous oestrogens

– HRT slightly increases risk (1.2-1.7 times), long term users of OCP possibly have an increased risk

(Wait a long time your epithelial cells have a change to pick up more mutations then proliferate due to late pregnancy more likely to have cancer (theory), or cell terminally differentiated less blue to divide and less and to divide?)

• Geographic influence
– Higher incidence in US and Europe
– Possible explanations include diet, physical activity,

  • Atypical changes on previous biopsy (4-5 times)
  • Previous breast cancer (10 times)

• Radiation
– Increased risk with previous exposure to therapeutic breast-feeding, environmental factors radiation (especially in childhood or adolescence), e.g. mantle radiation for Hodgkin’s lymphoma

• Hereditary breast cancer

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7
Q

Hereditary breast cancer

– 10% of breast cancers

– 3% of all breast cancers and 25% of familial cancers attributed to ?

  • 0.1% of population has BRCA1 germline mutations
  • Lifetime breast cancer risk for female carriers is 60-85%
  • Median age at diagnosis is approximately 20 years earlier than sporadic cases
  • Carriers may undergo ?
A

mutations in BRCA1 (BReast CAncer associated gene 1) or BRCA2

Both tumour suppressor genes – their proteins repair damaged DNA

prophylactic mastectomies

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8
Q

How do we diagnose breast cancer?​

A

• Triple approach

– Clinical – history, family history, examination

– Radiographic imaging – mammogram and ultrasound scan

– Pathology – core biopsy and fine needle aspiration cytology (FNAC)

2 week wait -> risk of cancer

leaflets of procedure etc

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9
Q

How do we classify breast carcinoma?

i.e. most common breasts carcinoma?

how is this subdivided?

how is this subdivided?

A
  • Approximately 95% are adenocarcinomas
  • Adenocarcinomas divided into in situ (ductal carcinoma in situ = DCIS) and invasive

• Invasive carcinomas classified by histological type:
– E.g., ductal, lobular, tubular, mucinous

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10
Q

What is DCIS? (3)

A
  • Neoplastic population of cells limited to ducts and lobules by basement membrane, myoepithelial cells are preserved
  • Does not invade into vessels and therefore cannot metastasise or kill the patient
  • Three grades showing increasing cytological atypia – low, intermediate and high
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11
Q

So why is ductal carcinoma in situ (DCIS) a problem then?

A

• Non-obligate precursor of invasive carcinoma

• High grade more likely to become invasive and produce a poor prognosis invasive
tumour

• Can spread through ducts and lobules and be very extensive

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12
Q

How is DCIS likely to present?

  1. Histologically
A
  1. Histologically often shows central (comedo) necrosis with calcification
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13
Q

How is DCIS likely to present on the mammogram?

A

Most often presents as mammographic calcifications (clusters or linear & branching) but can present as a mass

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14
Q

What is Paget’s disease?

A

Bone disrupts the normal cycle of bone renewal, causing bones to become weakened and possibly deformed.

• Cells can extend to nipple skin without crossing BM = Paget’s disease
– Unilateral red and crusting nipple

– Eczematous or inflammatory conditions of the nipple should be regarded as suspicious and biopsy performed to exclude Paget’s disease

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15
Q

How does invasive carcinoma differ from DCIS? (5)

A
  • Neoplastic cells have invaded beyond BM into stroma
  • Can invade into vessels and can therefore metastasize to lymph nodes and other sites
  • Usually presents as a mass or as mammographic abnormality
  • By the time a cancer is palpable more than half of the patients will have axillary lymph node metastases
  • Peau d’orange – involvment of lymphatic drainage of skin
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16
Q
A

Retraction of the nipple - central breast cancer just beneath the nipple
• one side
• Pulling inwards

Skin of an orange
Invasive malignancy of the breat
Blocked lymph cvessls
Become oedematous
Skiing firmly in place
In odema all around sweat glands an hair follicles = pits

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17
Q

How is invasive breast carcinoma classified? (4)

A
  1. Invasive ductal carcinoma, no special type (IDC NST)
    – 70-80%
    – Well-differentiated type – tubules lined by atypical cells
    – Poorly differentiated type – sheets of pleomorphic cells
    – 35-50% 10 year survival
  2. Invasive lobular carcinoma
    – 5-15%
    – Infiltrating cells in a single file, cells lack cohesion
    – Similar prognosis to IDC NST
  3. Other types, e.g. tubular (1-2%, excellent prognosis), mucinous (1-6%, excellent prognosis, often older women)
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18
Q
A
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19
Q
A
  • Invasive lobular carcinoma
  • Single file
20
Q
A

Tubular carcinoma

Much better prognosis
Looks a bit like an adenocarcinoma

21
Q

How does breast cancer spread?

