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Breast - YR3 > Breast Disease - teaching > Flashcards

Breast Disease - teaching Flashcards

1
Q

Breast surface anatomy

A
  • Axillary tail (inferolateral edge of pec major)
  • Montgomery glands (around areola, modified sebaceous gland)
  • Areola
  • Nipple - tends to be 4th ICS in men
  • Infra-mammary fold (below breasts)

Attached from ribs 2-6 and lateral border of sternum to mid-axillary line

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2
Q

Breast anatomy - inside

A
  • 15-20 lobules of glandular tissue within fat
  • Lobules converge and drain via lactiferous duct to nipple
  • Lobules seperated by fibrous septa from subcut fascia to chest wall fascia - suspensory ligaments

Lobules same amount, size difference due to fat

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3
Q

What causes dimpling in breast cancer?

A

If cancer has invaded suspensory ligaments

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4
Q

Arterial supply to breast

A
  • Axillary artery
  • Internal thoracic (mammary)
  • Intercostal artery - branches of 2nd, 3rd and 4th)
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5
Q

Lymphatic drainage of breasts

A
  • Axillary nodes - 75%, 3 levels
  • Parasternal lymph nodes - <25%

Parasternal never removed with surgery - always chemo

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6
Q

3 levels of axillary lymph node drainage of breast

A
  • Level 1 - lateralto pec minor
  • Level 2 - behind/deep to pec minor
  • Level 3 - medial to pec minor

Level 3 most difficult to remove due to it being near neck at apex

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7
Q

Reasons for pts being reffered to breast clinic

A
  • Self examination and then GP
  • NHS breast screening program
  • FH or high risk screening
  • Incidental finding on imaging
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8
Q

Common signs patients may find which can suggest breast cancer

A
  • Lump
  • Change to skin - puckering/dimpling
  • Change colour - red/inflamed
  • Nipple change - inverted
  • Rash/crusting around nipple
  • Discharge from nipple
  • Changes in size/shape of breast
  • Pain - not usually a sign of cancer esp if cyclical can just be hormonal
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9
Q

`

NHS breast screening program

A
  • Women aged 50-70
  • Mammogram
  • Every 3 years
  • After 71, can request to continue
  • Can be done with implants
  • If abnormal, recalled for another screen or sent for breast clinic appt
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10
Q

Screening program for moderate/high risk patients

A
  • Start at 40 and have annual mammograms
  • If younger can have annual MRI from 30-40 eg gene mutations p53 have MRI from 20 and BRCA1/2 have from 30
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11
Q

What is the triple assessment patients undergo at breast clinic?

A
  • Clinical assessment - history, examine breast and axilla
  • Radiological assessment - mammography/USS breast + USS axilla
  • Pathological assessment - core biopsy, FNAC or VAB
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12
Q

What to ask about in HPC for breast symptom?

A
  • Duration
  • Cyclical?
  • Trauma –> can cause fat necrosis of breast
  • Weight loss/night sweats
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12
Q

What imaging is used for men?

A

USS

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13
Q

PMH, DH, SH and FH for breast symptoms

A
  • DH - HRT/COCP?
  • PMH - Late menopause/early menarche?, Breast disease/surgery/bra size
  • SH - Smoking/alcohol
  • FH - First/second degree relative with breast cancer, ovarian, prostate, pancreatic or sarcoma
  • Jewish?
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14
Q

Imaging for triple assessment - over 35

A
  • Mammogram
  • Medial-lateral oblique and cranio-caudal views
  • Check for irregular opacity or microcalcification
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15
Q

Imaging for women under 35

A

USS

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16
Q

Mammogram views

A
Grey triangle on MLO is pec muslce
17
Q

Biopsy options for triple assessment

A
  • Core biopsy of breast lesion +/- axilla node - if US showed abnormal/palpable - GOLD STANDARD
  • Nipple discharge –> smear
  • FNA for cytology
  • Vaccum assisted biopsy - VAB
  • Vaccum assisted excision - VAE
18
Q

When is VAB and VAE used?

A
  • VAB if core biopsy was not adequate/unsure
  • VAE for pre malignant lesions, remove whole thing at once, no need for surgery

Usually done if B3 on histology score

19
Q

Histology score for breast tissue

A
  • B1 - normal
  • B2 - benign
  • B3 - uncertain, probably benign
  • B4 - suspicious of malignancy
  • B5 - malignant

Also used for M1-5, U1-5 and P1-5 for mammogram, US and exam findings

20
Q

Why are fibroadenomas >5cm often excised?

