3. Carcinoma of the female breast.(Clinical picture and investigations) Flashcards
(96 cards)
1
Q
Clinical picture of breast cancer
A
- Symptoms
* Examination
2
Q
Symptoms in Clinical picture of breast cancer
A
1- Mass : (commonest presentation)
2- Discharge per nipple :
3- Paget’s disease of the nipple.
4- Mastitis carcinomatosa.
5- Occult presentation :
6- Pain (10%)
3
Q
Mass in Symptoms in Clinical picture of breast cancer
A
- The commonest presentation
* Accidentally discovered painless mass in the breast
4
Q
The commonest presentation of breast cancer
A
Accidentally discovered painless mass in the breast
5
Q
Discharge per nipple in Symptoms in Clinical picture of breast cancer
A
Bloody commonly
or
thick greenish discharge
6
Q
Clinical picture of Paget’s disease of the nipple in Symptoms in Clinical picture of breast cancer
A
Usually occurs at menopause [6th decade]
Pricking sensation of the nipple with erosions & ulcerations
7
Q
Clinical picture of Mastitis carcinomatosa in Symptoms in Clinical picture of breast cancer
A
- Occurs mostly during pregnancy and lactation (due to high hormonal level)
- but may occur at any age unassociated with these events.
- The overlying skin is red, warm & Swollen.
8
Q
Occult presentation in Symptoms in Clinical picture of breast cancer
A
1- Dry irritative cough, haemoptysis & dyspnea.
2- Pathological fracture
3- Malignant jaundice or ascites.
9
Q
Pathogenesis of Pain in Symptoms in Clinical picture of breast cancer
A
most of breast cancer is painless but pain occurs in
10%
1- Advanced cases after extensive local infiltration.
2- Mastitis carcinomatosa.
10
Q
Examination in Clinical picture of breast cancer
A
- General Examination
* Local Examination
11
Q
General Examination in Clinical picture of breast cancer
A
Searching for signs suggestive of metastases:
1- Sclera examination
2- Chest examination
3- Abdominal examination
4- P.R. examination
5- Spine examination
12
Q
The reason why we do Sclera examination in General Examination in Clinical picture of breast cancer
A
for Jaundice
13
Q
The reason why we do Chest examination in General Examination in Clinical picture of breast cancer
A
for pleural effusion.
14
Q
The reason why we do Abdominal examination in General Examination in Clinical picture of breast cancer
A
for liver nodules, ascites or umbilical nodules.
15
Q
The reason why we search for ascitis in Abdominal examination in General Examination in Clinical picture of breast cancer
A
as liver secondaries cause ascitis
16
Q
The reason why we do P.R examination in General Examination in Clinical picture of breast cancer
A
for peritoneal nodules and Douglas pouch
17
Q
The reason why we do Spine examination in General Examination in Clinical picture of breast cancer
A
for bony metastasis.
18
Q
Local Examination in Clinical picture of breast cancer
A
- Inspection
* Palpation
19
Q
Inspection in Local Examination in Clinical picture of breast cancer
A
- Dimpling
2.Puckering.
3.Nipple Retraction - Peau d’orange
- Cancerous skin nodules (Sure sign of malignancy).
- Cancer en cuirasse (historical)
7- Medullary carcinoma.
8- Paget’s disease of nipple.
9- Mastitis carcinomatosa.
10- Dilated veins over the skin of the breast.
11- Lymphoedema of the arm.
20
Q
Dimpling in Inspection in Local Examination in Clinical picture of breast cancer
A
- Pathogenesis of Dimpling
- The reason why it’s Not pathognomonic
- Significance
21
Q
Pathogenesis of Dimpling in Inspection in Local Examination in Clinical picture of breast cancer
A
Contracture of Cooper’s ligaments
22
Q
The attachments of cooper’s ligament
A
Between breast and pectoralis major muscle
23
Q
The reason why Dimpling, in Inspection in Local Examination in Clinical picture of breast cancer, is Not pathognomonic
A
as it can occur in any fibrotic process e.g. chronic breast abscess & duct ectasia.
