Download Breast cancer - coreproblems

Breast Lump
Index conditions:
 Breast cancer
 Benign breast disorders
 Gynaecomastia
 Asymmetrical breast development
Clinical Skills
 Helping patient cope with disfigurement
 Understanding pain management and palliative care in terminal disease
 Knows about breast screening programs
 Knows risk factors in relation to breast lumps
 Able to instruct patient in breast self examination
 Focussed history
 Characterises features of the lump
 Regional exam on nodes
 General examination for existence of metastases
 Aware of stages of breast development in children
 Recognises obvious signs of malignancy
 Use in limitations of mammography, ultrasound and biopsy
 Seeks evidences of metabolic complications (eg hypercalcaemia)
 Aware of range of treatment options
 Aware of importance of patient involvement in decision making
Interpersonal skills
 Able to discuss the limp and its possible implications
 Aware of availability of rose of multidisciplinary team
 Able to deal sensitively with specific issues (eg body image, femininity, fear of death)
 Uses chaperone during breast examination
Professional behaviours
 Aware of national guidelines for breast cancer care (screening, investigation and
management)
Practical skills
 Prepares patient for biopsy
 Aware of what mastectomy involves
 Ensures consent in obtained for biopsy
 Recognises dangers of hypercalcaemia
 Recognises spinal cord compression
Basic medical sciences
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Structure and function of breast and chest wall, including effect of hormones and role of
receptors
Lymphatic drainage of breast
Stages of breast development
Know the anatomy of breast, including lymphatic system
Understand concepts of dysplasia, carcinoma in situ and invasive carcinoma.
Understand the role of hormones in breast cancer.
Understand staging and spread of breast cancer.
Understand genetic mechanisms in the development of breast cancer.
Clinical Sciences
 Pathology of main types of benign and malignant breast disease.
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Staging of breast cancer.
Understanding of how cancer spreads.
Basic genetics of breast cancer.
Knowledge of local and systemic complications.
Understanding of range of treatment strategies
Understand role and limitations of surgery for breast cancer.
Understand benign breast disease.
Differential diagnosis of breast lump.
Behavioural Sciences
 Psychological effects of the diagnosis and treatments (e.g. mastectomy; chemotherapy).
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Understanding of coping behaviours.
Population Health Sciences
 Screening theory.
 Screening programmes (e.g. mammography; self-examination).
 Risk factors (e.g. genetic; social factors; HRT).
 Evaluation of interventions.
Breast masses
Although breast lumps are anxiety provoking to patients and warrant evaluation because of the risk
of cancer, most breast lumps and other breast complaints are of benign origin. Multiple methods are
available to differentiate benign from malignant breast lesions, including clinical examination,
mammography, USS, fine needle aspiration and needle-core biopsy. More breast masses should be
examined radiographically, and solid lesions require biopsy to rule out malignancy. Tough rare,
breast cancer does occur in males
Diagnostic workup and initial management
History and physical examination
 Collect historical information to establish baseline risk, including age, menstrual status,
parity, family history, previous biopsy result and exogenous hormone use
 Clinical breast exam should document approximate size, site, mobility and shape of the mass
as well as associated skin retraction, erythema or adenopathy
o Indirect evidence supports the effectiveness of clinical breast exam: sensitivity 4069%; specificity 86-99%
o Normal physiologic nodularity (‘fibrocystic disease’) can be more difficult to
distinguish from a discrete mass; it is less likely to have clear borders, is often cordlike, and may change with menstrual cycle
o Benign features include smooth, well-demarcated and mobile lesions
o Malignant features include hard, irregular, fixed lesions; bloody nipple discharge,
nipple retraction; and skin dimpling or peau d-orange rash
Initial workup and management
 Diagnostic evaluation depends on age
o Age <35: USS to determine cystic versus solid lesion (cysts may be aspirated)
o Age >35: perform diagnostic bilateral mammography first; if lesion is benignappearing or not seen, USS is warranted to determine cystic versus solid
 Mammography is often the first test ordered but may not be helpful in younger patients
because of higher breast density
o Findings suggestive of malignancy include increased density, irregular margins,
speculation and irregular microcalcifications
 USS is used as an adjunct to delineate masses that cannot be seen on a mammogram, to
determine whether a lesion is solid or cystic.
