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Year 3 Surgery > 9 - Breast Cancer > Flashcards

9 - Breast Cancer Flashcards

1
Q

Which is the most common cancer in women?

A

Breast cancer

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2
Q

In the UK - women are assessed in specialist one stop clinics - what happens here? What is this called?

A

They get clinical, radiological and pathological evaluation

Called = triple assessment

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3
Q

What are red flags for breast cancer?

A

Inc / dec in size or symmetry
New or persistent skin changes
New nipple inversion or discharge
Breast pain or mass / lump
Hx of trauma to the breast

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4
Q

What Qs should you ask Ps about oestrogen exposure?

A

Age of menarche / menopause
Parity
Breastfeeding
Oral contraception
HRT
IVF

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5
Q

Who can have a mammogram?

A

Ps aged 40+ = skin too dense in younger Ps

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6
Q

What other imaging is used for breast cancer?

A

USS - inc imaged guided nodal biopsy
MRI

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7
Q

When is MRI used for breast cancer?

A

Women who have breast implants
Women who have dense breasts

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8
Q

What do we look for with breast histology?

A

Grade of cancer
DCIS - if high, low or intermediate
ER / PR / HER2 status (receptor)
Lymphovascular invasion
Lymph node assessment

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9
Q

What can breast pain be divided into?

A

Cyclical
Non-cyclical
Extramammary

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10
Q

Is pain a common feature of breast cancer?

A

No - <3% of breast cancers present with pain

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11
Q

What can extramammary pain be caused by?

A

MSK conditions - e.g. costo-chondritis

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12
Q

What percentage of palpable breast lumps in 20s-50s are benign?

A

> 90%

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13
Q

What a common cause of firm and mobile masses in the breast, mostly in younger Ps?

A

Fibroadenoma

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14
Q

What do fluid-filled masses tend to be?

A

Cysts

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15
Q

What changes can make breasts mildly tender and nodular in premenopausal women?

A

Fibrocystic changes

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16
Q

What is a milk retention cyst (cyst filled with milk) that is common in breastfeeding women?

A

Galactocele

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17
Q

Blunt trauma to the breast can cause?

A

Fat necrosis - can be difficult to distinguish from malignancy on mammogram

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18
Q

What is a fluctuant, tender, palpable mass with skin change likely to be?

A

Breast abscess

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19
Q

How are breast cysts ruled out as being malignant?

A

Usually USS sufficient but if in doubt - biopsy

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20
Q

What is the age of peak incidence of breast cysts?

A

35-50

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21
Q

How are breast cysts treated?

A

Often resolve within 5 years
If Sx can be aspirated but recurrence is common

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22
Q

When is nipple discharge more likely to be cancer?

A

In older Ps?
Only a sign in 3% of Ps <40 with cancer
10% 40-60
32% 60+

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23
Q

What can medications can cause nipple discharge?

A

Warfarin - can cause brown/ blood stained discharge
APs - can cause milky discharge
Smoking - can cause green/grey discharge

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24
Q

Persistent discharge for how long is more likely to be associated with a neoplastic lesion?

A

More than 2 weeks

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25
Q

What are the signs of galactorrhea?

A

Bilateral discharge
Pale milky colour
From multiple ducts

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26
Q

What should you check if galactorrhea is suspected?

A

Prolactin levels - if >1000 - is more likely to be secondary to medication or a pituitary tumour

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27
Q

What can produce serosanguinous or bloody discharge?

A

Duct papillomas
Epithelial hyperplasia
DICS or Invasive carcinoma

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28
Q

What colour discharge can duct ectasia produce?

A

Thick yellow

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28
Q

What investigations are done for duct discharge?

A

Cytology not done
Mammogram if >40
USS if nothing seen on mammogram

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29
Q

Which hormones can you test for in gynaecomastia?

A

LH
FSH
Testosterone
Prolactin
Α Fetoprotein
βHCG

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29
Q

Which drugs can cause gynaecomastia?

A

Digoxin
Amiodarone
Spironalactone

TCAs
Haloperidol

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29
Q

How is gynaecomastia Rx?

A

Often conservatively - reassure and explain. Remove cause if any.

