Breast Flashcards
Tamoxifen
MOA
Use
Side effects
Other drug that is similar?
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
Breast cancer screening
Who
When
Different for who?
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)
How to assess a breast lump
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
Clinical staging of breast cancer
TNM staging
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.
Other investigations for breast cancer
besides the main
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
Presentation of breast cancer
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
Breast cancer management
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.
What is sentinel node biopsy
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.
How to assess prognosis in breast cancer
Nottingham prgnostic index (NPI)
Predicts survival and risk of relapse
(0.2 x tumour size in cm) + histo grade + nodal status
female <30 mobile, non-tender discrete lump on breast
diagnosis
Managment
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,
Middle aged female, lumpy breast, may be painful
Symptoms around menstruation
Fibroadenosis
What is trastuzumab
Use
Contraindications
Herceptin
- biologic
For women with HER2 +ve cancer
contraindications
- Heart disorders
Mastectomy vs WLE in breast cancer
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
What is Paget’s disease
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.
ER +ve breast cancer - options for hormonal treatment
Tamoxifen = SERM
- Use for pre and peri menopausal
Anastrazole = Aromatase inhibitor
- Use for post-menopausal women
- Tamoxifen unacceptable due to risk of endometrial cancerf
Breastfeeding lady with inflammation of nipple
Diagnosis
Management
Progression
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
Bilateral, small volumes of pale or colourless discharge from nipples in a teenager
Likely to be hormonal changes
BRCA1 carrier
Chance of child having the gene?
Change of sibling having the gene?
There is a 50/50 chance of siblings and children of BRCA1 carrier to also have the gene
Breast cysts
Presentation
Who gets them
Mammography appearance
US appearance
Management
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
Duct ectasia
Presentation
Who gets it
Management
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.
The ‘snowstorm’ sign on ultrasound of axillary lymph nodes in a patient with breast change
diagnosis
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.
Complications of axillary node clearance for breast cancer
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.
Duct papiloma presentation
Pathophysiology
Management
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.
When to refer for breast cancer
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.
What is periductal mastitis
Who is at risk
Treatment
Common in smokers and may present with recurrent infections.
Treatment is with co-amoxiclav.
What is Mondor’s disease of the breast?
Mondor’s disease of the breast is a localised thrombophlebitis of a breast vein.
