1: Breast Carcinoma Flashcards
What is the most common type of breast cancer
Adenocarcinoma
Where do adenocarcinomas most commonly arise
Ductule (80%)
Aside from ductal tissue, where may adenocarcinomas arise
Lobule (20%)
How can breast carcinomas be divided
- Non-Invasive Carcinoma. (Carcinoma in situ) = not invaded past basement membrane
- Invasive Carcinoma
What is the most common type of non-invasive breast carcinoma
Ductule Carcinoma in Situ (DCIS)
Where does DCIS originate
Terminal Ductule Lobular Unit (TDLU)
What % of DCIS will become invasive ductal carcinoma
20-30%
What is lobular carcinoma in situ
Adenocaricnoma that originates from secretory lobule
How does the risk of LCIS compare to DCIS for invading the basement membrane
Higher risk of transforming to invasive cancer
What % of invasive cancers are ductal carcinomas
85%
Where do invasive ductal carcinomas arise
Terminal Ductule Lobular Unit (TDLU)
What % of invasive adenocarcinomas are invasive lobular carcinomas
15%
Where do invasive lobular carcinomas arise
Terminal Ductule Lobular Unit (TDLU)
Describe the epidemiology of breast carcinoma
Most common cancer in women
Which population does breast carcinoma typically occur
Post-menopausal women
What are three genetic syndromes that increase the risk of breast cancer
- BRCA I and II
- Peutz-Jegher
- Li Fraumeni
What percentage of women with BRCA genes develop breast cancer
70%
What is the inheritance pattern of BRCA
Autosomal Dominant
What is different to BRCA positive women with breast cancer, compared to BRCA negative
Develop breast cancer 15-20 years younger
What other cancer does BRCA increase the risk of
Ovarian
What 4 cancers does Li Fraumeni Syndrome increase the risk of (SBLA)
- Sarcoma
- Breast
- Lung
- Adrenal
What are 5 risk factors for breast cancer
- Increased Oestrogen
- Obesity
- Smoking
- Alcohol
- Radiation
- FH
- Breast cancer in contralateral breast
What are 5 factors that increase oestrogen, increasing the risk of breast cancer
- Early menarche
- Late menopause
- Nulliparous
- First pregnancy >35
- HRT
- COCP
Why does obesity increase the risk of breast cancer
Adipocytes covert androgens to oestrogen
How may breast cancer present
- Lump
- Asymmetry
- Skin dimpling
- Skin tethering
- Peu d’orange
- Paget’s disease
- Mastalgia
- Palpable axillary lump
If the GP suspects breast cancer what time-frame should they be referred for triple assessment
2W
What are the three stages of triple assessment
- Exam
- Imaging
- Biopsy
What imaging is used for females <35
USS
What imaging is used for females >35
Mammography
What imaging is used for males
USS
What is used to take a biopsy
Core needle biopsy and fine needle aspiration
Why is a core biopsy preferred to fine needle aspiration
Core biopsy can provide histology. Whereas FNA can only provide cytology
If suspicous of cancer on FNA what should be performed and why
Core needle biopsy = to distinguish whether invasive or non-invasive. As cannot tell from FNA alone
Explain scoring of triple assessment
Individual is given a score from 1-5 based on:
Exam (P)
Imaging (M or U)
Biopsy (B)
In triple assessment what does P stand for
Exam
What is P1
Normal
What is P2
Benign
What is P3
Unsure - likely benign
What is P4
Unsure - likely malignant
What is P5
Malignant
What is M1
Normal
What is M2
Benign
What is M3
Unsure - Likely Benign
What is M4
Unsure - Likely Malignant
What is M5
Malignant
What is B1
Normal
What is B2
Benign
What is B3
Unsure - Likely Benign
What is B4
Unsure - Likely Malignant
What is B5
Malignant
Who should BRCA gene testing be offered to
All women under 50-years presenting with breast cancer
What other imaging is used in diagnostic work-up of breast cancer
CT scan used to stage disease (TNM)
If micro calcifications is seen on breast screening (US or mammography) what type of cancer is it likely to be?
More likely to be DCIS, opposed to LCIS which does not present with micro calcifications.
Outline NHS screening program for breast cancer
Mammography is offered to women aged 50 - 70 every 3-years. Now trialling 47-73.
After 70 women can request screening appointment.
