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Year 3 - Reproductive and Sexual Health (DP) > Breast > Flashcards

Breast Flashcards

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1
Q

What risk factors result in a >4 times relative risk of breast cancer?

A

Gene mutation
Lobular carcinoma in situ
Ductal carcinoma in situ
Atypical hyperplasia

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2
Q

Who can an USS help define a solid mass particularly well in?

A

Young women

Women with mammographically dense breasts

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3
Q

What investigation is needed for definitive diagnosis of breast cancer?

A

Image-guided core-needle biopsy

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4
Q

Ductal carcinoma in situ is usually not palpable. How does it appear on screening?

A

Malignant calcifications:

  • Pleomorphic
  • Casting
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5
Q

How is ductal carcinoma in situ diagnosed definitively?

A

Stereotactic vacuum biopsy

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6
Q

How does invasive lobular carcinoma spread?

A

Diffusely

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7
Q

How does invasive lobular carcinoma appear histologically?

A

‘Indian file’ pattern (not visible or palpable early)

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8
Q

What is always required following breast-conserving surgery?

A

Radiotherapy

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9
Q

What is a modified radical mastectomy?

A

Removes entire breast including:

  • Overlying skin
  • Axillary lymph nodes
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10
Q

What is preserved in a modified radical mastectomy and why?

A

Pectoralis major:

  • Improve wound healing
  • Better reconstruction
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11
Q

What are the indications for post-mastectomy radiotherapy?

A

> 3 nodes involved
Positive surgical margins
Tumours >5cm

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12
Q

What is the first line targeted drug therapy for malignant breast cancer?

A

Bevacizumab:

- Recombinant humanised monoclonal Ab against VEGF

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13
Q

How does Lapatinib work?

A

Dual inhibitor for EGFR and HER2 tyrosine kinases

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14
Q

When and with what is Lapatinib prescribed?

A 
Advanced breast cancer and metastatic disease in those with HER+ disease and who have had previous therapy including:
- An anthracycline and
- A taxine and
- Herceptin
Prescribed with Capecitabine
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15
Q

What is Trastuzumab?

A

A HER2 inhibitor

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16
Q

How does cyclic mastalgia present?

A

Diffuse
Most intense premenstrual
Usually bilateral

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17
Q

How does non-cyclic mastalgia present?

A

Localised
Often persistent
Less responsive to treatment

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18
Q

How is mastalgia treated?

A

Evening primose oil
Tamoxifen
Topical NSAIDs

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19
Q

How does a breast cyst feel on examination?

A

Clearly defined
Soft
Mobile
Smooth

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20
Q

When is a breast cyst usually most tender?

A

Before menstruation

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21
Q

How can a breast cyst be diagnosed and treated?

A

FNA

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22
Q

How is mastitis treated?

A

Flucloxacillin 500mg PO every 6 hrs for 7 days
OR
Augmentin 625mg every 8 hrs for 7 days

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23
Q

When should antibiotics for mastitis be administered?

A

As soon as signs/symptoms:

  • Fever
  • Erythema
  • Induration
  • Tenderness
  • Swelling
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24
Q

After treating mastitis, how should examination be carried out?

A

Examine every 3 days:

