Breast Flashcards
What are the 4 most common pathogens causing breast abscesses?
- Staph aureus (most common)
- Streptococcal species
- Enterococcal species
- Anaerobic species (e.g. Bacteriodes species & anaerobic streptococci)
What is a breast abscess?
A collection of pus within an area of the breast. Infection can either present as simple mastitis or form a breast abscess.
What are the 2 types of breast abscess?
- Lactational abscess
- Non-lactational abscess
What is a lactational abscess related to?
Breastfeeding
What is pus?
Pus is a thick fluid produced by inflammation – contains dead WBCs and other waste
How does an abscess form?
When pus becomes trapped in a specific area and cannot drain, an abscess forms and gradually increases in size
Define mastitis
Inflammation of breast tissue
What may precede the formation of an abscess?
Mastitis
What is a key risk factor for infective mastitis and breast abscesses?
Smoking
Why is smoking a risk factor for mastitis?
People who smoke have an increased risk of periductal mastitis because substances in cigarette smoke can damage the ducts behind the nipple.
Give some risk factors for breast abscesses
- Smoking
- Breastfeeding
- Damage to nipple (e.g. nipple eczema, candida infection or piercings) provides bacteria entry
- Underlying breast disease (e.g. cancer) can affect the drainage of the breast, predisposing to infection
Why can cancer predispose to breast abscesses?
cancer can affect the drainage of the breast, predisposing to infection
Should breastfeeding be stopped in women with mastitis or breast abscesses?
No
Why should women with mastitis or breast abscesses continue to breast feed or regularly express breast milk?
This is NOT harmful to the baby and is important in helping resolve the mastitis or abscess.
Onset of mastitis/breast abscess?
Acute (within a few days)
Describe some breast signs/symptoms seen in mastitis with infection in the breast tissue
- Nipple changes
- Purulent nipple discharge (pus from nipple)
- Localised pain (acutely painful)
- Tenderness
- Warmth
- Erythema
- Hardening of skin or breast tissue
- Swelling
What key features of a breast lump would suggest its an abscess?
- Swollen
- Tender
- Fluctuant
Define fluctuance of a lump
being able to move fluid around within the lump using pressure during palpation
Lump in mastitis vs breast abscess?
when there is infection WITHOUT an abscess, there can still be hardness of the tissue forming a lump BUT will not be fluctuant (as not filled with fluid)
What makes a breast abscess fluctuant?
Fluid
Other signs seen in breast abscess?
- Muscle aches
- Fatigue
- Fever
- Signs of sepsis e.g. tachycardia, raised RR, confusion –> sepsis 6
Describe the management plan for lactational mastitis
Caused by blockage of ducts –> managed conservatively:
- Continued breastfeeding
- Expressing milk
- Breast massage
- Heat packs, warm showers & simple analgesia to manage symptoms
- Antibiotics (flucloxacillin or erythromycin/clarithromycin where there is penicillin allergy) – required where infection is suspected or symptoms do not improve
Describe the management plan for non-lactational mastitis
- Analgesia
- Antibiotics – need to be broad spectrum (co-amoxiclav or erythromycin/clarithromycin + metronidazole)
- Treatment for underlying cause (e.g. eczema or candida infection)
What Abx are indicated in non-lactational mastitis?
Broad spectrum e.g. co-amoxiclav or erythromycin/clarithromycin + metronidazole
Describe the management of a breast abscess
- Referral to on-call surgical team
- Antibiotics
- US
- Drainage (needle aspiration or surgical incision and drainage)
- MC&S of drained fluid
Define fibrocystic breast changes
The connective tissues (stroma), ducts and lobules of the breast respond to the female sex hormones (oestrogen and progesterone), becoming fibrous (irregular and hard) and cystic (fluid-filled). These changes fluctuate with the menstrual cycle.
What drives fibrocystic breast changes?
Female sex hormones: oestrogen & progesterone
Who are fibrocystic breast changes common in?