24
Q
Significance of Dimpling in Inspection in Local Examination in Clinical picture of breast cancer
A
The earliest skin sign of breast cancer
25
Meaning of Puckering in Inspection in Local Examination in Clinical picture of breast cancer
Gathered into wrinkles or folds
Karmasha
26
Nipple Retraction in Inspection in Local Examination in Clinical picture of breast cancer
* Pathogenesis
| * The reason why it's Not pathognomonic
27
Pathogenesis of Nipple Retraction in Inspection in Local Examination in Clinical picture of breast cancer
Infiltration and contracture of the main milk ducts
28
The reason why Nipple Retraction, in Inspection in Local Examination in Clinical picture of breast cancer, is Not pathognomonic
it can occur in any fibrotic lesion entangling the main milk ducts e.g. chronic breast abscess & duct ectasia.
29
peau d'orange in Inspection in Local Examination in Clinical picture of breast cancer
* Definition
* Pathogenesis
* The reason why it's Not pathognomonic
30
Definition of peau d'orange in Inspection in Local Examination in Clinical picture of breast cancer
It is a condition in which we get thick non-pitting edematous skin pitted at sites of hair follicles, sebaceous & sweat glands.
31
Pathogenesis of peau d'orange in Inspection in Local Examination in Clinical picture of breast cancer
due to obliteration & compression of the lymphatics of the skin by the tumour
32
The reason why peau d'orange, in Inspection in Local Examination in Clinical picture of breast cancer, is Not pathognomonic
as it can occur in any fibrotic mass causing obliteration & compression of the lymphatics of the skin
33
one of the following is pathognomonic for breast cancer:
* Dimpling
* Puckering
* Nipple retraction
* peau d'orange
* Cancerous skin nodules
Cancerous skin nodules
34
Cancerous skin nodules in Inspection in Local Examination in Clinical picture of breast cancer
* Definition
* Pathogenesis
* Significance
35
Definition of Cancerous skin nodules in Inspection in Local Examination in Clinical picture of breast cancer
They are Nodules may appear away from the mother carcinoma.
36
Pathogenesis of Cancerous skin nodules in Inspection in Local Examination in Clinical picture of breast cancer
Retrograde lymphatic permeation.
37
Significance of Cancerous skin nodules in Inspection in Local Examination in Clinical picture of breast cancer
* They are specific & diagnostic
| * Sure sign of malignancy
38
Cancer en cuirasse in Inspection in Local Examination in Clinical picture of breast cancer
* Significance
| * Morphology
39
Significance of Cancer en cuirasse in Inspection in Local Examination in Clinical picture of breast cancer
* It's a historical sign
* It represents:
1. very late stage of permeation
2. advanced stage of nodulation
40
Morphology of Cancer en cuirasse in Inspection in Local Examination in Clinical picture of breast cancer
* The skin is very thick hard, stretched, leathery, indurated metallic, brownish
* simulating shields of wars
* Not localized to the breast but extends to the chest wall & back.
41
Medullary carcinoma by Inspection in Local Examination in Clinical picture of breast cancer
Fungation & Ulceration is common with medullary carcinoma
42
Paget's disease of nipple by Inspection in Local Examination in Clinical picture of breast cancer
Superficial erosions, ulcerations & crustations
Edge of the ulcer is Well defined.
43
Mastitis carcinomatosa by Inspection in Local Examination in Clinical picture of breast cancer
The overlying skin is red
44
Palpation in Local Examination in Clinical picture of breast cancer
1. Breast
| 2. Axillary Lymph nodes
45
Breast Palpation in Local Examination in Clinical picture of breast cancer
Mass with the following criteria :
1. Site
2. Size
3. Shape
4. Mobility
5. Consistency
6. Edge
46
Site of the mass in Breast Palpation in Local Examination in Clinical picture of breast cancer
commonly upper lateral quadrant .
47
Size of the mass in Breast Palpation in Local Examination in Clinical picture of breast cancer
* small or moderate in NOS carcinoma
| * large in medullary carcinoma
48
Shape of the mass in Breast Palpation in Local Examination in Clinical picture of breast cancer
Irregular
49
Mobility of the mass in Breast Palpation in Local Examination in Clinical picture of breast cancer
* Early it is mobile
| * Late it becomes fixed.
50
Consistency of the mass in Breast Palpation in Local Examination in Clinical picture of breast cancer
* hard in NOS carcinoma
* soft in medullary carcinoma.
