Breast Flashcards
Breast cancer RFx
- FEMALE
- Increased OESTROGEN (early menarche + late menopase)
- More glandular tissue
- OBESITY
- ALCOHOL (metabolised into carcinogen) / SMOKING
- 1ST DEGREE RELATIVE (FHx)
cOCP + HRT (esp combined)
Breast Cancer pathophys
BRCA (BReast CAncer) gene = tumour suppressor -> mutation = cancer
- BRCA1 (chromosome 17)
- 70% breast cancer by 80 + 50% ovarian
- bowel + prostate
- BRCA2 (chromosome 13)
- 60% breast by 80 + 20% ovarian
Types of breast cancer
- Ductal carcnioma in situ
- lobular carcinoma in situ
- Invasive ductal carcinoma (no specific type - NST)
- Invasive lobular carcinoma
- Inflam breast cancer
- Paget’s disease of Nipple
Rare:
Medullary breast cancer
Mucinous breast cancer
Tubular breast cancer
+ more
Breast Cancer screening
NHS -> MAMMOGRAM every 3 YEARS for everyone 50-70 Y/O (post-menopausal typically)
Then call back + thermography if something seems unusual
Can also use a MRI in complex cases (useful in ppl with implants too)
Downsides to breast cancer screening
- Anxiety and stress
- Exposure to radiation, with a very small risk of causing breast cancer
- Missing cancer, leading to false reassurance
- Unnecessary further tests or treatment where findings would not have otherwise caused harm
- Expensive
But benefits outweigh risks usually
Which people are high-risk for breast cancer
People with significant FHx:
- 1st degree relative under 40
- 1st degree male relative
- 1st degree relative with bilateral breast cancer diagnosed under 50
- 2 or more 1st degree relatives
Interventions for women at high-risk of breast cancer
Secondary care clinic or specialist genetic clinic
- can get genetic testing (need genetic and pre-test counselling)
Get ANNUAL mammogram
May use CHEMOPREVENTION:
- Tamoxifen (premenopause)
- Anastrozole (postmenopause - CI if severe osteoporosis)
Risk -reducing bilateral mastectomy or oophrectomy (less common)
Clinical features suggestive of breast cancer
-
Lumps: HARD, IRREGULAR, PAINLESS or FIXED
- may be tethered to skin/chest wall
- NIPPLE RETRACTION
- Skin dimpling (peau d’orange)
- LYMPHADENOPATHY (esp axilla)
When is a 2 week wait referral recommended for breast cancer
- An unexplained breast lump in patients aged 30 or above
- Unilateral nipple changes in patients aged 50 or above (discharge, retraction or other changes)
Consider for:
- unexplained axilla lump in over 30s
- indicative skin changes
What is the algorithm for once someone gets a 2 week referral for breast ca
Triple diagnostic assessment:
- Clinical assessment (history and examination)
- Imaging (ultrasound or mammography)
- also of lymphnodes in the axilla + to guide biopsy of any abnormal nodes - Biopsy (fine needle aspiration or core biopsy)
USS vs mammography for breast cancer
- USS better for younger women (have more glandular tissue)
- good to distinguish between solid and cystic
- Mammogram better for older
- can pick up calcifications
Can also use MRI for screening high-risk or to further assess tumour dimensions
What is a sentinal node biopsy
A sentinal node is the first node in the lymphatic drainage of a tumour area
Injecting isotope contrast and dye into tumour area highlights the sentinal node. A biopsy can be taken and nodes removed if cancer found.
Done if initial USS shows no abnormal nodes
Breast Cancer Receptors
Oestrogen receptors (ER)
Progesterone receptors (PR)
Human epidermal growth factor (HER2)
Treatment depends on which is present. Cancer can be triple negative = worse prognosis,
Where can breast cancer metastesise
Anywhere in body. But Main sides are:
- LUNGS
- LIVER
- BRAIN
- BONES
Breast Cancer Tx
- Surgery
- Breast conservation + radiotherapy
- Mastectomy
- Axillary clearance (SE: chronic Lymphoedema)
- Adjuvent Radiotherapy (SE: fatigue, irritation, fibrosis, shrinking)
- Chemo (typically if sensitive):
- Neoadjuvant
- Adjuvant
- treat mets/recurrance
- Hormone therapy (for 5-10 years)
- Tamoxifen, goserelin (- a GnRH agonist) (premonopause) (SE: risk of endometrial cancer)
- Aromatase inhib (postmenopause)
- Adjuvent bisphosphonates in postmenopausal women
Tamoxifen MOA
Selective oestrogen receptor modulator (SERM)
Blocks oestrogen receptors in breast tissue, and stimulates oestrogen receptors in the uterus and bones
helps prevent osteoporosis, but it does increase the risk of endometrial cancer
Aromatase inhib MOA
Aromatase is found in fat - converts androgens to oestrogen -> primary oestrogen sourse post-menopause
Inhibs stop oestrogen production in fat
Examples of targeted therapy for breast cancer
Basically just HER2 Ab
Trastuzumab (Herceptin) is a monoclonal antibody that targets the HER2 receptor. It may be used in patients with HER2 positive breast cancer. Notably, it can affect heart function; therefore, initial and close monitoring of heart function is required.
Pertuzumab (Perjeta) is another monoclonal antibody that targets the HER2 receptor. It may be used in patients with HER2 positive breast cancer. This is used in combination with trastuzumab (Herceptin).
Neratinib (Nerlynx) is a tyrosine kinase inhibitor, reducing the growth of breast cancers. It may be used in patients with HER2 positive breast cancer.