 MRI may be considered for indeterminate mammogram or USS
 Biopsy of masses, nonpalpable lesions, or suspicious calcifications on mammogram may be
indicated
o Fine-needle aspiration extracts cells for cytologic exam to assess benign for
malignany
o Needle-core biopsy of solid lesions or complex cysts extracts tissue and provides a
definitive diagnosis
o Excisional biopsy is definitive and may be curative if the full lesion is removed
 Perform a cytologic exam of any nipple discharge
Follow-up
 Frequent follow up (every 3-6 months) if an exam is particularly difficult in order to maintain
familiarity and confirm stability
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Cystic masses require follow up 4-6 weeks after aspiration to ensure no reaccumulation;
recheck every 6 months thereafter, and perform biopsy if the cyst recurs
Enlarging masses require surgical excision, even if benign
Differential diagnosis
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Fibroadenoma
o The most common cause of a unilateral discrete breast mess in young women
o A painless, mobile mass, may be bilateral and/or multiple
o Growth is stimulated by exogenous oestrogen or progesterone, laceration, and
pregnancy
o Common in women with ‘fibrocystic change’ of the breast
o A benign lesion; requires surgical excision for diagnosis and treatment, but patient
has no increased risk for malignancy after excision
Cystic disease
o Gross cystic disease is found in about 7% of adult women in the US, most
frequenctly during the fourth decade and perimenopause
o Arise from dilatation or obstruction of the collecting ducts
o May be painful and may vary in size with menses
Intraductal papilloma
o Associated with nipple discharge
Normal physiologic nodularity
o Often incorrectly called fibrocystic disease
o Found in more than 60% of adult women in the US
o May be treated by reducing dietary caffeine or fat intake, wearing well-fitted bras,
aspiration of large or painful cysts, ad medical therapies (eg Danazol, OCP) for pain
relief
Breast cancer
o The most common cause of a discrete breast mass in women >50 years
o Types include infiltrating ductal (most common), infiltrating lobular and medullary
carcinoma
o Increased risk with advancing age and with obesity, infertility, Nulliparity or late first
pregnancy )after the age of 30), early menarche or late menopause, uterine cancer,
history of breast cancer in a 1st degree relative )up ot a 10-fold increase), BRCA gene
mutation, HRT use and post-radiation
 In 75% of women with breast cancer, advanced age is their only apparent
risk
o Often presents with a non-tender mass, nipple discharge, or (occasionally) a
bleeding nipple.
Galactocele
o Presents during or shortly after breast-feeding
o Needle aspiration is often curative
o If fluid is bloody or mass doesn’t disappear, an excisional biopsy is required
Breast abscess
o Commonly caused by Staph. aureus or Streps
o Usually presents as a painful, nonmobile mass with rapid onset
o Associated with mastitis
o May be associated with overlying blanching erythema, fevers and chills
Other
o Gynaecomastia
o Fat necrosis
o Cystosarcoma phylloides
o Cystic mastitis
o Mammary duct ectasia
o Lymphoma
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Lipoma
o Trauma
Intramammary nodes
o Radial scar
Myoid hamartoma
Metastatic disease to the breast (eg carcinoid, gastric adenocarcinoma)
Breast cancer
Most common cancer in women
Second most common cause of death from cancer in the UK
Pathology
Most breast cancers arise from either:
 The epithelial lining of ducts, called ductal
 The epithelium of the terminal ducts of the
lobules, called lobular
Can be invasive or in situ
Most cancers arise from intermediate ducts and
are invasive
Paget’s disease of the breast is an infiltrating
carcinoma of nipple epithelium (about 1% of
breast cancers)
Inflammatory carcinomas (about 3% breast
