- Dense breast tissue/young women - Lobular carcinoma - Assess disease extent (esp if multicentric) - Assess deep nodal involvement - Assess chest wall invasion - Assess response to neoadjuvant therapy

Breast Flashcards by James Crichton

Indications for neoadjuvant chemo

Locally advanced (T3/4) tumour
cN1 nodes (try and avoid ALND)
Increase chance of BCS
Triple neg or ER/PR- HER2+
Temporary contraindication to surgery (pregnancy, anticoagulation)
Delay surgery while genetic testing undertaken (that may affect surgery chosen)

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Indications for MRI

Dense breast tissue/young women
Lobular carcinoma
Assess disease extent (esp if multicentric)
Assess deep nodal involvement
Assess chest wall invasion
Assess response to neoadjuvant therapy

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Disadvantages of MRI

Higher rates of false positives

No improvement in outcomes according to studies

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Indications for adjuvant chemo?

Node + disease
Tumour >20mm (T2+)
Triple neg
High risk according to PREDICT or Adjuvant! calculators
High risk according to Oncotype DX or Mammaprint calculators

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Indications for adjuvant radiotherapy?

Post wide local excision
- whole breast irradiation with boost to tumour bed

Nodes:
• Irradiate “regional nodes” (supra- and infraclavicular) if nodes positive at SLNB/ALND
• Irradiate axilla as well if no ALND performed (AMAROS trial)
• Irradiate axilla, supra and infraclavicular nodes post ALND if extensive axillary involvement (extranodal spread, >50% nodes involved)

After mastectomy, give if high chance of local recurrence
• Tumour >5cm (T3 - T4)
• >4 positive nodes - controversial, some say less
• Stage III disease
• Chest wall invasion/margin involvement

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Adjuvant chemo after neo adj?

Not always necessary.
Give if:
- Residual disease post surgery (give Capecitabine)
- Didn’t complete neo adj regime -> continue regime (AC-T)

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How do you assess grade of breast ca?

Bloom and Richardson classification

“TNM”

Tubule formation
Nuclear pleomorphism
Mitotic count

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How do you assess prognosis of breast ca?

Nottingham prognostic index

“SiNG”

Size
Nodal involvement
Grade

The index is calculated using the formula:
NPI = [0.2 x S] + N + G
Where:
• S is the size of the index lesion in centimetres
• N is the node status: 0 nodes = 1, 1-3 nodes = 2, >3 nodes = 3
• G is the grade of tumour: Grade I =1, Grade II =2, Grade III =3

Gives survival at 10 years
•	2 – 2.4 = 93%
•	2.4 – 3.4 = 85%
•	3.4 – 5.4 = 73%
•	>5.4 = 50%

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Definition of ALH?

Atypical proliferation of monomorphic dyscohesive epithelial cells in a breast lobule
- with no/minor distortion of lobule (this is how it differs from LCIS)

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Risk of ALH or LCIS on biopsy being upgraded to invasive cancer on excision?

<3%

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Risk of ADH being upgraded to DCIS?

30%

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Risk of DCIS being upgraded to invasive ductal carcinoma?

30%

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Risk of overall malignancy in either breast when ALH or LCIS found?

ALH: 4-fold
LCIS: 8-fold

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Types of LCIS? Why do these matter?

Classic
Pleomorphic
Mass-forming

Classic LCIS alone does not require excision but can be observed. Pleomorphic or mass-forming should be excised.

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How does ADH differ from DCIS?

Both = atypical proliferation of epithelial cells arising from breast ducts, with no invasion of basement membrane
In DCIS the abnormal cells FILL the ducts

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Subtypes of DCIS?

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Papillary
Comedo
Solid
Micropapillary
Cribriform

Staging/prognosticating for DCIS?

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Van Nuys index

"SMAG"
Size
Margins
Age
Grade

When should you perform SNB for DCIS?

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If doing mastectomy
High suspicion of upgrading lesion (eg big - >5cm)
Mass-forming DCIS

Aetiology/classification of Nipple Discharge?

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Normal (lactation)

Physiological (galactorrhoea)

usually bilateral
never bloody
usually hyperPRL

Pathological

Unilateral, persistent, spontaneous, bloody
Papilloma >50%
Duct ectasia
Cancer
Infection

Gynaecomastia aetiology?