  • Ensure response to therapy
  • Ensure no abscess formation
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25
How is an abscess in mastitis treated?
Drainage
26
What can cause non-puerperal mastitis?
Staph. aureus Peptostreptococcus magnus Bacteroides fragilis
27
How is non-puerperal mastitis treated?
Augmentin 625mg every 8 hrs for 7 days OR Cephalexin 500mg PO every 6 hours
28
What is chronic mastitis associated with?
Subareolar abscess
29
What can occur in chronic mastitis?
Periareolar fistulae
30
What cells are seen in an apocrine metaplasia of breast epithelial cells?
Eosinophils (in the lining of a cyst)
31
What is a galactocoele?
Palpable milk-filled cyst
32
What are galactocoeles associated with?
Pregnancy | Lactation
33
How are galactocoeles diagnosed and treated?
FNA
34
How do lipomas appear on mammography?
Thin border (they are palpable)
35
What is Mondor's Disease?
Phlebitis | Subsequent clot formation in superficial breast veins
36
How does Mondor's Disease look and feel?
Firm, vertical, cord-like structure
37
What is Mondor's Disease associated with?
Breast trauma (eg. Surgery)
38
How long does Mondor's Disease take to resolve?
8-12 weeks
39
What is the routine screening for breast cancer?
Mammography: - Aged 50-70 - Every 3 years - Picks up small and impalpable tumours
40
How many palpable lumps (breast cancer) are operable?
84%
41
What triple assessment occurs at the one stop clinic?
``` Physical examination of the breasts Breast imaging: - Mammogram +/or - USS FNA or Needle-core biopsy if lump found ```
42
If breast cancer is confirmed, what further investigations are done?
Staging CT Breast MRI (especially if lobular) ?Bone scan
43
How is a ductal carcinoma in situ treated?
Breast-conserving therapies OR Mastectomy
44
What radiotherapy follows the treatment of a DCIS?
Radiotherapy of the whole breast: - 40Gy in 15 sessions over 3 weeks - Using 2 tangential fields
45
When can the breast alone be irradiated following breast conserving surgery?
Negative sentinel node biopsy (SNB) Micromets. (>0.2mm but <2mm) in SNB <4 nodes involved in adequate axillary node clearance
46
When is there a radiotherapeutic boost to the tumour bed following breast conserving surgery?
Women under age 54 on day of surgery | Posterior margin <1mm for invasive disease after full thickness excision
47
When is chest wall radiotherapy carried out following mastectomy?
Tumour size >5cm >=4 nodes involved Involved resection margins T4 disease
48
When is the ipsilateral axilla irradiated following breast surgery?
>1 positive macrometastases in sentinel node biopsy | Extensive ECS post-axillary clearance
49
Following neo-adjuvant treatment, when is a node considered involved?
If there is a pathological response (scarring) in the node
50
Where is 5 field radiotherapy directed?
Whole breast OR Chest wall Axilla Supraclavicular fossa
51
When is tamoxifen used in breast cancer?
ER+ disease | Preferred in premenopausal women
52
How long can tamoxifen be given?
10yrs
53
When is letrozole used in breast cancer?
Preferred in postmenopausal women
54
How long can tamoxifen be given?
5yrs
55
When is trastuzumab used in breast cancer?
HER+ patients (as measured by IHC or FISH)
56
How many breast cancer patients are HER+?
25-30%
57
For locally advanced breast cancer, when is radiotherapy considered?
As initial therapy for a primary inoperable tumour Patients still inoperable after primary systemic therapy Post-surgery for all patients
58
In locally advanced breast cancer, what can be done in patients with T>4b tumours?
0.5cm bolus following mastectomy | Increase skin does
59
What cancers tend to metastasise to the breast?
``` Lung Liver Bone Brain Skin ```
60
How are the symptoms of metastatic breast cancer treated?
Bisphosphonates Radiotherapy Chemotherapy
61
When not lactating, what is the structure of the mammary gland?
Secretory lobe -? Extralobular duct -> Lactiferous duct -> Lactiferous sinus -> Nipple
62
How many lobes are there per breast?
15-25
63
What is each lobe in the breast associated with?
A compound tubulo-acinar gland
64
What tissue is adjacent to lobes?
