Met 3B. Breast disease and cancer. – Flashcards
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What are the two main types of breast cancer
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1. Ductal 2. Lobular Others: medullary, mucinous, tubular, Paget's disease of nipple, met, inflammatory (peau d'ornage)
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What is triple assessment
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1. Hx+Ex 2. Imaging: mammogram (not under 40) (looking for opacity) or USS 3. Cytology (aspirate cyst) or Histology (core biopsy - NB cysts and masses can be biopsied)
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What does a one stop clinic offer
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1. GP referral 2. Triple assessment (Hx+Ex, Imaging, Cytology/Histology) 3. Same day results 4. MDT
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What are the common symptoms with breast cancer
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1. Mass 2. Enlarged lymph nodes (axilla) - lymphoedema in arm 3. Discharge from nipple 4. Inverted nippled (if changed - quite usual to have for a long time) 5. Pain (usually not indicative as only ~2.7% are Ca, more to do with skeletal) - can be axillary 6. Thickening 7. Oedema, erythema
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With the triple assessment, what is the usual grading system
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1-5. P(alpation) M(ammo) U(SS) C(ytology) B(iopsy) 1 = normal / unable to determine due to sample (more B/C) 2 = tumour but benign 3 = tumour, inderterminate but probably benign 4 = tumour, probably malignant 5 = tumour, definitely malignant B5A = in situ, B5B = invasive C1 = aspirate inadequate
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How do you describe a tumour
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TNM 1. Tumour: size (T1-4), grade (1-3 for differentiation), staging (1 = mobile in breast, 2 = breast, mobile LN axilla, 3 = tumour fixed to muscle, not chest wall, LN ipsilateral axilla, skin involved larger than tumour, 4 = complete fixation of tumour to chest wall, mets) 2. Nodes: (N1 = -ve, N2 = 1-3, N3 = >3) how many are enlarged. NB prognosis worsens with increasing number of LN affected. Sentinel / lymphoedema 3. Met: (M1) and where NB also receptor sensitivity NB: treatment can be broadly divided to stage 1-2, then 3-4
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What is the difference between cytology and histology for breast cancer
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1. Cytology is FNA = only comment on cells within fluid 2. Histology is biopsy = comment on cells as well as structure (3D slice/preparation) therefore can distinguish if in situ vs invasive (NB biopsy can be for both solid mass and cyst - although FNA cyst first)
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Where are the most common sites for met from breast cancer
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1. Lung 2. Liver 3. Bone Others: brain, skin, LN
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What is trastuzamab
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1. Other name for herceptin 2. Inhibits the HER II receptor - this is a growth promoter receptor 3. A MAB 4. Given to those who are sensitive to HER 2 receptor
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What drug therapy is there for oestrogen receptors
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1. Tamoxifen 2. An oestrogen receptor (ER) inhibitor Other types: aromatase inhibitor (anastrolozole, letrozolole, exemestane) NB adipose conversion to oestrogen
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What are the two broad procedures for surgery
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1. Lumpectomy + radiotherapy +/- chemotherapy (if big then neo-adjuvant or adjuvant if Pt is young / N +ve) - 80% treated by lumpectomy + radiotherapy 2. Masectomy + reconstructive surgery NB sentinel guided removal/biopsy carried out if +ve with radioactivity and dye. Further axillary node removal if nodes are +ve
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What are the broad endocrine treatments
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Endocrine treatments aim to lower oesterogen activity PRE-MENO: 1. Anti oestrogen receptors (tamoxifen) 2. Anti GnRH (goserilin) 3. Oopherectomy POST-MENO: 4. Add Aromatase inhibitors: prevents conversion of oestrogen peripherally (anastrolozole / letrozolole)
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What specific gene mutations have a higher incidence of breast cancer
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BrCa 1 & 2 Seen in Ashkinazy Jewish families more
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What are the risks of having breast cancer
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1. Age 2. FHx of breast cancer (BrCa, ethnicity (more W than E, Jewish Ashkenazi)) 3. Diet/lifestyle 4. Smoking 5. Alcohol 6. Obese (adipose converted to oestrogen by aromatase) 7. Nulliparus 8. Children after 30 9. Increased oestrogen exposure (early menarche / late menopause / HRT) Not breast fed children
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What factors would influence the prognosis of breast cancer
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1. Tumour size 2. Tumour grade 3. Mets 4. Her 2 r 5. BrCa 1/2 6. Oestrogen / progesterone r sensitivity 7. Histology / cytology 8. LNs 9. Invasion of lymph or vasculature
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Broadly describe early breast cancer treatment
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1. Surgery for local control 2. Systemic treatment for micro-mets: radiotherapy, chemo, endocrine, targetted MAB, bisphosphanates 3. Rehab and surveillance