Common in women of menstruating age
Prognosis of fibrocystic breast changes?
Is a benign (non-cancerous) condition but can vary in severity an affect patient’s quality of life if severe.
When do Fibrocystic Breast Changes tend to appear? When do they tend to resolve?
Symptoms usually occur prior to menstruating (within 10 days) and resolve once menstruation begins
How does menopause typically affect fibrocystic breast changes?
Symptoms usually improve or resolve after menopause
Breast symptoms seen in fibrocystic breast changes?
- Lumpiness
- Breast pain or tenderness (mastalgia)
- Fluctuation of breast size
Management of fibrocystic breast changes?
After exclusion of cancer, management involves managing symptoms:
- Wearing a supportive bra
- NSAIDs
- Avoiding caffeine
- Applying heat to area
- Hormonal treatments (e.g. danazol and tamoxifen) under specialist guidance
Define a ductal papilloma
A warty lesion that grows within one of the milk ducts in the breast.
Is a ductal papilloma associated with cancer?
It is a benign tumour but can be associated with atypical hyperplasia or breast cancer.
A ductal papilloma is a proliferation of what cells?
Proliferation of epithelial cells that line the ducts.
Presentation of a ductal papilloma?
Often asymptomatic – often picked up incidentally on mammograms or ultrasound.
- Nipple discharge – clear or blood-stained
- Tenderness or pain
- Palpable lump –> Usually found <1cm from nipple
Where is the lump of a ductal papilla located?
<1cm from nipple
Describe triple breast assessment
1) Clinical assessment (history & examination)
2) Imaging (US, mammography & MRI)
3) Histology (usually by core biopsy or vacuum-assisted biopsy)
Management of ductal papilloma?
- Complete surgical excision is required
- After removal, tissue is examined for atypical hyperplasia or cancer that may not have been picked up on biopsy
What is the most common benign breast lump?
Fibroadenoma
Where does a fibroadenoma arise from?
Stromal/epithelial breast duct tissue
Who are fibroadenomas typically seen in?
Younger women (20-40) i.e. of reproductive age.
Why are fibroadenomas typically seen in younger women?
These tumours respond to the female hormones (oestrogen & progesterone) which is why they are more common in younger women and often regress after menopause.
Are fibroadenomas associated with breast cancer?
Not cancerous and not usually associated with an increasing risk of developing breast cancer.
Features of a fibroadenoma breast lump
- Small (usually up to 3cm diameter)
- Mobile within breast tissue (moves freely) – sometimes called a ‘breast mouse’ as they move around within the breast tissue
- Painless
- Smooth
- Round
- Well circumscribed (well-defined borders)
- Firm
Give some red flags for a breast lump
- Tethered to skin
- Nipple discharge (especially bloody)
- Irregular shape
- Lymphadenopathy
- Dimpling of skin
- Puckering of nipple
Describe the breast lump in fibrocystic change
Tender & rubbery
What is a lipoma? Where can they occur?
Benign tumours of fat (adipose) tissue. Can occur almost anywhere on the body where there is adipose tissue, including the breasts.
Presentation of a lipoma?
- Soft
- Painless
- Mobile
- Does NOT cause skin changes
Management of lipomas?
- Often conservative (reassurance)
- Can be surgically removed (only if a) rapidly enlarging or b) symptomatic or aesthetic problems)
What is a Phyllodes tumour?
Rare tumour of the connective tissue (stroma) i.e. fibroepithelial tumours
What age group do Phyllodes tumours typically affect?
Occurring most often between ages 40-50.
Are Phyllodes tumours malignant or benign?
Can be benign (50%), borderline (25%) or malignant (25%).
Phyllodes tumours can metastasise.
Which 2 features characterise a Phyllodes tumour?
Large and fast growing
Management of Phyllodes tumour?
- Surgical removal of tumour and surrounding tissue (wide excision)
- Can reoccur after removal
- Chemotherapy in malignant/metastatic tumours
What is the most common form of cancer in the UK?
