Breast Flashcards
Name 8 risk factors breast cancer
• Female!
• increasing age!
• direct family member history
• brca 1 and 2 mutations (also ovarian, colon, gastric, prostate cancer )
• smoking
• alcohol
• early age menarche, later age menopause
• hormonal use, unproven
• obesity, first child after 30 or no children, history chest radiation
(Breast feeding = protective)
What type of biopsy should be done for suspected benign breast lump?
Fine needle aspiration
What type of biopsy should be done for suspected malignant breast lump?
Core needle biopsy
Excision biopsy only indicated if imaging guided core needle biopsy failed
What does presence of progesterone receptor on breast biopsy pathology indicate?
Positive predictor that anti-oestrogen treatment should be effective if > 30% positive
What is HER and Cerb and what does it indicate?
Human epidermal growth factor
Positive = much higher recurrence rates of breast cancer
What is ki-67 and what does it indicate?
Assess proliferation: which percentage of cells are in mitotic process (breast cancer)
Main areas metastasis of breast cancer? (5)
• Lung
Lymph
Brain
• pelvis
• Liver
• ovaries
• bone
Indication radiotherapy for breast cancer? (5)
. After mastectomy if >4 nodes involved after axillary dissection (high risk chest wall recurrence)
• metastatic disease with spinal cord compromise or vertebral involvement
. Brain metastasis to decrease pressure (chemo ineffective)
• inoperable lesion
• after breast conserving surgery
Indications adjuvant chemo and hormonal therapy in breast cancer? (3)
• Any nodal involvement
• lympho-vascular involvement
. Biologically aggressive tumours
Start ASAP after surgery, no later than 3-4 weeks
Standard chemo regimen for breast cancer? (3)
• 5-fluorouracil
• cyclophosphamide
• adriamycin (cardiotoxic. If poor cardiac function, give methotrexate )
For 6 months
New chemo regimen for breast cancer in healthy young patients? (3)
Cyclophosphamide and adriamycin monthly for 4 months
Weekly taxane for 12 weeks
Which hormonal therapy for breast cancer are used in pre-menopausal women?
Selective estrogen receptor modulators (serms) eg tamoxifen daily 5-10 years
Which hormonal therapy for breast cancer are used in post -menopausal women?
Aromatase inhibitors eg anastrasole, letrosole daily 5-10 years
Clinical features early stage breast cancer?
Single, nontender, firm palpable mass
Usually in upper outer quadrant
Clinical features locally advanced breast cancer? (5)
• Changes in size/shape breast (assymetry)
• skin retractions/ dimpling (fixation to pectoralis muscle, coopers lig/overlying skin)
• peau d’orange: blockage lymphatic drainage
• nipple inversion
• blood tinged discharge
Diagnosis breast cancer? (3)
3 stage assessment
• clinical features
• radiological
- <30 y → ultra sound (dense breast tissue difficult to see on mammogram ) (benign = wide > tall, malignant = tall > wide)
-> 30 y → mammogram mediolateral oblique and craniocaudal view (stellate solid mass)
• Biopsy
TNM Staging breast cancer?
Tumour
• T1: <2cm
- mi:microinvasion ≤ 0,1 cm
- a: 0,1-≤0,5
- b: 0,5- ≤1
-c: 1-≤2
• t2: 2-5 cm
• T3:>5 cm
• T4:local invasion
- a: infiltrate chest wall
- b: ulcerations, skin oedema , peau d’orange, and ipsilateral satellite skin lesions, nodules
- c: a and b
-d: inflammatory carcinoma (advanced invasive cancer - erythematous, oedema, skin plaques over rapidly growing mass)
Nodes
• n1: mobile ipsilateral (1-3 nodes)
• N2: ipsilateral fixed (4-9 nodes)
- A: axillary lymph nodes
-B: internal mammary lymph nodes
• n3: (more than 10 nodes)
-A: infra-clavicular lymph nodes
-B: axillary and ipsilateral internal mammary
-C: supra-clavicular
Metastasis
Mo
M1 distant
Histological Classification breast cancer? (4)
• non-invasive carcinoma in situ: ductal/lobular
• invasive
- ductal: subtypes = medullary (brca), tubular/cribiform, mucinous/ colloid, papillary
-Lobular
-Paget’s disease: ductal carcinoma that invades nipple with scaling and eczematoid lesion
• progressive disease: ulcerations, arm oedema, Paget’s disease of nipple
• Metastatic disease: lymph, bone, lungs, liver, brain
Bi-rads findings on mammography?