cancers) are rapidly growing, sometimes
painful. The overlaying skin becomes red and
warm
Risk factors
Female sex
Age – rare under 30, risk increases with age
Born in North America or Northern Europe
High menopausal blood insulin-like growth
factor level
Having a sister and mother with breast cancer
The BRCA1, BRCA2 and TP53 genes predispose
women to breast cancer (they account for
under 5% of cases)
Higher socio-economic status
Aged over 30 at first full term pregnancy
Nulliparity
Early menarche (under 11 years)
Classification:
Non-invasive carcinomas
 Ductal carcinoma in situ
 Lobular carcinoma in situ
Invasive carcinomas
Epidemiology
45,000 new cases in UK each year
Life time risk for women: 1/9
Increasing incidence of breast cancer
(75/100,000 in 1977, 122/100,000 in 2006)
In 2005, 11,040 death from breast cancer (81
of which were men)
20% all cancers in women
Commonest cause of death in the 35-55 age
group
Aetiology
Over exposure to oestrogens and underexposure
to progesterone
No definite relationship to oral contraceptive pill
Some tumours contain receptors for oestrogen
and progesterone and respond to hormone
manipulation
No good evidence for viral involvements
Ductal carcinoma in situ
Pre- and post- menopausal women
40-60 years
Pathology
Epidemiology
Development if cancer cells in the milk duct of
the breast
Mist common non-invasive breast cancer or precancer in women,
Risk factors
Histology
It is a risk factor for ‘real cancer’
Changes in small and medium ducts, although
large ducts can be involved in older women.
Cytoplasmic and nuclear polymorphisms
Ducts may show central necrosis
Ductal carcinoma may spread along the duct
system or into the lobules.
Classification:
Aetiology:
Stage 0 breast cancer
History:
Examination:
Palpable mass especially if extensive and
associated with fibrosis
Nipple discharge if large ducts are involved
Paget’s disease of the nipple
Size: 10-100mm diameter
Unifocal confined to one quadrant of the nipple
bilateral disease is uncommon
Complications:
Investigation:
Metastases in 2%
Almost always found on mammogram - microcalcifications
Management:
Generally mastectomy
One third to one half residual carcinomas change to invasive
Prognosis
Prognosis excellent with complete removal.
Can be a precursor for ‘real breast cancer’
Lobular carcinoma in situ
Predominantly in pre-menopausal women
If found after the menopause it is usually associated with an infiltrating tumour
Pathology
Problem: does not generally present as a palpable mass and is usually found incidentally in biopsies
taken for other reasons
Not considered cancer but indicated a future risk for cancer
Risk factors
Histology:
Increasing age
Female gender
FH, BRCA1, BRCA2
Early menarche / late menopause
Alcohol use
Late parity / null parity
Diethylstilboestrol
HRT
Radiation
Changes found in the acini although may extend
to extra lobular ducts and replace ductal
epithelium
Cells appear loose and non-cohesive
Acini size increases, lobular shape retained
Single detached cells
History:
Typically an incidental finding found by biopsy for other reasons
Breast lump, change in skin colour, change in nipple
Late signs: bone pain, breast pain and discomfort, skin ulcers, swelling in ipsilateral arm, weight loss
Complications:
Investigation:
Breast cancer
Mammogram
Close follow up clinic
MRI, USS, biopsy, PET
Management:
A third to a quarter treated by biopsy alone will go on to develop an invasive carcinoma
Tamoxifen
Mastectomy
Prognosis
Risk of cancer – greater ipsilaterally
Invasive carcinomas
A tumour whose cells have broken through the basement membrane and spread into the
surrounding tissue.
Pathology
Epidemiology
The current understanding of breast
tumorigenesis is that invasive cancers arise
through a series of molecular alterations at
the cellular level, resulting in the outgrowth
and spread of breast epithelial cells with
immortal features and uncontrolled growth.