Breast carcinoma (around 1 in 8 women will develop breast cancer in their lifetime)
Give some risk factors for breast carcinoma
- Female (99% of breast cancers)
- Increased oestrogen exposure (earlier onset of periods and later menopause)
- More dense breast tissue (more glandular tissue)
- Obesity
- Smoking
- Family history (1st degree relatives)
- COCP gives small increase in risk of breast cancer, but risk returns to normal 10 years after stopping the pill
- HRT (particularly combined HRT containing oestrogen & progesterone)
Why is obesity a risk factor for breast cancer?
Obesity increases oestrogen levels as adipose tissue is the main source of oestrogen biosynthesis
Presentation of breast lump in breast carcinoma
- Lumps that are hard, irregular, painless or fixed in palce
- Lumps may be tethered to the skin or chest wall
- Nipple retraction
- Skin dimpling or oedema (peau d’orange)
- Lymphadenopathy, particularly in the axilla
What are BRCA genes?
Anti-oncogenes that both code for tumour suppressor proteins which reduce the risk of breast cancer when functioning normally.
Mutations in BRCA genes can increase your risk of what cancers?
Breast, ovarian, prostate, bowel etc
What chromosome is BRCA1 and BRCA2 on?
BRCA 1 –> 17
BRCA 2 –> 13
What is the risk of develop breast & ovarian cancer in those with the BRCA1 mutation?
Breast –> around 70% will develop breast cancer by age 80
Ovarian –> around 50% will develop ovarian cancer
What is the risk of develop breast & ovarian cancer in those with the BRCA2 mutation?
Breast –> Around 60% will develop breast cancer by aged 80
Ovarian –> Around 20% will develop ovarian cancer
Is a mutation in BRCA1 or BRCA2 a higher risk for breast cancer?
BRCA1
Breast cancer is typically divided into what two classifications?
1) non-invasive
2) invasive
What defines a non-invasive breat cancer?
These tumour cells have NOT invaded the basement membrane
Can be referred to as premalignant or pre-cancerous.
They may progress to an invasive form of breast cancer.
What are the 2 types of non-invasive breast cancers?
1) Ductal carcinoma in situ (DCIS)
2) Lobular carcinoma in situ (LCIS)
What are the main types of breast cancer?
1) Ductal carcinoma in situ (DCIS)
2) Lobular carcinoma in situ (LCIS)
3) Invasive ductal carcinoma
4) Invasive lobular carcinokma (ILC)
5) Inflammatory breast cancer
6) Paget’s disease of the nipple
What is the most common type of non-invasive breast malignancy?
Ductal carcinoma in situ (DCIS) (20% of all breast cancer diagnoses)
What is DCIS? What cells does it arise from?
Pre-cancerous or cancerous epithelial cells lining the ductal tissue of the breast
What are the 4 subtypes of DCIS?
1) papillary
2) cribriform
3) solid
4) comedo
Knowing the subtype of cancer can help predict the rate of transformation to invasive cancer.
Can DCIS spread?
- Potential to spread locally over years
- Potential to become an invasive breast cancer (around 30%)
How is DCIS often picked up?
Mammogram screening
Prognosis of DCIS?
Good if fully excised and adjuvant treatment is used
What LCIS? Where does it arise from?
A pre-cancerous condition of the secretory lobules.
It is confined to the acini cells.
Who does LCIS typically occur in?
Occurs typically in pre-menopausal women (90%)
How is LCIS often picked up?
- Often asymptomatic and undetectable on a mammogram
- Usually diagnosed incidentally on a breast biopsy
Prognosis of LCIS?
Higher risk of invasive malignancy in the future (around 30%)
Management of LCIS?
Often close monitoring (e.g. 6 monthly examination and yearly mammograms)
Which type of non-invasive breast cancer is found:
a) only in one breast (unilateral)
b) in both breasts (bilateral)
a) DCIS
b) LCIS
What defines an invasive cancer?