0: need additional imaging or prior examinations
1: negative, do routine screening
2: benign, do routine screening
3: probably benign (≤2% chance malignancy), short interval follow up in 6 months
4: suspicious,biopsy
5: highly suggestive of malignancy, biopsy
6: biopsy proven cancer, excise
Molecular subclassification of breast cancer? (5)
• Luminal A: er and /or Pr positive, her negative, ki-67 low <14%. Most common, lower grade, good prognosis
• luminal B: er and /or Pr positive, her negative, ki-67 high > 14%. Recur more than luminal A
• her-2 enriched: er negative, Pr negative, her 2 positive (respond to herceptin, trastuzumab..)
• Triple negative (basal like): er negative, Pr negative, her negative ( ck 5/6 positive and or egfr positive) (aggnessive, always need chemo. High grade, usually young black female)
• normal breast-like breast cancer: er and or Pr positive, her 2 positive, low ki-67 < 14% (similar to luminal A but worse prognosis)
Staging (o-4) of breast cancer?
• Stage 0: tis No Mo
• Stage 1
A- t1 No Mo
b- T 0/1 N 1mi ( micro metastasis > 0,2 mm and or > 200 cells but none >2mm) Mo
• stage 2
A- t1 n1 Mo or t2 No Mo
B- t2 N1 Mo or t3 No Mo
• stage 3
-A: t1-3 n2 Mo
-b : T4 No-2 Mo
-C: N3 Mo
• stage 4: m1
Treatment stage o breast cancer? (3)
• Surgery: Breast conserving surgery lumpectomy (remove cancerous tissue with clear margins) or modified radical mastectomy (breast, axillary tail, axillary nodes level one (below pec minor) and 2 (under/post to pec minor), skin and nipple/areolar complex) if BCS contraindicated ; with sentinel lymph node biopsy SNLB
• adjuvant radiotherapy after BCS
• hormone treatment if positive
Treatment stage 1 breast cancer? (5)
• Surgery: bcs/ mastectomy with snlb/ axillary dissection (alnd)
• adjuvant radiotherapy after bcs
• hormone therapy if positive
• chemo if tumour >1 cm and or hormone negative
• targeted If her positive
Treatment stage 2 breast cancer? (6)
• Surgery: bcs/ mastectomy with snlb/ axillary dissection (alnd)
• adjuvant radiotherapy after bcs or mastectomy if lymph nodes involved or unclear margins
• hormone therapy if positive
• chemo if hormone negative
• targeted If her positive
• can use neo-adjuvant chemo/hormone/targeted to reduce tumour size before surgery
Treatment stage 3 breast cancer? (6)
• Neo - adjuvant chemo with or without targeted therapy to shrink tumour
• Surgery: mastectomy with axillary dissection (alnd)
• adjuvant radiotherapy
• adjuvant hormone therapy if positive
• adjuvant chemo if hormone negative
• adjuvant targeted If her positive
Treatment stage 4 breast cancer?
• Palliation: systemic chemo/hormone/ targeted/immune treatment with or without radiotherapy
• relieve symptoms eg analgesia, radiation for back pain
• consider mastectomy surgery to control local symptoms
Name 3 contraindications breast conserving surgery
• Large tumour-to-breast ratio
• involvement skin or chest wall
• clear margins not guaranteed
What is modifed radical mastectomy?