Dense fibrous tissue | Adipose tissue
65
What is the structure of the duct system?
Terminal ductules -> Intralobular collecting duct -> Lactiferous duct
66
What does the lactiferous duct expand into?
Lactiferous sinus
67
What is the lining of larger ducts?
Columnar
68
In secretory acini, what is the structure of the epithelium?
Cuboidal OR Low-columnar
69
What are the epithelial cells in secretory acini surrounded by?
Myoepithelial cells
70
What is the potential origination of breast lobes?
Modified sweat glands
71
What is the epithelium covering the nipple?
High pigmented keratinised stratified squamous epithelium
72
What is at the core of the nipple?
Dense irregular connective tissue with smooth muscle bundles
73
What is the lining of the ducts near the surface?
Stratified squamoues
74
What is the lining of the ducts deeper than the surface?
Stratified cuboidal
75
What is the lining of the deepest ducts?
Cuboidal (1 cell thick)
76
What glands are on the surface of the nipple?
Sebaceous glands
77
What happens to the structure of the breast during the luteal phase of menstruation?
Epithelial cells increase in height Lumina of ducts increase in diameter Small secretions
78
What happens to the structure of the breast following menopause?
Secretory cells degenerate so only ducts are left Reduced fibroblasts: - Reduced collagen and elastic fibres
79
What happens to the structure of the breast during the 1st trimester?
Elongation and branching of smaller ducts | Proliferation of gland epithelium and myoepithelial cells
80
What happens to the structure of the breast during the 2nd trimester?
Differentiation of secretory alveoli | Plasma cells and lymphocytes infiltrate connective tissue
81
What happens to the structure of the breast during the 3rd trimester?
Secretory alveoli mature | Development of extensive RER
82
What are the breast changes in pregnancy accompanied by?
Reduced amount of connective and adipose tissues
83
What is the main component of milk?
88% water
84
What are the main proteins in breastmilk?
Lactalbumin | Casein
85
What is the main carbohydrate in breast milk?
Lactose
86
What is present in small amounts in breast milk?
Ions Vitamins IgA
87
How are lipids secreted into the breast milk?
Secretory cell cytoplasm contains lipid droplets As droplets bud off they are surrounded by some: - Cytoplasm - Plasma membrane Apocrine secretion
88
How are proteins secreted into the breast milk?
Made in rER Packaged in golgi and released via vesicles: - Merge with apical membrane and release contents Merocrine secretion
89
What is breast FNA cytology C1?
Unsatisfactory
90
What is breast FNA cytology C2?
Benign
91
What is breast FNA cytology C3?
Atypia, probably benign
92
What is breast FNA cytology C4?
Suspicious of malignancy
93
What is breast FNA cytology C5?
Malignant
94
What is the benefit of a vacuum assisted biopsy over a needle-core biopsy?
Large volume/mammotome
95
What is breast needle-core biopsy B1?
Unsatisfactory/Normal
96
What is breast needle-core biopsy B2?
Benign
97
What is breast needle-core biopsy B3?
Atypia, probably benign
98
What is breast needle-core biopsy B4?
Suspicious of malignancy
99
What is breast needle-core biopsy B5a?
Malignant: | - Carcinoma in situ
100
What is breast needle-core biopsy B5b?
Invasive carcinoma
101
What breast developmental diseases are benign?
Hypoplasia Juvenile hypertrophy Accessory breast tissue Accessory niple
102
What inflammatory breast diseases are benign?
Fat necrosis Duct ectasia Acute mastitis/abscess
103
What non-neoplastic breast diseases exist?
``` Gynaecomastia Fibrocystic change Hamartoma Fibroadenoma Sclerosing lesions ```
104
How does sclerosing adenosis appear?
Radial scar/Complex sclerosing lesions
105
What breast tumours are benign?
Phyllodes tumours | Intraduct papilloma
106
What prescription drugs can cause gynaecomastia?
Cimetidine 5-alpha-reductase inhibitors Spironolactone Calcium channel blockers
107
Apart from prescription drugs, what else can cause gynaecomastia?
Exogenous/Endogenous hormones Cannabis Liver disease
108
When do the majority of breast fibrocystic changes occur?
Between the ages of 40-50
109