Has invaded the basement membrane
What are the 2 types of invasive breast cancer?
- Invasive ductal carcinoma (also called no special type - NST)
- Invasive lobular carcinoma
Where do invasive ductal carcinomas originate?
Originate in cells from the breast ducts
What is the most common type of breast cancer?
Invasive ductal carcinoma - 80% of invasive breast cancers fall into this category
What does invasive ductal carcinoma NST mean?
It is called ‘no special type’ because when it is examined under the microscope the cancer cells have no particular features.
How are invasive ductal carcinomas often picked up?
Can be seen on mammograms
Who are invasive lobular carcinomas normally seen in?
Much more common in older women
Where do invasive lobular carcinomas arise from?
Originate in cells from breast lobules
How are invasive ductal carcinomas often picked up?
Not always visible on mammograms
Diffuse spread makes detection more difficult
There are two rare types of breast cancer that are important to know about, as they can easily be mistaken for other benign conditions.
What are they?
- Inflammatory breast cancer
- Paget’s disease of the nipple
What is inflammatory breast cancer?
Cancer cells block lymph vessels in skin of breast, causing breast to appear swollen and red or inflamed.
What age group is inflammatory breast cancer typically seen in?
Younger women (<40 y/o)
What does inflammatory breast cancer present similarly to?
Presents similar to a breast abscess or mastitis → swollen, warm, tender breast with pitting skin (peau d’orange)
How does inflammatory breast cancer present?
Presents with an erythematous oedematous breast and is often mistaken for an infection (mastitis) or breast abscess.
Note: patients will NOT have a fever, chills or elevated white cell count.
What type of cancer does peau d’orange of the breast indicate?
Inflammatory breast cancer
Prognosis of inflammatory breast cancer?
- Worse than other breast cancers as tends to be more aggressive and spread more quickly
- Typically at a locally advanced stage when 1st diagnosed
- 1/3 cases have already metastasised
What is Paget’s disease of the breast?
A rare condition associated with breast cancer
Is Paget’s disease of the breast related to Paget’s disease of the bone?
No
How does paget’s disease of the nipple present?
Presents with rough, dry, erythematous and ulcerated skin surrounding the nipple. It can look similar to eczema, however, it must be distinguished from this as Paget’s disease is often associated with an underlying in-situ or invasive cancer.
What is Paget’s disease of the nipple often associated with?
An underlying in-situ or invasive cancer.
Other rare types of breast cancer – described as ‘special type’ as they have features under the microscope which allow us to classify them more specifically.
What are some examples of these?
mucinous; medullary; papillary; tubular; phyllodes; metaplastic; basal-like and primary breast lymphoma.
What are some factors that may cause an increased exposure to oestrogen (and therefore an increased risk of breast cancer)?
- Nulliparity and increasing age of first childbirth
- Early menarche (menstruation starting in girls under 12 years old): causing early exposure to oestrogen
- Late menopause (>55-years-old): increasing the length of exposure to oestrogen
- Hormone replacement therapy (HRT) with oestrogen and progestogen
- Obesity: increases oestrogen levels because more adipose tissue leads to increased expression of an enzyme called aromatase which increases the synthesis of oestrogen
What is a protective factor for breast cancer?
Breast feeding
Who is offered mammograms and how often?
Women aged 50-70 y/o every 3 years
What is the aim of mammograms?
Detect breast cancer early – roughly 1 in 100 women are diagnosed with breast cancer after going for a mammogram
Disadvantages of breast cancer screening?
- Anxiety & stress
- Exposure to radiation, with very small risk of causing breast cancer
- Missing cancer – false reassurance
- Unnecessary further tests or treatment where findings would not have otherwise caused harm
Generally, the benefits far outweigh the downsides and screening IS recommended
Genetic testing for breast cancer can be performed in high risk patients. What must happen first?
