Breast Flashcards
what percentage of women will develop breast cancer?
1 in 8
what are some risk factors for breast cancer?
first child birth >35 alcohol consumption atypical ductal hyperplasia lobular carcinoma in situ HRT for more than 5 years OCP post-menopausal obesity
what are the genes that increase your risk of breast cancer?
BRCA 1 - female breast, ovarian (40-80% life time risk of breast cancer)
BRCA 2 - female and male breast, ovarian, prostate and pancreatic cancers (20-80% lifetime risk of breast cancer)
Tp53 (Li-Fraumeni syndrome) - breast, sarcoma, leukaemia, brain, adrenocortical, lung cancers - (56-90% life time risk of breast cancer
PTEN (Cowden’s syndrome) - breast, thyroid and endometrial (25-50% lifetime risk of breast cancer)
STK11 (Peutz-Jeghers syndrome) - breast, ovarian, cervical, uterine, testicular, colon, small bowel (32-54% lifetime risk of breast cancer)
CDH1 (hereditary diffuse gastric cancer) early onset diffuse gastric cancer, lobular breast cancer - 60% lifetime risk of lobular breast cancer
what are some modifiable and non-modifiable risk factors for breast cancer?
modifiable - weight, exercise, alcohol, exogenous oestrogen
Non- modifiable - age of menarche and menopause, early parity and breast feeding, breast density, heredity
what is the NHS breast cancer screening programme?
it is now for woman aged between 47 and 73
it improves stage at diagnosis so 5 year survival rises from 80 to 95%
how is breast screening carried out?
Mammography: low dose X rays
Breast compressed to increase definition
Recall for assessment where have further views and ultrasound/biopsy
MRI screening for BRCA gene carriers from age 30
what are the negatives of mammography?
Overdiagnosis: a small low grade cancer or DCIS in a frail older lady will almost certainly not kill her but she may suffer from adverse treatment effects and psychological effects
Anxiety when recalled
Costs
X ray dose: may cause 2-3 cancers per million screened but will diagnose 6-8000
what is the efficacy of breast screening programme?
Reduces stage of diagnosis: median size of symptomatic cancers 2.5cm versus 1.5 for screening, Node positivity rates lower, mastectomy rate lower.
Diagnoses the majority of DCIS which is rarely diagnosed symptomatically
Trials suggest a survival advantage with screening or 25-30% BUT huge debate about this due to concerns about trial design, confounders such as lead time bias and worries about overdiagnosis
what assessment is used to diagnose breast cancer?
Triple assessment
- clinical examination
- imaging score (<35 years = USS, >35years mammography and
- biopsy score
what are the presenting symptoms and signs of breast cancer?
Presenting symptoms: painless lump, nipple discharge, nipple in-drawing (pain and tenderness is not a common feature)
Presenting signs: irregular, hard, fixed, painless lump, skin tethering, indrawn nipple
what are the surgical treatments for primary operable breast cancer?
breast conservation
mastectomy
when would you consider breast conservation plus radiotherapy as a treatment for breast cancer?
small tumour relative to breast size
<25% volume or 25-50% if can do oncoplastic reshaping
no previous radiotherapy to the breast
pre-operative chemotherapy may allow breast conservation
patient choice
when would you consider mastectomy for the treatment of breast cancer?
large tumour size
more than one cancer in the same breast if in different quadrants
may have immediate or delayed reconstruction
patient choice
what are the different types of breast reshaping?
Grissoti type or wise pattern variants Batwing mammoplasty (for central tumours) round-block or donut mastopexy J mammoplasty for lower lateral cancers
what is the likelihood of a woman with breast cancer having axillary disease at presentation?
40% of women with breast cancer have axillary disease at presentation
In 10% this is palpable and clinically obvious
In 30% this is clinically occult
what are the types of axillary surgery?
full axillary clearance - used if the glands are involved (there is high complication rate-seromas, arm stiffness, drain axillary numbness, 10-12% will get lymphoedema)
Limited axillary surgery - used if the glands are not involved - removes either targeted hot node or blindly samples 4-6 nodes. No significant complication and no drains - may need clearance or axillary radiotherapy
how is breast cancer staged?
TNM staging
T1: <2cm, T2: 2-5cm, T3:>5cm, T4: extends to chest wall or skin or inflammatory
N0: no nodes, N1: mobile node, N2: fixed, matted nodes, N3: internal mammary nodes
M0: no mets, M1: mets
what are the different types of adjuvant therapies for breast cancer?
endocrine: all woman with ER+ disease - 5 years of treatment. Tamoxifen if pre-menopausal, aromatase inhibitors if post-menopausal.