Pre- and post- menopausal women
1.4m new cases worldwide yearly
Risk factors
Histology
Female gender
Increasing age
Not child bearing or breast feeding
Higher hormone levels
Race
Economic status
Dietary iodine deficiency
ER/PR status
Dependant on type
Classification:
Infiltrating ductal of no special type (75%)
Infiltrating lobular (10%)
Mucinous (3%)
Medullary (3%)
Tubular (2%)
Papillary (2%)
Others (5%)
History:
Examination:
Firm on palpation
Often 20-30mm at presentation
Tethering of the overlying skin
Peau d-orange (due to lymphatic permeation)
Retracted due to tethering and contraction of
the intramammary ligaments
Pain
10mm-80mm diameter
Skin dimpling
Change of skin colour or texture
Change in nipple appearance
Nipple discharge – clear or bloody
Complications:
Investigation:
Related to treatment:
 Radiation: breast lymphoedema, aches and
pains
Mammogram
USS
MRI
PET scan
Biopsy, histology and staging
Management:
Breast-conserving radiation therapy
Mastectomy and post radiotherapy
Systemic treatment – hormone therapy and chemotherapy
Prognosis
Dependant on many factors: axillary lymph node status, tumour size, lymphatic and vascular
invasion, age, histological grade, histological subtype, response to therapy, ER/PR status,
5-year survival: stage 0 99-100%, stage 1 95-100%, stage II 86%, stage III 57%, stage IV 20%
Benign breast disorders
85% of breast disorders are benign
 Fibrocystic breast disease
 Fibroadenoma
 Cysts
 Fat necrosis
 Lipoma
Fibrocystic breast disease
Aka Fibrocystic change
Pathology
Epidemiology
During a woman's menstrual cycle, the breasts
are affected by hormones made in the
ovaries. These hormones can cause the
breasts to feel swollen, lumpy, and painful.
After menopause, these changes in the
breasts usually stop happening.
Fibrocystic changes in the breast with the
menstrual cycle affect over half of women,
and most commonly start during their 30s.
Women who take hormone replacement
therapy may have more symptoms. Women
who take birth control pills have fewer
symptoms.
Risk factors
Aetiology:
Female sex
Hormone fluctuations
There is no definite cause of painful, lumpy
breasts. Some women feel that eating
chocolate, drinking caffeine, or eating a highfat diet can cause their symptoms, but there
is no clear proof of this.
History:
Examination:
Usually menstrual cycle related
Pain and discomfort, usually both breasts
‘full’, ‘swollen’, ‘lumpy’, ‘heavy’
There may be slight discharge
Usually normal breast examination with cycle
dependant lumps
Complications:
Investigation:
May be more difficult to examine
Mammograms may be hard to interpret
Mammogram
USS
Management:
Meds: ibuprofen
Heat or ice on breasts to ease symptoms
Wear a well fitting bra
Prognosis
No increased risk of cancer
Fibroadenoma
Pathology
Epidemiology
Lumps of fibrous and glandular tissue arising in
the terminal duct lobular unit of the breast
Hypovascular compared to neoplasms
Common in adolescent women
Not overly common in post-menopausal women
Risk factors
Histology
Black women tend to develop fibroadenomas
more often and at an earlier age than while
women
Diagnostic findings:
 Abundant stromal cells, bipolar nuclei
 Uniform epithelial cells, ‘antler’ or
‘honeycomb’ pattern
 Foam cells and apocrine cells may be seen,
less diagnostic
Classification:
Aetiology:
Partially hormone dependent
No known cause
History:
Examination:
Breast lump: in both breasts in 10-15%
Lumps are usually: easily movable under the
skin, firm, painless, and rubbery. Smooth well
defined boreders. May grow in size during
pregnancy
Usually reduce in size after menopause
Breast lump is: painless, firm, mobile, slowly
growing
Complications:
Investigation:
Slightly increased risk of breast cancer later in
life
USS
Mammogram
Needle biopsy
Management:
Monitor
Some require surgical removal
Prognosis
good
Fat necrosis
Pathology
Aetiology
A lump which forms as a result of damage to an
area of fatty breast tissue
A benign condition – no increased risk of breast
cancer
Trauma
Previous breast surgery
Radiotherapy
History:
Examination:
Trauma
Firm round lump, doesn’t usually cause pain.