Genetic counselling & pre-test counselling to discuss benefits and drawbacks of genetic testing .g. implications for family members and offspring.
Give some management options for high risk breast cancer patients
- Annual mammogram screening (as opposed to every 3 years)
- Chemoprevention
- Bilateral mastectomy or bilateral oophorectomy –> significant counselling required
What is the pharmacological agent for chemoprevention of breast cancer in premenopausal women?
Tamoxifen
What is the pharmacological agent for chemoprevention of breast cancer in postmenopausal women?
Anastrozole
When is anastrozole contraindiated in the chemoprevention of breast cancer in postmenopausal women?
Patients with severe osteoporosis
Clinical presentation of breast cancer?
Most patients present with a painless lump in the breast or axilla. The patient may have noticed nipple discharge.
- Lumps that are hard, irregular, painless or fixed in place
- Lumps may be tethered to the skin or the chest wall
- Nipple retraction
- Skin dimpling or oedema (peau d’orange)
- Lymphadenopathy, particularly in the axilla
- Symptoms of metastasis (e.g. weight loss, anorexia, bone pain, jaundice, fatigue, breathlessness)
what type of nipple discharge is often deemed abnormal?
If the nipple discharge is UNILATERAL or BLOODY this is abnormal and needs investigating for breast cancer.
what type of nipple discharge is often deemed benign?
Bilateral clear or milky nipple discharge is usually benign and is not associated with breast cancer, although further investigation is required to rule out other causes.
Describe features of breast lumps that are more commonly associated with breast cancer
- Hard with a gritty texture
- Ill-defined, irregular margins
- Tethered (attached to the surrounding breast tissue or skin) or fixed (attached to the chest wall)
- Most breast cancers arise in the upper outer quadrant of the breast
- A suspicious lump felt in the axilla may indicate metastasis to the lymph nodes.
Describe nipple changes that may be associated with cancer
- Bleeding, discharge, inversion or deviation of the nipple.
- Paget’s disease, as explained earlier, can mislead clinicians as the rough, dry, erythematous, and ulcerated skin surrounding the nipple can be misdiagnosed as eczema (this requires a punch biopsy to distinguish between Paget’s and eczema).
What is required to distinguish between Paget’s and eczema?
Punch biopsy
What skin changes can be associated with breast cancer?
- Rough, dry, erythematous, and ulcerated skin surrounding the nipple can be caused by Paget’s disease
- A cancerous breast lump beneath the skin can cause dimpling or puckering of the skin.
- Peau d’orange: the skin looks like the surface of an orange. This occurs when the lymphatic system that drains the skin is blocked by cancer cells causing the skin to become oedematous. This can be easily misdiagnosed as an infection.
What is the NICE criteria for a 2 week wait referral for suspected breast cancer?
- Unexplained breast lump in patients aged 30 and above
- Unilateral nipple changes in patients aged 50 and above e.g. discharge, retraction or other changes
- Unexplained lump in axilla in patients aged 30 and above
- Skin changes suggestive of breast cancer
Give some differential diagnoses of breast lumps
- Fibroadenoma
- Breast cyst
- Intraductal papilloma
- Breast abscess
- Fat necrosis
What features would distinguish a fibroadenoma from a breast cancer lump?
Fibroadenomas are benign overgrowth of collagenous mesenchyme of one breast lobule
Present with firm, non-tender, highly mobile palpable lumps
What features would distinguish a breast cyst from a breast cancer lump?
Breast cysts are palpable, benign, fluid-filled rounded lumps that are not fixed to surrounding tissue
What features would distinguish an intraductal papilloma from a breast cancer lump?
Intraductal papillomas are benign, warty lesion usually located just behind the areola.
Present as a small lump and a sticky, possibly blood-stained discharge may be noticed
What features would distinguish a breast abscess from a breast cancer lump?
