Week 7 Flashcards
US vs mammogram in breast lump assessment
US >40 years or targetted lump
Mammogram >40 years or screening 50-70
When would you offer excision in fibroadenoma?
Rapidly growing (consider phyllodes tumour - may be benign/borderline/malig)
Discomfort to patient
Where does fibroadenoma arise from?
Overgrowth of epithelium and stroma of breast
(overdevelopment of normal breast tissue)
Management of breast abscess
Continue breast feeding/expressing
Aspiration and Flucloxacillin
Prevent cracked nipples
What are you lookig for in mammogram?
Microcalcifications ≤100nm with high inherent contrast
Soft tissue abnormalities with lower intrinsic contrast
Two views of mammogram
Mediolateral oblique
Craniocaudal CC
Inidcations for mammography
Symptomatic assessment > 40 years
Screening (50 – 70yrs)
Higher risk ‘family history’ screening > 40 years
Benign calificiations on mammogram
Vascular calcification
Oil cyst eggshell calcification
Plasma cell mastitis (long, bilat, points to nipple)
Dystrophic calicification in scar
Features of DCIS on mammogram
Shape: Linear or branching
Distribution: Cluster or segmental
Pleomorphic (varying) size and density
Use of US in breast imaging
Targetted breast imaging
E.g. known lesion, suspicion on mamm.
Axilla lymphadenopathy
Tall mass on US suggests
Masss breaking through tissue layers, indicates malignancy
Anechoic mass on US?
Cyst
Features of concerning lymph nodes on US
Round shape
Absence of the fatty hilum
Increased concentric or focal cortical thickness
Imaging pathway in one stop breast clinic
Under 40 (or pregnant / breast-feeding)
- Ultrasound first
- Mammogram only if concerning finding requiring biopsy
40 years and over
- Mammogram first
- Targeted ultrasound
Types of image-guided biopsy in breast assessment
US or mammographic
Core 14G
- diagnostic, mass lesions, nodes
Vacuum assisted
- diagnostic, microcalcification
Vacuum assisted excision
- 2nd line, instead of surgery for B3
Function of radioopaque clips
Confirm position
Neoadjuvant chemotherapy
Localisation
Follow-up post surgery in breast cancer
5 year annual mammography
Most sensitive assessment of breast cancer
MRI
- IV gadolinium
- Lie prone with MRI scanner
- used for locoregional staging
- not highly specific
Indications for staging for distant mets
- T3 and T4 primary cancers (≥5cm or locally invasive)
- ≥4 abnormal nodes at axillary ultrasound or ≥4 macrometastatic nodes at axillary surgery
- If symptoms raise the suspicion of metastatic disease.
ANDIs include…
Fibroadenoma
Cysts (happens in run up to period, most common >40)
Papilloma (essentially skin tag inside cyst)
Pain (usually chest wall or hormonal)
When should nipple discharge be investgated?
Blood stained or associated with other red flag features
- Normal otherwise
Inflammatory conditions of breast
Mastitis
Fistula
Abscess
Why is HER2 status important in breast cancer?
ER vs PR positive
Triple neg is worst prognosis
PR is prognosticator and determines likelihood of chemo response
HER2 pos can determine type of hormonal/chemo needed
Types of chemo in breast cancer
Anthracyclines and Taxanes
- anti-HER2 as well
6-8 cycles, 3 weekly
Side effects of anthracyclcines
Heart effects
Small leukaemia risk
How can neutropenic sepsis be prevented in chemo pts?
GCSF
– stimulates bone marrow to differentiate and release stem cells
Give 1st dose tazocin
Chemo treatment reg in triple negative breast cacer
EC (3 weekly) followed by 12 continous weeks of weekly Carboplatin+Paclitaxel.
Indications for neoadjuvant chemo NACT
Inflammatory breast cancer
Downstaging required e.g. nodal burden
T2 +HER2 or triple neg
Tany N>1
What drugs can be used in adjuvant chemo?
Carboplatin and Pembrolizumab
What treatments follow adjuvant chemo?
Radiotherapy and endocrine therapy
- 3-4 weeks after
Use of anti herceptin antibodies in adj chemo
Given for 1 year
- herceptin if node neg
- herceptin/pertuzumab if node pos
- regular echos
How is endocrine treatment used in breast cancer?
5 years, 10 if high risk
Determine if pre/post menopausal
Tamoxifen - pre/perimenomausal
Letrozole - postmenopausal or in induced ovarian suppression
Mechanism of tamoxifen
ANTAgnosies the oestrogen receptors around breast tissue
AGONISTIC around Uterus, hence small risk of uterine cancer
Flushes, mood change, tiredness
Mechanism of letrozole
Stops fat and other peripheral cells producing estrogen
Flushes, tiredness and joint pain
Watch for bone density changes with DEXA scans!
Contraindications in hormone treatment of breast cancer
HRT
- also in ER cancers
Hormonal contraception
- copper coil is fine
Use of radiotherapy in breast cancer
Local treatment of breast and lymph nodes
No survival benefit, not used if theres been mastctomy unless 4 or more nodes involved
Blasts left behind cells
Side effects of radiotherapy
Warm/Red breast, tiredness
Lymphoedema (less compared to node clearance)
Skin changes/fibrosis
Rib fracture, stiffness of shoulder, sarcoma, lung fibrosis
Define high risk of breast cancer
Lifetime risk of developing breast cancer of 30% or more
Define moderate risk of breast cancer
Lifetime risk of breast cancer of greater than 17% but less than 30%
(just higher than 12% population risk)
Define low risk of breast cancer
17% or less lifetime risk
Screening for moderate risk of breast cancer
Annual mammogram 40-50y then join population screening
High risk screening for breast cancer
Biennial mammograms from 35 – 39
Annual mammograms from 40 – 59
18 monthly mammograms from 60 – 70
Think ab prophylactic chemoprevention
(or 5 years earlier than youngest cancer onset)
Management of very high risk of breast cancer
Extra breast screening with annual mammograms from 30 till 70 and annual breast MRI from 30 till 50
Options for double mastectomy and BSO
No routine prostate screening
Define lead time in screening
Difference in time between cancer diagnosed and screening and cancer diagnosed symptomatically
Scottish breast screening programme
Three yearly screening 50-70
Bilateral 2 view mammogram
3 in 1000 detection rate
If abnormality detected = triple assessment at one-stop clinic
Use of tomosynthesis
Takes several images in similar sense to CT
Used to assess abnormalities on mammogram to ensure it’s nt breast tissue pushed together in weird ways
What is normal size of an axillary node?
<3mm cortex
Radial scar indicates slightly higher risk of which cancer?
DCIS
Childhood subdiaphragmatic radiotherapy as a child incr risk of which type of cancer?
Breast
- incr screening, MRI
Mammogram contraindicated in which breast cancer mutation?
TP53
BRCA1 features
More commonly triple neg
More rapid growth
Look benign on imaging
BRCA2 features
Look more like sporadic
More DCIS