A
  • Could be phyllodes tumour
  • These often benign too but can be very aggressive malignant cancer that behave like sarcomas
21
Q

RF for breast cancer

A

MORE EXPOSURE TO OESTROGEN - just think this in an exam eg:
* Female
* Early menarche, late menopause
* HRT, COCP
* Few/no children

Also BRCA1/BRCA2 gene mutation, previous radiotherapy to chest, higj alcohol

22
Q

Problem with radiotherapy to the chest

A

Used as treatment for BC but can then increase risk of angiosarcoma - aggressive cancer

23
Q

Types of breast cancer

A
  • DCIS
  • Ductal carcinoma - “No special type” is majority
  • Lobular carcinoma
  • Mixed ductal/lobular
  • Pagets disease
  • Inflammatory - LOOKS LIKE MASTITIS, be aware if resistant/chronic mastitis
  • Rarer - mucinous, tubular, medullary, papillary
24
Q

DCIS vs ductal carcinoma

A
  • DCIS has not invaded the BM
25
Q

Lobular CIS vs ductal CIS

A
  • Lobular not typically treated like cancer
  • BUT DCIS is as high likelihood of progression
26
Q

Receptors for breast cancer

A
  • Oestrogen
  • Progesterone
  • HER2 - human epidermal growth factor
  • NONE = TRIPLE -ve
27
Q

Differentiation breast cancer

A
  • 1 - well differentiated, like normal tissue
  • 2 - moderate
  • 3 - poor, very abnormal cells
28
Q

Surgical treatment for breast cancer (breasts)

A
  • Mastectomy - simple, skin sparing or nipple sparing
  • Breast conserving surgery - wide local excision
29
Q

What can all breast surgery have with it?

A
  • Partial/reconstruction
  • Contralateral surgery if need to match breasts
30
Q

Options for axillary surgery (can have any combo with any breast surgery)

A
  • Sentinal node biopsy - done if no US findings in axilla
  • Axillary node sampling - done if cannot have dye for sentinal node
  • Axillary node clearance - done if abnormality found already and tested
31
Q

Breast reconstruction options

A
  • Implants
  • Lipofilling - liposuction elsewhere and then fill gap with this
  • Pedicled flap - using skin under breast and around back to flip around on pedicle under skin, keep original blood supply
  • Free flap - flap from elsewhere on body, replumb in new blood supply
32
Q

How is sentinal node biopsy done?

A
  • Dual technique
  • Patent blue dye and radio-isotope
  • So looking for bright blue node and high gamma count when removed
  • Then send for histology
33
Q

Which is only cancer which doesnt have axillary surgery?

A
  • DCIS
  • Technically should not be invasive so should not have spread
  • BUT if when remove cancer and test it has spread beyond BM may need to go back in and do again
34
Q

Deciding mastectomy vs wide local excision

A
  • Patient preference
  • Tumout:breast ratio
  • Location of tumout
  • MDT
  • Multi-focal - mastectomy
  • Risk of local recurrence
35
Q

Complications of breast surgery

A

All of the typical surgical ones +:
* Fat necrosis
* Nipple necrosis

36
Q

Complications of axillary surgery

A
  • Seroma
  • Shoulder stiffness
  • Cording - thick scar tissue
  • Lymphoedema
  • Damage to vessels/nerves
37
Q

Medical treatment options for BC

A
  • Hormone therapy
  • HER2 inhibtors
  • CDK4 and 6 inhibitors (cyclin dependent kinase)
  • Bisphosphonates
  • Chemotherapy
  • Radiotherapy - used ALWAYS if wide local excision
38
Q

Hormone therapy for BC

A
  • ER +ve and pre menopausal - Tamoxifen
  • ER +ve and post menopausal - aromatase inhibitors eg anastrozole
  • Can be neoadjuvant or adjuvant for 5+ years
39
Q

When is chemotherapy used?

A
  • Triple -ve breast cancer
  • Her2+ve
  • Can be neoadjuvant or adjuvant
40
Q

Prognostic calculators for breast cancer

A
  • Predict - website
  • Nottingham prognostic index - (sizex0.2) + nodal status + grade
  • Oncotype - for ER+ve, HER2-ve, send off sample to America and it sees how it behaves with chemo
41
Q
A

Breast - YR3 (7 decks)

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