Breast abscesses:
- Most common in breastfeeding mothers
- Presents with malaise and fever accompanied by a throbbing pain
- The breast will be hot and red and may have tender ipsilateral lymphadenopathy in the axilla
What features would distinguish fat necrosis of the breast from a breast cancer lump?
Fat necrosis of the breast would have fibrosis and calcification of the breast tissue usually due to trauma and can present as an irregular craggy mass, skin tethering, nipple retraction, thus mimicking a cancer
Once a patient has been referred for specialist services under a two week wait referral for suspected cancer, they should initially receive a triple diagnostic assessment.
What is this comprised of?
1) Clinical assessment (history and examination)
2) Imaging (ultrasound or mammography)
3) Biopsy (fine needle aspiration or core biopsy)
What imaging modality is used for breast cancer assessment in younger women (<30/40)?
Why?
Ultrasound as more dense breasts (more glandular tissue)
What imaging modality is used for breast cancer assessment in older women (>30/40)?
Mammogram
What can mammograms pick up that may be missed by US?
Calcifications
What is US of the breast useful in differentiating?
Helpful in distinguishing solid lumps (e.g. fibroadenoma or cancer) from cystic lumps (fluid-filled)
What imaging may be recommended after a mammogram?
MRI
What imaging may be recommended for screening in women at higher risk of developing breast cancer (e.g., strong family history)?
MRI
What are the 2 options for biopsy in breast cancer triple assessment?
1) Core biopsy
2) Fine needle aspiration
What is fine needle aspiration (FNA)?
Fine needle aspiration (FNA) uses a single fine needle to collect cells allowing for cytology to examine isolated cells.
When is FNA typically used in breast lump assessment?
This technique is often used for smaller more cystic lumps and is usually performed under ultrasound guidance.
What is core biopsy?
Core biopsy uses a wider needle often performed under ultrasound guidance. It takes a core of tissue, which provides much more information about the cancer and its involvement with surrounding tissues leading to a higher diagnostic yield compared to FNA.
What staging system is used in breast cancer?
TNM
Why is a sentinel lymph node biopsy performed in breast cancer?
A sentinel lymph node biopsy may be used during breast cancer surgery where the initial ultrasound does not show any abnormal nodes.
An isotope contrast and a blue dye are injected into the tumour area. The contrast and dye travel through the lymphatics to the first lymph node (the sentinel node). The first node in the drainage of the tumour area shows up blue and on the isotope scanner. A biopsy can be performed on this node, and if cancer cells are found, the lymph nodes can be removed.
What are the 3 types of breast cancer receptors?
1) Oestrogen receptors (ER)
2) Progesterone receptors (PR)
3) Human epidermal growth factor (HER2)
Why is it important to know the breast cancer receptors?
Breast cancer cells may have receptors that can be targeted with breast cancer treatments. These receptors are tested for on samples of the tumour and help guide treatment.
What is triple negative breast cancer?
Triple-negative breast cancer is where the breast cancer cells do not express any of these three receptors.
Why does triple negative breast cancer carry a worse prognosis?
This carries a worse prognosis, as it limits the treatment options for targeting the cancer.
What are the 4 most common sites for breast cancer to metastasise to?
- Bone (hypercalcaemia)
- Lungs
- Liver
- Brain
Give some management options for breast cancer
- Surgery
- Radiotherapy
- Chemotherapy
- Hormone therapy
What are the surgical options for breast cancer?
The objective is to remove the cancer tissue along with a clear margin of normal breast tissue. The options are:
1) Breast-conserving surgery e.g. wide local excision
2) Mastectomy (removal of the whole breast), potentially with immediate or delayed breast reconstruction
3) Ovarian ablation - used to stop oestrogen synthesis (women with BRCA 1 or 2 are also predisposed to ovarian cancer)
If cancer cells are found in the lymph nodes in breast cancer, what is offered?
Removal of the axillary lymph nodes.
Usually, the majority or all lymph nodes are removed from the axilla.