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Broadly describe advanced breast cancer treatment
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1. Endocrine: anti-oestrogen (tamoxifene), anti GnRH, oopherectomy, aromatase inhibitors (anastrolozole, exemestane) 2. Chemo (which is cancer specific eg CMF) 3. Targetted biologicals (trastuzumab) 4. Radiotherpay 5. Surgery to chest wall 6. Supportive care (esp palliative): eg bisphosphanates, laxatives, analgesics, diet/anti emetics 7. Psychological support/therpay
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What are the benign causes of breast lumps
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Aberrations of Normal breast Development and Involution (ANDI) 1. Fibrous adenoma (FAD) - lobular 2. Lipoma 3. Involutions NB: along this route of normal development benign masses can form - breast tissue is made of fibrous stroma or fatty tissue hence FAD and lipoma
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Describe FAD
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1. FibroADenoma 2. Lobular origin (either stromal or epithelial proliferation) 3. V mobile, discrete and rubbery (Ca is opposite to this) - can be multiple hence surgery may not be optimal 4. >40 need to distinguish from carcinoma 5. Mx depends on age, size and triple assessment 6. Phyllodes tumour (60-70% are benign)
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What types of breast cysts are there and what age do they usually present
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1. Microcysts 2. Macrocysts 3. Perimenopause (~50) NB when a lobule balloons then goes saggy, this can be filled with fluid
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How do sclerotic/fibrotic breast lesions occur
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1. Involution that then becomes fibrotic 2. Sclerosing adenoma or stroma sclerosis 3. Microcalcification can occur - palpable 4. Palpable mass with pain 5. Can be asymptomatic 6. Difficult to tell from malignancy
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Name non-ANDI benign lumps
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1. Lipoma 2. Breast infections: lactational (eg mastatis) / non 3. Fat necrosis (blunt trauma) 4. Montgomery's glands 5. Gynaecomastia
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How would you, braodly, describe a malignant tumour
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TNM(r) 1. Tumour: size, grading (1-3 for differentiation) 2. Nodes (LN) affected - also if lymphoedema 3. Mets 4. Sensitivty to r (oestrogen, progesterone, Her 2)
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What are the broad treatment options for breast cancer
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1. Surgery (lumpectomy, masectomy, conservation, reconstruction, sentinel node sampling) 2. Chemotherapy (neo-adjuvant, adjuvant) 3. Endocrine (tamoxifen, aromatase inhibitors, oopherectomy) 4. Other drugs (MAB vs Her II = trastuzamab)
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What are the main causes of breast cancer
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1. IDC 2. DCIS 3. ILC 4. Paget's of nipple - destroyed then through to breast 5. Lymphoma
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What is the UK screening age and how often
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1. 50-70 2. Every 3 years
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What imaging is effective for detecting invasive breast carcinoma
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1. USS is best for detecting invasive carcinoma 2. Mammogram is best for DCIS
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What is sentinel node sampling and why is it advantageous
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1. Insert dye (blue) and radiological colloid into periareolar area of tumour - double confirmation 2. Inspect where sentinel node is (the first one) both visually and by radioactive monitor 3. Sentinel node is removed or biopsied/histology - study if LN spread 4. 90% of Pt this can be identified - therefore prevents needless clearance of axillary LN of LN-ve Pt
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A 20 year old female finds a mass in her right breast. Her GP notes that this 1 to 2cm mass is firm but moveable & sends her to the one stop breast clinic. After ultrasound she has another procedure.
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The first most appropriate invasive investigation is fine needle aspirate of the breast lesion
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A firm 2 to 3cm mass is palpable in the upper outer quadrant of the right breast of a 52 year old woman. There are palpable axillary nodes. After a mammogram, which shows a focus of microcalcification, she has another procedure.
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The first most appropriate invasive investigation is a fine needle aspirate of the lymph nodes
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Breast carcinoma is diagnosed on biopsy of the right breast of a 52 year old female. Which feature of her carcinoma after a definitive operation & histology suggests a worse prognosis?
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Axillary lymph node metastases
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61 year old female has noted a rough, reddened appearance of the nipple which persists despite application of a corticosteroid cream. The most likely cause of this "persistent eczema"?
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Paget's disease
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In women of reproductive age the most likely cause of a palpable breast "lump" is?
