MEDI7302 Study Guide - Final Guide: Psychological Trauma, Myalgia, Edema
Breast Cancer
Learning
objectives
Explain the rationale for breast screening and understand the imaging used
Understand the triple assessment approach to work up of a breast lump
Distinguish benign from malignant nipple discharge
Contrast the breast conserving approach with mastectomy for treatment of breast
cancer
Understand the role of sentinel node biopsy and axillary lymph node dissection in
the treatment of invasive breast cancer
Outline the indications for adjuvant chemotherapy, hormone therapy and
radiotherapy in the treatment of breast cancer
Correlate the pathological and radiological features of ductal carcinoma in situ and
be familiar with the approach to treatment
Recognize the clinical presentation of Paget’s disease of the nipple and be familiar
with the treatment options
Introduction Breast cancer is the most common cancer apart from non-melanomatous skin
cancer
Leading cause of cancer-related death
15% breast cancers are DCIS
Tumour
classification
Benign
Intraduct papilloma
Phyllodes tumour
Malignant
Primary
oDCIS (precursor), invasive duct carcinoma
oLCIS (not precursor; just risk factor) invasive lobular carcinoma
oInflammatory carcinoma (usually found at TMN stage 3b to 4d;
40% have distant mets at presentation)
oPaget's disease of nipple
oSarcoma
Secondary
oDirect invasion form tumours of chest wall
oMetastatic deposits (eg melanoma derived)
Pathology Normal epithelium
Hyperplastic change (acquire genetic defects)
Carcinoma in situ
Ductal or lobular
Local invasion of breast parenchyma, overlying skin or underlying fascia
Invasive cancer
Regional spread to axillary LNs via lymphatics (eg 50% 5cm+ tumours will
spread to axillary LNs, 4+ nodes involved has bad prognosis)
Distant mets via haematogenous spread to bone, liver or lung
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Risk factors Female sex
Increasing age (mean age of diagnosis ~60yo)
Genetic predisposition (BRCA1, BRCA2)
1st degree relative (mother, sister, daughter) with breast cancer, especially
diagnosed <50yo
Past hx of breast cancer
Previous hx of benign proliferative disease (B3 lesions) - cellular atypia, multiple
papillomatosis, ADH or ALH or LCIS, radial scar, sclerosing adenosis, flat epithelial hyperplasia
80% benign, 20% malignant
Other factors - nulliparity at 40yo, younger age of menarche + late age menopause,
previous breast irradiation
HRT or OCP
Clinical
presentation
Most are asymptomatic
Breast lump
Pain (rare, generally benign cause)
Nipple discharge
Benign - bilateral, multiple ducts, massage to induce discharge, milky
discharge
Suspicious - unilateral, solitary duct, spontaneous discharge, blood stained
or serous
Inflammation
Usually infective mastitis, sometimes inflammatory breast cancers (dermal
lymphatics of breasts)
Punch biopsy of skin will confirm dermal-situated cancer
Breast lesion
workup
Breast screening
Screening aims to identify breast cancers at pre-clinical stage (before sx
onset)
2 yearly-screening of women aged 50-75 (accepts women from 40yo
though)
Components - MMG screening with MLO and CC views read by 2
independent clinicians
Any suspicious lesion or microcalcification is subjected to further MMG and
US workup + clinical assessment +/- biopsy
Confirmed cancers referred for surgical management
Triple assessment approach
Overview 3 main diagnostic components
+ve triple test (any component is +ve) is
indeterminate, suspicious or malignant
-ve triple test (all 3 components are -ve) is benign
Most common presenting sx of breast cancer
Lump alone 76% > pain alone 10% > nipple
changes 8% > breast asymmetry or skin dimpling 4% > nipple discharge
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2%
Medical hx
+ clinical
breast
exam
5 common symptoms
New discrete lump
Nipple discharge - blood stained
Nipple retraction or distortion of recent onset
Altered breast contour or dimpling
Suspected Paget's disease
History of presenting sx
Site - constant or changing
Duration - when and how first notes
Any changes since first noted
Associated sx
Other pertinent hx
Current or recent changes in medication (eg
exogenous hormones)
Hormonal status/ menstrual hx (eg cyclical
hormonal exposure with menses, early menses and late menopause,
OCP, HRT)
Parity/ age at first full term pregnancy
Previous breast problems (eg past investigations,
biopsy results,
Risk factors (eg strong family hx of breast/ ovarian
cancer via BRCA1 or BRCA2 or family member with breast/ ovarian
cancer)
Most recent imaging/ date and results screening
or diagnostic
Radiation, alcohol, excess weight
Clinical breast exam
Inspection
oPosition: arms by side -> arms above head
-> arms pressed on hips & leaning forward (contract pectoral
muscles)
oBreast contours (erythema, dimpling or
puckering, peau d'orange, visible lumps)
oNipples - height, erythema, eczema,
nodules, ulcers, any inversion
Palpation
oSeated or standing - supraclavicular and
axillary fossa -> breast in circular motion
oLying flat with ipsilateral arm behind head
- breast in circular motion + axillary tail + around and behind nipple
oLymph nodes - axillary + supraclavicular
fossa (number, size, mobile or fixed)
Record detail of lump - size, shape, consistency,
mobility, tenderness, fixation, exact position
Nipple discharge
Blood stained - duct papilloma, intraduct
carcinoma, Pagets disease, invasive carcinoma (rare)
Clear - intraduct carcinoma
Multi-coloured - duct ectasia (yellow, green or
brown discharge)
Milky - galactorrhoea
Purulent - breast abscess
Nipple changes
Benign - slit like retraction, able to be everted
Abnormal or suspicious - colour change, fixed
whole nipple inversion, ulceration
find more resources at oneclass.com
find more resources at oneclass.com
Document Summary
Explain the rationale for breast screening and understand the imaging used. Understand the triple assessment approach to work up of a breast lump. Contrast the breast conserving approach with mastectomy for treatment of breast. Understand the role of sentinel node biopsy and axillary lymph node dissection in the treatment of invasive breast cancer. Outline the indications for adjuvant chemotherapy, hormone therapy and radiotherapy in the treatment of breast cancer. Correlate the pathological and radiological features of ductal carcinoma in situ and be familiar with the approach to treatment. Recognize the clinical presentation of paget"s disease of the nipple and be familiar with the treatment options. Breast cancer is the most common cancer apart from non-melanomatous skin. Lcis (not precursor; just risk factor) invasive lobular carcinoma. Inflammatory carcinoma (usually found at tmn stage 3b to 4d; 40% have distant mets at presentation) o o o o. Local invasion of breast parenchyma, overlying skin or underlying fascia.
