Breast Flashcards

1
Q

Tamoxifen

MOA

Use

Side effects

Other drug that is similar?

A

Tamoxifen is a Selective oEstrogen Receptor Modulator (SERM) which acts as an oestrogen receptor antagonist and partial agonist.

It is used in oestrogen receptor positive breast cancer

Adverse effects
Menstrual disturbance: vaginal bleeding, amenorrhoea
Hot flushes - 3% of patients stop taking tamoxifen due to Climateric side-effects
Venous thromboembolism
Endometrial cancer
Osteoporosis

Tamoxifen is typically used for 5 years following removal of the tumour.

Raloxifene is a pure oestrogen receptor antagonist, and carries a lower risk of endometrial cancer

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2
Q

Breast cancer screening

Who

When

Different for who?

A

he NHS Breast Screening Programme is being expanded to include women aged 47-73 years from the previous parameter of 50-70 years. Women are offered a mammogram every 3 years. After the age of 70 years women may still have mammograms but are ‘encouraged to make their own appointments’.

The effectiveness of breast screening is regularly debated although it is currently thought that the NHS Breast Screening Programme may save around 1,400 lives per year.

Familial breast cancer

If the person concerned only has one first-degree or second-degree relative diagnosed with breast cancer they do NOT need to be referred unless any of the following are present in the family history:
- age of diagnosis < 40 years
- bilateral breast cancer
- male breast cancer
- ovarian cancer
- Jewish ancestry
sarcoma in a relative younger than age 45 years
- glioma or childhood adrenal cortical carcinomas
- complicated patterns of multiple cancers at a young age
- paternal history of breast cancer (two or more relatives on the father’s side of the family)

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3
Q

How to assess a breast lump

A

All should have triple assessment
1) Hx and clinical examination

2) Radiology: <35 - US, >35 - US and mamography
3) Cytology/Histology

If cystic: FNAC (green/18G)

  • Bloody fluid –> send cytology
  • Clear fluid –> reassure
  • Residual mass –> core biopsu

If solid lump: triple core biopsy

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4
Q

Clinical staging of breast cancer

TNM staging

A

Stage 1
Confined to breast, mobile, no LNs

Stage 2
Stage 1 + nodes in ipsilateral axilla

Stage 3
Stage 2 + Fixation to muscle (not chest wall)
- LNs matted and fixed, large skin invovement

Stage 4
Complete fixation to chest wall +mets

T1 <2cm,
T2, 2–5cm
T3 >5cm
T4a invades chest wall
T4b Invades skin (ulcer/oedema/Peaud'orange)
T4c Invades chest wall and skin
T4d Invades chest walls and skin
n1, mobile ipsilateral nodes; 
n2, fixed nodes
m1, distant metastases.
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5
Q

Other investigations for breast cancer

besides the main

A

Bloods: FBC, LFTs, ESR, bone profile

Imaging: To help staging

  • CXR
  • Liver US
  • CT scan
  • Breast MRI
  • Bone scan and PET -CT

May need wire-guided excision biopsy

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6
Q

Presentation of breast cancer

A

Lump

  • Usually painless
  • 50% in upper outer quadrant
  • +/- axillary nodes

Skin changes

  • Paget’s: persistent eczema
  • Peau d’orange

Nipple

  • Discharge
  • Inversion

Mets

  • pathological fractures
  • SOB
  • abdominal pain
  • Seizures

May present through screening

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7
Q

Breast cancer management

A

MDT: Oncologist, Breast surgeon, Breastcare nurse, Radiologist, histopathologist

Factors: Age, fitness, wishes, clinical stage
1-2: Surgical
3-4: Chemo + palliation

Treating local disease - stage 1-2

1) Surgery: Removal of tumour by WLE or mastectomy ± breast reconstruction + axillary node sampling/surgical clearance or sentinel node biopsy (box ‘Sentinel node biopsy’).
2) Radiotherapy: Recommended for ALL patients with invasive cancer after WLE.
- Risk of recurrence decreases from 30% to <10% at 10yrs and increases overall survival.
- Axillary radiotherapy used if lymph node +ve on sampling and surgical clearance not performed (↑risk of lymphoedema and brachial plexopathy). se: pneumonitis, pericarditis, and rib fractures.
3) Chemotherapy: Adjuvant chemotherapy improves survival and reduces recurrence in most groups of women (consider in all except excellent prognosis patients), eg epirubicin + ‘cmf’ (cyclophosphamide + methotrexate + 5-fu). Neoadjuvant chemotherapy has shown no difference in survival but may facilitate breast-conserving surgery.
3) Endocrine agents: Aim to ↓ oestrogen activity and are used in oestrogen receptor (er) or progesterone receptor (pr) +ve disease. The er blocker tamoxifen is widely used, eg 20mg/d po for 5yrs post-op (may rarely cause uterine cancer so warn to report vaginal bleeding). Aromatase inhibitors (eg anastrozole) targeting peripheral oestrogen synthesis are also used (may be better tolerated). They are only used if post-menopausal. If pre-menopausal and an er+ve tumour, ovarian ablation (via surgery or radiotherapy) or gnrh analogues (eg goserelin) ↓ recurrence and ↑ survival.

  • Support: Breastcare nurses
  • Reconstruction options: Eg tissue expanders/implants/nipple tattoos, latissimus dorsi flap, tram (transverse rectus abdominis myocutaneous) flap.
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8
Q

What is sentinel node biopsy

A

Decreases needless axillary clearances in lymph node −ve patients.