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30
Q

What causes gynaecomastia in men?

A

Imbalance of androgen and oestrogen
- idiopathic 58%
- hypogonadism 25%
- hyperprolactinemia - 9%
- chronic liver disease 4%
- drugs
- testicular cancer

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31
Q

What can cause mastitis?

A

Lactation (75%)
Inflammatory cancer
Infected foreign body (implant)

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31
Q

What are the RF for mastitis?

A

Smoking
DM
Immunosuppression
Sore/cracked nipples
IBD

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32
Q

What is the Rx for mastitis

A

Abx

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33
Q

What complication can mastitis cause?

A

10% will develop breast abscess

34
Q

What is the most common bacteria that causes breast abscess?

A

Staph aureus

35
Q

What are the RF for mastitis?

A

> 30
First pregnancy
Smoking
DM, RA, Steroid Rx and trauma

36
Q

What do you need to check if a P has a non-lactating abscess?

A

Check for cancer - <1% of cancers can cause this but they trend to be aggressive ones.

37
Q

How do breast abscesses present?

A

Localised, painful inflammation
Fever malaise
Fluctuant, tender, palpable mass

38
Q

How is breast abscess confirmed?

A

USS - often combined with needle aspiration

39
Q

What percentage of cancers in F are breast cancer?

A

15%

40
Q

What are the RF for breast cancer?

A

Young menarche
Old first birth
Old menopause
Past use contraceptive pills
HRT
Alcohol
Dense breasts
Obesity

41
Q

Which familial cancers are relevant to increasing a P’s chance of getting breast cancer?

A

Ovarian or breast cancer in the family are relevant - look at number of cases, relationship, age at diagnosis

42
Q

Which race has a higher risk of getting breast cancer?

A

Ashkenazi Jews

43
Q

Which genetic mutations are linked to inc risk of breast cancer?

A

BRACA1
BRACA2
TP53 80-90%
Li Fraumeni 80-90%

44
Q

How do BRACA genes cause an inc risk of breast cancer?

A

BRACA1 & 2 are tumour suppressor genes - AD inheritance - mutations mean that tumours are not suppressed as well

45
Q

What does being BRACA1 or 2 positive do to your risk of
(1) breast cancer
(2) ovarian cancer?

A

Breast = x5 higher than normal pop
Ovarian = 10-30x higher than normal pop

46
Q

How are Ps with BRACA gene mutations managed?

A

Annual breast MRI 30-49
Mammography from 40

47
Q

What is the current screening for breast cancer in the UK?

A

Mammography from 50-70 every 3 years

48
Q

What are the classic characteristics of a cancerous breast lesion?

A

Hard
Immoveable
Single dominant lesion with irregular borders

49
Q

What is it called when you have eczematous change to the nipple-areolar complex (that is 80% associated with cancer)

A

Paget’s disease

50
Q

What breast findings can indicate locally advanced disease?

A

Axillary adenopathy
Erythema
Thickening of skin
Peau d’orange
Function of tumour

Distant disease - bone pain, pathological fractures, hepatomegaly

51
Q
A
52
Q

What surgical management is done for DCIS?

A

Wide local excision + radiotherapy
Axillary node biopsy - can do sentinel lymph node biopsy using radioisotope.

53
Q

What complications can arise from axillary node clearance?

A

Lymphodema of the arm

54
Q

What are poor prognostic factors for chemo?

A

High grade tumour
Negative receptor cancer

55
Q

Which Rx is given for HER-2 positive cancer?

A

Herceptin

56
Q

What possible hormone receptors are linked to breast cancer?

A

ER = oestrogen receptor
PR = progesterone receptor
HER2 = Human Epidermal Growth Factor 2

57
Q

What are poor prognostic factors for breast cancer surivial?

A

Advanced stage - esp involving axilla
High grade
Inflammatory cancer = poor prognosticator
Young diagnosis
Triple negative - HER2, ER and PR negative

58
Q

What is used to block ER receptors?

A

If a cancer is ER +ve = it receives signals from oestrogen to grow

Can use SERMS = selective ER modulators - these block the ER receptors and prevent hormones from binding to them

SERDS = selective ER degraders - block and damage ER receptors

Can also use aromatase inhibitors - stops conversion to oestrogen.

