Oncology - Breast cancer Flashcards
(39 cards)
What causes acute inflammation of the breast?
Mastitis is an occasional complication of lactation. Fissures or abrasions in the nipple predispose to the condition. Infection is transmitted by the suckling neonate who is carrying hospital staphylococci. Abscesses may form in the lobules of the breast leading to scarring.
The patients presents with a red, hot tender lump and systemic upset.
How is mastitis managed?
If an abscess is present then it should be aspirated (this may need to be repeated) and sent for MC&S. The mother should not stop breast feeding and oral antibiotics (e.g. flucloxacillin) should be given. It is also worth arranging an ultrasound (young women/ dense breast tissue) or mammogram (older woman, small breasts).
Non lactational abscesses are usually recurrent, associated with smoking and underlying ductal ectasia (plasma cell mastitis). Treatment is outpatient aspiration, oral antibiotics, smoking cessation and prophylactic metronidazole for sepsis, and repeat aspiration if necessary.
What causes chronic mastitis?
Chronic infection is uncommon, but can be associated with tuberculosis.
What is duct ectasia? How do women present?
This is a chronic inflammatory reaction associated with ectasia of the ducts (cystic dilatation). Infection of the dilated ducts allows escape of contents into the tissues resulting in a granulomatous reaction. Clinically, it may raise suspicion of duct carcinoma. Patients often present with nipple discharge, which may be from single or multiple ducts. The discharge is usually thick and green.
Macroscopically, there is thickening of the fibrous tissue around cystic ducts which are themselves filled with lipid laden fluid and fatty macrophages. Lymphocytes and plasma cells are located in the tissue around the dilated ducts.
What is traumatic fat necrosis?
This occurs in obese pendulous breasts and results in an irregular granulomatous fibrous reaction which may mimic carcinoma. It is uncommon, and most women report some history of trauma to the breast.
What non breast diseases can cause mastalgia?
- Tietze’s condition (chostochondritis) = tenderness over the medial ends of the ribs (typically 2nd/3rd/4th), not limited to the breast area of the chest, typically unilateral, relieved by NSAIDs
- Bornholm’s disease (epidemic pleurodynia caused by coxsackie A virus) = marked pain with no physical signs in the breast, worse with inspiration, no underlying respiratory disease, relieved with NSAIDs
- Pleurisy = associated respiratory infection, pleural rub
- Angina = usually atypical angina, may be hard to diagnose, previous history of associated vascular disease
How should mastalgia of non breast origin be investigated?
ECG
CXR
Stress test
What is fibrocystic change? What are its key features?
In this condition there are four characteristic features, and the form which the disease takes varies according to the relative proportions of these features:
1) Fibrosis - there is progressive hyalinization of the stroma
2) Cyst formation - obstruction of ducts leads to dilatation of the ducts and acini. The lining epithelium may show apocrine metaplasia
3) (a) Adenosis - this is an increase in the number of lobules and in the size of existing lobules
(b) Sclerosing adenosis - this is a localised condition which may simulate carcinoma. There is proliferation of acini and stroma and mitotic activity can be marked but there is NO danger of malignancy
4) Epithelial hyperplasia - is the most important component because it forms a link between simple proliferation and malignancy change
How can fibrocystic change be classified?
Fibrocystic change can be classified as nonproliferative (cystic) or proliferative.
Proliferative lesions include epithelial proliferations of ducts and lobules (with or without features of atypia) and adenosis, sometimes associated with fibrosis.
These changes are further divided into usual type and atypical. In “usual type hyperplasia”, there is proliferation of uniform “benign” epithelium with “streaming” pattern.
Atypical hyperplasia can be ductal (ADH) or lobular (ALH). In ADH here is proliferation of ductal epithelium forming an irregular network: epithelial cells show mild atypia. There is still retention of the myoepithelial layer however. In ALH there is uniform proliferation of acinar epithelium without acinar expansion but the myoepithelial layer is lost.
What is the relationship between fibrocystic change and breast carcinoma?
Fibrocystic change is very common, and the various changes are ascribed to abnormal and exaggerated responses of the breast tissue to cyclical changes in female hormones, they are essentially benign. But a link with carcinoma has been established when there is hyperplasia with cytological atypia (i.e. ADH, ALH). Atypical hyperplasia is associated with a five fold increase in the risk of developing carcinoma.
How does fibrocystic change present?
Women present with breast discomfort, dull heavy pain that is worse premenstrually. The breasts have a cobblestone appearance on palpation.
How is fibrocystic change managed?
Women over 45 should be referred for mammogram to rule out occult carcinoma. General advice involves restricting dietary fat, and avoiding caffeine.
Treatment for cyclical mastalgia should be with paracetamol, danzol, tamoxifen, and bromocriptine.
