Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Breast pathology Mo KhundaLearningObjectives • Understand theanatomy of the breast, including itsstructureand function. • Learn how toperform athorough breast examination, recognizing key signs and symptoms of both benign and malignant conditions. • Identify common benign breast conditions such as fibroadenomas, cysts, and mastitis,and understand their management. • Understand theprocess of breast cancer screening and the importance of early detection. • Review the diagnostic and treatment approaches for breast cancer, including the tripleassessment, surgery,and adjuvant therapies.AnatomyAnatomyAnatomy Structure Composed of glandular, connective, and adipose tissue. Lobules & Ducts (glandular tissue) Milk-producing lobules drain into lactiferous ducts, converging at the nipple. Blood Supply Mainly from the internal thoracic, lateral thoracic, and intercostal arteries. Lymphatic Drainage* Predominantly to the axillary nodes, but also to the supraclavicular and internal mammary nodes. Nerve Supply Intercostal nerves provide sensory and autonomic innervation.ExaminationExaminationsteps • General principles • Inspection • Palpation • Assessinga lump • Further stepsInspection Positioning the Patient • Relaxed with arms by the sides • Hands pressed into hips (tocheck for tethering) • Hands placed behind the head KeyInspection Findings • Asymmetry(size/shape) • Scars or cosmetic augmentation (e.g., implants) • Tethering or fixation of skin • Nipple changes (eversion/inversion, discharge) • Skin abnormalities: erythema, Peau d'orange, Paget'sdiseasePalpation Patient Positioning Sit back at 45 degrees with hand behind head on the side being examined Methods for Examination • Vertical lines (up and down) • Quadrants (assess each quadrant) • Spirals (from nipple outwards) • Radial/Wedge (clock face pattern) Important Areas to Cover • Four quadrants of each breast • Subareolar area (under nipple) • Axilla (armpit) and Tail of Spence (extension to axilla)Assessingalump • Location • Size • Shape (round / oval / irregular) • Consistency (soft / firm / hard / fluctuant) • Margins (irregular/ smooth) • Mobile or fixed (tethered) tothe skin or chest wall • Tenderness (e.g., abscess) • Skin colour (e.g., erythema indicating inflammation orinfection) • Nipple discharge (e.g., mammary ductectasia or intraductal papilloma)Furthersteps Check for Lymphadenopathy Examine for cervical and supraclavicular lymphadenopathy Assessfor Metastasis Liver, lungs, bones and brain Triple Assessment of a Breast Lump Clinical assessment: History and physical examination Imaging: Ultrasound ormammography Histology: Fine needle aspiration (FNA)or core biopsyBreast cancerScreening • NHS Breast Screening Programme: Women aged50–70 invited every 3 years. • High-risk women (e.g., BRCA/p53 carriersor strong family history):May start earlier with MRI ± mammograms. • Over 70s: Can self-refer for screening.Referrals 2-Week Wait Referral • Age≥30 with an unexplained breast lump(withor withoutpain). • Age≥50 with unilateralnipple changes (discharge,retraction, or concern). Consider for: • Skin changes suggestiveof breast cancer. • Age≥30 with an unexplained axillary lump. Non-Urgent Referral • Age<30 with abreast lump.Tripleassessment Clinical Examination Inspection & palpation of both breastsand axillae. Imaging • < 40 years: Ultrasound (better for dense breast tissue). • ≥ 40 years: Mammogram ± ultrasound. TissueSampling: • Fine Needle Aspiration (FNA) – Cytology, quick but limited. • Core Biopsy – Preferred, provides histology for definitive diagnosis.Typesandclassification Ductal Carcinoma In Situ (DCIS)– Confined toducts. Invasive Ductal Carcinoma (IDC) – Most common, spreads beyond ducts, AKA non-specific type. Lobular Carcinoma In Situ (LCIS) – Confined tolobes. Invasive Lobular Carcinoma (ILC) –Less common, often multifocal & bilateral. Less common: Paget’s Disease of the Nipple –Eczematous nipple changes Inflammatory Breast Cancer – Presentswith red, swollen, peau d’orange skin due tolymphatic invasion.Breastcancerreceptors Estrogen Receptor (ER) +ve -cancer cells growin response tooestrogen Progesterone Receptor (PR) +ve -cancer cells growin response toprogesterone HER2 +ve -overexpression of the HER2 protein, which accelerates tumourgrowthSurgicalmanagement Absence of Axillary Lymphadenopathy (during the tripleassessment) Primary Tumour Surgery: • Either breast conserving therapy or mastectomy Axillary Surgery: • Sentinel Lymph Node Biopsy (SLNB): • Negative → No further axillary surgery. • Positive → Further management based on node involvement: • 1-2positivenodes:Radiotherapy. • ≥3positivenodes:Axillary LymphNodeDissection(ALND).Surgicalmanagement Presence of Axillary Lymphadenopathy (during tripleassessment) Axillary Investigation: • Ultrasound-FNA/Core Biopsy: • If negative,proceedwith SLNB. • If positive,patientis node-positive. Primary Tumour Surgery: • BCT or Mastectomy Axillary Surgery: • Axillary Lymph Node Dissection (ALND):Removal of Level I & IIaxillary nodes • Axillary Radiotherapy: Alternative to ALNDfor 1-2 nodes.ComplicationsofAxillarySurgery Chronic Lymphoedema • Due todisruption of lymphatic drainage after axillary lymph node dissection (ALND). • Presents with: Arm swelling, heaviness, and increased infection risk. • Management: Limb elevation, compression therapy, physiotherapy. Other Complications • Nerve injury • Shoulder stiffness (reduced mobility post-surgery). • Seroma formation (fluidcollection needing drainage). • Infection (wound siteor deep tissue).Nervedamagecomplications in breastsurgery Nerve Function Injury Cause Clinical Consequences Canbedamagedduringaxillarynode Wingedscapula(scapulaprotrudes Longthoracicnerve Innervatesserratusanterior clearance(runson chestwall) whenpushing againstwall) Difficultyelevatingthearmabovehead Weak armadduction,extension,and Thoracodorsalnerve Innervateslatissimusdorsi May beinjuredduringaxillary internalrotation dissection May affectshouldermovement/function (though oftensubtle) Weaknessin shoulderadductionand May beinjuredduringmastectomyor internalrotation Medialand lateralpectoralnerves Innervatepectoralismajorand minor implantplacementundermuscle Muscleatrophyor asymmetry Cosmeticdeformityif implantsused Rare,butcan beinjuredin deep Weaknessin shoulderabduction Axillarynerve Innervatesdeltoidand teresminor dissectionnearaxilla apex or if (especiallyfrom15–90°) retractorsplacedaggressively Lossof sensationoverlateraldeltoid ("regimentalbadge"area)Primarytumoursurgery Mastectomy WideLocal Excision Multifocaltumour Solitarylesion Centraltumour Peripheraltumour Large lesioninsmall breast Smalllesioninlarge breast DCIS>4cm DCIS<4cm PatientChoice Patient choiceAdjuvanttherapy Radiotherapy After wide local incision, mastectomy or axillary surgery for high-risk recurrence. Chemotherapy For high-risk/node-positive cancer. Can be given neoadjuvantly Hormonal Therapy Given to ER-positive cancers for 5-10 years • Tamoxifen (pre-menopausal) • Aromatase inhibitors- letrozole (post-menopausal). Biological Therapy For HER2-positive cancers E.g Trastuzumab (Herceptin) and PertuzumabStagingsystems NottinghamPrognostic Index (NPI): • Used to predictprognosis based on tumoursize, lymphnodestatus, and histological grade. • Formula:NPI = (0.2× tumour size incm) +lymphnodescore+ grade score. Triple Assessment Notation: Combinesclinicalexamination,imaging, and biopsy results to categorizebreastcanceras: • Benign • Suspicious • Malignant TNM StagingSystem: • T (Tumour):Size and extent of the primarytumour. • N (Nodes): Extent of regionallymphnodeinvolvement. • M (Metastasis):Presenceor absenceofdistant metastasis.Benign breast conditionsFibroadenoma Presentation: Common in young women (under 30). Painless, mobile, well-defined breast lump("breast