Please enable JavaScript.

Coggle requires JavaScript to display documents.

BREAST (CARCINOMA OF THE BREAST (HORMONAL FACTORS (minor inc in risk, most…

- - - - premenopausal first degree relative
    - - BRCA1, BRCA2 tumour suppressor genes - autosomal dominant
        BRCA1 has inc risk of ovarian cancer
        PTEN and TP53 also assoc with breast cancer
  - - - mucin visible histologically surrounding and within the cells. core biopsy may even appear gelatinous - it is less aggressive and metastasizes less
    - - more common in BRCA1 pts - well circumscribed characterised by lymphocytic infiltrate - better prognosis than ductal carcinoma
    - - cells look like tubes - less aggressive than ductal - less likely to spread or recur. often assoc with DCIS
    - - aka adenoid cystic carcinoma - slow growing, rarely metastasises = good prognosis
  - - - blockage of dermal lymphatics = cutaneous oedema pitted by the orifices of the sweat ducts = peau d'orange
        
        dermal lymphatic invasion produces daughter skin nodules and eventually 'cancer en cuirasse' - the whole chest wall becoming a firm mass of tumour tissue
        main lymph channels pass directly to axilla and internal thoracic lymph nodes - later spread supraclavic, intra-abdo, mediastinal, inguinal and contralateral axillary nodes
    - - to lungs, liver and bones (at sites of red bone marrow ie skull, vertebrae, pelvis, ribs, sternum, upper end of femur and upper end of humerus)
        Brain ovaries and adrenals are also frequent deposit sites
    - - involve skin and subcut tissues = skin dimplin, nipple retraction and eventual ulceration.
        Extension deeply involves pec major, serratous anterior and eventually the chest wall
  - - - I - well differentiated = good prognosis
      - based on tubular differentiation, nuclear pleomorphism, mitotic rate
    - - hormone receptor expression implies less aggressive hormone responsive tumour
      - HER2 overexpression = more aggressive
      - histological type
      - vasc invasion
  - - - triple assessment: clin exam, imaging (mammography and/or US) and biopsy
    - - FBC - anaemia and leucopenia suggest widespread bone marrow invovlement
      - LFT -inc ALP may signify liver secondaries
      - CXR
      - isotope bone scan
      - liver US (liver and chest imaging may be a CT alternatively
  - - - Endocrine
        
        tamoxifen (oest recep antag) - reduce incidence of recurrence in ER pos women
        
        ovarian ablation by radiotherapy, surg, drug therapy (LHRH inhibition eg goserelin) in premenopausal women with ER - pos symptoms
        
        aromatase inhibitors eg anastrozole, block extra-ovarian oest production in postmenopausal women
        
        combo chemo eg anthracyclines and taxanes
        
        monoclonal antibody therapy
        
        trasuzumab (herceptin) - monoclonal antibody to HER2
        
        Pertuzumab (Perjeta) also effectivein HER pos disease
      - hormonal therapy
      - chemotherapy
    - - surgery to axilla
        
        on all pts with invasive operable breast cancer, not gen required for in situ disease 2 surg options:
        
        sentinel lymph node biopsy
        
        first lymph draining tumour is excised
        
        axillary sampling
        
        then may need radiotherapy or clearance if pos for tumour
      - breast reconstruction
      - tumour excision
    - - small tumour (<3cm) may be suitable for breast-conserving surgery (wide local excision)
      - larger ~(>3cm), central tumours or multifocal tumours require mastectomy with or without breast reconstruction
- - - - Often present with short hx as painful, tender swelling in the breast
      - lump may be fluctuant but tense cysts may mimic a solid lump
      - may be multiple and bilateral
      - appear as well defined, rounded opacities on mammography and are clearly differentiated from a solid lump by US
    - - uniformly blood-stained fluid or fluid containing debris should be sent for cytology
      - if a palpable mass remains following aspiration or if there is evidence of septae or a solid area in the cyst wall on US further IX is necessary - either by fine needle aspiration cytology or by core biopsy
      - should be aspirated to dryness - the aspirate may be clear, yellow, or green
      - may have inc risk of breast cancer
  - - - affects women of all ages but typically occurs in those under 30yrs
      - usually presents as discrete, firm, mobile lump usually under 3cm in diameter - some have multiple - may be bilateral - highly mobile = breast mice - not attached to skin
      - grow rapidly during preg
    - - must be investigated by triple assessment
      - if multiple fibroadenomas = largest lump should undergo core biopsy as should a lump in any of the following circumstance:
        
        symptomatic lump - pain or tenderness
        
        patient preference
        
        lump inc in size (clinically and or at US)
  - - - cirrhosis of the liver
      - renal failure
      - drugs: digoxin, spirinolactone, cimetidine, oestrogens or androgens
      - hypogonadism
      - adrenal tumours
      - testicular tumours
      - idiopathic
    - - diffuse, bilateral soft swelling but may be unilateral
      - in pts with any suspicious features (firm or eccentric lump or skin changes), carcinoma must be excluded
      - care to not miss testicular tuMour in young man
    - - majority resolve with no intervention
      - surgery considered if doesnt settle, symptomatic or causes embarassment
      - current surg practice favours liposuction and or excision biopsy
- - - - clear single duct discharge
        
        if mammography is normal, the diagnosis is likely to be an intraduct papilloma and excision of the affected duct (a microdochectomy) is indicated
      - bloody nipple discharge
        
        the presence of blood in the discharge should be confirmed by cytology
        
        if blood is present a mammogram (for women over 35 yrs) is performed with a biopsy of any abnormal tissue
        
        if mammography is normal, a microdochectomy is performed if a single duct can be identified
        
        a total duct clearance (hadfield's procedure) is performed if a single duct cannot be clearly identified
      - multicoloured multiduct discharge
        
        if clinical exam and mammography are normal, a diagnosis of duct ectasia is likely and no further treatment is required
- - - - inflam may be localised with eryhtema and tenderness of a segment of the breast or may spread to involve the entire breast
      - in the later stages there may be a fluctuant mass and pts may have a pyrexia, tachycardia and leucocytosis
      - Common symptoms: pain, swelling, tenderness of the breast
    - - CELLULITIS
        
        in lactational mastitis, breastfeeding should be continued as it may speed up recovery.
        
