Breast Flashcards
How is the Nottingham Prognostic Index Calculated?
(Size (cm) x 0.2) + N + G
Where:
N = 0LN=1, 1-3LN=2, >3LN=3
G1 = 1, G2 = 2, G3 = 3
What are the Nottingham Prognostic Index stage groupings?
2-2.4 - Excellent 93% 5 year survival
2.4-3.4- Good 85%
3.4-5.4 - Moderate 70%
>5.4 - Poor 50%
What are the classical characteristics of a fibroadenoma?
Highly mobile discrete breast lump typically diagnosed in teens/twenties.
Should be excised if >4cm, concerns over histopathology or patient choice
13% of all palpable breast lesions (60% of 18-25)
How are tubular adenomas of breast diagnosed?
On histopathology they are comprised almost entirely of glands with little intervening storm.
Treat similarly to fibroadenomas.
Similar to lactating adenoma in lactating women
What are the characteristic mammography findings of a hamartoma?
1) Circumscribed area of soft and lipomatous tissue
2) Surrounded by thin radiolucent zone
How frequently should patients with the BRCA1/2 gene mutations be imaged?
Annual MRI 30-49, annual mammography 40-69
What is the minimum excision margin recommended for Invasive breast cancer and DCIS?
1mm
What is the management of Paget’s disease of the Nipple?
Excision of nipple areolar complex and radiotherapy
In patients with ER positive breast cancer, which trial was suggestive of clinical benefit to Tamoxifen?
The Early Breast Cancer Trials Collaborative Group (EBCTCG) showed 5 years of tamoxifen reduces recurrence and improves overall survival for the first decade.
What dose of radiotherapy is used for the treatment of bony metastases from breast cancer?
8Gy
What classification system is used for breast capsular contractures?
Baker Classification:
1: Breast soft, impalpable implant
2: Breast solid, implant palpable but not visible
3: Breast hardened, implant is palpable and visible
4: Breast is hard, deformed and painful. Implant is palpable and clearly visible
What condition does a biopsy reported as sclerosing lymphocytic lobulitis suggest?
Diabetic mastopathy
What is the difference between Duct Ectasia and periductal mastitis?
Duct ectasia - older, non smokers creamy yellow
Periductal mastitis - younger, smokers, creamy yellow and green
What is Mondors disease?
Inflammation of breast vein, leading to erythema of overlying skin and underlying hard structure (palpable vein).
Usually treated conservatively with anti-inflammatories and generally never affects upper inside aspect of breast
What are the histological characteristics of fat necrosis?
Anucleate fat cells surrounded by histolytic giant cells
In what circumstances should breast MRI be offered to people with invasive breast cancer? (3)
1) If there is discrepancy regarding extent of disease from examination, mammography and USS
2) If density precludes accurate mammography
3) To assess tumour size if breast conserving surgery is considered in Lobular Cancer.
When should the axilla be staged?
In all patients with early invasive breast cancer, and any abnormal LNs should have USS guided FNAC
When should genetic testing be offered to women diagnosed with breast cancer?
To women <50 with triple -ve breast cancer
Testing for BRCA1 and BRCA2
When and how is SLNB performed?
In all patients with invasive cancer, no obvious nodes on USS.
In patients with DCIS if they are high risk - palpable mass, extensive disease
Dual technique - isotope and blue dye (NSABP-B32 trial showed more accurate)
When should patients be offered further axillary treatment after SLNB?
If there are MACROmetastasis i.e. >2mm present (not micro metastasis <2mm).
If there are 1 or 2 macrometasis and the patient will already be having whole breast radiotherapy and systemic therapy, it may be appropriate to omit clearing the axilla (NICE - could have POSNOC trial)
Can offer clearance or axillary radiotherapy
Isolated tumour cells only should be regarded as node-negative
What are the different patterns of complications after immediate and delayed breast reconstruction?
Immediate - lower tissue breakdown
Delayed - lower mastectomy site complications, flap or implant failure, capsular contracture
What tool is recommended for estimation of prognosis in breast cancer?
Predict 2.0 tool.
In whom is Predict less accurate? (4)
Women <30 ER+
Women ≥70
Women >5cm tumours
Men
What endocrine therapy should be offered for patients with breast cancer?
Premenopausal ER+ –> Tamoxifen
Postmenopausal ER+ low risk –> Tamoxifen
Postmenopausal ER+ medium/high risk –> Aromatase inhibitor
In premenopausal women, also consider ovarian suppression (oophrectomy or radiation menopause)
What are the risks of Tamoxifen treatment?
Thrombosis, endometrial cancer, osteopenia (premenopausal)
In what circumstances is endocrine therapy recommended for DCIS?
BCS without radiotherapy ER+
No effect on OS, but lower rates of DCIS/Invasive cancer at 5-10 years
What adjuvant treatments should be offered to patients with breast cancer?
A regime containing both
1) a taxane (Paclitaxel, Docetaxel)
2) an anthracycline (Epirubicin, Doxorubicin)
Sometimes adding in Cyclophosphamide or 5-FU.
What are the benefits of adding a taxane to an anthracycline containing regimen?
Reduced dose of anthracycline - reduced risk of cardiac toxicity and second malignancies, reduced risk of side effects
Additional side effects of joint and muscle pain, nerve damage, febrile neutropenia
Given as 9-12 week course
When should Trastuzumab be used?
T1c+ HER2+ breast cancer
Given at 3 weekly intervals for 1 year
Consider at T1a/T1b
What are relative contraindications to trastuzumab use?
LVEF≤55%
History of CHF, MI, Angina Pectoris or Cardiomyopathy
Cardiac Arrythmia, valvular heart disease pericardial effusion, poorly controlled hypertension
How should cardiac function be assessed during Trastuzumab treatment?