Skin may be red, bruised or dimpled. The
nipple may be retracted.
Triple examination: breast examination,
mammography or USS, fine needle aspiration
or core biopsy
Complications:
Investigation:
No associations with cancer
Triple examination: breast examination,
mammography or USS, fine needle aspiration
or core biopsy
Management:
Usually no treatment required. Will often go away by itself.
May require surgical removal if it doesn’t resolve.
Prognosis
Normal life
Lipoma
Most common soft-tissue tumour
Pathology
Epidemiology
Slow growing, benign fatty tumours form soft,
lobulated masses enclosed by a thin, fibrous
capsule.
1% population (lipomas may occur anywhere in
the body)
Histology
Aetiology:
Mesenchymal tumours derived from adipocytes.
Possible link with trauma
History:
Examination:
Painless breast lump
Complications:
Investigation:
Usually none.
Subcutaneous lipomas require no imagine.
May need imaging
Fine needle aspiration
Management:
Removal for: cosmetic reasons, evaluate histology (rule out liposarcoma), if causing symptoms, later
than 5cn.
Prognosis
Excellent, recurrence uncommon
Gynaecomastia
Pathology
Epidemiology
Benign enlargement of the male breast tissue
resulting from a proliferation of the glandular
component of the breast
Altered oestrogen-androgen balance or
increased breast sensitivity to normal
circulating oestrogen development,
Increasing with raising obesity rates.
60-90% infants have transient gynaecomastia
due to the high oestrogen state of pregnancy.
Next peak at puberty (4-69%)
Third peak with increasing age.
Risk factors
Histology
Obesity
Increasing age
History of mumps, testicular trauma, alcohol use,
drug use.
Family history
Kleinfelters
Oestrogen induced ductal epithelial hyperplasia
and ductal elongation and branching,
proliferation of the ductal fibroblasts and
increase in vascularity
Aetiology:
Persistent pubertal gynaecomastia, drugs, unknown, cirrhosis or malnutrition, primary
hypogonadism, testicular tumours, secondary hypogonadism, hyperthyroidism, chronic renal
insufficiency.
History:
Examination:
Changes with age
Changes in nipple size and shape, may have
nipple discharge.
Rubbery or firm mass extending concentrically
from the nipple. Usually bilateral, but may be
unilateral.
Complications:
Investigation:
None
Most require no investigations. Investigate if:
macromastia (>5cm), tenderness, rapid
growth, signs of malignancy.
Bloods: renal or liver disease
Hormone tests: testosterone, LH, oestradiol, TSH
Imaging: mammogram, testicular ultrasonogram
Management:
Generally no treatment required.
Clomiphene (an anti-oestrogen) 50-100mg OD for 6/12
Tamoxifen (oestrogen antagonist) 10-20mb BD
Danazol (synthetic derivative of testosterone) 200mg BD
Testolactone (peripheral aromatase inhibitor) 150mg TDS for 6/12
Surgery: reduction mammoplasty
Prognosis
90% pubertal gynaecomastia resolve within a period of months or years.
Most respond to treatment if patients want it
Macromastia seldom resolves completely and often requires surgery.
Asymmetrical breast development
The most common abnormality seen in a primary caregiver’s office in children younger than 12 years
is a unilateral breast mass corresponding to asymmetric breast development. One breast commonly
develops earlier than the other. Ultimately, the breasts are symmetric, despite the discrepancy in
the initial development.
Anatomy of breast, including lymphatic system
Breast screening
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50-70 years olds offered 3 yearly screening
Mammogram
USS
US guided biopsy
Misdiagnosis in 10-30% malignant cases – repeat follow ups help catch ones slipping through
10-20% biopsies are malignant
Mammograms detect
o Masses
o Micro-calcifications – tiny flecks of calcium in the soft tissue that sometimes indicate
and early breast cancer
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Different mammogram views:
o Side to side
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Breast disfigurement
Breast conservation
Reconstructions:
Mastectomy
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