Treatment for non cyclical mastalgia is with paracetamol and NSAIDs.
What lesions are related to fibrocystic change?
1) Fibroadenoma = benign, nodular proliferation now considered to be a component of fibrocystic change and NOT a true neoplasm. It is usually single, occurring in young women. It presents clinically as a small, firm, mobile lump. Radiologically is appears as a well demarcated mass. Microscopically, the proliferation of intralobular stroma compresses the entrapped glands, creating a “pushing” border that sharply separates it from the surrounding normal tissue
2) Radial scar = this small, firm lesions shows a central dense fibrous core with radiating fingers of fibrosis entrapping and distorting glandular elements. It is benign, but can be confused with a carcinoma even on histological examination. Similar but larger lesions, also detected by mammography, are known as complex sclerosing lesions
What is Phyllodes tumour?
This tumour is a large, bulky mass of variable malignancy with ulceration of overlying skin. Cystic spaces contain leaf like projections from the cyst wall and myxoid contents are characteristic.
What is a ductal papilloma?
Ductal papilloma is local areas of epithelial proliferation in large mammary ducts. This proliferation is hyperplastic rather than malignant or premalignant. Can present with blood stained discharge.
What are the 2 types of ductal papilloma?
1) Solitary papilloma - lesions found almost always near the nipple. Macroscopically, the tumour is a complex, branching pedunculated tumour filling the lacteal sinus.
Microscopically, the branches have a connective tissue core covered by columnar epithelium with underlying myoepithelium - this gives a double layer of cells covering the fronds
2) Multiple papillomata - these may be distributed throughout the duct system. In this form multicentric carcinoma can develop
These are the only important benign breast tumours, other types are rare.
What is DCIS?
This is one of the two forms of non invasive carcinoma, and affects the ducts. It may be visible as a greyish white material filling the dilated ducts, and central necrotic debris may be squeezed out of the ducts. DCIS tends to fill and distort ductal spaces.
Solid or cribriform cylinders of cells show the usual features of malignancy. It is important to differentiate the condition from atypical ductal hyperplasia. DCIS is graded into high and low grade, the former having a higher risk of invasive carcinoma. DCIS is a precursor of invasive carcinoma and can often be seen as calcifications on mammography.
How is Paget’s disease of the nipple related to DCIS?
Paget’s disease of the nipple is caused by the extension of DCIS up the lactiferous ducts and into the overlying skin of the nipple. It produces a crusty exudate over the nipple and areolar skin. In almost ALL cases an underlying carcinoma is present, and approximately 50% of the time the carcinoma is invasive.
What is LCIS?
This lesion is usually multifocal and bilateral. The breast acini of affected lobules are distended by fairly uniform carcinoma cells which grow into the duct system or break through the basement membrane to become infiltrating carcinoma.
Why is LCIS an important lesion?
Approximately 1/3 of women with LCIS will develop invasive carcinoma. Unlike DCIS, subsequent invasive carcinomas may arise in either breast. Most of these cancers are invasive lobular carcinomas, but invasive ductal carcinomas can also arise in LCIS. LCIS is therefore both a marker of increased risk of carcinoma in BOTH breasts and a direct precursor to some cancers.
What is the most common type of breast carcinoma?
Infiltrating (or invasive) ductal carcinoma is the commonest form of breast cancer. It presents as a firm lump. Pathological features are:
- surface shows a coarse texture (peau d’orange)
- strands of fibrous tissue extend in all directions
- nipple often retracted in late stages
- localised hard, craggy mass, greyish white in colour with yellow flecks (“unripe pear appearance”)
- often fixed to the underlying muscle
What are the microscopic features of invasive ductal carcinoma?
Neoplastic cells are spherical and arranged in cords separated by dense collagenous stroma. Cancer cells may form occasional acini. The microscopic appearance can vary, and these carcinomas are often grouped under the heading of “invasive breast carcinomas of no special type”.
What is infiltrating lobular carcinoma?
10% of breast cancers are of this type. Based on distribution of the “in situ” precursor, this tumour may be multicentric within the breast and there is a 30% change of a similar tumour arising in the contralateral breast. Microscopically the tumour infiltrates the tissues as single files (Indian file pattern) of malignant cells. Almost all of these carcinomas express hormone receptors.
Give some examples of rarer forms of breast cancer
These include tubular carcinoma - showing well differentiated cells often with intratubular calcification - medullary carcinoma - a highly cellular tumour with florid lymphocytic infiltrate - and mucoid carcinoma, where malignancy cells lie in pools of mucin.
Inflammatory carcinoma is another rare breast cancer that is defined by the clinical presentation of an enlarged, swollen, erythematous breast, usually without a palpable mass.
