Breast Flashcards
Breast lumps
Cyst (female >35)
Fibroadenoma (female <35)
Carcinoma
Breast examination - triple assessment
Examination
Imaging - us, mammography
Fine needle aspiration (cytology) or core biopsy (histology)
Mammography in premenopausal women
Not useful due to ‘white-out’ of breast tissue due to high levels of oestrogen
NICE guidelines for MRI use in breast ca
MRI may be used:
In addition if high tissue density on mammography
If discrepancy between clinical assessment and mammography
When planning breast conserving surgery
Three important outcomes for breast ca
Psychological morbidity
Local recurrence
Mortality, micro metastasis
NICE guidelines for investigations in breast ca
All women with cancer should have an us of axilla
Needle biopsy of axillary node if positive
Sentinel node biopsy if negative
Surgery breast options
Wide local excision - lumpectomy with free margin
Partial mastectomy - at least 20cm normal surrounding tissue plus segment from periphery to nipple (eg quadrantectomy)
Simple mastectomy: total mastectomy
Radical: include pectorals and axillary contents (no additional benefit)
Supraradical: plus internal mammary chain
Bone metastases typically due to
Breast Bronchus Thyroid Kidney Prostate
Chemotherapy after breast ca
Greatest advantage in pre-menopausal node positive women
Monthly cycles for 4-6 months
No benefit from giving for longer
Radiotherapy after breast ca
Routinely used after wide local excision or partial mastectomy
Reduces risk of local recurrence but no effect on mortality
Allows breast conserving surgery to achieve similar results as simple mastectomy
10 yr survival rates in breast ca
50% in node positive
70% in node negative
Chemotherapy improves this by 5-10%
Reason for peau d’orange appearance
Due to obstruction of dermal lymphatics
Breast reconstruction surgery
Use latissimus dorsi flap
Paget’s disease of the nipple
Spread from intraductal carcinoma
Terminal care sequence
Analgesic ladder
Syringe driver
Transdermal opiate patches
Sentinel node
The first node which drains an area of tissue, giving access to the local lymphatic basin
Tumours progress in an orderly way (“skip nodes” are rare)
Sentinel node identification
Operative injection of vital blue dyes plus technetium labelled colloids - gamma probe
Possible to identify the sentinel node >90%
Intensive histology on single node better than quick check on 15 nodes from axillary clearance
Sentinel node biopsy
Easily identifiable - highly predictive of axillary status
Helps with prognosis and decisions about chemotherapy
If positive, most surgeons would undertake axillary clearance
Saves 80% of N0 women from this procedure
Herceptin (Transtuzumab) (anti-HER2)
25% of women with breast ca over-express human epidermal growth factors, type 2 (HER2) on the surface of tumour cells
Herceptin blocks cell growth and division
It blocks the binding of endogenous oestrogen to the cell and helps attract NK cells (Ab dependent cytotoxicity)
Results:
Immunotherapy with herceptin can improve survival by 3-6 months in HER2 positive women with late metastatic disease
Increase in disease-free survival and a reduction in distant metastasis in early HER2 positive breast ca
Regime: every 3 weeks for 1 year, ECHO every 3 months
Serious side effect of cardiomyopathy and CCF
Tamoxifen
SERM selective estrogen receptor modulator
Blocks breast, receptors, causes hot flushes and vaginal dryness
Stimulates bones and endometrium
Reduces both recurrence and death rates
5% benefit at 10 years if node negative, 10% benefit at 10 years if node positive
Increased risk of thromboembolic events and endometrial ca (1/500)
Aromatase inhibitors
Selective aromatase inhibitors used in post menopausal women
E.g. Anastrozole
MOA: block peripheral conversion of andostendione (adrenals) to oestrogen Results: as effective as tamoxifen in controlling metastatic disease, fewer thromboembolic events and endometrial ca, but more osteoporosis. Hot flushes and vaginal bleeding less common. ATAC trial (arimidex / tamoxifen alone or in combination)