Positive results are referred for triple assessment
How is DCIS managed
Wide local excision
How is LCIS managed
Observation
If individuals are found to have BRCA genes what is performed
Prophylactic bilateral mastectomy
What is offered to all patients following WLE
Radiotherapy
What are indications for mastectomy
- Multi-Focal Disease
- High-Grade
- BRCA1/2
- Disease recurrence
- Patient Choice
What is sentinel node biopsy surgery
The sentinel node = first node cancer will pass too, is identified by injecting blue radio-isotrope. Then is removed and sent for histology
What is axillary node clearance and when is it done
Removal of all axillary lymph nodes = done if the sentinel node biopsy is positive.
Why may hormonal therapy be used as an adjuvant
prevent recurrence or those unfit for surgery
What hormonal adjuvant is used for PRE-MENOPAUSAL patients
Tamoxifen
How does tamoxifen work
Binds and inhibits oestrogen receptors at the breast
What are two risks of tamoxifen
Increased risk of:
- Endometrial Cancer
- VTE
Why does tamoxifen increase risk of endometrial cancer
Due to being pro-oestrogenic on endometrial tissue
What hormonal medication is used in POST-MENOPAUSAL WOMEN
Aromatase inhibitors
What are three aromatase inhibitors
- Anastrozole
- Letrozole
- Exemestane
How do aromatase inhibitors work
Decrease peripheral conversion of androgens to oestrogen
When may Herceptin be given as adjuvant therapy
If HER2 receptor positive
When may Herceptin be used as mono therapy
Metastatic disease not responded to at least two rounds of chemotherapy
What is the purpose of oncoplastic breast surgery
To reconstruct breast following mammectomy
What are the two techniques of oncoplastic breast reconstruction
- Mammoplasty
2. Flaps
What is a mammoplasty
WLE with breast reduction technique. Results in smaller, uplifted breast with preserved nipple and areolar
What three flaps can be used to reconstruction breast
- Latissimus Dorsi Flap
- Transversus Rectus and abdominal muscle (TRAM) flap
- Deep inferior epigastric perforator (DIEP) flap
What is latissimus dorsi flap
Uses latissimus dorsi muscle and overlying skin to reconstruct breast
When are latissimus dorsi flaps used and why
Smaller breast - only take portion of muscle
What is a TRAM flap
Transversus rectus and fat are used to reconstruct the breast
What is deep inferior epigastric perforator flap
tissue from abdomen and overlying skin used to reconstruct breast
What is the most important prognostic factor for breast cancer
Node status
What else can influence prognosis of breast cancer aside from node status
Grade
Size
Receptor Status
What should all breast cancers undergo and why
Receptor status (PR, ER, HER2) as this can influence prognosis
What scoring system is used to predict prognosis of breast cancer
Nottingham prognostic index
What is the Nottingham prognostic index score
(Size x 0.2) + Node Status + Grade
What are 6 causes of nipple discharge
- Physiological (Breast Feeding)
- Galactorrhoea
- Carcinoma
- Intraductal Papilloma
- Hyperprolactinaemia
- Mammary ductal ectasia
What is the most common pathological cause of nipple discharge
Galactorrhoea - occurs around breast feeding
What is a distinguishing feature of hyperprolactinaemia
May have bitemporal hemianopia due to pressure on optic chasm
How will nipple discharge present in mammary ductal ectasia
Thick yellow-green discharge
Which population is mammary ductal ectasia common in
Post-menopausal women
If a post-menopausal women smoker presents with green-yellow nipple discharge, what is it
Mammary ductal ectasia
What type of discharge is present in carcinoma
Blood-stained
What can cause blood-stained nipple discharge in younger patients
Intraductal papilloma
What are three factors protective from breast cancer
- Physical activity
- Breastfeeding
- NSAIDs
Explain NHS advice for self-examination of breasts
5 Steps to be breast aware
What are the 5 steps for self-breast examination
- Know Normal
- Look and Feel your breasts
- Know what changes to look for
- Report concerns without delay
- Attend routine screening if >50
What are 5 differentials for breast lump in a male
- Gynaecomastia
- Lipoma
- Cyst
- Breast cancer
- Fat necrosis
What is Paget’s disease of the nipple
Ductal carcinoma that infiltrates the nipple
How will the nipple present in paget’s disease
- Erythematous
- Thickened, Flaking skin
- Vesicular rash
- Pruritus
- Bloody discharge
What is a contraindication of tratszumab
heart disease
What are 4 indications for mastectomy
- Large lesion in small breast
- DCIS >4
- Central tumour
- Multifocal lesion
What are 4 indications for WLE
- Small lesion
- DCIS <4
- Peripheral tumour
- Solitary tumour
What is possible complication of axillary node clearance
Lymphoedema and functional arm impairment