        rarely necessary to suppress lactation unless the abx are contraindicated for newborn
        
        In early phase of mastitis, appropriate abx can prevent abscess formation
      - ABSCESS
        
        repeat aspiration may be necessary amd resolution of the abscess can be monitored with sequential US
        
        if abscess fails to resolve or the overlying skin is thin or necrotic, incision and drainage should be performed
        
        pts with clinical or radiological evidence of pus should have US guided aspiration performed in addition to appropriate abx therapy
  - - - Pain and thick, pasty nipple discharge
      - there may be cellulitis, nipple retraction or a mass deep to the nipple
      - an associated mammary duct fistula may be presetn in the periareolar region
      - US may confirm a thickened or dilated duct or abscess formation
    - - appropriate abx and advice to stop smoking
      - remove nipple rings
      - pts with recurrent periareolar inflam and duct discharge => total duct excision
      - a mammory duct fistula is treated by total duct excision combined with excision of the fistulous track between the duct and skin
- - - - radiological imaging
        
        US - both diagnostic and to guide biopsy
        
        MRI - useful in symptomatic pts with breast implants in whom US is not diagnostic. It is also used to detect local recurrence when US and mammography are unhelpful
        
        mammography, usually in older pts (over 35 yrs)
      - biopsy, usually US guided
        
        fine-needle aspiration cytology
        
        core biopsy
      - clinical exam
      - the predictive value for benign disease when all three components of the triple assessment are benign is 99%. if there is discordance between any of the 3 tests, open biopsy is considered
- - - - occurs in the large subareolar ducts and is a result of epithelial proliferation
      - may be single or multiple and present with intermittent watery -clear or blood-stained nipple discharge from a single duct
      - if papilloma is large there may be a palpable mass in the periareolar area
      - multiple papillomas (papillomatosis) are assoc with inc risk of breast cancer
      - treatment involves excision of the affected duct (microdochectomy) through a circumareolar incision
    - - although it has many of the clinical features of fibroadenomas they are true neoplasms with a wide range of characteristics from benign to malignant
      - they arise from stromal cells and are classified as low intermediate or high grade depending on their microscopic features
      - they rarely metastasize but can recur locally if indaequately excised
      - CLINICAL FEATURES
        
        usually present firm, discrete lump and pts may note a recent size inc.
        
        should be investigated by triple assessment to confirm the diagnosis
      - TREATMENT
        
        wide excision to achieve a clear margin around tumour
        
        large lesion may require mastectomy with immediate reconstruction
  - - - duct carcinoma in situ
      - invasive duct carcinoma
      - lobular carcinoma in situ
      - invasive lobular carcinoma
      - inflammatory carcinoma
      - paget's disease of the nipple
      - lymphoma
      - sarcoma
    - - metastatic deposits eg from melanoma
      - direct invasion from tumours of the chest wall
- - - - it usually occurs in young women <35 and other potential RF for development of breast pain include diet (caffeine, dietary fat intake), hormone preparations (OCP) and HRT and other meds
      - pts >35 have mammography, mammograms, suspicious areas should be subjected to core biopsy
      - breast pain that usually bilateral, worse premenstrually and relieved following menstruation
      - MANAGEMENT
        
        Initial therapy = GLA - gamma-linolenic acid -** can take 4-6wks to have an effect**
        
        pt adivsed to reduce her intake of caffeine and animal fats
        
        an alteration to or introducing OCP or HRT should be considered. if the pt remains symptomatic despite GLA following may be considered
        
        danazol - antigonadotrophin that binds to oest and progesterone receptors in breast
        
        tamoxifen - an oest recept inhib
        
        LHRH analogues = inhibit ovarian hormone production
    - - causes:
        
        carcinoma of the breast: an uncommon presenting symptom, this may give rise to heaviness or a pricking sensation
        
        Tietzes syndrome, chondritis of the costal cartilage is of unknown aetiology, affects one or more of the 2md 3rd or 4th cpstpchondral junctions and, left alone, resolves over a number of months
        
        breast abscesses
        
        chest wall lesions eg herpes zoster
- - - - occurs in pts with autoimmune disease particularly T1DM and usually presents with a firm irregular lump - diagnosis is made on core biopsy, with fibrosis and lymphoid infiltrate on microscopy. NO FURTHER TREATMENT REQUIRED
    - - may be secondary to systemic conditions (Sarcoidosis), infections (TB, fungi) or foreign material (silicone). Management includes treatment of any organisms cultured and exclusion of malignancy
- - - - Distant metastasis (M)
      - M0 No clinical or radiographic evidence of distant metastasis
      - cM0(i+) No clinical or radiographic evidence of distant metastases, but deposits of molecularly or microscopically detected tumor cells in circulating blood, bone marrow, or other nonregional nodal tissue that are no larger than 0.2 mm in a patient without symptoms or signs of metastases
      - M1 Distant detectable metastases as determined by classic clinical and radiographic means and/or histologically proven > 0.2 mm