How do fibrocystic breast changes affect menstruation?
Menstrual abnormalities Early menarche Late menopause
110
How do fibrocystic breast changes present?
``` Smooth discrete lumps Sudden pain Cyclical pain Lumpiness Incidental finding/Screening ```
111
How do the cysts appear in fibrocystic breast changes?
1mm - Several cm Blue domed with pale fluid Usually multiple Associated with other benign changes
112
How do fibrocystic cysts appear microscopically?
Cysts: - Thin walled (maybe fibrotic) - Lined by apocrine epithelium Fibrosis
113
How are fibrocystic breast changes treated?
Exclude malignancy Reassure Excise (if necessary)
114
What is the following describing: | A circumscribed lesion composed of cell types normal to the breast but present in an abnormal pattern or distribution?
Hamartoma
115
How does a breast fibroadenoma present?
Screening Painless, firm, discrete, mobile mass: - "Breast mouse"
116
In who is a breast fibroadenoma most common?
African women | Peak incidence in 3rd decade
117
How does a breast fibroadenoma appear on USS?
Solid
118
How does a breast fibroadenoma appear macroscopically?
``` Circumscribed Rubbery Grey-white colour Biphasic tumour/lesion: - Epithelium - Stroma ```
119
How is a breast fibroadenoma treated?
Diagnose Reassure Excise
120
What are sclerosing breast lesions?
Benign, disorderly proliferation of acini and stroma
121
How does sclerosing adenosis present?
``` Pain, Tenderness Lumpiness/Thickening OR Asymptomatic ```
122
Between what ages does sclerosing adenosis present?
20-70 years
123
How big are radial scars?
1-9mm
124
How big are complex sclerosing lesions?
>=10mm
125
What is the pathology of a radial scar?
Stellate architecture Central puckering Radiating fibrosis
126
How do radial scars appear on histology?
Fibroelastic core Radiating fibres containing distorted ductules Fibrocystic change Epithelial proliferation
127
Radiologically, what does a radial scar mimic?
Carcinoma
128
How is a radial scar treated?
Excise | Sample extensively by vacuum biopsy
129
What can cause breast fat necrosis?
Local trauma: - Seat belt injury - Frequently no history Warfarin therapy
130
What is the pathology behind fat necrosis?
Damage and disruption of adipocytes Infiltration by acute inflammatory cells "Foamy" macrophages Subsequent fibrosis and scarring
131
How can fat necrosis be treated?
Confirm diagnosis | Exclude malignancy
132
What do the following clinical features describe: - Affects subareolar ducts (dilatation) - Pain - Acute episodic inflammatory changes (Periductal) - Blood +/or purulent discharge - Fistulation - Nipple retraction and distortion
Duct ectasia
133
What is duct ectasia associated with?
Smoking
134
How is duct ectasia managed?
Treat acute infections Exclude malignancy Stop smoking Excise ducts
135
What organisms are indicated in mastitis/abscess in duct ectasia?
Mixed organisms | Anaerobes
136
What organisms are indicated in mastitis/abscess during lactation?
Staph. aureus | Strep. pyogenes
137
What are the clinical features of a Phyllodes Tumour?
Age 40-50 | Slow growing unilateral breast mass
138
What is the alternative name for a Phyllodes Tumour?
Cystosarcoma phyllodes
139
How does a Phyllodes Tumour appear?
Biphasic | Stromal overgrowth
140
What dictates the behaviour of a Phyllodes Tumour?
Stromal features
141
How does a Phyllodes Tumour tend to behave?
``` Local recurrence (if not adequately excised) Rarely metastasise ```
142
How does an intraduct papilloma present?
Age 35-60 | Nipple discharge +/- blood
143
How does an asymptomatic intraduct papilloma appear at screening?
Nodules | Calcification
144
What size are intraduct papillomas?
2-20mm
145
How do intraduct papillomas appear?
Papillary fronds containing a fibrovascular core | Covered by myoepithelium and epithelium
146
Where do breast carcinomas arise?
Glandular epithelium of the terminal duct lobular unit
147
What type of cancer are breast carcinomas?
Adenocarcinomas
148
How is an in situ carcinoma confined?
Within basement membrane of acini and ducts
149
How much of the lobule is involved in atypical lobular hyperplasia?
<50%
150
