Breast Flashcards
What are risk factors for breast cancer?
Female gender Age Family history Personal history of breast cancer Genetic predispositions (e.g. BRCA 1, BRCA 2) Early menarche and late menopause Nulliparity Increased age of first pregnancy Multiparity (risk increased in period after birth, then protective later in life) Combined oral contraceptive (still debated, effect likely minimal if present) Hormone replacement therapy White ethnicity Exposure to radiation
How are patients with BRCA1/2 mutations treated when asymptomatic?
Prophylactic bilateral mastectomy
Annual MRI scans
What is BRCA 1?
Mutation on chromosome 17
Lifetime risk is 65-80%
What is BRCA 2?
Mutation on chromosome 13
Lifetime risk is 45-70%
What can BRCA mutations, primarily 2, also increase the risk of?
Peritoneal Endometrial Fallopian Pancreatic Prostate cancer
What does it mean if a cancer is ‘in situ’?
Not penetrating the basement membrane
What are the types of breast cancer?
Ductal
Ductal carcinoma in situ
Invasive ductal carcinoma
Lobular
Lobular carcinoma in situ
Invasive lobular carcinoma
Rare
Inflammatory breast cancer - erythematous oedematous breast, often mistaken for infection
Paget’s disease of the nipple
Often associated with an underlying in situ or invasive cancer
‘Special type’ - type of invasive breast cancer
Mucinous, medullary, papillary, tubular, phyllodes, metaplasia, primary lymphoma
What are the molecular subtypes of breast cancer?
Luminal A
Luminal B
Basal
HER2
Based upon receptor status of oestrogen receptors and progesterone receptors, HER2 and Ki-67
How can DCIS be categorised?
High, intermediate and low grade
What is a protective factor?
Breastfeeding
What is the NHS screening programme?
Screening from 50-71
Every 3 years
Satisfactory
Abnormal - further investigations needed
Unclear - inadequate
What are the clinical features?
Often presents with breast or axillary lump, often hard, irregular and fixed to surrounding structures
Breast pain
Changes to skin - tethering, oedema, peau d-orange
Dimpling or puckering
Nipple - inversion, discharge especially if bloody, dilated veins
Paget’s disease - rough, dry, erythematous and ulcerated skin around the nipple
Features may also reflect metastatic spread - bone pain (bone), malaise and jaundice (liver), SOB, cough (lung), confusion, seizures (brain)
Who should be referred on two week wait?
30 and over with unexplained breast lump with or without pain
50 and over with any of the following symptoms in one nipple only:
discharge, retraction, any other changes of concern
Who should be considered for two week wait suspected cancer pathway?
Skin changes than suggest breast cancer
Aged 30 and over with unexplained lump in axilla
Who should be given a non-urgent referral for breast cancer?
Those under 30 with an unexplained breast lump with or without pain
What occurs at a review in the one stop breast clinic?
Triple assessment: History and examination Imaging: Mammogram, USS modality of choice in women under 40 Histopathology: Fine needle aspiration or core biopsy
What are additional investigations after the one stop clinic?
Bloods: FBC, U&Es, LFT, bone profile
Imaging: CXR Breast tomosynthesis use of mammogram to make it 3D MRI breast CT chest abdomen pelvis CT brain Contrast enhanced liver USS Bone scan PET/CT
Receptor testing, HER2 status to see if will benefit from Herceptin (Trastuzumab) monoclonal antibody blocking HER2
What is a triple positive breast cancer?
Those that are positive for ER, PR and HER2
How does breast density affect cancer risk?
Women with dense breast tissue in 75% or more of their. breasts, as determined by mammography, are 4-6 x more likely to develop breast cancer than those with minimal dose breast tissue
Also decreases sensitivity of mammography for detection of breast malignancies.
What is the classification of invasive breast cancers?
Stromal (rare) - phyllodes or sarcoma
Epithelium derived - invasive ductal, invasive lobular inflammatory breast carcinoma, Paget’s
Other - lymphoma, metastasis to the breast
What are the differentials for breast lumps?