mouse"). Diagnosis: Triple assessment Management: Reassuranceif small and asymptomatic. Excision if - Rapid growth, ≥3 cm in sizeor patient preference.Cyclicalmyalgia Breast pain linked tothemenstrual cycle. Presentation Often bilateral, diffuse, and worse premenstrually. Diagnosis History + Clinical exam. Management Lifestyle changes (reduce caffeine, wear supportive bra), NSAIDs, hormonal therapy if severe. Fibrocystic changes are themost common causeFibrocysticchanges Common in premenopausal women (hormone-related). Most common cause of cyclical myalgia Presentation Lumpy, tender breasts, worse before menstruation. Can improve post-menopause but may reoccur with HRT Diagnosis Clinical exam + Ultrasound/Mammogram if needed. Management Reassurance, supportive bra, NSAIDs if painful.Intraductalpapilloma Benign tumourof the breast ducts, often near thenipple. Presentation (Premenopausal women) Bloody orclear nipple discharge(most common symptom). May have asmall, subareolar lump, but often not palpable. Diagnosis Triple assessment Management Surgicalexcision (to ruleout malignancy). Regular follow-up if multipleor high-riskfeaturespresent.Mammaryductectasia Benign condition where milk ducts become dilated and inflamed Presentation: (often affects perimenopausal women) • Green/yellow nipple discharge (non-bloody). • Nipple retraction or tenderness or a possible subareolar lump. Diagnosis: • Clinical exam – check for nipple changes and discharge. • Ultrasound ± mammogram to exclude malignancy. • Biopsy if suspicious features (e.g., bloody discharge, irregular mass). Management: • Reassurance (if asymptomatic). • Warm compresses & NSAIDs for discomfort. • Duct excision if symptoms persist or infection develops.Mastitis(lactational vsnon- lactational) Lactational – Infection due to milk stasis (common in breastfeeding women). Non-lactational (periductal) – Often inflammatory, seen in smokers or diabetics. Presentation: Breast pain, redness, swelling, fever (if infective). Diagnosis: • Clinical ± ultrasound (if abscess suspected). Management: • Continue breastfeeding (if lactational).* • Antibiotics (flucloxacillin for Staph aureus). • Drainage if abscess forms.Phyllodestumour • Rare fibroepithelial breast tumour,can be benign, borderline, ormalignant. • More common in middle-aged women. Presentation • Painless, fast-growing breast lump. • Well-defined, smooth, and mobile (similar tofibroadenoma but largerand growsrapidly). Diagnosis • Triple assessment: Management • Widelocal excision orMastectomyPollquestion1 A 32-year-old woman presentsto her GP with apainless, firm lumpin her right breast that she noticed twoweeks ago. She hasno nipple discharge, skin changes, or axillary lymphadenopathy. She has nosignificant family history of breast cancer. What is themost appropriate next stepin management? A) Urgent 2-weekwait referral B) Non-urgent referral C) Routine mammogram D) Reassure and reviewin 6 weeksPollanswer1 • Option A (Urgent2-week wait referral): as she is over 30 with an unexplained breast lump. • Option B (Non-urgentreferral): This wouldbe considered for women under 30 with a lump, but this patient is over 30, warranting an urgentreferral. • Option C (Routine mammogram):Mammography isthe primary screening tool for breast cancer, but it is not the first-lineinvestigation for anew lump, especially in youngerwomen whohave denser breast tissue.Instead, triple assessment (clinical exam, imaging, biopsy if needed) shouldbe arrangedvia a breast clinic referral. • Option D (Reassureand review in 6 weeks):Delaying assessment is inappropriate when an urgentreferral criterion is met, asearly detection significantly improves outcomes.Pollquestion2 A 55-year-old postmenopausal woman is diagnosed with a 3 cm, node- positive, ER-positive, HER2-negative invasive ductal carcinoma. She undergoes breast conservation surgery. Which combination of adjuvant therapies is most