CPC 4 Breast Cancer. Rochelle Harwood, a 35 year old sales assistant, presents to her GP because she has noticed a painless lump in her left breast.

Transcription

1 CPC 4 Breast Cancer Rochelle Harwood, a 35 year old sales assistant, presents to her GP because she has noticed a painless lump in her left breast. 1. What are the most likely diagnoses of this lump? Fibroadenoma Fibrous cyst Traumatic fat necrosis Breast Carcinoma 2. What further info would you seek from the Hx? Lump When first appeared? Painful? Cyclical? Nipple changes? Rate of growth? Mobile/fixed? Female health Menarche Menopause? Age at first pregnancy? Use of hormone therapies and contraception General health Weight Smoker? Drinker? History of breast disease Family history of breast or any other cancer? 3. What feature on physical examination? General examination Appearance Asymmetry Movement of breasts Skin/nipple appearance Paget s, peau d orange Palpation Breast Site, size, shape & texture of lesion Axiallary/supraclavicular nodes 4. What initial investigations would you order? US in young, maybe MRI Mammogram in > 35 s FNAC/Biopsy 5. What are the features of fibroadenoma on U/S? Cancer? Fibroadenoma Well defined margins Hypoechoic Not cystic Shadowing Cancer Less defined margins Invasion/disruption of tissue plains Shadowing

2 6. What is FNAC? Who does it? Is it helpful? The passing of a small needle guage through a lesion to collect some cells for cytological analysis Allows comment on cell type and differentiation via staining and light microscopy Pathologists, radiologists, or surgeons usually perform FNAC 7. What should you tell the patient about FNAC? May not rule out cancer or provide a definitive diagnosis There is a likelihood of false positives/negatives Risks bleeding, pneumothorax, pain, infection. Overall FNA is a safe and simple test with severe complications being rare. Limitations OPERATOR does not hit lesion, TECHNICAL non diagnostic, too much blood, crushed cells, problems with staining PATHOLOGIST incorrect interpretation NATURE OF LESION unable to differentiate between insitu v invasive malignancy; papillary lesions, mucinous lesions OTHER TRAPS mimics fat necrosis, nodular fasciitis, cellular fibroadenoma 8. What info should be included in a cytology report for FNAC? Cellularity type of cells and any arangement Background features other cells, stroma Cytological cellular features of malignancy present/absent Tumour giant cells Mitotic figures Cellular and nuclear pleomorphism Increased nucleus to cytoplasmic ratio Nucleoli 9. How is a core biopsy different to a cytology smear? Gives info about the architecture as well as cellularity 10. The FNAC indicates fibroadenoma but patient still wants excision, what further investigations are required prior to surgery? None as far as the lesion is concerned General pre-op health screening 11. What is the histology of normal breast tissue? Breast ducts and acini are lined by epithelium and myoepitheium (incomplete layer of muscle cells) Fibrofatty stroma

3 Normal breast histology Brs3 Fibrofatty stroma Breast duct lined by epithelial and myoepithelial cells Breast lobule, containing acini lined by epithelial and myoepithelial cells A. Mammograms in young women are typically "dense" or white in appearance In this setting, mass-forming lesions or calcifications can be difficult to detect B. Young women s dense breasts are due to abundant fibrous interlobular stroma and the paucity of adipose tissue Prior to pregnancy, the terminal duct lobular units (TDLUs) are small and are invested by loose cellular intralobular stroma. Larger ducts interconnect the TDLUs. C. During pregnancy, branching of terminal ducts results in more numerous TDLUs, and the number of acini per TDLU increases. Luminal cells within TDLUs (but not the large duct system) undergo lactational change in preparation for milk production. D. With increasing age, the TDLUs decrease in size and number, and the interlobular stroma is replaced by adipose tissue. An older woman's breast typically consists of small ducts and atrophic lobules in adipose tissue. E. Mammograms become more radiolucent (darker) with age owing to the increase in adipose tissue. Radio-dense mass-forming lesions, and calcifications become easier to detect. 12. What is carcinoma in situ? What might be the clinical consequence of lobular carcinoma in situ? CIS is carcinoma confined by the basement membrane to the duct or lobule and is therefore not invasive.

4 Therefore neoplastic cells will not have metastasised and prognosis is better than invasive carcinoma Lobular carcinoma in-situ (LCIS) refers to CIS found within the terminal duct-lobular unit (the breast lobules as opposed to the ducts). It has a distinctive morphology and comprises lobules expanded by atypical cells, which are usually small and loosely cohesive. LCIS is multicentric in ~85% of patients and bilateral in ~30% of patients. The relative risk for development of invasive cancer in patients with LCIS is approximately 12 times that of the background population. The subsequent cancer may demonstrate either lobular or ductal morphology. Both the ipsilateral and contralateral breast show a similar risk of developing invasive carcinoma. 13. How does infiltrating LC differ histologically from normal breast? Gross Most tumors are firm to hard with an irregular margin. Architecture Infiltrating cords of cells (Indian file) are the characteristic feature A desmoplastic stroma is usually present Cords may arrange around existing ducts Cytology small cells relatively uniform intracytoplasmic inclusions no formation of tubules or papillae There is often associated LCIS 14. What key features should be included in a pathology report of a carcinoma in the breast? Specimen type including location in breast History Macroscopic appearance Microscopic description Non-neoplastic breast findings Tumour type Grade Bloom and Richardson Tubule formation Nuclear grade score Mitosis score Surgical margins Invasion of other tissue nerves, lymph, nipple Nodes number taken and number malignant Receptor type ERP, PRP, HRP Diagnosis 15. What is a sentinel node biopsy? What is its role in breast cancer management? It is injection of dye into the tumour to identify the first nodes that the region containing the tumour drain to

5 It s role in breast cancer management is in staging the tumour and evaluating the likelihood of metastasis A disease free node means that disease is probably confined to the breast and axillary clearance is not required 16. What are the known risk factors for breast cancer? Age Early menarche Late menopause Nulliparous or Late age of first baby >35 Family history risk with each 1 st degree relative BRCA1/2 mutation Use of combined HRT Radiation history Past history of biopsy for atypical proliferative breast disease 17. What is a clinical multi-disciplinary team? A team of health professionals from different skill backgrounds working as a team to achieve a positive health outcome for the patient 18. List the members of this team in management of breast Ca? Radiologist Surgeon Pathologist oncologist(medical and radiation) specialist nursing staff general practitioner Oncology/Palliative care nurses