1.05 - Breast & Cervical Cancer Flashcards
Definition of breast cancer.
Neoplastic changes in the epithelial cells that line milk ducts, or in breast alveolar lobules.
What are the categories of breast cancer?
Invasive breast cancer: ductal, lobular, mucinous, papillary cancers.
Noninvasive cancer: ductal carcinoma in situ (DCIS) and lobular carcinoma in situ (LCIS).
How is breast cancer phenotypically classified?
Using immunohistochemistry to determine receptor status:
- oestrogen receptor (ER)
- progesterone receptor (PR)
- HER2 receptor
What are the risk factors for breast cancer?
- female gender
- increasing age
- elevated oestrogen levels (ie. early menarche, late menopause, late parity, nulliparity, prolonged HRT)
- personal history of breast cancer
- family history of breast cancer
- obesity
- germline mutation
- alcohol
- thoracic radiation
NB: up to 80% of newly diagnosed women with breast cancer do not have risk factors.
Which germline mutations are associated with breast cancer?
- BRCA1
- BRCA2
These are proteins involved in DNA repair; mutated proteins mean DNA can pass through the cell cycle unrepaired and increase the risk of breast cancer by 80%.
Breast cancer screening programme in UK.
Women aged between 50 and 71 are invited for a mammogram every 3 years.
Mammogram takes xrays of the breast tissue. If pathological tissue is identified, the women will be referred for triple assessment. Otherwise, they will be recalled in 3 years.
When should a GP refer down a breast cancer pathway?
- aged >30 with an unexplained breast lump (with or without pain)
- aged >50 with unilateral nipple changes (ie. discharge, retraction)
- further investigation required following mammogram results
Consider urgent referral for people of any change with skin changes suggestive of breast cancer; or aged >30 with an unexplained lump in the axilla.
What happens in a triple breast assessment?
- History and examination
- Imaging
- Histology
What imaging modalities are used in triple assessment clinics?
- mammography, allowing for detection of mass lesions or microcalcifications
- ultrasound scanning
When is an ultrasound of the breast preferential over mammography?
Women <35 years
Men
due to higher density of breast tissue
What histology technique is used in breast triple assessment?
Core biopsy provides full histology, allowing differentiation between invasive and in-situ carcinoma.
If a woman has cystic disease, this can be aspirated using FNA for cytology and to relieve symptoms.
Primary prevention of breast cancer.
- breastfeeding children
- prophylactic bilateral mastectomy in BRCA germline mutation carriers
Secondary prevention of breast cancer.
- weight maintenance and avoid obesity
- reduce alcohol ≤1 unit per day
- physical activity
Differential diagnoses to breast cancer.
- fibroadenoma
- ductal hyperplasia
- lymphoma
- sarcoma
Breast cancer history - key points.
- family history of breast and ovarian cancer
- age of menarche
- age of menopause
- number of years of HRT
- exposure to mediastinal radiation
- symptoms (ie. bloody discharge, erythema, palpable masses)
What is the primary goal of treatment for stages I-III breast cancer?
Curative intent (ie. dying of a cause other than breast cancer).
What hormonal therapy is given in ER/PR+ breast cancer?
Tamoxifen if premenopausal / perimenopausal
Aromatase inhibitors if postmenopausal (anastrazole)
What hormonal therapy is given in HER2+ breast cancer?
Trastuzumab / Herceptin
What tumour marker is associated with breast cancer?
CA 15-3
What is the most common type of breast cancer?
Invasive ductal carcinoma.
When is mastectomy used for surgical treatment of breast cancer?
- multifocal tumour
- central tumour
- large lesion in small breast
- DCIS >4cm
- patient preference
When is a wide local excision used for surgical treatment of breast cancer?
- solitary lesion
- peripheral tumour
- small lesion in a large breast
- DCIS <4cm
- patient preference
What score is used to give an indication of survival of breast cancer?
Nottingham Prognostic Index
(Tumour Size * 0.2) + Lymph node score + Grade score
MOA of anastrazole.
Aromatase inhibitor.
Aromatisation accounts for majority of oestrogen production in post-menopausal women, therefore effective in ER / PR + breast cancer.
Side effects of tamoxifen.
Increased risk of endometrial cancer.
VTE
Menopausal symptoms
Which condition of the breast is blood stained discharge most likely to be associated with?
Intraductal papilloma
Why can tamoxifen cause abnormal vaginal bleeding?
Agonises endomtrial tissue, resulting in endometrial hyperplasia.
Lifetime risk of breast cancer in the UK.
1/7
When is axillary lymph node clearance performed?
When nodal spread is confirmed on biopsy during initial investigations.
Inheritance pattern of BRCA1/BRCA2.
Autostomal dominant
What are the most common sites of metastases in breast cancer?
- lungs
- bone
- liver
- brain
During axillary node clearance, which structures of the brachial plexus are at risk of injury?
Medial cord - therefore the median and ulnar nerve.
What complication is axillary node clearance associated with?
Arm lymphoedema and functional arm impairment (median n. and ulnar n.)
Risk factors for cervical cancer.
- HPV infection
- smoking
- multiparity
- long term oral contraceptive use
Primary prevention of cervical cancer.
HPV vaccination
Presentation of cervical cancer.
Cervical screening programme OR:
- bleeding
- dyspareunia
- back pain
- risk factors
Treatment of cervical cancer.
- loop excision of transitional zone (LETZ)
- hysterectomy
- chemoradiation
- sentinel node biopsy
Appearances of the cervix that may suggest cervical cancer.
- ulceration
- inflammation
- bleeding
- visible tumour
How is cervical cancer screened for?
Speculum examination and a smear to collect cells from the cervix using a small brush.
The samples are initially tested for high-risk HPV.
If the HPV test is negative, the cells are not examined; if the HPV test is positive, the cells are examined for dyskaryosis.
Cervical cancer screening ages and intervals.
25-49: invited for smear every three years.
50-64: invited for smear every 5 years.
Management of smear results (PHE 2015):
a) inadequate sample
b) HPV negative
c) HPV positive + normal cytology
d) HPV positive + abnormal cytology
a) repeat after 3 months
b) continue routine screening
c) repeat HPV test after 12 months
d) refer for colposcopy
Can the body clear HPV?
Usually, the body’s immune system clears HPV infection naturally within 2 years.
When is colposcopy used to investigated cervical cancer?
Smear showing HPV positive and cytology shows dyskaryosis.
What stains are used in colposcopy?
Acetic acid
Iodine solution
What are the staining results for acetic acid on colposcopy?
a) normal cells
b) abnormal cells
a) no change
b) stained acetowhite
What are the staining results for iodine on colposcopy?
a) normal cells
b) abnormal cells
a) stained brown
b) no change
LLETZ procedure.
Local anaesthetic using diathermy to remove abnormal epithelial tissue on the cervix.
Complications of LLETZ.
- increases the risk of preterm labour
Risks of cone biopsy.
- pain
- bleeding
- infection
- scar formation with stenosis of the cervix
- increased risk of miscarriage
- increased risk of premature labour
Staging of cervical cancer.
FIGO staging
HPV vaccination programme.
HPV vaccine is given to boys and girls before they become sexually active, at around age 13 years.
Protects against strains:
- 6 and 11 (genital warts)
- 16 and 18 (cervical cancer)