Baseline cardiac function + repeat every 3 months
If LVEF drops by ≤10% or to below 50%, stop
Repeat every 6 months until 24 months after stopping
When should bisphosphonates be used in patients with breast cancer?
1) N+ invasive cancer
2) N- high risk
Risks - osteonecrosis of jaw and external auditory canal, atypical femoral fractures
What radiotherapy should be offered to patients with breast cancer?
BCS with clear margins - whole breast radiotherapy, 40Gy in 15 fractions
BCS with clear margins and low risk of recurrence and having adjuvant treatment - partial breast radiotherapy (external beam)
Consider omitting if very low risk of local recurrence. Risk of recurrence is still reduced from 0.5% to 0.1% at 5 years, but OS is the same at 10 years
Consider for DCIS with clear margins
When should radiotherapy be given to patients after mastectomy?
1) N+ or R1
2) Consider if T3/T4
Radiotherapy to nodal areas is given when?
1) To SCF with 4+ LNs
2) To SCF if 1-3LNs + other poor prognostic factors
3) Consider including internal mammary chain in radiotherapy field if N+
What are the indications for neoadjuvant chemotherapy in breast cancer?
If HER2+ve Consider neoadjuvant chemotherapy, trastuzumab and pertuzumab combination
IF ER-ve consider chemo to reduce tumour size
If ER+ve consider chemo to reduce tumour size if chemo is indicated, otherwise can consider endocrine therapy (if postmenopausal)
What chemotherapy is typically used in the neoadjuvant setting in Breast cancer
Anthracycline +/- taxane +/- platinum
How should patients treated for breast cancer be followed up?
1) Annual mammography (including for DICS) until screening age or at least 5 years from diagnosis (not ipsilateral after mastectomy)
What is the NHS breast screening programme?
1) Starts at 50-53
2) Every 3 years until 71
3) beyond 71 if choose to
What are the chemotherapy options for advanced breast cancer?
1st line - docetaxel
2nd line - vinorelbine or capecitabine
3rd line - capecitabine or vinorelbine
How can risk of Breast cancer gene mutations be estimated? (e.g BRCA1 BRCA2 etc)
BODICEA tool or Manchester Index
When is Oncotype DX indicated for use?
ER+Her2-ve LN-ve breast cancer of intermediate risk
Why is trastuzumab ineffective for Brain metastases?
It does not cross the BBB
What is lapatinib?
It is a dual TKI - interrupting both the HER2/neu and EGFR pathways. Can be used if relapse on Herceptin
How do bisphosophonates work?
Reduce osteoclast activity and decrease bone resorption.
Side effects - renal impairment, osteonecrosis of jaw
Alendronate/risedronate (PO), Pamidronate (IV)
Nb Raloxifene SERM
What are the USS features of suspicious lymph nodes in the Axilla?
Shape - round (not elliptical)
Increased size
Absence of fatty hilum
Thickened/irregular cortex measuring >3mm
What evidence supports the use of SLNB?
ALMANAC trial
- SLNB vs Axillary clearance
- Improved QoL and arm morbidity with SLNB - no difference in DFS/OS
How are intraoperative SLNB assessed?
Frozen section (half LN snap frozen and analysed)
- Sens/specific
- requires pathologist, only half node
Touch imprint cytology (TIC half LN imprinted on slides and assessed)
-High specificity, low sens, cheap
- cytologist required
One step nucleic acid amplification assay (OSNA -whole node homogenised and PCR)
- Very sensitive and specific
- Expensive, tissue destroyed, some false positives
In what percentage of patients with a +ve SLNB will there be further positive lymph nodes?
47-68%
How should the Axilla be treated where this is indicated?
For T1-T2 cancers the AMAROS study demonstrated equivalent 5-year recurrence between radiotherapy and ANC (1.19% vs 0.43%), with less morbid with radiotherapy
What percentage of breast cancers have a genetic cause?
4-5%
Rises to 25% for under 30s
How would you classify risk of developing breast cancer?
Population risk - 17% lifetime, 10 year risk <3% 40-49
Moderate risk - 17-30% lifetime, 10 year risk 3-8% 40-49
High risk - >30% lifetime, 10 year risk >8% 40-49, >20% chance of faulty BRCA1/2/TP53
What are the cancer risks associated with BRCA 1/2?
Breast 1>2
Ovarian 1>2
Prostate 2>1
Also risk of melanoma, colon, haematological
What are the pathological characteristics of BRCA2 breast cancers?
Similar to non-familial, lower grade, more ER/PR, more DCIS. Mammograms more useful
What are the pathological characteristics of BRCA1 cancers?
High grade, less ER/PR, less DCIS, mammograms less sensitive
More basal cytokeratins - CK5/6, CK14, CK17
How should patients with TP53 mutations be screened for breast cancer?
Annual MRI (high risk of radiotherapy induced cancer) from 20
How should high risk patients be screened for breast cancer?
> 30% lifetime
–<30% BRCA - annual mammography 40-59
–>30% BRCA - annual MRI 30-49 then mammography
What syndromes are associated with increased breast cancer risk?
Li-Fraumeni (TP53) - 18 fold increased risk, annual MRI from 20
Cowden (PTEN/SEC23B) - 85% lifetime
Hereditary diffuse gastric cancer (CDH1 gene) - invasive lobular
Peutz Jaegers (STK11 gene)
Lynch syndrome (MSH6 and PMS2) - x 2 4isk
PALB2 station (similar to BRCA2) - 33-58% risk
CHEK 2 mutation (tumour suppressor) - double in F and x10 in M