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Fibrocystic disease
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A 40 year old lady with multiple painful lumps in her breast, which are painful & tender premenstrually. A Fibroadenoma B Breast cyst C Fibroadenosis D Breast abscess E Duct ectasia F Carcinoma of the breast G Lipoma H Sebaceous cyst I Gynaecomastia
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Fibroadenosis
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A 25 year old lady with a discrete, non-tender, mobile lump in one breast A Fibroadenoma B Breast cyst C Fibroadenosis D Breast abscess E Duct ectasia F Carcinoma of the breast G Lipoma H Sebaceous cyst I Gynaecomastia
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Fibroadenoma
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A 35 year old lady is generally unwell with a tachycardia & a fever. A segment of the right breast is painful, tender, red & warm. A Fibroadenoma B Breast cyst C Fibroadenosis D Breast abscess E Duct ectasia F Carcinoma of the breast G Lipoma H Sebaceous cyst I Gynaecomastia
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Breast abscess
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A 14 year old boy with bilateral breast enlargement. A Fibroadenoma B Breast cyst C Fibroadenosis D Breast abscess E Duct ectasia F Carcinoma of the breast G Lipoma H Sebaceous cyst I Gynaecomastia
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Gynaecomastia
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A 40 year old lady with a green nipple discharge & tender lumpiness beneath the areola. A Fibroadenoma B Breast cyst C Fibroadenosis D Breast abscess E Duct ectasia F Carcinoma of the breast G Lipoma H Sebaceous cyst I Gynaecomastia
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Duct ectasia
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A 50 year old man with a painless enlargement of the left breast. A Fibroadenoma B Breast cyst C Fibroadenosis D Breast abscess E Duct ectasia F Carcinoma of the breast G Lipoma H Sebaceous cyst I Gynaecomastia
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Gynaecomastia
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A 40 year old lady with a hard lump in the right breast. The skin overlying the lump has an orange peel appearance. A Fibroadenoma B Breast cyst C Fibroadenosis D Breast abscess E Duct ectasia F Carcinoma of the breast G Lipoma H Sebaceous cyst I Gynaecomastia
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Carcinoma of the breast
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A 40 year old obese woman presents with a long history of pain in both breasts. This is worse just before her period starts. She is also taking omeprazole for GORD. A Breast carcinoma B Fibroadenoma C Breast abscess D Benign cyst E Duct ectasia F Paget's disease G Abnormality of normal development & involution H Fat necrosis I Mastitis J Gynaecomastia K Bruising
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Mastitis
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A 19 year old girl has noticed a lump in the right breast. It is smooth, 2cm in diameter, non-tender, & highly mobile. A Breast carcinoma B Fibroadenoma C Breast abscess D Benign cyst E Duct ectasia F Paget's disease G Abnormality of normal development & involution H Fat necrosis I Mastitis J Gynaecomastia K Bruising
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Fibroadenoma
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A 30 year old lady, who is breast feeding, has developed an extremely painful, hard, red 4cm lump at the edge of the left nipple. A Breast carcinoma B Fibroadenoma C Breast abscess D Benign cyst E Duct ectasia F Paget's disease G Abnormality of normal development & involution H Fat necrosis I Mastitis J Gynaecomastia K Bruising
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Breast abscess
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A 65 year old lady has noticed a 3cm lump behind the right nipple. It is hard, non-tender, mobile & has an irregular edge. She has had a small amount of bloody nipple discharge. A Breast carcinoma B Fibroadenoma C Breast abscess D Benign cyst E Duct ectasia F Paget's disease G Abnormality of normal development & involution H Fat necrosis I Mastitis J Gynaecomastia K Bruising
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Breast carcinoma
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50 year old extremely obese lady presents with a tender, hard, 3cm lump in the left breast which has appeared quite rapidly. She remembers knocking the breast against a table edge 1 month ago. A Breast carcinoma B Fibroadenoma C Breast abscess D Benign cyst E Duct ectasia F Paget's disease G Abnormality of normal development & involution H Fat necrosis I Mastitis J Gynaecomastia K Bruising
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Fat necrosis
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23 city female PC: tense heavy uncomfortable breast, prickling sensation deep inside breast. She has noticed enlargement & breast feels lumpy & subcut. veins are dilated. Skin of breast is warm. A Ca breast B Nodularity C Mastalgia D Fibroadenoma E Breast abscess F Ductal papilloma G Pregnancy H Brodie's disease
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Pregnancy
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17 school girl, PC: pain, changed from dull ache to severe continuous throbbing pain. Breast feels hot on palpation, & she CO hot flushes. OE whole breast tender & engorged & nipple is tender. A Ca breast B Nodularity C Mastalgia D Fibroadenoma E Breast abscess F Ductal papilloma G Pregnancy H Brodie's disease
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Breast abscess
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20 car sales woman PC with non-painful lumps. OE unremarkable, except for a 5cm smooth bosselated firm mass, highly mobile. A Ca breast B Nodularity C Mastalgia D Fibroadenoma E Breast abscess F Ductal papilloma G Pregnancy H Brodie's disease
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Fibroadenoma