* Cystic in mucinous carcinoma
51
Edge of the mass in Breast Palpation in Local Examination in Clinical picture of breast cancer
* Early well defined edge
| * but late ill defined after infiltration of deeper structures.
52
Axillary Lymph nodes Palpation in Local Examination in Clinical picture of breast cancer
If enlarged they are:
* Hard
* Early mobile & later on fixed.
53
Investigations of breast cancer
A- Investigations for the primary lesion :
B- Investigations for metastases :
54
Investigations for the primary lesion in Investigations of breast cancer
1- Biopsy:
2- Mammography:
3- Breast ultrasound : complementary
4- MRI
5- Tumour markers
55
The most important single diagnostic investigation for the primary lesion in a case of breast cancer
Biopsy
56
Investigations for metastases in Investigations of breast cancer
* Chest : Plain X - ray chest.
* Liver : Gamma GT, ALP & abdominal U.S.
* Bone : Bone scan (99Tcm).
57
which is better? to do abdominal U/S or order liver enzymes to detect liver secondaries
order liver enzymes as they inc before mass is seen by US
58
Biopsy in Investigations for the primary lesion in Investigations of breast cancer
* Significance
| * Types
59
Significance of Biopsy in Investigations for the primary lesion in Investigations of breast cancer
The most important single diagnostic investigation for the primary lesion in a case of breast cancer
60
Types of Biopsy in Investigations for the primary lesion in Investigations of breast cancer
a) Fine Needle Aspiration Cytology (FNAC)
b) Tru cut needle biopsy
c) Frozen section biopsy
d) Excision biopsy
e) Image guided biopsy.
61
Fine Needle Aspiration Cytology (FNAC) in Types of Biopsy in Investigations for the primary lesion in Investigations of breast cancer
* Advantages
| * Disadvantages
62
Advantages of Fine Needle Aspiration Cytology (FNAC) in Types of Biopsy in Investigations for the primary lesion in Investigations of breast cancer
* Has got excellent patient compliance Simple
| * Quick to perform in out patient clinic "OPC''
63
Disadvantages of Fine Needle Aspiration Cytology (FNAC) in Types of Biopsy in Investigations for the primary lesion in Investigations of breast cancer
* Does not differentiate between invasive carcinoma & carcinoma in situ.
* Good (+ve) but bad (- ve).
64
Tru cut needle biopsy in Types of Biopsy in Investigations for the primary lesion in Investigations of breast cancer
* Alternative name
* Procedures
* Advantages
65
Alternative name of Tru cut needle biopsy in Types of Biopsy in Investigations for the primary lesion in Investigations of breast cancer
Core needle biopsy
66
Procedures of Tru cut needle biopsy in Types of Biopsy in Investigations for the primary lesion in Investigations of breast cancer
* It is done under local anesthesia
| * Done by a special needle that cut a core of tissue out of the tumour
67
Advantages of Tru cut needle biopsy in Types of Biopsy in Investigations for the primary lesion in Investigations of breast cancer
* Done by a special needle that cut a core of tissue out of the tumour
* Does not cause dissemination of malignant cells
68
Frozen section biopsy in Types of Biopsy in Investigations for the primary lesion in Investigations of breast cancer
* Procedures
* Advantages
* Disadvantages
69
Procedures of Frozen section biopsy in Types of Biopsy in Investigations for the primary lesion in Investigations of breast cancer
* Done intraoperative.
| * The mass is excised, the specimen is frozen and slides are prepared from the frozen block.
70
Advantages of Frozen section biopsy in Types of Biopsy in Investigations for the primary lesion in Investigations of breast cancer
* A diagnosis is obtained within 20-30 minutes.
| * If it was +ve for malignancy, the surgeon proceeds for radical surgery.
71
Disadvantages of Frozen section biopsy in Types of Biopsy in Investigations for the primary lesion in Investigations of breast cancer
Sometimes a firm diagnosis can not be obtained by frozen biopsy and the surgeon should wait for the result of the paraffin section
72
Procedures of Excision biopsy in Types of Biopsy in Investigations for the primary lesion in Investigations of breast cancer
Excision of the mass and is sent for paraffin section.