59
Q

What is it called when cells grow and divide more than they should, or do not die when they should, creating an abnormal mass of tissue?

A

Neoplasia

60
Q

Where do the majority of breast cancers arise?

A

In the terminal duct lobular units

61
Q

What is the breast?

A

A modified exocrine gland

62
Q

What is the breast microbiome?
Why do we have it?

A

Breast has more diverse bacterial populations living in it than then skin - over 200 species.

Have it to establish gut microbiome of breastfeeding babies and infants

63
Q

Which chromosomes have BRACA 1 and 2 on them?

A

1 = Chr 17
2 = Chr 13

64
Q

Which ethnic groups have persistent mutations of the BRACA gene?

A

Ashkenazi Jews
Icelanders

65
Q

Apart from BRACA, which other gene mutations are linked to inc breast cancer risk?

A

CHEK2
PALB2
ATM
TP53

66
Q

What does SNP stand for?

A

Single nucleotide polymorphism - give small but cumulative risk of developing BC

67
Q

What is it called when cells have the hallmarks of breast cancer but have not broken through the walls of the duct?

A

Pre-invasive breast cancer - DCIS or pleomorphic lobular carcinoma in situ

68
Q

How does invasive cancer differ from pre-invasive?

A

Cancer cells have breached the basement membrane to invade local tissues - can enter BVs and lymph

69
Q

What are Risk Lesions?

A

Aka Cellular Atypia

Disorder where the cells look abnormal, but not sufficiently to be called pre-invasive breast cancer.

Is a risk that they can increase risk of BC.

Different types of these lesions inc
- Atypical intraductal epithelial proliferation
- ALH or LCIS
etc

70
Q

What is then most common type of breast cancer?

A

Invasive ductal carcinoma of no special type = 75%

71
Q

What types of breast cancer are there?

A
72
Q

How is breast cancer graded?

A

Score each of these -
Look at the nucleus compared to normal cells = nuclear grade
Mitotic rate
Tubule formation

Combine the scores

3-5 = low grade (1)
6-7 = intermediate grade (2)
8-9 = high grade (3)

73
Q

How are lymph node mets classified?

A

Isolated tumour cells
Micromets <2mm
Macromets >2mm
Extracapsular spread - has pushed through the capsule of the lymph node

74
Q

How are isolated tumour cells treated?

A

Dealt with as a negative lymph node finding but indicate the need for more treatment

75
Q

How is breast cancer staged?

A

Stage 1 = confined to breast
2 = breast and regional (axilla) lymph nodes
3 = skin or muscle + regional lymph
4 = mets to other parts of the body

76
Q

How does TNM staging work?

A

T = size
N = nodes involved
M = mets

77
Q

What percentage of breast cancers are picked up via screening?

A

1/3 = from screening
2/3 = from symptomatic presentation

78
Q

What is the aim of breast screening?

A

To detect cancers at an early stage before they are big enough to be felt - this allows inc survival but also less invasive Rx.

79
Q

How much radiation in a mammogram?

A

7 weeks background
20 CXR

80
Q

Due to screening - in 1000 Fs how many will be diagnosed with cancers that would not have caused harm?

A

17

81
Q

What do we look for on mammogram?

A

Masses
Microcalcifications
Distortion
Asymmetry

82
Q

What percentage of breast cancers are DCIS?

A

20%

83
Q

How is DCIS seen on mammogram?

A

Microcalcification

84
Q

How many women will develop cancer between mammograms? What percentage of these were missed cancers?

A

3 in 1000

20% were subtly seen on first mammogram

85
Q

What happens in triple assessment?

A
86
Q

Are mammograms effective in dense breasts?

A

The are less accurate in dense breasts.

Normally - 80-85% accurate
But in dense tisse - only 60%

Dense breasts are also MORE likely to develop breast cancer!

87
Q

What imaging can you do for very dense breasts?

A

Contrast enhanced mammogram
3D mammogram

88
Q

If a P is under 40 - what first test should they have when presenting with a breast lump?

A

USS

Year 3 Surgery (15 decks)

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