How much of the lobule is involved in lobular carcinoma in situ?
>50%
151
How does the intralobular proliferation of lobular in situ neoplasms appear?
Small-intermediate sized nuclei Solid proliferation Intracytoplasmic lumens/vacuoles
152
What receptors are lobular in situ neoplasms positive for?
ER+
153
Lobular in situ neoplasms are E-cadherin negative. What does this mean?
Deletion and mutation of CDH1 gene on Chromosome 16q22.1
154
When does the incidence of a lobular in situ neoplasm decline?
After menopause
155
How is a lobular in situ neoplasm managed if discovered on core biopsy?
Excision/Vacuum biopsy to exclude higher grade lesion
156
How is a lobular in situ neoplasm managed if discovered on vacuum/excision biopsy?
Follow up | Clinical trials
157
Ductal carcinomas in situ are unicentric. What does this mean?
Single duct system
158
What is the cytological appearance of a ductal carcinoma in situ?
Malignant epithelial cells
159
Where are ductal carcinomas in situ confined to?
Basement membrane of duct
160
What is Paget's Disease of the Nipple?
High grade ductal carcinoma in situ extending along ducts to reach epidermis of nipple (still in situ)
161
How can ductal carcinoma in situ be classified?
Cytological grade Histological type Presence of necrosis (comedo)
162
What is the significance of a ductal carcinoma in situ?
Risk factor for invasive carcinoma | True precursor lesion
163
How is a ductal carcinoma in situ managed?
``` Diagnosis Surgery: - Mammographic follow-up in low risk DCIS - Adjuvant radiotherapy - Chemoprevention (trial) ```
164
What is a microinvasive breast carcinoma?
A ductal carcinoma in situ with invasion <1mm
165
How is a microinvasive breast carcinoma treated?
Treat as high grade ductal carcinoma in situ
166
What are the low grade breast carcinomas?
Tubular carcinoma Lobular carcinoma G1 ductal carcinoma
167
What are the intermediate grade breast carcinomas?
G2 ductal carcinoma | Pleo Lobular carcinoma
168
What is the main high grade breast carcinoma?
G3 ductal carcinoma
169
How is an invasive breast carcinoma generally defined?
Malignant epithelial cells which have breached the basement membrane
170
In terms of the UK population, how common is invasive breast carcinoma?
Most commonly diagnosed UK cancer
171
What reproductive history features increase the risk of breast carcinoma?
``` Early menarche (younger than 12 years) Late pregnancy (First pregnancy at age >30) Low/No parity Not breastfeeding Late menopause (Older than 55) ```
172
What lifestyle features increase the risk of breast carcinoma?
``` Overweight Low physical activity Alcohol Poor diet Smoking ```
173
How do NSAIDs affect the risk of breast carcinoma?
Lower it
174
In what populations is breast carcinoma more common?
White populations | Western Europe >
175
How does a first degree relative of breast carcinoma affect the risk?
Doubles risk
176
What syndrome is the TP53 gene associated with?
Li Fraumeni Syndrome
177
What cancers does TP53 mutation predispose to?
``` Childhood sarcoma Brain Leukaemia Adrenocortical carcinoma Early-onset breast ```
178
What cancers does BRCA2 predispose to?
Breast (inc. male) Ovarian Prostate Pancreatic
179
What cancers does BRCA1 predispose to?
Breast Ovarian Bowel Prostate
180
What syndrome does PTEN mutation cause?
Cowden's Syndrome
181
What cancers does PTEN mutation predispose to?
Breast GI Thyroid (benign and malignant)
182
What syndrome does STK11/LKB1 predispose to?
Peutz-Jeghers Syndrome
183
What cancers does STK11/LKB1 mutation predispose to?
Breast GI Pancreatic Ovarian
184
What syndrome does ATM mutation predispose to?
Ataxia telangiectasia
185
What cancers does ATM mutation predispose to?
NHL Ovarian Breast (in heterozygote carriers)
186
Where do breast carcinomas invade locally?
Stroma of breast Skin Muscles of chest wall
187
Where do breast carcinomas spread haematogenously?
``` Bone Liver Brain Lungs Abdominal viscera Female genital tract ```
188
What percentage of breast carcinomas are ER+?
80%
189
What percentage of breast carcinomas are progesterone receptors +?
67%
190
What percentage of breast carcinomas are HER+?
14%
191