This increases the risk of chronic lymphoedema in that arm.
What is chronic lymphoedema?
Lymphoedema is a chronic condition caused by impaired lymphatic drainage of an area.
Lymphoedema can occur in an entire arm after breast cancer surgery on that side, with removal of the axillary lymph nodes in the armpit.
Management options for chronic lymphoedema after breast cancer surgery?
- Massage techniques to manually drain the lymphatic system (manual lymphatic drainage)
- Compression bandages
- Specific lymphoedema exercises to improve lymph drainage
- Weight loss if overweight
- Good skin care
TIP
Breast cancer can spread to any region of the body. In patients with a metastatic tumour, regardless of where it is, the primary could be breast cancer. This is worth remembering, as you may be asked “where might this metastasis have originated” in an exam or OSCE scenario. If the patient is female, answering “breast cancer” will be a good answer. The other cancer that can spread practically anywhere, and may be less obvious, is melanoma (a type of skin cancer).
Why should you avoid taking blood or putting a cannula in the arm on the side of previous breast cancer removal surgery?
There is a higher risk of complications and infection due to the impaired lymphatic drainage on that side.
When is radiotherapy used in breast cancer?
Radiotherapy is usually used in patients with breast-conserving surgery to reduce the risk of recurrence.
Common side effects of radiotherapy?
- General fatigue from the radiation
- Local skin and tissue irritation and swelling
- Fibrosis of breast tissue
- Shrinking of breast tissue
- Long term skin colour changes (usually darker)
Chemotherapy is used in 1 of which 3 scenarios in breast cancer?
1) Neoadjuvant therapy – intended to shrink the tumour before surgery
2) Adjuvant chemotherapy – given after surgery to reduce recurrence
3) Treatment of metastatic or recurrent breast cancer
Neoadjuvant vs adjuvant chemotherapy?
Neoadjuvant chemotherapy is used prior to surgery to help shrink the cancer to allow for breast-conserving surgery.
Adjuvant chemotherapy is used after surgery to try and prevent the recurrence of the cancer and increase survival.
What is the purpose of an oncotype DX breast recurrence score assay?
The patient’s breast cancer cells are sent for genetic testing, where a 21 gene panel is used to analyse the cells and produces a score between 0 and 100.
The higher the score the more likely the cancer will recur.
So, it is used to decide if adjuvant chemotherapy is warranted, helping to avoid patients from being subject to chemotherapy that they may not benefit from.
What can be used in premenopausal women to help protect their ovaries from premature ovarian failure which is a potential side effect of the chemotherapy?
Gonadotropin-releasing hormone agonists e.g. goserelin
What is the 1st line pharmacological option for hormone therapy in ER-positive breast cancer in premenopausal women?
Tamoxifen
How does tamoxifen work?
Tamoxifen is a selective oestrogen receptor modulator (SERM).
It either blocks or stimulates oestrogen receptors, depending on the site of action. It blocks oestrogen receptors in breast tissue, and stimulates oestrogen receptors in the uterus and bones.
This means it helps prevent osteoporosis, but it does increase the risk of endometrial cancer.
What is the 1st line pharmacological option for hormone therapy in ER-positive breast cancer in postmenopausal women?
Aromatase inhibitors (Letrozole, Anastrozole, Exemestane)
How do aromatase inhibitors work?
Aromatase is an enzyme found in fat (adipose) tissue that converts androgens to oestrogen. After menopause, the action of aromatase in fat tissue is the primary source of oestrogen. Aromatase inhibitors work by blocking the creation of oestrogen in fat tissue.
How long is tamoxifen/aromatase inhibitors given for in women with oestrogen-receptor positive breast cancer?
5-10 years
What are some other hormonal options for women with oestrogen-receptor positive breast cancer?
Fulvestrant (selective oestrogen receptor downregulator)
GnRH agonists (e.g., goserelin or leuprorelin)
Ovarian surgery
Which monoclonal antibody is used for breast cancers that express HER2?