Radiotherapy: all woman who have undergone a lumpectomy, women withy aggressive disease after mastectomy, some tumour subtypes more sensitive to radiotherapy than others
Chemotherapy: aggressive disease phenotype, her-2 + or ER-ve, grade 3 or node positive, complex algorithms, selective use in the over 70s
Trastuzumab: all her-2 positive disease, pertuzumab can now be combined with trastuzumab in the neoadjuvant setting
Bisphosphonates - for high risk cancer in post menopausal women with ER positive disease
what is tamoxifen?
tamoxifen inhibits the oestrogen receptor on breast cancer cells
It increases survival by 15-25% in woman with ER+ cancer
give for 10 years in higher risk women
what are the complications of tamoxifen?
hot flushes
nausea
vaginal bleeding
rarely thrombosis and endometrial cancer
what are aromatase inhibitors?
letrozole
Inhibit aromatase enzyme responsible for the conversion of androgens to oestogen in post-menopausal woman
slightly better anticancer efficacy than tamoxifen
what are the side effects of aromatase inhibitors?
hot flushes
reduced bone density
joint pains
what is Her-2?
HER2-positive breast cancer is a breast cancer that tests positive for a protein called human epidermal growth factor receptor 2 (HER2), which promotes the growth of cancer cells
long known as a marker for poor prognosis
how is her-2 + breast cancer managed?
Currently 1 year of 3 weekly adjuvant Trastuzumab given alongside chemotherapy (usually FEC-T).
how can you find impalpable cancers?
wire localisation
what are the advantages and disadvantaged of primary reconstruction?
Advantages: Increased options for skin preservation and therefore better objective cosmesis, Reduced psychological trauma from disfigurement
Disadvantage:May delay chemotherapy or radiotherapy if complications, Radiotherapy may spoil result. Indications may broaden after the recent EBCTCG data
what are the advantages and disadvantages of delayed reconstruction?
advantages: Minimal risk of delays in other adjuvant therapies from complications, Irradiated tissue may be excised when reconstructing and healthy tissue used to recreate breast
Disadvantages: Limited skin preservation options, Loss of the infra mammary fold, Period without a breast-may never have reconstruction or face long delays as no longer urgent
when will radiotherapy be need for breast cancer treatment?
Difficult to predict before surgery.
T3 and T4 cancers usually attract a recommendation for post-operative chest wall radiotherapy.
High grade PLUS nodal disease may be offered radiotherapy
Close margin posteriorly: careful review of imaging
what are the problems with radiotherapy?
high rate of capsule formation with implants skin viability risk wound healing loss of elasticity fat necrosis implant extrusion
what are the different methods of breast recreation?
implant based _ implant alone, expander/implant, implant augmented latissimus dorsi
Autologous (use patients own tissues) - autologous latissimus dorsi, TRAM/DIEP (transverse upper gracilis flap/deep inferior epigastric perforators), superior/inferior gluteal artery perforator
what are the different implant positions?
Sub-mammary or sub-pectoral are standard for augmentation.
Post-mastectomy, subcutaneous seems logical, especially with a skin sparing technique, BUT high risk of implant loss, wrinkling, infection…..
Partial or fully sub-muscular is therefore preferred.
what muscle is sometimes used for breast implants?
latissimus dorsi
flat sheet of muscle
blood and nerve supply from axilla
can be moved as muscle only, muscle and fat and skim minimal physical limitation afterwards
what are the contraindications for latissimus dorsi flap?
long term back pain
physical job or hobby
previous axillary surgery with evidence of pedicle damage
what can be used to refine contour after breast conservation?
lipomodelling (reversed liposuction)
increases volume to symmetrize
to improve flap quality after mastectomy and RT
how would you treat locally advanced disease?
locally advanced disease = ulceration and bleeding fixed to chest wall
- attempt to shrink with either radiotherapy, chemotherapy or hormone therapy.
- stage for metastases - US liver, CXR, bone scan, nloods
very high recurrence/mets risk
salvage surgery may be possible
what are the common sites of metastases in breast cancer?
Bone 70% Soft tissue 25% Pleura 48% Lung 67% Liver 50% Brain 20%
how is metastatic breast disease managed?