What is the most common histopathological type of breast carcinoma?
Ductal
192
What intrinsic breast cancer sub-type is ER-, HER2- and Basal CK+?
Basal-like
193
What intrinsic breast cancer sub-type is ER- and HER2+?
HER2
194
What intrinsic breast cancer sub-type is ER- and non-epithelial?
Normal breast-like
195
What does ER receptor expression in breast cancer predict?
Response to anti-oestrogen therapy: - Oophorectomy - Tamoxifen - Aromatase inhibitors (Letrozole) - GnRH antagonists (Goserelin)
196
What is HER2?
Human Epidermal GF Receptor 2
197
What does HER2 expression in breast cancer predict?
Response to Trastuzumab (Herceptin)
198
What is the Nottingham Prognostic Index?
A histopathological prognostic index: - 0.2 x tumour diameter (cm) - Tumour grade (1 - 3) - LN status (1 - 3)
199
What factors does the Adjuvant! Online prognostic index take into account?
Histopathology ER Clinical features
200
What factors does the PREDICT prognostic index take into account?
``` Histopathology ER Clinical features HER2 Mode of detection ```
201
How is a breast mass imaged in women ages <40 years?
USS
202
How is a breast mass imaged in women aged >40 years?
Mammography +/- USS
203
What is mammography designed to do?
Maximise contrast between the breast tissues whilst minimising radiation dose
204
What is the only method of breast imaging that reliably visualises microcalcifications (<0.5mm)?
Mammography
205
When is digital mammography better?
Dense breasts | Younger women
206
What are the advantages of digital mammography?
``` Better contrast Faster Fewer technical repeats Fewer films Easier image storage and transfer ```
207
How does glandular tissue appear on a normal mammogram?
Higher density
208
How do trabeculae appear on a normal mammogram?
Thin | Sharply defined
209
How do lymph nodes appear on a normal mammogram?
Oval/Horseshoe Fatty hilum 25% have intramammary nodes (upper outer quadrant)
210
How do calcifications appear on a normal mammogram?
Bright white: - Arterial - Sebaceous glands (polo mints) - Eggshell curvilinear (oil cysts)
211
What views are taken in mammograms?
Mediolateral oblique Craniocaudal Extended craniocaudal
212
What is the best single view in mammography?
Mediolateral oblique: | - Least foreshadowing
213
What does a craniocaudal view allow visualisation of?
Retromammary fat | Medial and most of lateral tissue
214
What do paddle view mammograms allow demonstration of?
Borders of mass
215
What are the BIRADS parenchymal patterns on a normal mammogram?
``` a = Nearly all fat b = Scattered fibroglandular densities c = Heterogeneously dense d = Extremely dense ```
216
If calcifications on a mammogram are in a cluster or segmental, what does this suggest?
Suspicious
217
If calcifications on a mammogram are scattered or diffuse, what does this suggest?
Benign
218
What MRI sequences help determine breast cancer morphology?
High resolution T1 and T2
219
What MRI sequences help determine breast cancer vascularity?
Dynamic contrast enhancement kinetics
220
What MRI sequences help determine breast cancer cellularity?
Diffusion-weighted imaging
221
What MRI sequences help determine breast cancer metabolism?
Spectroscopy
222
What MRI sequences help determine breast cancer oxygenation?
Intrinsic susceptibility-weighted MRI
223
What can cause false negatives on MRI?
Invasive lobular carcinoma DCIS Mucinous carcinoma
224
What can cause false positives on MRI?
``` Normal BBC Fibroadenomas Post-therapy changes Fat necrosis Intramammary nodes ```
225
In breast conservation surgery, how big do the margins need to be for equivalent disease free and overall survival when compared to mastectomy?
Clear margins >=1mm
226
What is the standard chemotherapy treatment following breast surgery?
``` Standard FEC100: - Fluorouracil, Epirubicin + Cyclophosphamide AND Taxane (eg. Docetaxel) +/- Herceptin ```
227
What free-flap options are available for breast reconstruction?
Latissimus dorsi pedicled flap Deep inferior epigastric artery perforator Inferior gluteal artery perforator

Year 3 - Reproductive and Sexual Health (DP) (7 decks)

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