Fibroadenoma - benign overgrowth of collagenous mesenchyme of lobule
Firm, non tender, mobile
Breast cyst - palpable benign, fluid filled, rounded, not fixed
Intraductal papilloma - benign warty lesion behind areola
Small sticky lump
Breast abscess - most common in breastfeeding mothers, malaise, fever, throbbing pain
Fat necrosis - fibrosis and calcification of breast tissue due to trauma, irregular craggy mass, nipple retraction
What is mastitis?
Inflammation of breast tissue, most commonly from staph aureus
Can be lactational, or non lactational
Tender, erythematous, swelling, nipple retraction
Treat with broad spectrum abx e.g. co-amoxiclav, continue milk drainage or feeding
Can become an abscess
What are breast cysts?
Epithelial lined, fluid filled cavity presents as smooth tender mass
Shows as halo on mammography, aspiration
Self-resolving
May cause fibrocystic change
What is mammary duct ectasia?
Dilation and shortening of major lactiferous ducts
Common in menopausal women
Green/yellow coloured nipple discharge, palpable mass
Symmetrical slit like nipple retraction
Mammography - dilated calcified ducts
What medical management is available?
Endocrine therapy:
Tamoxifen - in premenopausal women with ER+ cancer, blocks oestrogen receptors
Aromatase inhibitors e.g. Letrozole, Anastrozole, only used in postmenopausal women with ER+ cancer
Blocks enzyme which converts androgens to oestrogen
Biologics
HER2 - Trastuzumab (Herceptin) monoclonal antibody targeting HER2
Chemo
Neoadjuvant before chemo
Oncotype DX breast recurrence score assay can say if cancer likely to recur and if adjuvant chemo after is needed
Gonadotropin releasing hormone agonists e.g. goserelin can protect ovaries from premature ovarian failure in chemo
Radiotherapy
What surgical management is available?
Wide local excision
Mastectomy
Senitnel node sampling - radioactive technetium and blue dye to detect sentinel node, sent for analysis and surgical clearance of axillary nodes can be performed
What are examples of adjuvant chemo regimes?
Contain a taxmen and anthracycline
Fluorouracil
Epirubicin
Cyclophosphamide
How long does endocrine therapy last?
Commenced after any adjuvant chemotherapy
5 years
What medications can be given in mets?
Denosumab and bisphosphonates to prevent lytic bone lesions and reduce bone pain and fractures
What is DCIS?
Atypical proliferation of ductal epithelium that eventually plugs the duct.
It is maintained within the basement membrane
How would DCIS present?
Often not palpable lump so shown as an area of microcalcification on screening
How is LCIS found?
Where does LCIS spread to?
Incidentally during a biopsy since it is not palpable and won’t show as microcalcification
The contralateral breast
Which is the most common type of breast cancer?
75% are invasive ductal cell carcinomas
How do Invasive Ductal Carcinoma’s spread?
Regional nodes (internal mammary or axillary)
Systemically spread to bone, lung, pleura, liver, skin and the CNS
How is Invasive Ductal Carcinoma graded?
Histologically based on:
Tubule formation
Nuclear Pleomorphism
Mitotic frequency
Where can invasive Lobular Carcinoma’s spread to?
Peritoneum, meninges and uterus
How can Pagets and Eczema be differentiated?
Eczema spares the nipple
What is a triple negative cancer? How are they treated?
ER, PR and HER2 negative tumours
Respond to chemo
What are complications of axillary surgery?
lymphoedema long thoracic nerve damage - winging of scapula arm pain shoulder stiffness skin numbness
What 3 ways can breasts be reconstructed?
Lat Dorsi
TRAM - uses abdominal fat, muscle and skin
DIEP - uses abdominal fat and skin but leaves muscle meaning don’t lose as much strength
How are bone metastases in breast cancer managed?
Low dose radiotherapy and bisphosphonates
How does male breast cancer present?
Subareolar mass
Nipple retraction
Nipple bleeding
How is male breast cancer managed?
