Breast Flashcards
What is pagets disease of the breast?
eczematoid change of the nipple associated with an underlying breast malignancy and it is present in 1-2% of patients with breast cancer
When is trastuzumab used in breast cancer?
In HER2 positive patients
What are Anastrozole and letrozole?
aromatase inhibitors that reduces peripheral oestrogen synthesis
Adjuvant hormonal therapy is offered if tumours are positive for hormone receptors. What is used in pre menopausal women and what is used in post?
Tamoxifen is still used in pre- and peri-menopausal women. In post-menopausal women, aromatase inhibitors such as anastrozole are used for this purpose
Chemotherapy in breast cancer?
Cytotoxic therapy may be used either prior to surgery (‘neoadjuvanant’ chemotherapy) to downstage a primary lesion or after surgery depending on the stage of the tumour, for example, if there is axillary node disease - FEC-D is used in this situation.
The ‘snowstorm’ sign on ultrasound of axillary lymph nodes indicates what?
extracapsular breast implant rupture. It is due to leakage of the silicone, which then drains via the lymphatic system, giving the ‘snowstorm appearance’ both in the breast and the lymph nodes.
What is mammary duct ectasia?
Dilatation of the large breast ducts
Most common around the menopause
May present with a tender lump around the areola +/- a green nipple discharge
If ruptures may cause local inflammation, sometimes referred to as ‘plasma cell mastitis’
Diagnosis of Paget’s disease of the nipple?
punch biopsy, mammography and ultrasound of the breast
First line abx for lactational mastitis?
Oral flucloxacillin
What is seen in mammography of a breast cyst?
Halo appearance
What is used in the management of oestrogen receptor positive breast cancer in pre-menopausal women?
Tamoxifen
Age for breast screening?
50-70 years
Factors of screening?
sensitivity, specificity, positive predictive value and negative predictive value
Ideally should have a detectable pre invasive stage
Should detect at a pre symptom stage
Treatment should improve prognosis
Asymptomatic stage where treatment improves prognosis
Easy test
Public health problem
Cost effective
What is ductal carcinoma in situ?
DCIS is an early form of breast cancer.
Memory aid for sensitivty and specificty
Think about heroine
Bags at baggage reclaim
Dogs sniffer
Sensitvity- Sniffs every bag
Specific sniffer dog will only indicate bags with drugs
Who do fibroadenoma most commonly occur in?
Younger people of childbearing age
Who do breast cysts often occur in?
Middle aged women
What promotes breast development?
Oestrogen
Cause of gynaecomastia
Increased oestrogen production or decreased testosterone production
When does gynaecomastia often occur?
Puberty and old age
Drugs that cause sprinolactone?
Sprinolactone
Steroids
Marajuana
There are 3 classes of medical treatment for gynecomastia:
androgens (testosterone, dihydrotestosterone, danazol), anti-estrogens (clomiphene citrate, tamoxifen), and aromatase inhibitors such as letrozole and anastrozole
Why is tamoxifen pre menopausal women and aromatase inhibitor post menopausal women
AIs stop the body from making estrogen, and as a result hormone receptor-positive tumors do not get fed by estrogen and die. AIs are not given to premenopausal women because their ovaries still produce estrogen. AIs will not stop the ovaries from making the estrogen that feeds the tumor.
What is a triple assessment?
History and examination
Mammogram
Biopsy and histology
Symptoms of breast cancer?
New lump in the breast or underarm (armpit).
Thickening or swelling of part of the breast.
Irritation or dimpling of breast skin.
Redness or flaky skin in the nipple area or the breast.
Pulling in of the nipple or pain in the nipple area.
Nipple discharge other than breast milk, including blood.
Any change in the size or the shape of the breast.
Pain in any area of the breast.
HPC questions for breast exam
Is it related to menstral cycle
Is it causing any discomfort?
Painful- More likely to be a cyst
Has there been an injury- May have drawn patient’s attention to lump or was it always there
PMH questions for breast cancer?
Ovarian cancer in the past
Breast cancer in the past
Haematological malignancy- Rt can increase risk of breast cancer
DH questions for breast cancer?
Combined oral contraceptive
HRT
Anything that has exogenous hormones
Anticoagulants- Important if going to biopsy
SH questions to ask breast cancer?
Alcohol is possibly the higher risk factor
Smoking is possibly a risk factor but not definite
BMI
Social support
Work
FH questions ask breast cancer?
BRAC1 and BRAC2 gene
First and second degree relatives
How many relatives
Was it breast or was it ovarian cancer?
Bilateral breast or one side?
Male breast cancer?
Oestrogenic exposure to breast cancer questions to ask?
Early menarche and late menopause
Number of pregnancies. Age of first pregnancy- Younger being protective
Breast feeding- Thought to be protective
How many views do you do in mammogram?
Bilateral
2 view mammography
Why is mammography a less useful test in younger patients
Ionising radiation and more fibrous at this stage
Apart from mammogram what should you do in breast tissue?