appropriate? A) Radiotherapy + Tamoxifen B) Chemotherapy + Aromatase inhibitor C) Biological therapy + Chemotherapy D) Radiotherapy + Biological therapyPollquestion2 Correct Answer:B) Chemotherapy + Aromatase inhibitor Chemotherapy is recommended for node-positive breast cancer toreduce recurrence risk. Aromatase inhibitors(e.g., letrozole) are usedfor ER-positive, postmenopausal patients. Radiotherapy is not routinely needed post-mastectomyunless there are high- riskfeatures(e.g., ≥4 positive nodes or chest wall involvement). Biologicaltherapy (e.g., trastuzumab)is only used for HER2-positive cancers, which this case doesnot have.Pollquestion3 A 62-year-old woman undergoesa mastectomy with axillary lymph node dissection (ALND) for node-positive breast cancer. Six months later, she presents with progressive swelling and heaviness in her right arm. Given themost likelydiagnosis, how should it bemanaged? A) Anticoagulation B) Limb elevation and compression C) IVantibiotics and surgicaldrainage D) Urgent vascular reviewPollquestion3 The timing (developing months after ALND) and progressive swellingsuggest chronic lymphoedema, not an acuteprocess like DVT or cellulitis. A) Deep vein thrombosis (DVT)→ Anticoagulation B) Chronic lymphoedema → Limb elevation and compression C) Cellulitis → IV antibiotics and surgicaldrainage D) Axillary vein thrombosis → Urgentvascular reviewPollquestion4 A 52-year-old woman presentswitha 2.5 cm ER-positive, HER2-negative invasive ductal carcinoma. She has no palpable axillary lymphadenopathy. An ultrasoundof the axilla is normal. She undergoes sentinel lymph node biopsy (SLNB), which reveals four positive lymph nodes. What is themost appropriate next stepin axillary management? A) No further axillary treatment B) Repeat SLNB to confirm findings C) Axillary radiotherapy alone D) Axillary lymph node dissection (ALND)Pollquestion4 Correct Answer:D) Axillary lymph node dissection (ALND) SLNB showed ≥3 positive nodes → ALND is recommended toremove Level I & II axillary lymph nodes for better disease control. Axillary radiotherapy alone (C) is not sufficient when ≥3 nodes are involved— ALND is thepreferred option. No further axillary treatment (A)is incorrect as thesignificant nodal burden requiresintervention. Repeat SLNB (B)is unnecessary, as the initial biopsy already confirmed nodal involvement.Pollquestion5 A 30-year-old smoker presentswith a painful, erythematous lump near the nipple. There is associated nipple retraction, but nodischarge. Examination shows an areaof induration, and ultrasound suggestsan inflamed duct. What is thebest initial treatment? A) Urgent widelocal excision B) Radiotherapy C) Antibiotics and smoking cessation advice D) Hormonal therapyPollquestion5 Correct Answer:C) Antibioticsand smoking cessation advice Periductal mastitisis an inflammatory condition affecting smokers dueto ductal inflammation and bacterial superinfection. Antibiotics (e.g., co-amoxiclav) and smoking cessation help resolve infection and prevent recurrence. Widelocal excision (A)is only for chronic cases with abscess formation. Radiotherapy (B)and hormonal therapy (D) are not usedfor this condition.Pollquestion6 A 55-year-old woman presentswithnipple dischargethat isgreenish and thick. She alsoreports mild breast discomfort but nopalpable lump. On examination, there isnipple retraction, but no erythema oraxillary lymphadenopathy. What is themost likelydiagnosis? A) Mammary duct ectasia B) Ductal carcinoma in situ(DCIS) C) Intraductal papilloma D) Breast abscessPollquestion6 Correct Answer:A) Mammary duct ectasia Mammary duct ectasia is a benign condition causingnipple discharge (often green/yellow), nipple retraction, and ductal dilatation. DCIS (B)may present with bloody discharge, microcalcifications on imaging. duct dilation.pilloma (C) often causesbloody dischargebut does not lead to Breast abscess (D)presents with erythema, pain, and fever.