Breast Flashcards
Give some differentials for breast lump?
Fibroadenoma (smooth, rubbery, mobile)
Cyst (rubbery, smooth, mobile - may be pain fluctuating with menstrual cycle)
Fat necrosis (firm, irregular mass - Hx trauma)
Intraductal papilloma (bloody nipple discharge)
Breast abscess (pain, fever, erythema)
Invasive breast cancer
Ductal carcinoma in situ (DCIS)
Give 3 genes associated with development of breast cancer?
BRCA1
BRCA2
TP53 (Li-Fraumeni syndrome)
Give 4 signs of breast cancer
Painless lump (irregular, hard, fixed) Skin tethering Indrawn nipple Nipple discharge Peau d'orange (dimpled skin)
What makes up the ‘triple assessment’ of a breast lump?
1) Clinical examination
2) Imaging (USS <35, USS + mammogram >35)
3) Biopsy (FNA of core biopsy)
When is breast cancer screening offered?
Every 3 years for women 50-70yrs
What is the lifetime risk of breast cancer in women?
1 in 8
Why are mammograms a good screening tool?
Acceptable test
Early detection means disease can be found before metastatic spread
Important problem (1 in 8 women affected)
Reduces morbidity and mortality by up to 30%
Acceptable treatment for those screened +ve
Not compulsory
What are some controversies surrounding breast cancer screening?
?overdiagnosis
3 in 4 women that are called back will NOT have cancer - so can cause a lot of undue worry
Which lymph nodes to breast cancer spread to?
Axillary (40% have this at presentation)
Supraclavicular
Infraclavicular
Neck (always examine from behind)
What are some features of a benign mass on mammogram?
Rounded, smooth shape
Well-defined margins
What are some features of a suspicious mass on mammogram?
Rough edges
Poorly defined margins
Give 3 RFs for breast cancer
FHx Increasing age Obesity BRCA genes Not breastfeeding Uninterrupted oestrogen exposure - nulliparity, early menarche, late menopause, HRT, OCP
Give 3 protective factors against breast cancer
Breastfeeding
Multiparity
Late menarche
Early menopause
What is the most common type of breast cancer?
Invasive ductal carcinoma
Which is the type of breast cancer that can look like eczema?
Paget’s disease of the breast
What are the different stages of breast cancer?
1 - confined to breast, mobile
2 - confined to breast + nodes in ipsilateral axilla
3 - fixed to muscle, ipsilat LNs, skin involvement
4 - fixed to chest wall, distant mets
What is the index used to predict survival?
How is it calculated?
Give 2 good prognostic factors
Nottingham prognostic index
Grade (1-3) + Nodes (1-3) + 0.2(size, cm)
ER+ve
Low grade, stage and size
Give some differentials for breast pain
Angina Lung disease Oestrogens/HRT Cyclical breast pain Thoracic outlet syndrome Gallstones Costochondritis
Give 4 differentials for nipple discharge
Duct ectasia
Cancer
Lactation
Infection
What are the 2 views taken of each breast in a mammogram?
Cranio-caudal
Mediolateral oblique
What is the role of MRI in breast assessment?
Not routine - can help in difficult cases
Screening in high risk ladies
Assessment of implants
What are the 2 surgical options for treating primary operable breast cancer?
Breast conservation
Mastectomy
What are the indications for breast conservation surgery?
Small tumour relative to breast size (<25% vol)
Not underneath nipple
No prev. radio to breast
Pre-op chemo may allow breast conservation
Patient choice
What are the indications for mastectomy?
Large tumour relative to breast Tumour underneath/in-drawing of nipple >1 cancer in same breast Immediate/delayed reconstruction Patient choice
What are the 2 types of axillary surgery involves in breast cancer treatment?
1) Full axillary clearance (S/E: arm stiffness, lymphedema, numbness)
2) Limited axillary clearance
What is meant by a triple negative breast cancer?
No ER/PR, HER2 or Ki67 (proliferative marker)
What medication can be used to treat ER+ breast cancer?
1) Tamoxifen (if PRE-menopausal) *think Tammy girl
2) Aromatase inhibitors (e.g. anastrozole) if POST-menopausal
(ER+ women should receive 5yrs of one of these)
How does tamoxifen work?
Anti-oestrogen: blocks ER on surface of breast cancer
in pre-menopausal women
How does anastrozole work?
Aromatase inhibitor: prevents peripheral oestrogen synthesis
When should radiotherapy be used in breast cancer treatment?
1) Lumpectomy/WLE (wide local excision)
2) Aggressive disease (after mastectomy)
3) Some tumour subtypes
When should chemotherapy be used?
1) Aggressive disease phenotypes (HER2+, ER-. grade 3, node positive)
2) Complex algorithms
3) Selective use in >70s
Which medication should be used for HER2+ breast cancer?
Trastuzumab (herceptin)
- monoclonal antibody, given with chemo
What treatment options need to be considered for the future in someone with breast cancer?
PARP inhibitors
TDM1 - multiple HER2 pathway blockade
Bisphosphonates (protection against bone disease)
What are some side effects of tamoxifen?
Hot flushes
Nausea
Vaginal bleeding
Rare: thrombosis, endometrial Ca
What are some side effects of anastrozole (aromatase inhibitors)?
Hot flushes
Reduced bone mineral density
NO risk of DVT or endometrial Ca
What are the 2 types of reconstruction surgery?
1) Primary
- skin preserved better, less psychological impact
- may delay chemo/radio if complications
2) Delayed
- does not risk delaying adjuvant Rx
- limited skin preservation, may take a long time to reconstruct
Give some side effects of radiotherapy
Skin viability risk (for reconstruction) Loss of elasticity Fat necrosis Fibrosis High rate of capsule formation with implants
2 methods of breast mound recreation?
1) implant based - implant alone, implant augmented lat dorsi
2) autologous (use patent’s own tissue) - lat dorsi, TRAM flap
Local complications of breast implants?
Capsule formation
Infection
Rupture
Shape changes with age and gravity
Contraindications for lat dorsi flap?
Long term back pain
Physical job/hobby
Prev axillary surgery w/ evidence of pedicle damage
What breast screening is done for women known to be BRCA1/2+?
30-40: annual MRI
40-50: annual mammogram + MRI
50-60: annual mammogram (+ MRI if dense breasts)
60-70: 3-yearly mammograms (MRI if dense breasts)