73
Image guided biopsy in Types of Biopsy in Investigations for the primary lesion in Investigations of breast cancer
* U.S. or MRI guided biopsy.
| * Mammography guided stereotactic biopsy
74
Advantages Mammography guided stereotactic biopsy in Image guided biopsy in Types of Biopsy in Investigations for the primary lesion in Investigations of breast cancer
stereotactics provide us with coordinates ( W H D ) to locate exact location in case of impalpable masses
75
what should be done in cases of impalpable masses in breast cancer
Do either:
Mammographic guided stereo-tactic biopsy: stereotactics provide us with coordinates ( W H D ) to locate exact location
Or
Mammographic guided wiring : then intraoperative remove wire with safety margin
76
Mammography in Investigations for the primary lesion in Investigations of breast cancer
* Definition
* Findings suggestive of malignancy
* Normal variation Findings
* Advantages
* Disadvantages
77
Definition of Mammography in Investigations for the primary lesion in Investigations of breast cancer
It is a soft tissue X- ray
78
Findings suggestive of malignancy in Mammography in Investigations for the primary lesion in Investigations of breast cancer
a. Asymmetry or distortion of breast outline.
b. Increased skin thickness.
c. High density mass with inc. Vascularity.
d. Mass with speculations & stellate configuration
.
e. Micro-calcification
79
Micro-calcification in Findings suggestive of malignancy in Mammography in Investigations for the primary lesion in Investigations of breast cancer
* Morphology
| * Pathogenesis
80
Morphology of Micro-calcification in Findings suggestive of malignancy in Mammography in Investigations for the primary lesion in Investigations of breast cancer
1- clustered
2- Linear or branching
3- Pleomorphic.
4- Opaque center (radiolucent center is benign).
81
what is the meaning of clustered in mammography of breast cancer
not diffuse
82
Pathogenesis of Micro-calcification in Findings suggestive of malignancy in Mammography in Investigations for the primary lesion in Investigations of breast cancer
cell death
83
Normal variation Findings in Mammography in Investigations for the primary lesion in Investigations of breast cancer
* Dense breast ( inc. glandular element) in young female appear white
* Fatty breast in old female appear grey
84
Advantages of Mammography in Investigations for the primary lesion in Investigations of breast cancer
1- It can detect non palpable mass (detects carcinoma 2 years before clinical manifestations with accuracy rate 90%).
2- Evaluates other breast even after biopsy
3- screen occult breast cancer in patients with axillary lymph node enlargement
85
Disadvantages of Mammography in Investigations for the primary lesion in Investigations of breast cancer
1- It is not a substitute for biopsy.
2- Doesn't differentiate between solid and cystic
3- False - ve results in : Medullary & lobular carcinoma.
4- can't be used for Dense breast in young females
86
Breast ultrasound in Investigations for the primary lesion in Investigations of breast cancer
* Significance
| * Advantages
87
Significance of Breast ultrasound in Investigations for the primary lesion in Investigations of breast cancer
It's complementary to the mammography
88
Advantages of Breast ultrasound in Investigations for the primary lesion in Investigations of breast cancer
1- Useful in dense breast.
2- Can distinguish between solid and cystic lesions
.
3- We can do U.S guided biopsy.
89
Advantages of MRI in Investigations for the primary lesion in Investigations of breast cancer
1- It is the gold standard for imaging the breasts of women with implants.
2- Screening of patients with LN and no breast masses detected clinically or by mammography
3- Assessment of the axilla for non palpable L.N
4- Useful to distinguish scar from recurrence in women who have had previous conservative breast therapy 6 month before
90
The reason why women with breast implants shouldn't do mammography or ultrasound
because implants mask breast cancer and they should do MRI instead
91
postoperative scar in women who have had previous conservative breast therapy
* may be a scar from fibrotic hematoma
or
* recurrence distinguished by MRI
92
Tumour markers in Investigations for the primary lesion in Investigations of breast cancer
CA 15.3
93
what is Triple assessment?
* Indication:
* Procedures
* The accuracy
94
Indication of Triple assessment
Any patient who presents with breast lump
95
Procedures of Triple assessment
The diagnosis should be made by a combination of:
1- Clinical assessment
2- Radiological imaging (mammography and complementary breast U/S)
3- Biopsy
96
The accuracy of Triple assessment
99.9%