Remove whole breast, axillary tail, axillary lymph nodes levels 1 and 2, skin and nipple/areolar complex
Spare pectoralis minor and level 3 nodes
Indication for SNLB breast cancer?
All patients with no clinical LN
What is ALND breast cancer? How do?
Removal > 10 lymph nodes and histopathology
What is targeted therapy in breast cancer? What use?
Target her 2 tyrosine kinase receptor if positive
Monoclonal antibody: trastozumab (cardiotoxic and contraindicated pregnancy)
Name 4 complications breast cancer that pts may present with
• Malignant pleural effusion
• paraneoplastic syndrome
• secondary lymphoedema of arm
• endometrial cancer (high risk due to tamoxifen)
Lymph drainage of breast? (4)
• axillary nodes 75% (including skin) to subclavian then L thoracic duct/R lymphatic trunk
• parasternal nodes (20%)
• posterior intercostal nodes (5%)
(Skin also to inferior deep cervical, infraclavicular)
(Nipple and aerola to subareolar lymph plexus)
Name 6 indications for BRCA genetic testing in patients with breast cancer
• Strong direct family history
• Breast cancer diagnosed age 50 or younger
. Bilateral breast cancer
. Personal or family history ovarian cancer
• Ashkenazi Jew
• male breast cancer in direct family
Name 3 indications modified radical mastectomy
• Unsuitable for breast conserving surgery eg unclear margins, patient unwilling to receive post-op radiation
•axillary lymph nodes positive
• clinical evaluation suitable for R0 resection where no macro or micro scopic tumour remains
Name the 3 levels of axillary lymph nodes
• Level 1: lateral to pectoralis minor
• 2: between lower and upper edge, beneath pec minor
• 3: above/medial to pec minor.
Name 3 peri-operative complications of modified radical mastectomy
• Thoracodorsal nerve (and artery) injury → latissimus dorsi atrophy → unable to fully extend, rotate and adduct arm.
• intercostal - brachial nerve injury → numbness, hypoesthesia, loss sensation to Axilla, lateral chest wall, medial arm.
. Long thoracic nerve injury → serratus anterior atrophy → scapular winging
Name 9 post- op complications modified radical mastectomy
• Dehisced wound
• Seroma ( fluid build up )
• surgical site infection
• haematoma
• altered sensation and pain
• haemorrhage
• subcutaneous hydrops (oedema)
• skin paraesthesia
• lymphoedema affected upper limb: complication of node dissection and radiotherapy to Axilla
Most common causes breast pain? (3)
- Fibroadenoma.
- Costochondritis
- Mastitis
- Cyst
- Abscess
- Fat necrosis
Name and describe the 2 types of mastitis
• Lactational ( more common) - usually during first 3 months breastfeeding or during weaning. Associated with cracked nipples and milk stasis (poor feeding technique,) more common with first child .→ infection mostly S aureus or other skin and mouth commensals
• non-lactational: women with other conditions eg duct ectasia, as a peri-ductal mastitis. Rf tobacco smoking → damage to subareolar duct walls and predispose to bac infection
Clinical presentation mammary duct ectasia? (3)
• Coloured green/yellow nipple discharge
• palpable mass
.Nipple retraction
Causes fat necrosis of the breast? (2)
• Trauma 40%
•60% previous surgical or radiological intervention
Define mammary duct ectasia
Dilatation and shortening of major lactiferous ducts. Common presentation peni-menopausal women
Name 5 benign breast tumours
• Fibroadenoma (most common,low malignant potential)
• adenoma (glandular tumour in older women)
• papilloma (subareolar. Nipple discharge clear /bloody)
• lipoma
• phyllodes tumour ( fibroepithetial tumour, rare, malignant potential)
Define fibroademona
Benign proliferation of stromal and epithelial tissue of duct lobules. Proliferation due to progesterone.
Simple terms-proliferating glandular tissue caught up in connective tissue