Types of breast reconstruction
After breat-conserving surg:
- Partial reconstruction (using a flap or fat tissue to fill the gap)
- Reduction and reshaping (removing tissue and reshaping both breasts to match)
Mastectomy:
- Breast implants (inserting a synthetic implant)
- Flap reconstruction (using tissue from another part of the body to reconstruct the breast)
Breast implants pros + cons
Pros:
- simple
- minimal scarring
Cons:
- Less natural
- Long term problems
- Hardening
- Leakage
- Shape change
Types of flap breast reconstruction
- Latissimus Dorsi Flap
- Transverse Rectus Abdominis Flap (TRAM Flap)
- Deep Inferior Epigastric Perforator Flap (DIEP Flap)
Pedicled vs Free flap
“Pedicled” - keeping the original blood supply and moving the tissue under the skin to a new location.
“Free flap” - cutting the tissue away completely and transplanting it to a new location.
In situ breast carcinoma defination
non-invasive breast cancer that is confined to the duct or lobule in which it originated and does not extend beyond the basement membrane
Potential precursor to invasive carcinoma
Types of breast carcinoma in situ
Ductal Carcinoma In Situ (DCIS)
Lobular Carcinoma In Situ (LCIS)
- classical
- pleomorphhic
- florid
Ductal Carcinoma In Situ (DCIS)
- Pre-cancerous or cancerous epithelial cells of the breast ducts
- Localised to a single area
- Often picked up by mammogram screening
- Potential to spread locally over years
- Potential to become an invasive breast cancer (around 30%)
- Good prognosis if full excised and adjuvant treatment is used
Lobular Carcinoma In Situ (LCIS)
- Pre-cancerous condition occurring typically in pre-menopausal women
- Usually asymptomatic and undetectable on a mammogram
- Usually diagnosed incidentally on a breast biopsy
- increased risk of invasive breast cancer in the future (around 30%)
- Often managed with close monitoring (e.g., 6 monthly examination and yearly mammograms)
Paget’s Disease of the Nipple
- Looks like eczema of the nipple/areolar
- Erythematous, scaly rash
- Indicates breast cancer involving the nipple
- May represent DCIS or invasive breast cancer
- Requires biopsy, staging and treatment, as with any other invasive breast cancer
Breast abscess
Collection of PUS within breast, usually caused by BACTERIAL INFECTION
Can be lactational (related to breastfeeding) or non-lactational
Abscess pathophys
Inflam -> PUS -> trapped -> abscess
RFx for mastitis/abscesses
- SMOKING
- Damage to nipple (eczema, piercings, candida)
- Underlying breast disease (e.g. cancer) affecting DRAINAGE
Most common causative organisms of breast absecess
- Staphylococcus aureus (the most common)
- Streptococcal species
- Enterococcal species
- Anaerobic bacteria (such as Bacteroides species and anaerobic streptococci)
Mastitis/breast abscess Sx
If infection is present:
- Nipple changes
- Purulent DISCHARGE
- PAIN + TENDERNESS
- Warmth, Erythema, Swelling
- HARDENING OF SKIN/TISSUE
KEY FEATURE of BREAST ABSCESS = swollen, tender lump which i FLUCTUANT (fluid moves on palpation)
+/- general symps e.g. myalgia, fatigue, fever, septic
Mastitis management
Lactational = conservative
- continue breastfeeding
- express milk
- breast massage
- Warm packs/showers + analgesia for symps
Non-lactational
- Analgesia
- ANTIBIOTICS (broad spec as can be aerobic or anaerobic -> CO-AMOX or MACROLIDES AND METRONIDAZOLE)
- Treat underlying causes (eczema, candida)
Breaset abscess management
- Referral to the on-call surgical team
- Antibiotics
- Ultrasound (confirm the diagnosis and exclude other pathology)
- Drainage (needle aspiration or surgical incision and drainage)
- MS+C of drained fluid
Fibroadneoma
Small, MOBILE benign tumours of stromal/epithelial breast duct tissue
More common in 20-40 y/o (due to response to female hormones)
On examination, fibroadenomas are:
Painless
Smooth
Round
Well circumscribed (well-defined borders)
Firm
Mobile (moves freely under the skin and above the chest wall)
Usually up to 3cm diameter
Breast cysts
Benign, individual, fluid-filled lumps - most common cause of lumps.
Typically in 30-50 y/o
On examination, breast cysts are:
- Smooth
- Well-circumscribed
- Mobile
- Possibly fluctuant
Can be painful and fluctuate in size with menstrual cycle
Management of breast cysts
further assessment to exclude cancer (may slightly increase risk), with imaging and potentially aspiration or excision.
- Aspiration can resolve pain
What is included in a triple assessment for breast cancer
Clinical score 1-5 (1 = norm; 5 = malignant)
Imaging score 1-5
Biopsy score 1-5
Aim for concordence in MDT
When would you do mastectomy vs Breast conservation
- Extensive disease through breast
- THe lump is too large in relation to the breast to be able to conserve (tho can use neoadjuvent chemo to shrink first and then do conservation therapy)
- preferance of the individual
Grade vs stage
Grade - how abnormal cancer looks down microscope + how likely it is to progress
Stage - the anatomical extent
What genetic factors affect breast cancer Tx succes
- Oestrogen sensitivity
- Progesteron sensitivity
- Herceptin sensitivity
Factors to consider if considering chemo for more complex breast cancer
- Young age
- Oestrogen receptor +ve
- High grade
- Node positive
- Ki67 pos
- ## Tumour size