Hormonal treatments- slow acting, only suitable for hormone sensitive cancers, longer lasting control
Bisphosphonates and denosumab
Radiotherapy-Bone, Brain, soft tissues, axillary nodes. Palliative surgery
Chemotherapy, CMF, Doxorubicin, Taxanes, Herceptin. Rapid action, high toxicity.
Newer agents: multiple trials. WonderMABs
Symptom control and social/financial support.
what risk assessment tools can be used for breast cancer?
Manchester Claus tables Tyrer Cuzick BRCA PRO Boudicea
they all have pros and cons
what are the 4 risk levels of breast cancer?
Population Risk: Lifetime risk 12%
Near population risk: Lifetime risk less than 17%
Moderate risk: Lifetime risk 17-30%
High risk: Lifetime risk over 30% (definite gen carriers (80%)
how do you manage women with moderate risk?
annual mammograms
lifestyle advice
consider prophylactic SERM (selective oestrogen receptor modulator)
what are some moderate penetrance genes for breast cancer?
ATM CHEK2 PALB2 RAD51C BRIP1 ABRAXAS
how do you manage women with a high risk of breast cancer?
enhanced screening risk reducing mastectomy risk reducing salpingo-oophorectomy lifestyle advice prophylactic SERM
if someone has positive BRCA1/2 what screening is offered?
30-40 - annual MRI
40-50 - annual mammograms, annual MRI
50-60 - annual mammograms, annual MRI if dense breasts
60-70 - triennial mammograms, MRI is dense breasts
what are some different causes of breast lumps?
Benign breast change Fibroadenoma Cyst Sebaceous cyst Papilloma Fat necrosis/haematoma Mastitis/abscess Cancer Sarcoma, lymphoma, metastases Implant related: (capsule, rupture, edge or crease)
what are the characteristic of a malignant breast lump?
hard - lobular cancer/ ductal carcinoma in situ may be a diffuse thickening
Irregular margin - high grade cancer may have a pushing edge and feel and look on imagining like a fibroadenoma
skin tethering/fixation - pathognomic if presents but it is rarely seen
nodal swelling - pathognomic if presents but only 1 in 10 will have
what are the characteristics of a fibroadenoma?
firm smooth mobile non tender usually 1-3cm
what is a breast fibroadenoma?
benign overgrowth of collagenous mesenchyma of one breast lobule - usually present <30 years but can occur up to the menopause
how should you manage a breast fibroadenoma?
leave alone unless:
- increasing in size
- atypical history
- tenderness
what are the different types of benign breast disease?
Fibroadenoma Breast cysts Infective mastitis/breast abscesses duct ectasia fat necrosis
what is a breast cyst?
benign, fluid filled rounded lump. Not fixed to surrounding tissue.
common in >35 years especially perimenopausal
how do you manage breast cysts?
Aspirate symptomatic cysts. Will cease at menopause unless on HRT
what are the characteristics of a breast cyst?
Size varies from 1mm to 20 cm but on average, symptomatic ones are 1-2 cm and often multiple
may feel cystic but if tense may be hard and irregular and difficult to tell from cancer
what are the problems with breast implants?
capsule formation
rupture - incidence relates to duration of implantation
migration
what is mastitis?
infection of a breast duct is often associated with lactation
breast sepsis
red, tender, swollen, painful area
may have associated pyrexia and flu-like symptoms
usually responds to Abx in 48 hours
may progress to abscess formation
what is the common cause of acute peripheral or lactational sepsis? what causes it and what is the treatment?
<40 years
cause: staph aureus
cause: pregnancy and lactational blocked duct, diabetes
treatment: serial aspiration, avoid drainage surgically as may cause lactational fistula
antibiotics: flucloxacillin
what is the common cause of acute peri areolar sepsis? what causes it and what is the treatment?
age <50 years
caused by - staph aureusm strep, Bacteroides, enterococci
causes - ducts ectasia and periductal mastitis. smoking
treatment - serial aspiration, surgical drainage, total duct excision, fistulectomy
Abx - co amoxiclav
when should surgery be use for an abscess?
failure of repeated aspiration and antibiotics large multiloculated collection overlying skin necrosis patient intolerance of aspiration unable to aspirate - pus to viscid
what is duct ectasia?
typically around menopause -
ducts become blocked and secretions stagnate.
they may present with green/brown/bloody discharge +/- nipple retraction +/- lump.