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Physiological
- Neonates, elderly, teenagers

Pathological

Reduced oestrogren clearance (liver dis)
Increased oestrogen production (testicular, pituitary, adrenal tumours, hepatoma)
Decreased testosterone (klinefelters, cryptorchidism, hypopituitarism)

Drug-related

Hormones
Cimetidine
Spironolactone
Digoxin
Phenothiazines
Methyldopa
Tricyclics
Marijuana

Bloods for Gynaecomastia workup?

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CBC
LFT
UEC
Prolactin
SHBG
Testosterone
Oestradiol
B-HCG
Cortisol
FSH+LH

Classification of Phyllodes tumour

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“MIPS”

Mitotic rate
Infiltration/invasion
Pure stromal overgrowth
Stromal atypia

Classifies into benign, borderline and malignant

What margins will you accept?
DCIS
Invasive carcinoma
LCIS
Phyllodes

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DCIS - 2mm
Invasive carcinoma - 1mm
LCIS - involved margin fine if classic LCIS
Phyllodes - 1cm

Indications for frozen section

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Evaluate nipple margin if planning nipple sparing mastectomy
Sentinel lymph node evaluation to determine need for ALND
Assess margins during BCS

Flat Epithelial Hyperplasia - Definition - Risk of malignancy - Management

= Change in breast epithelial cells to columnar, in more than two layers, with cytological atypia Risk of breast ca increased, though not to as great an extent as ADH or ALH 8-10% upgraded on excision to atypical hyperplasia or cancer Manage with excision

Sclerosing Adenosis - Definition - Risk of malignancy - Management

= benign proliferation of ductal elements (lobular acini, myoepithelial cells) and stromal tissue Characterised by distorted breast lobules, a painful mass or calcs on mammo No significant risk of malignancy Observe if imaging and path concordant

Radial scar - Definition - Risk of malignancy - Management

= dense collagenous fibroelastic core with trapped epithelial components Aka complex sclerosing lesion if >1cm Look very suspicious on imaging and can harbour cancers or premalignant lesions Manage with excision biopsy

Fibrocystic change - Definition - Risk of malignancy - Management

= Generalised involutional changes of breast characterised by shift from predominance of lobules and glands to increased fibrosis and cyst formation Basically lumpy breasts in older women Not premalignant/disease Can leave alone

Mild (usual) ductal hyperplasia - Definition - Risk of malignancy - Management

= increase in normal duct epithelial cells - >2 and <4 cells thick, not filling the lumen Non-proliferative disease, no significant increased risk of breast ca Observe if imaging and path concordant cf florid (normal cells filling lumen) and atypical (atypical cells filling lumen)

Florid ductal hyperplasia

= overgrowth of normal ductal epithelial cells that fill lumen Two-fold increased risk of breast ca Observe if imaging and path concordant

What's the difference between ADH and DCIS?

ADH is atypical cells that do not fill/distort a duct. Not more than 2 ducts and no more than 2mm in size DCIS is atypical cells filling/distorting the ducts - >2mm in size or >2 ducts involved

What's the difference between ALH and LCIS

Extent. ALH = proliferation of monomorphic dyscohesive cells in a terminal ductal-lobular unit, either filling a lobule without distending and enlarging it; or some distension but only partial filling LCIS = complete (rather than partial) involvement of terminal ductal-lobular unit, with much greater degree of expansion

Breast pain - Classify aetiology - Management

Cyclical vs non-cyclical (breast, non-breast) Cyclical: - Fibrocystic change - Hormones (OCP, HRT) Non-cyclical - Mastitis - Superficial thrombophlebitis - Haematoma from trauma - Fibroadenoma, lipoma - Chest wall pain - Coronary artery disease - GI: hiatus hernia, GB disease - Radiculopathy Management - Reassurance - Supportive bra - NSAIDs - Tamoxifen - Danazol

BIRADS classification

Breast imaging, reporting and data system ``` 0 = inadequate 1 = normal 2 = benign lesion - 0% 3 = probably benign - <2% malignancy 4 = suspicious - 2-95% 5 = high suggestive of ca - >95% 6 = biopsy-proven ca ``` Closer surveillance for 3, surgical excision for 4-6

Bethesda classification - breast

``` 1 = insufficient 2 = benign 3 = atypical 4 = suspicious for malignancy 5 = malignant ```

Breast Flashcards

(35 cards)