A
  • Lymph nodes via lymphatics– usually in the ipsilateral axilla
  • Distant metastases via blood vessels – bones (most frequent site), lungs, liver, brain

• Invasive lobular carcinoma can spread to odd sites – peritoneum, retroperitoneum,
leptomeninges, gastrointestinal tract, ovaries, uterus

22
Q

What factors determine prognosis in breast cancer?

A
  • In situ disease or invasive carcinoma
  • Tumour stage:

– Tumour size and locally advanced disease, invading into skin or skeletal muscle

– Lymph Node metastases

– Distant Metastases

  • Tumour grade
  • Histologic subtype – IDC NST has poorer prognosis
  • Molecular classification and gene expression profile
23
Q

What is a gene expression profile and why is it important in breast cancer?

A
  • Microarrays have been used to examine the expression patterns of some 25,000 genes in tissues from breast cancer patients.
  • Computer cluster analysis of the patterns led to the identification of about 17 marker genes that can correctly identify about 90% of women who would eventually develop metastases.
24
Q

What are the therapeutic approaches in breast cancer?

Local and regional control – DCIS and invasive carcinoma:

  1. What surgeries are available? What can influence your decision?
  2. What can be offered after surgery?
A
  1. – Breast surgery – mastectomy or breast conserving surgery – decision depends on
    patient choice, size and site of tumour, number of tumours, size of breast

– Axillary surgery – extent depending on whether there are involved nodes (sentinel
node sampling or axillary dissection)

  1. Post-operative radiotherapy to chest & axilla
25
Q
  1. What is sentinel lymph node biopsy?
  2. Why is it of benefit?
A
  1. • Intraoperative lymphatic mapping with dye and/or radioactivity of the draining or ‘sentinel’ lymph node(s) – the one vmost likely to contain breast cancer metastases

• If the sentinel node(s) is negative axillary dissection can be avoided

  1. Reduces the risk of postoperative morbidity

Take ll lymph nodes
Swollen and oedematous arm
• predispose to a certain sarcoma in the arm
thus doing sentinel node sampling

26
Q

What are the therapeutic approaches in breast cancer?

Systemic control – invasive carcinoma only

  1. Chemotherapy – if benefits thought to outweigh the risks; if given before surgery = ?
  2. What should be given if ER positive? What percentage of cancers are ER positive?
  3. What should be given if patient is Her2 positive? What percentage of cancers are Her2?
A
  1. neoadjuvant
  2. Hormonal treatment, e.g. tamoxifen – depending on oestrogen receptor status (approximately 80% of cancers are ER positive)
  3. Herceptin treatment – depending on Her2 receptor status (approximately 20% of cancers are Her2 positive):
  • Her2 is a member of the human epidermal growth factor receptor family
  • Encodes a transmembrane tyrosine kinase receptor
  • Herceptin = trastuzumab = humanised monoclonal antibodies against the Her2 protein
27
Q

What is mammographic screening?

A
  • Women 47–73 years
  • 2 view mammograms every 3 years
  • Aim is to detect small impalpable cancers and DCIS (incidence of DCIS has increased from 5% of breast cancers to 25% in screened populations)
  • Look for asymmetric densities, parenchymal deformities, calcifications
  • Assess abnormalities using further imaging, core biopsy and FNAC
28
Q

Why aren’t younger women offered breast screening?

A
  • Lower incidence of breast cancer in young women
  • With increasing age fibrous stroma replaced by adipose tissue and mammograms easier to interpret
  • Lifetime cumulative exposure to radiation
29
Q

Which breast conditions cause mammographic abnormalities?

A

• Densities:
– Invasive carcinomas, fibroadenomas, cysts

• Calcifications:
– DCIS, invasive carcinomas, cysts and other benign changes

30
Q

What is this image showing

A

Calcification

31
Q

How do we improve survival from breast cancer? (5)

A

• Early detection – awareness of disease, importance of family history, self-examination,
mammographic screening

  • Neoadjuvant chemotherapy – early treatment of metastatic disease
  • Use of newer therapies – e.g. Herceptin
  • Gene expression profiles

• Prevention in familial cases
– genetic screening, prophylactic mastectomies

32
Q

Learning objectives:

  • To understand the most common clinical presenting features of breast disease
  • To understand the most common conditions accounting for benign breast disease such as fibrocystic changes
  • To understand the commonest benign lesions of the breast such as fibroadenoma
  • To be aware of benign conditions causing nipple discharge such as duct ectasia and

lactation related problems such as mastitis

• To realise what the current UK referral guidelines are for women with breast symptoms

A

-

33
Q

• To understand the most common clinical presenting features of breast disease LO

Clinical presenting features for breast disease

A
  • Physiological swelling and tenderness.
  • Nodularity.
  • Breast pain (not usually associated with malignancy)
  • Palpable breast lumps.
  • Nipple discharge including galactorrhoea.
  • Breast infection and inflammation - usually associated with lactation.
34
Q

What is thelarche

A

Physiological swelling and tenderness

  • Puberty
  • Breast enlargement, sometimes initially unilateral, is the first obvious sign of puberty in girls. Breast buds may initially be unilateral.
35
Q

• To understand the most common conditions accounting for benign breast disease such as fibrocystic changes LO

Benign Breast Disease

  1. ? is the most common benign breast disorder
  2. This usually affects women aged ?

3 Aetiology?

  1. Most often presents with?
A
  1. Fibrocystic change
  2. 20-50
  3. hormonal
  4. pain and nodularity
36
Q

NODULARITY

  1. The symptoms are greatest about?
  2. Examination may reveal an area of ?
  3. If the changes are bilaterally symmetrical, they are rarely pathological. If there is asymmetry it is acceptable to review the patient after one of two menstrual cycles, seeing her mid-cycle. Treatment is with ?
A
  1. one week before menstruation and decrease when it starts.
  2. nodularity or thickening, poorly differentiated from the surrounding tissue and often in the upper outer quadrant of the breast.
  3. analgesia and a good, well-fitting bra
37
Q

What is Cyclical mastalgia (breast tenderness)?

A

The breasts are active organs that change throughout the menstrual cycle and some degree of tenderness and nodularity in the premenstrual phase is so common that it may be considered as normal, affecting up to two thirds of all menstruating women. It rapidly resolves as menstruation starts.

38
Q

• To understand the commonest benign lesions of the breast such as fibroadenoma LO

Palpable benign breast lumps

Most benign lumps will be either cysts or fibroadenomas.

A benign mass is usually?

A

three-dimensional, mobile and smooth, has regular borders and is solid or cystic in consistency

39
Q

Breast Cysts

Cysts are most common between the ages of ? They are palpable as discrete lumps and may be recurrent. They cannot be reliably distinguished from solid tumours on clinical examination.

A

35 and 50

40
Q

Benign Breast Disease - Fibroadenomas

  1. These are benign tumours that are common in ?
  2. They are the ? type of breast lesion.
  3. Fibroadenomas arise in breast lobules and are composed of ?
  4. They present as ?
  5. Aetiology?
A
  1. young women, with incidence peaking at 20-24 years of age.
  2. most common
  3. fibrous and epithelial tissue.
  4. firm, non-tender, highly mobile palpable lumps
  5. Hormones seem to be involved in aetiology, and hormone replacement therapy (HRT) increases the incidence.
41
Q

• To be aware of benign conditions causing nipple discharge such as duct ectasia & lactation related problems such as mastitis LO

Name conditions causing nipple discharge

A
  • Intraductal Papilloma
  • mammary duct ectasia
  • mastitis
42
Q

Intraductal Papilloma

  1. What is it?
  2. Common in?
  3. Symptoms:
A
    • benign
      - grow inside the ducts of the breast, often near to the nipple
  2. Women > 40
  3. a lump

a clear or bloodstained discharge coming from the nipple

pain or discomfort

43
Q

Duct ectasia of breast

  1. What is it?
  2. Symptom
  3. Treatment
A
  1. the lactiferous duct becomes blocked or clogged
  2. greenish discharge

Mammary duct ectasia can mimic breast cancer. It is a disorder of peri- or post-menopausal age.

44
Q

Mastitis

  1. What is it?
  2. Treatment?
  3. Secondary symptoms
  4. Cause?
A
45
Q

• To realise what the current UK referral guidelines are for women with breast symptoms LO

A
  • Consider a suspected cancer pathway referral (for an appointment within 2 weeks) people:
  • With skin changes that suggest breast cancer or
  • Aged 30 and over with an unexplained lump in the axilla (new NICE recommendation for 2015).

• Consider non-urgent referral in people aged under 30 with an unexplained breast
lump with or without pain (new NICE recommendation for 2015).

Integration To Clinical Anatomy (4 decks)

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