Refer for conformation of diagnosis - often treatment is not needed.
how would you treat chronic periductal mastitis? what are the risks of the treatment?
total duct excision
use either a radial or peri-areoalar incision to resect all the sub-areolar ducts
risks: nipple numbness, nipple necrosis, recurrent sepsis
how is breast fistulation managed?
it will not heal spontaneously
recurrent bouts of sepsis/abscess formation
progressive scarring
fistulectomy and total duct excision
when should you suspect inflammatory breast cancer?
Important differential
May look very similarly: breast red, oedematous, swollen, axillary lymphadenopathy, mass or thickening
If fails to settle with 1-2 weeks of antibiototics, always refer for imaging and biopsy.
what are the different causes of nipple discharge, what is the discharge like and how should it be managed?
Physiological - non spontaneous, bilateral, yellow or creamy - just give reassurance
Hormonal - milky, multiduct, large volume, rarely bloody in epithelial hyperplasia of pregnancy - pregnancy test, serum hormone profile, if bloody - monitor
Duct ectasia - greenish brown, multiduct - reassure or total duct excision if volume is excessive
Papilloma - clear or bloody uniduct - imaging and proceed to microdochectomy
DCIS - clear or bloody, uniduct - imaging and proceed to microdochectomy
if there is bloody nipple discharge what is the likely cause?
Majority due to duct ectasia, then papillomas then DCIS. Rarely bilateral in pregnancy due to epithelial hyperplasia (papillary like overgrowth of the duct epithelium)
what is a papilloma?
Often seen on imaging as a small mass within a dilated ductal system.
The mass is usually biopsied under ultrasound guidance.
Papillomas are usually benign but are generally removed.
Multiple papillomas associated with increased breast cancer risk
what are some causes of breast pain ?
cyclical breast pain (hormonal)
non cyclical breast pain (MSK, trauma, tender lump
On HRT
what is cyclical breast pain?
Extremely common
Breast swelling, tenderness
Usually in the week prior to menstruation
Settles after menses commences
Usually mild, self limiting and lasts for a few cycles only
Aetiology? Poorly understood. No consistent histological correlates, no endocrine correlates
how do you manage cyclical breast pain?
Reassurance. NSAIDs PRN. Low fat diet and avoid methylxanthines (coffee, tea, chocolate)
Ensure has correctly fitting bra (70-80% don’t!)
Reassure: usually settles within a few months
No benefit to Evening Primrose Oil derivates, vitamins, diuretics.
If very severe, may consider danazol, bromocriptine, tamoxifen, GNRH agonists and even surgery.
what is fat necrosis of the breast?
More common in obese women with large breasts
May follow trivial or unnoticed trauma
Initial inflammatory response, the lesion is typical firm and round but may develop into a hard, irregular breast lump
Rare and may mimic breast cancer so further investigation is always warranted
what is breast cancer in situ?
Breast cancer in situ is cancer that is confined to the duct or lobule in which it originated and does not extend beyond the basement membrane. The cancer does not have access to distant spread through lymphatics or the bloodstream. Ductal carcinoma in situ (DCIS) is a potential precursor of invasive carcinoma and suggests that cancer will become invasive at that site
Lobular carcinoma in situ (LCIS) develops in breast lobule(s) and is usually found incidentally.
what is Paget’s disease of the nipple? what are the symptoms?
it is a rare type of cancer involving the areolar
symptoms: eczema like, itchy, red rash on the nipple and surrounding area.
It usually suggests there is breast cancer behind thenipple
what are the four stages of the breast screening programme?
Invitation
Screening mammography
Assessment - average about 5% recalled
Surgery and further treatment
what are the reasons to recall in breast screening?
Mass: this may be well-defined, poorly defined or spiculate Microcalcification Parenchymal deformity/distortion Asymmetric density Enlarged axillary lymph nodes Clinical recall Technical Recall
what things should you look for on mammography?
Asymmetrical densities Focal masses Parenchymal distortion Microcalcification Skin thickening Enlarged axillary nodes
what kind of MRI should be used for breast cancer?
Contrast-enhanced MRI has high sensitivity for invasive breast carcinoma
Does not use ionising radiation
what are the current indications for MRI for breast cancer?
Evaluation of possible recurrence of breast cancer following breast conserving surgery
The detection of suspected multifocal breast carcinoma
Evaluation of response in women undergoing primary chemotherapy for breast cancer
Screening of women at high risk of breast cancer inherited or iatrogenic e.g. genetic mutations, following radiation therapy for previous lymphoma
Assessment of breast implant integrity or the presence of suspected malignancy in women with breast implants