Trastuzumab (Herceptin)
What is the 1st line pharmacological option in HER2-positive breast cancer?
Trastuzumab (Herceptin)
Notable side effect of Herceptin?
It can affect heart function; therefore, initial and close monitoring of heart function is required.
Who is tamoxifen indicated in?
Oestrogen-receptor positive breast cancer in pre-menopausal women
Who are aromatase inhibitors indicated in?
Post-menopausal women with ER positive breast cancer
Give some examples of aromatase inhibitors
Anastrozole, letrozole, exemestane
After menopause, what is the primary source of oestrogen in women?
Action of aromatase converted androgens to oestrogen in fat tissue
What is another name for Trastuzumab?
Herceptin
What class of drug is Trastuzumab?
Monoclonal antibody (immunotherapy)
Mechanism of Trastuzumab (Herceptin)?
Cell signalling inhibitor:
1) Blocking HER-2 activating ligand from binding
2) Activating the body’s own immune response against these cells
What is another monoclonal antibody that targets the HER2 receptor?
Pertuzumab (Perjeta)
What are 3 targeted treatment options that can be used in patients with HER2 positive breast cancer?
1) Trastuzumab (Herceptin)
2) Pertuzumab (Perjeta)
3) Neratinib (Nerlynx)
What is Neratinib (Nerlynx)?
a tyrosine kinase inhibitor, reducing the growth of breast cancers. It may be used in patients with HER2 positive breast cancer.
Reconstructive surgery is offered to all patients having a mastectomy.
What are the 2 options?
1) Immediate reconstruction, done at the time of the mastectomy
2) Delayed reconstruction, which can be delayed for months or years after the initial mastectomy
After breast-conserving surgery, reconstruction may not be required.
What are the standard options, if needed?
1) Partial reconstruction (using a flap or fat tissue to fill the gap)
2) Reduction and reshaping (removing tissue and reshaping both breasts to match)
After mastectomy, what are the options for reconstructing the breast(s)?
1) Breast implants (inserting a synthetic implant)
2) Flap reconstruction (using tissue from another part of the body to reconstruct the breast)
Implants vs flap reconstruction?
Implants:
Inserting an implant is a relatively simple procedure (compared with a flap) with minimal scarring. It gives an acceptable appearance but can feel less natural (e.g., cold, less mobile and static size and shape). There can also be long-term problems, such as hardening, leakage and shape change.
Different flap reconstruction options?
- Latissimus Dorsi Flap
- Transverse Rectus Abdominis Flap (TRAM Flap)
- Deep Inferior Epigastric Perforator Flap (DIEP Flap)
What is a Latissimus Dorsi Flap?
The breast can be reconstructed using a portion of the latissimus dorsi and the associated skin and fat tissue. The tissue is tunnelled under the skin to the breast area.
“Pedicled” refers to keeping the original blood supply and moving the tissue under the skin to a new location.
“Free flap” refers to cutting the tissue away completely and transplanting it to a new location.
What is a Transverse Rectus Abdominis Flap (TRAM Flap)?
The breast can be reconstructed using a portion of the rectus abdominis, blood supply and skin. This can be either as a pedicled flap (tunnelled under the skin) or a free flap (transplanted). It poses a risk of developing an abdominal hernia due to the weakened abdominal wall.
What is a Deep Inferior Epigastric Perforator Flap (DIEP Flap)?
The breast can be reconstructed using skin and subcutaneous fat from the abdomen (no muscle) as a free flap. The deep inferior epigastric artery, with the associated fat, skin and veins, is transplanted from the abdomen to the breast. The vessels are attached to branches of the internal mammary artery and vein. This is a complex procedure involving microsurgery. There is less risk of an abdominal wall hernia than with a TRAM flap, as the abdominal wall muscles are left intact.
Which type of non-invasive breast cancer typically occurs in pre-menopausal women?
LCIS