US
Mammogram vs US
Mammogram is the whole breast
US is just a part of the breast
Histology vs cytology
Histology help show how invasive the breast cancer is
Risk factors for histology
Infection
Bleeding
Pneumothorax
Getting muscle or pleural tissue
Questions for nipple discharge?
Bilateral?- Better if it is
Colour
If get to squeeze the nipple does it come from many ducts or just one duct?
What is Paget’s disease?
nipple, also known as Paget’s disease of the breast, is a rare condition associated with breast cancer.
It causes eczema-like changes to the skin of the nipple and the area of darker skin surrounding the nipple (areola). It’s usually a sign of breast cancer in the tissue behind the nipple.
Should involve the nipple
Most likely not bilateral
Causes of gynaecomastia?
Hypogonadism. Conditions that lower testosterone production, such as Klinefelter syndrome or pituitary insufficiency, can be associated with gynecomastia.
Aging. Hormone changes that occur with aging can cause gynecomastia, especially in men who are overweight.
Tumors. Some tumors, such as those involving the testes, adrenal glands or pituitary gland, can produce hormones that alter the male-female hormone balance.
Hyperthyroidism. In this condition, the thyroid gland produces too much of the hormone thyroxine.
Kidney failure. About half the people being treated with dialysis experience gynecomastia due to hormonal changes.
Liver failure and cirrhosis. Changes in hormone levels related to liver problems and cirrhosis medications are associated with gynecomastia.
Malnutrition and starvation. When your body is deprived of adequate nutrition, testosterone levels drop while estrogen levels remain the same, causing a hormonal imbalance. Gynecomastia can also happen when normal nutrition resumes.
2 types of breast surgery?
Lumpectomy and mastectomy
Aims of wide local excision
Remove all the cancer
Maintain the breast so if small breast and tumour taken out will we still have a breast looking area
Can you give radiotherapy to the breast twice?
No not technically
What is inflammatory breast cancer?
rare type of breast cancer. The cancer cells block the smallest lymph channels in the breast. The lymph channels (or lymph ducts) are part of the lymphatic system. They normally drain excess tissue fluid away from the body tissues and organs. mimics lymphatic flow of the tumour
Types of axillary surgery?
Sentinel node biopsy and axillary clearance
How to identify sentinel node biopsy?
In sentinel node biopsy, a tracer material is used to help the surgeon find the sentinel nodes during surgery. The sentinel nodes are removed and tested in a lab.
What happens to patient with Negative axillary nodal staging?
Sentinel node biopsy
What happens to patient with positive axillary nodal staging?
Nodal clearance
What does a positive sentinel node biopsy indicate?
A clearance
can you do a sentinel node biopsy after a mastectomy
No as breast not there
does in situ disease get a biopsy
No as not removing whole breast so still could do it after
What is adjuvant treatment of breast cancer?
Doing something other than surgery to help downstage the cancer
Treatments for breast cancer
Bisphosphonates
Hormonal therapy
RT
Biological therapy
Chemotherapy
Aspirin
What is the local treatment for breast cancer?
RT
Who is offered radiotherapy for breast cancer
Everyone if not having a mastectomy
Who gets rt after a mastectomy?
4 or more positive lymph nodes get rt
Ans some other people
Rt side effects?
Damage to skin, fat, fibrous and connective tissue, damage to organs nearby
Radiation injury to the skin
When can radiotherapy be done palliatively?
Bony mets
Adjuvant chemo reasons to give after surgery?
Her positive
Lymph node involvement
More invasive/higher grade
Oestrogen negative
Chemotherapy side effects?
Immunosuppression
Hair loss
Diarrohea and vomiting
Neutropenic sepsis
Fatigue
Mucosal lining issues
Infertility
Peripheral neuropathy
What can cause death due to chemotherapy side effects?
Immunosuppression and neutropenic sepsis
What can happen if put toxic IV into vessels?
Phlebitits
Why is chemo put into a central vein?
Much larger vein so less likely to get issues with phlbeitis
But still at risk of infection
How is chemotherapy often done?
3 drugs 8 weeks apart
Then switch to another drug
Takes 18 weeks
How do we know if adjuvant chemo is working?
We don’t. You can’t check it. Have to guess :(
What can adjuvant chemo do?
Make an inoperable cancer operable
Make a mastectomy into a wide local excision
Make an excision smaller
Inflammatory breast cancer
Can also downstage the axilla
When can’t transtuzumab not be used?
Cardiotoxicity
Example of biologic therapy used after chemo?
Transtuzumab
What is important before giving transtuzumab?
Need to have had chemo first and be HER2 positive
When can transumab also be given?
Neo adjuvantly and palliatively
What kind of drug is tamoxifen?
Selective oestrogen receptor modifier
Stops modulatory effects of oestrogen
If pre menopausal where does the oestrogen come from?
Ovaries
Where does post menopausal oestrogen come from?
Fat
So this is why tamoxifen can still be used if ER positive in any age
What kind of drug is anastrazole
Aromatase inhibitor
How to temporarily make someone post menopausal?
GnRH
Zoladex
Why is bisphosphonates used after breast cancer?
Help protect from bone thinning
Follow up for breast cancer?
Mammography 5-10 years after diagnosis
