Triple Assessment of Breast Lumps Flashcards
What structures of the breast are represented by 1-8?
- chest wall
- pectoralis major
- lobule
- nipple
- areola
- lactiferous duct
- adipose tissue
- skin
What is the role of the breast lobules?
they are the functioning part of the breast that make milk during breast feeding
all lobules drain into lactiferous ducts and out through the nipple
What 2 different types of breast tissue are visible here?
the light pink area is stroma
Where are ducts and lobules located?
What is shown in the following images?
What is the NICE recommendation when GPs are referring patients presenting with breast lumps?
refer using suspected cancer pathway (appointment within 2 weeks) if the patient is 30 or older and has an unexplained breast lump
consider referring if the patient is under 30
What % of breast lumps are due to benign breast disease?
around 80%
What is a lipoma and a fibrocystic change/cyst?
a lipoma is a lump arising from fat in the breast
a cyst arises from ducts or lobules and may cxause a lump
What is a fibroadenoma/hamartoma?
regions composed of stroma and epithelial elements (biphasic)
benign cause of breast lumps
From which cells do breast carcinomas arise?
from epithelial cells or cells of lobules/ducts
What are the 3 stages in the triple assessment of breast lumps?
What procedures are carried out at each stage?
What are the 5 features of a breast lump that should be observed on clinical examination?
- is it mobile or fixed?
- is the lump well-defined?
- is it smooth or irregular?
- firmness
- location of lump
What features tend to be observed on clinical examination if a breast lump is malignant?
- it is fixed and does not move around
- it is not-well defined and feels irregular
- it is more firm and hard
Why does the location of the breast lump need to be recorded on clinical examination?
sometimes patients will present with multiple lumps
the location needs to be known so that the imaging team knows which lump to focus on
How is the location of a breast lump recorded?
each breast is divided into quadrants
the ultrasound needs to be performed on the quadrant where the lump is present
What 3 nipple symptoms need to be looked for on clinical examination?
- nipple inversion that has not always been present
- rash
- discharge
What 4 skin changes need to be looked for on clinical examination?
- tethering/retraction
- oedema
- peau d’orange
- ulceration/fungating lesion
What is meant by tethering/retraction of the skin?
where the skin is being pulled in by something underneath it
this is a sign of advanced cancer
What is meant by peau d’orange?
skin changes that make the skin look like orange peel
this is a sign of potentially advanced breast cancer
What are the 5 stages in the clinical P code?
What is the purpose of this code?
it gives the imaging team and pathologists a clear guide as to how worried the clinician is about the lump
P1 - normal
P2 - benign lesion
P3 - atypical, probably benign lesion
P4 - atypical, probably malignant lesion
P5 - malignant
How does fat and fibroglandular breast tissue appear on ultrasound?
fat is hypoechoic and appears white
fibroglandular breast tissue is echogenic and appears black
Which of the following ultrasounds is more likely to be malignant and why?
left - benign:
lesion appears circular, regular, well-defined
right - malignant:
lesion appears less defined and the edges merge with the adjacent fatty tissue
What is a mammogram?
How do fat and solid masses appear?
it is an X-ray of the breast from several angles
fat is radiolucent so appears black
solid masses are radio-opaque so appear white
Which of the mammograms shows a lesion that is likely to be malignant?
Why?
left - benign:
there is a well circumscribed, solid white area
right - malignant:
white area is more irregular and looks stellate
it is possibly pulling in the skin on the surface
What are the 5 stages in the imaging R code?
- R1 Normal
- R2 Benign lesion
- R3 Atypical, probably benign lesion
- R4 Atypical, probably malignant lesion
- R5 Malignant
What is the main pathology procedure performed to look at breast lumps?
core biopsy
this involves taking a core of tissue from the region of concern
it is done under X-ray or ultrasound guidance to ensure the region of interest is not missed
What is involved in a fine needle aspiration (cytology)?
aspiration of loose cells from the lesion using a fine needle
you can tell if the cells are cancerous or not, but cannot tell how they relate to the surrounding cells
What are the advantages of cytology over biopsy?
- it is a cost-effective procedure
- minimal trauma to patient
- high acceptance rate
- rapid assessment and results
What are the disadvantages of cytology over biopsy?
- you cannot identify the location of malignant cells and whether they have spread
- lack of specific diagnosis for most benign lesions
What are the 5 stages in the pathology B code?
- B1 Normal
- B2 Benign lesion
- B3 Atypical, probably benign lesion
- B4 Atypical, probably malignant lesion
- B5 Malignant
What are the 5 stages in the pathology C code?
- C1 Insufficient
- C2 Normal or Benign lesion
- C3 Atypical, probably benign lesion
- C4 Atypical, probably malignant lesion
- C5 Malignant
What is shown?
How can you tell?
fibroadenoma
it has a well-defined edge and is made up of stroma and epithelial cells
What is the role of the BRCA genes?
they encode tumor suppressor proteins
these are critical for cells to repair damaged DNA
What happens if there is a mutation in a BRCA gene?
the tumor suppressor proteins are not made or do not work properly
this means that DNA damage in cells is not repaired properly and there is a higher chance of the cell becoming cancerous
What is significant about women who carry the BRCA gene mutations and the age at which they get breast cancer?
there is a peak incidence at a lower age
there is a 70% chance of developing breast cancer by 80
What is meant by an ER positive breast cancer?
80% of breast cancers are ER positive
oestrogen plays a key role in the development of breast cancer and stimulates the growth of tumours that express oestrogen receptors (ER positive)
What type of targeted treatment can be used in ER positive breast cancers?
How does it work?
endocrine therapy using tamoxifen
this blocks the oestrogen receptors, meaning that oestrogen cannot act on the tumour cells
this stops the tumour cells from growing and improves prognosis
What is Her2 and how is it related to breast cancer?
it is a human epidermal growth factor receptor
Her2 gene is amplified in 20-25% of breast cancers and predicts poorer prognosis as it drives tumour growth
What targeted treatment is used in Her2 breast cancers?
How does it work?
Trastuzamab (Herceptin) is an antibody that targets and blocks the Her2 receptors
this prevents tumour growth and improves prognosis
What are the 2 types of surgical options in breast cancer?
wide local excision:
this is removal of the tumour and a surrounding ring of local tissue
mastectomy:
this involves removing the whole breast
radiotherapy must be given after local excision to keep the recurrence risk as low as in mastectomy
What are the 2 types of surgical options if breast cancer has spread to the lymph nodes?
- sentinel lymph node biopsy
- axillary node clearance