  • Patent blue dye and/or radiocolloid injected into periareolar area or tumour.
  • A gamma probe/visual inspection is used to identify the sentinel node.
  • The sentinel node is biopsied and sent for histology ± immunohisto-chemistry; further clearance only if sentinel node +ve.

Sentinel node identified in 90%. False −ve rates <5% for experienced surgeons.

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9
Q

How to assess prognosis in breast cancer

A

Nottingham prgnostic index (NPI)
Predicts survival and risk of relapse

(0.2 x tumour size in cm) + histo grade + nodal status

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10
Q

female <30 mobile, non-tender discrete lump on breast

diagnosis

Managment

A

Fibrodenoma

  • Develop from a whole lobule
  • Mobile, firm breast lumps
  • 12% of all breast masses
  • Over a 2 year period up to 30% will get smaller
  • No increase in risk of malignancy

Management
If >3cm surgical excision is usual,

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11
Q

Middle aged female, lumpy breast, may be painful

Symptoms around menstruation

A

Fibroadenosis

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12
Q

What is trastuzumab

Use

Contraindications

A

Herceptin
- biologic

For women with HER2 +ve cancer

contraindications
- Heart disorders

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13
Q

Mastectomy vs WLE in breast cancer

A

NB: Surgery is first line for breast cancer patients

Mastectomy for:

  • Multifocal
  • Large
  • Central tumours
  • > 4cm

Wide local excision for

  • Solitary lesion
  • Peripheral lesion
  • Small lesion in large breast
  • <4cm
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14
Q

What is Paget’s disease

A

Paget’s disease is an eczematoid change of the nipple associated with an underlying breast malignancy and it is present in 1-2% of patients with breast cancer. In half of these patients, it is associated with an underlying mass lesion and 90% of such patients will have an invasive carcinoma. 30% of patients without a mass lesion will still be found to have an underlying carcinoma. The remainder will have carcinoma in situ.

Paget’s disease differs from eczema of the nipple in that it involves the nipple primarily and only latterly spreads to the areolar (the opposite occurs in eczema).

Diagnosis is made by punch biopsy, mammography and ultrasound of the breast.

Treatment will depend on the underlying lesion.

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15
Q

ER +ve breast cancer - options for hormonal treatment

A

Tamoxifen = SERM
- Use for pre and peri menopausal

Anastrazole = Aromatase inhibitor

  • Use for post-menopausal women
  • Tamoxifen unacceptable due to risk of endometrial cancerf
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16
Q

Breastfeeding lady with inflammation of nipple

Diagnosis

Management

Progression

A

Mastitis

Management

  • If febrile/systemic symptoms - 10-14days flucloxacillin
  • Continue breast feeding with or w/o antibiotics

progression
- May lead to breast abscess - would need incision and drainage

17
Q

Bilateral, small volumes of pale or colourless discharge from nipples in a teenager

A

Likely to be hormonal changes

18
Q

BRCA1 carrier

Chance of child having the gene?

Change of sibling having the gene?

A

There is a 50/50 chance of siblings and children of BRCA1 carrier to also have the gene

19
Q

Breast cysts

Presentation

Who gets them

Mammography appearance

US appearance

Management

A

Palpable cysts constitute 15% of all breast lumps. They occur most frequently in perimenopausal females and are caused by distended and involuted lobules.
They may be readily apparent on clinical examination as soft, fluctuant swellings. It is important to exclude the presence of an underlying mass lesion. On imaging they will usually show a ‘halo appearance’ on mammography. Ultrasound will confirm the fluid filled nature of the cyst.

Symptomatic cysts may be aspirated and following aspiration the breast re-examined to ensure that the lump has gone

20
Q

Duct ectasia

Presentation

Who gets it

Management

A

As women progress through the menopause the breast ducts shorten and dilate.

In some women this may cause a cheese like nipple discharge and slit like retraction of the nipple.

No specific treatment is required.

21
Q

The ‘snowstorm’ sign on ultrasound of axillary lymph nodes in a patient with breast change

diagnosis

A

The ‘snowstorm’ sign on ultrasound of axillary lymph nodes indicates extracapsular breast implant rupture. It is due to leakage of the silicone, which then drains via the lymphatic system, giving the ‘snowstorm appearance’ both in the breast and the lymph nodes.

22
Q

Complications of axillary node clearance for breast cancer

A

Besides the risks common to all surgical procedures (e.g. infection, post-operative pain, bleeding), axillary node clearance is associated with a 14% risk of LYPHOEDEMA which can cause functional arm impairment1.

23
Q

Duct papiloma presentation

Pathophysiology

Management

A

Unilateral blood stained discharge is likely to be associated with a duct papilloma. This is a small harmless growth in one of the breast ducts, often behind the nipple. It does have malignant potential and so is often removed.

24
Q

When to refer for breast cancer

A

Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer if they are:

  • aged 30 and over and have an unexplained breast lump with or without pain or
  • aged 50 and over with any of the following symptoms in one nipple only: discharge, retraction or other changes of concern

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer in people:
with skin changes that suggest breast cancer or
aged 30 and over with an unexplained lump in the axilla

Consider non-urgent referral in people aged under 30 with an unexplained breast lump with or without pain.

25
Q

What is periductal mastitis

Who is at risk

Treatment

A

Common in smokers and may present with recurrent infections.

Treatment is with co-amoxiclav.

26
Q

What is Mondor’s disease of the breast?

A

Mondor’s disease of the breast is a localised thrombophlebitis of a breast vein.