1 Breast Cancer Flashcards
List some common presenting symptoms of Breast Cancer
- Lump
- Pain
- Nipple Discharge
- Nipple Retraction
- Change in the breast shape/appearance
- Skin changes
List some questions that could be asked of the patient’s past history
Breast cancer history
- Similar symptoms
- Surgery (remember ovarian surgery)
- Close relatives
- Breast/Ovarian
- History of breast cancer (on the male side)
- Family history
- Gynaecological (Menarche/Menopause - age), parity, breastfeeding, OCP/HRP
- Systemic features (anorexia, weight loss, bone pain, respiratory symptoms)
Describe a common breast examination
Can be done in different positions
- Start in sitting position
- Place patient arms on the side
- Make observations on any obvious signs
- Palpation - in lying down position; use the palm to examine against the chest wall; on the contralateral wall of asymptomatic breast, then move onto symptomatic breast and the quadrant in question
- Examine axilla - (lypmh nodes)
What to look for in a breast lump
- Tenderness
- Size
- Site
- Skin above lump
- Composition
- Fixity (to skin or deeper structures)
- Mobility
What could some differential diagnoses be (if not breast cancer)?
- Asymmetrical dense glandular tissue
- Cyst
- Fibroadenoma/Hamartoma
- Inflammatory/Abscess
- Phyllodes
- Cancer
Describe the information needed on any nipple discharge
- Colour
- Spontaneous or not?
- Uniductal/Multiductal
- Any medications?
- Smoking?
Describe the triple assessment method used in the identification of breast cancer
- History/examination
- Imaging: Mammogram/USS/MRI
- Tissue biopsy: FNAC (fine needle assisted cytology), Core biopsy, vacuum biopsy, punch biopsy
Describe the use of mammography
It is an X-ray of the breast
- Two views of each breast are taken (MLO - mediolateral oblique, and CC craniocaudal view)
Advantages:
- fast, easy processing, can manipulate pictures, easily stored and accessed
What to look for in a mammogram
- Calcifications (micro/macro)
- Mass
- Architectural distortion
Describe how a patient can get into a breast clinic
Different pathways:
- When a patient notices some problem with breast > GP refers to the clinic (symptomatic)
- When a patient attends the national breast screening program (healthy, asymptomatic patients, from 50-70 years, every 3 years > can be referred on
Describe the use of an ultrasound of the breast
Another commonly used modality
- Not used as a screening tool - not used for the whole breast, rather for a targeted assessment in the breast
- Can also be used to assess for lymph glands
- Used for younger patients - younger breasts = denser
A mammogram is the primary imaging tool (as younger, ultrasound is used, which is a smaller proportion)
Describe the use of MRI of a breast
It is selectively used
- Used to see the extent of the cancer (as mammogram may struggle if very dense)
- Assessing implant integrity
- Response to treatment
- Significant disconcordance between imaging/clinical examination
Describe biopsy use in breast cancer identification
- FNAC (fine needle aspiration cytology)
- Core biopsy (most common)
- Vacuum-assisted biopsy (bigger needle - for more tissue)
- Punch biopsy (from skin lesions/surface lesions > very rarely it has to be removed for diagnosis)
List some risk factors of breast cancer
- Females
- Age (older)
- Increased breast density
Hormonal factors
- Increasing levels of oestrogen increases the risk
- Early age at menarche
- Late age at menopause
- Nulliparity
- Late age at first childbirth
What is a mutation in which one can be predisposed to breast cancer
- BRCA1
Describe the histological classification of breast cancer
2 types:
- Ductal
> In situ (15%) in ducts, not breached basement membrane
> Invasive (75%) - has breached the basement membrane
- Lobular
> In situ (15%) - only this form is considered as cancer
> Invasive (5%) - not formed as cancer
Other rarer types are tubular, medullary, metaplastic, mucinous, lymphoma
Describe the distribution of breast cancer in breast cancer
- Most common is in the right upper breast - the highest proportion of glandular tissue is found here
Describe non-invasive cancer in breast cancer
Ductal Carcinoma in situ (DCIS)
Pleomorphic lobular carcinoma in situ
- Proliferation of malignant epithelial cells completely contained within the breast duct
- Risk of development of invasive cancer in the same breast is 20-30%
- Considered a pre-invasive lesion
Describe Paget’s disease
- Involves the nipple
- Could be associated with a mass
- Presents as an eczematoid lesion of the nipple
- Treated similar to in situ cancer
Describe the use of TNM staging in breast cancer
It depends on size, local spread, involvement of regional lymph nodes
- Tumour is given a rating based on size and properties
- Nodes are also given a score
- Metastasis is rated too
Describe the management options available for breast cancer
Following triple asseement + confirmation of diagnosis of cancer from biopsy, case details are discussed in MDT meeting,
5 treatment options
- Surgery (breast conservation, mastectomy +/- reconstruction, axillary node clearance
- Chemotherapy (neo adjuvant - before, adjuvant)
- Radiotherapy (whole breast, nodal regions)
- Immune therapy (anti HER2 treatment e.g. Herceptin used for a HER2 +ve px)
- Endocrine (tamoxifen/aromatase inhibitors for ER +ve)
Describe adjuvant therapy for breast cancer
Radiotherapy to breast
- Most patients after any form of breast conservation surgery
- Some patients after mastectomy may need radiotherapy to the chest wall
- Radiotherapy also needed for lymph nodes
Chemotherapy
- Various prognostic tools are used to assess the benefit of chemotherapy
Describe the use of surgery in breast cancer
Breast-conserving surgery
- Wide local excision (tumour removed) + Axillary surgery
- Oncoplastic surgery
o Therapeutic mammoplasty
o Resection with partial breast reconstruction with chest wall perforator flaps
- Mastectomy + axillary surgery +/- reconstruction