Mastectomy + SLNB/axillary clearance
Adjuvant radio, tamoxifen, chemo should be considered
What is inflammatory breast cancer?
cancerous cells block the lymph drainage leading to a swollen erythematous breast
If there are no palpable lymph nodes at presentation of breast cancer, how is she managed?
Pre-op USS and if +ve then SLNB at primary surgery
When is radiotherapy used in breast cancer?
Always post WLE
Post mastectomy if T3/T4 tumour or if >4 axillary nodes were +ve
What are the side effects/risks of tamoxifen?
endometrial cancer
VTE
menopause symptoms
What are the side effects/risks of anastrazole?
osteoporosis
joint aches
What are the side effects/risks of goserelin?
tumour flare initially
amenorrhoea
reduced libido
depression
When is chemotherapy used in breast cancer management?
Neoadjuvant to downstage the primary lesion
After surgery if axillary node disease
Describe the staging investigations for cancers picked up on triple assessment (7) and when is it done?)
- MRI if dense breast, lobular carcinomas and for high risk screening
- Full staging only done where chemo is an option and when higher risk/ suspicion of mets
- ER and progesterone receptor status using monoclonal antibody assay
- epidermal GF and HER2 receptor status
- LFTs and other routine bloods
- CXR for lung mets
- CT if mets suspected (abnormal CXR, neuro symptoms, hepatosplenomegaly, lymphadenopathy, LFT derangement)
- bone scintigraphy if distant mets, bone pain, LN mets
- PET scan if distant mets suspected (often fails to detect mets <5mm)
name and describe the staging system for breast cancer
bloom richardson staging
EARLY: T1-2= up to 5cm, N0 or N1 (up to 3 nodes)
LOCALLY ADVANCED= T3= >5 cm or T4= fixed to skin or chest wall, N2= 4 or more nodes, or fixed nodes or N3= nodes other than in axilla
METASTATIC= M1 (mets)
What prognostic indicators are there for breast cancer?
- blood richardson stage
- axillary node status
- tumour size
- tumour grade
- lymphatic or vacular grade
- pt age and BMI
- ER and PR status are weak prognostic factors
- oncotype dx: microarray to look at 21 genes gives indicator of chance of re- occurrence after mastectomy and guides decision to give chemo
- PREDICT tool online, NPI (cancer size x 0.2 + grade + node stage)
Where does breast cancer spread to and how?
Lymph node- to axially nodes
Blood- to bone, liver and lung commonly but can go anywhere
Directly- into chest wall and skin
How are lobar carcinomas in situ managed?
usually picked up incidentally on biopsies as usually asymptomatic and doesnt cause micro-calcifications visible on mammogram
- usually only monitored and bilateral prophylactic mastectomy offered if BRAC1 or 2 +ve
How are DCIS managed?
mastectomy or wide local excision then radiotherapy
Give 3 side effects of radiotherapy for breast cancer
skin reaction, chest wall pain and fatigue acutely.
fibrosis, atrophy of breast and telangiectasia later. Brachial plexopathy is rare now
What chemo regime is used for breast cancer
FEC- T
5FU, epirubicin, cyclophosphamide +/- docetaxel
How does tamoxifen work
Selectively blocks oestrogen (SERM) in breast tissue but increases oestrogens effect in bones, endometrium and blood (so prothombotic)
When are aromatase inhibitors used over tamoxifen and what are the risks and benefits of each?
Aromatase inhibitors used in post menopausal women, lower risk of DVT but higher risk of osteoporosis so bone protection is given with it.
Tamoxifen used in pre and post menopausal women, less expensive but slightly less effective. It increases DVT and endometrial ca risk but is bone protective.
What are abnormal features to look out for on mammography?
Irregular, spiculated
Radioopaque mass
Microcalcification
What are the pros and cons of FNA vs core biopsy?
FNA - quick, less uncomfortable, but cytological assessment only so if malignant core biopsy needed
Core biopsy
Removes small amount of tissue, higher morbidity and pain, takes longer
Can determine receptor status and grade of tumour
